The surgery was long and complicated. Then Dr. Murano had to take the patient back to the OR for bleeding. It was well after midnight when he got home. The ICU nurse kept calling him with the updates, and it didn’t sound like his patient was stable. Blood pressure was low, the heart didn’t beat properly, and the intraaortic balloon couldn’t be synchronized with its erratic contractions. The patient was fighting the ventilator, and the sedative dropped his blood pressure even more. And then there was no urine output, and it looked as now the kidneys were shutting down. Jack didn’t sleep the entire night and at six in the morning, while driving back to the hospital, he was thinking of the case.
The surgery was done technically well and there were no major surprises. He couldn’t recall any major mistakes. There was nothing he thought of he could have done differently. The patient was old and frail and just didn’t respond to surgery well. The next twenty-four hours will be critical, and he will see if the patient will turn the corner and start to recover.
In the ICU, he spoke with Dara, the nurse working with his patient.
“He is on the ventilator, has an intraaortic balloon in, and looks like we soon will have to dialyze him.” Dara was an experienced nurse and Jack liked working with her. “Where do you get all these interesting cases from, Dr. Murano? Please give some of them to your partners.” They were good friends.
“I know, Dara. Sometimes it feels like I have a magnet for them.” Jack thought for a second.
“Do you know, Dara, what’s the definition of an interesting case?” She looked at him, not knowing what to think. It was early in the morning, and she was overwhelmed with all the work she had to do with his patient during her shift.
“The interesting case is the case someone else has problems with.” She knew it, she’s seen many of them.
If there will be no improvement by tomorrow, he will have to have a meeting with the family, discuss plans for the future and talk about their options. The most important thing will be to find what their expectations are.
By the next morning, there was no improvement, and they put the dialysis machine in his ICU room.
Jack scheduled a family meeting in his office after the afternoon patients.
After the last patient had left, his patient’s daughter and son entered the office. They were quiet and really not sure what to expect.
“How is my father doing?” son seemed a little unnerved. He really didn’t expect all the tubes in the patient’s body and the machines taking the free space in his room.
“Well,” Jack started, “his kidneys are not working well, and we will have to start the dialysis today.”
The son was not happy and it showed. He was moving in his chair, sitting deep and then back to the edge. His hands were restless and his face worried. The sister was quiet and more composed.
“We are doing everything necessary, but he is responding poorly. His heart, lungs and kidneys are failing. He’s critical.” Jack was looking at their faces and trying to gauge the responses. The woman was sitting still with her head down, her brother was agitated, fidgeting on his chair with an angry look on his face.
“Is there any hope?” She finally broke the silence.
“The hope is always there.” Jack said in a soft voice. The daughter’s face lit up some. “But I want to talk to you about what to do if there will be no improvement in your father’s condition.”
They looked at each other and then the daughter dropped her head looking at her feet.
“What do you mean?” The son blurted out and suddenly became still.
“Well, in the case, when there will be no improvement, how long do you want us to keep him on the machines?” Jack thought he gave them an idea.
“What do you mean? You want us to stop the life support?” son was getting more angry.
“I want you to think how long do you want him to be kept alive by the machines, just in case when there will be no improvement,” Jack was getting more specific.
“Never!” the son was irate, “I will never allow to stop the machines and let my father die.” He was again agitated. “I want to do everything humanly possible to save my father!”
His sister looked at him.
“You just feel guilty for not spending enough time with him,” she said quietly. “Now you want to show that you care.”
He looked at her. “You were always a daddy’s girl, you should fight for him too.”
“I think the time for that was when he was alive.”
“He is not dead yet.”
“You know what I mean.” She was composed, but Jack could see her eyes welling.
Jack looked at them.
It’s going to be a long and windy road, he thought.