Great Doctors, Terrible Outcome


I stood silently by his bedside in the Intensive Care Unit listening to the rhythmic hissing sounds of the ventilator as it repeatedly pushed oxygen into what was left of his lungs. “Poosh, poosh, poosh,” the sound a constant reminder of how sick he was. On the monitor above the bed the tracing of his heart rate kept its own rhythm, an almost mocking evidence of life. Although he felt nothing, I felt a pain deep in my stomach and an ache in my heart. I asked myself, “How did we end up here?”

He seemed perfectly healthy a few weeks earlier when he came to see me in the office for his check up. His blood pressure was good, his heart was strong, his lab work was normal. He exercised regularly and was in near perfect shape for a man in his early seventies. The only blemish on his health record was a distant one. He had once been a heavy smoker but had stopped 10 years earlier.

If his visit had been scheduled a few months earlier I would not have ordered any additional tests, but he came in shortly after a study on lung cancer had been announced. Less than a month before his physical I had been a part of a team of doctors involved in drafting a new lung cancer screening protocol for the hospital. The recent study had shown for the first time that early detection of lung cancer could have a positive impact on survival. The evidence revealed a 20% decrease in lung cancer mortality when patients over the age of 50 with a heavy smoking history had annual CT scans to screen for small tumors. He was the first patient of mine who met the criteria for testing and I enthusiastically recommended the test.

I was stunned when the test revealed a cancer but was hopeful that we had found it in time. That was, after all, the purpose of the test. I referred him to the thoracic surgery team for removal of the tumor. The surgeon, one of the very best at his craft, met with the patient, did the appropriate evaluation and scheduled him for surgery. Everyone was upbeat and hopeful. The day before the operation he played basketball in the driveway with his grandchildren.

The first hint that things might not go as hoped happened in the operating room. The initial plan had been to resect the tumor and leave most of the lung intact. The plan fell to the wayside when the surgeon discovered that the tumor was larger and more invasive than the scan had suggested. The cancerous mass had wrapped itself around the bronchus, the air tube supplying a major portion of the lung. The surgeon had no choice but to remove the entire lobe, significantly more tissue than he had planned. The doctor was disappointed, but was still confident that he had removed all of the tumor and the patient had a good chance at recovery. He sewed the patient up and moved him to the ICU, where all chest surgery patients go after leaving the recovery room. The plan was to keep him on the ventilator for a day or too while the lungs healed and then allow him to breath on his own.

That never happened. The years of smoking had caused another previously unknown problem. Although he was physically active, he had undiagnosed COPD, chronic obstructive pulmonary disease. The combination of the stress of surgery and the chronic disease were too much to overcome. The remainder of his lungs were too diseased to support him breathing on his own. Lung specialists, heart specialists, and other specialists were all asked to help but there was nothing anyone could do. He was never going to get off of the ventilator. It was up to me to inform the family of the bad news.

The conversation with the wife was intense. The question was asked, “What went wrong.” The answer was both nothing and everything. Each and every doctor had done everything exactly right. I had ordered the right tests, as had the surgeon. The surgeon had made no mistakes during the operation and the correct medications and treatments had been prescribed. In spite of our combined efforts  he remained unconscious and dependent on a ventilator. It was a hard message to accept. The wife and I agreed to wait a few more days to give him a final chance to respond, praying for a miracle. It was understood that if no improvement came that we would have to let him go. A few days later we said our tearful goodbyes.

His death was a devastating loss for all who were involved in his care. I found myself wishing I had never ordered the CT scan and grieving the decision to proceed with surgery. I wrestled with the reality that while his death from lung cancer was a certainty, it need not have happened so soon. I will never forget the anguish of his wife as we stood at his bedside, nor the heartfelt tears in the eyes of the surgeon when he told me there was nothing more that he could do. He was a good and kind man and the loss was real.

I have also never forgotten the truth that excellent care does not guarantee good outcomes. Life happens, and death happens, even when doctors do everything right. I am reminded not to assume the worst when bad things happen and to avoid placing blame and pointing fingers. Sometimes our best just isn't good enough, in all areas of life.

- Bart

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