American Medical Student Association

It’s 7:15 a.m., and I’m a third-year on my first rotation ever, surgery. Today is day four, and while I’m still com-pletely unsure of myself, at least now I have a general idea of where I’m supposed to be and when, even if it does still take me twice as long as it does the residents who have figured out our rat’s maze of a hospital. To-day’s first patient is Mary Whitter, a 52-year-old woman with a past history of controlled diabetes who is having an abdominal aortic aneurysm (AAA) repair. This is a fairly routine procedure whereby the surgeon puts a stent into the abdominal aorta to keep it from bursting. I’d already assisted one or two of them, and while it’s a fairly large surgery, the surgeon on this procedure has conducted three or four of them every week for the past 20 years.

Mary seems calm for someone about to undergo surgery, and in retrospect I realize that she had a some-what flat affect. In lay terms, this means that she did not show appropriate emotion for her situation—nothing seemed to move her. Maybe that would impress me now, but at the time, I hadn’t done my psychiatric rotation yet. And all I did was note it vaguely in the back of my mind. Besides, the surgeon that morning was the chief of surgery and my brain was busy running through all the questions I might be pimped on during the procedure.

I asked Mary a little about her history and her symptoms, and asked if she had any questions of her own, but I was quickly cut short as the nurse arrived and announced that for Mary it was time to go into the OR.

“Don’t worry, you’ll do just fine. We’ll take good care of you,” the nurse assured Mary as she was wheeled by.

The procedure started routinely. We made our incisions, clamped the aorta above and below the aneurysm, and the stent was painstakingly sewn into place. As we started to close her back up, though, she began to ooze blood. We checked the stent. We checked above and below the stent. We fused any capillaries along the side walls that looked like we might have missed beforehand. We made sure she’d been given an appropriate dose of protamine sulfate to reverse the heparin. Still her blood pressure dropped. We gave her more fluids and packed the abdominal cavity with lap pads to try to tamponade the bleed. Still she bled. The surgeon and the resident resewed spots along the stent in case there was a tiny leak somewhere. We gave her blood. Still she oozed, her blood pressure falling. We tried again, more packing, more fluids, more blood. This was all extremely unusual. While major bleeds need to be either sewn or burned shut, minor bleeds clot on their own once the heparin has been reversed, usually within a couple of minutes.

The entire AAA repair usually takes about three hours. Five hours in, we were still trying to control her bleeding. We had given her 10 units of blood—enough to replace her entire blood volume, as well as 12 units of fluids. We had given her twice as much protamine sulfate as needed. We had packed and unpacked her four times. But she still bleeds.

Miserably, I continue to push on the packing, willing her to stop oozing, to please, please stop bleeding. I glance at her blood pressure, 60/40. “Oh my God, this woman is going to die,” the surgeon states. Please don’t say that. If the surgeon says that, what hope can she have? We had told her she’d be OK.

“All right. That’s it. Let’s sew her up.” The surgeon is grim. The resident is expectant. I am confused. But Mary’s not stable yet. Are we just going to give up on her? We told her we’d take care of her. But this is sur-gery. I’m only a third-year med student, and I say nothing. Blinking back tears, I remove the soaked towels from her abdominal cavity and do my job. I pull back on the retractor. I cut suture. I aspirate blood.

We wheel Mary into the surgical intensive care unit (SICU). It’s my first time in there, and I hate it imme-diately. The monitors beeping and toning in melodic sequences every few seconds. The glass closets. The smell of sterility. At this point our job is done, but I cannot leave.

“Go get something to eat,” the resident tells me. I shake my head and say I’d rather stay. “Go on,” she urges. “You should grab something while you can.” I’m nowhere near hungry, but everyone knows the three rules of surgery, and so I run down to the locker room, wolf down a granola bar, and return to the SICU.

Chaos. The resident is straddling the patient’s chest, applying chest compressions. There are people flying all over Mary’s room, monitors flaring and lights flashing Code Blue. Oh my God. I was only gone for five mi-nutes.

After 15 minutes, the resident climbs off. There is a stillness, and then the mundane background beeping and toning of the SICU returns. Mary Whitter is pronounced dead.

Tears fill my eyes, and this time they will not be blinked back. I was talking to her only six hours ago. She was alive six hours ago. I am a third-year medical student, on my fourth day of my first rotation, and I have lost a patient.

Stunned and empty, I sit in the chair the resident and a nurse tell me to take. I’m fine, I insist. I don’t need a break. For some reason, it is important to me that they do not think I am fazed by this. I’m trying to become a doctor, after all. This is all part of the deal—isn’t it?

Because of the way the scheduling worked out, Mary’s case would not be presented for two weeks at the morbidity and mortality conference, a weekly meeting where physicians review cases with bad outcomes to see if anything could or should have been done differently. Mary’s was the last case to be presented, and the resident went through the details. Her history. Her condition. The surgery. The SICU.

In the end, it was unanimously concluded that there was nothing we could have done better. Some surgeons, in fact, noted that they would have stopped earlier, since it was fairly obvious after the first hour of trying that there was nothing that we could do.

By this point, I’d finished the vascular surgery rotation, and it had been almost two weeks since Mary’s death. I’d had time to assimilate her story into my own, and the conference’s verdict gently sealed the whole story to a quiet conclusion. We had done everything we could. It wasn’t our fault, I think.

Thankfully, surgical deaths are a rare occurrence at my hospital, and it was only natural that the floors had been abuzz with gossip on the topic in the weeks after the event.

“The surgeon always takes it so hard when a patient dies,” or “sometimes there’s just nothing you can do. They just up and die!”

And then: “She told me that her husband had just died three weeks ago and she didn’t want to live any-more.”

Wait. What?

“Apparently he’d just had an AAA of his own and died a few weeks ago. She told me she just didn’t care whether or not she lived anymore.”

I am shocked and disappointed with myself for not having gotten this history from her myself in my short interview with her before the surgery. It had never occurred to me to ask her social history, or whether she cared about the surgery at all. I had just assumed.

Science will tell you that there is no physical way that a person can will themselves to bleed out during surgery. We just don’t have that kind of control. But any oncologist will tell you that a person’s will to live plays a significant role in how they respond to treatment, in how long they survive. It’s not uncommon for someone who has been fighting cancer for years to die within days if they give up hope. Not purposely by refusing food or committing suicide or anything so dramatic, but quietly. Because they just don’t care.

We’ll never have a satisfying medical reason for why Mary Whitter, who otherwise was in relatively good health, died that day in the middle of a routine procedure in the hands of a skilled surgeon who seems to have made no mistakes. Mary’s story was a severe lesson, but one that I needed to learn: Never underestimate the interdependence and power of the connection between the physical body and the spiritual mind. There was no reason for Mary to die on the operating room that day. Except that she wanted to. And that was enough.

Dr. Angela Lo is a PGY-1 resident in internal medicine at the University of Massachusetts Medical Center. Mary Whitter is a pseudonym.