The man on the table was a stranger to me as many patients tend to be in healthcare. I had never heard his voice nor seen him awake. He was already prepped and draped in the typical sterile fashion ready for his liver transplant. Although I had never met him, I knew several scraps of information about this person. I knew that he had a MELD score of 39; without this new liver, he had over a 50% chance of mortality within the next 3 months. I knew that this operation had the potential to extend his life by many years, decades even. I knew his family was waiting to hear how the surgery went.
Approaching the table, I examined the yellow stomach sticking out from the blue tarp marked with a large, backwards L indicating where the incision would be made. Steel and electricity unceremoniously made short work of the previously untouched muscle, fat, and blood vessels. The surgeons peeled back layer after layer, made suture after suture to control the destruction they were causing to extract this rubbery, bumpy liver. This was not my first time spectating during a surgery–nor will it be my last–still, I could not help but wonder about the role of pain in medicine as I watched these well-choreographed events unfold. How could therapeutically hurting a patient play into the role of being a healer?
I think everyone who goes into medicine wants to help people who are suffering. The idea of being the source of that suffering seemingly goes against the vow of beneficence and non-maleficence providers take. In a much less theoretical sense, it makes me uncomfortable to hurt someone even with good intention and sound reasoning. Take, for instance, minimally invasive surgery. We are told that laparoscopic procedures are lighter on the body and yield quicker recovery times. I remember one patient describing feeling like he was just beat up by a bunch of baseball bats after his robotic gallbladder removal. Statements like that put larger, more aggressive procedures into perspective on how a patient feels afterwards. Imagine how someone must feel after an hours long open procedure — the kind with midline incisions that are the full length of the abdomen. This does not even include the anxiety someone might feel just having to go into the operating room for a surgery. Suffering is not limited to surgery either. Medicine is rife with discomfort and pain due to various procedures that range from benign to absolutely life changing. Range of motion tests cause patients with rotator cuff injuries and muscle sprains to wince. Medications we may prescribe can have severe side-effects. It is not uncommon to break life changing news to patients and families causing stress and psychological suffering well beyond just one individual. Inducing some level of discomfort for the patient is common as a physician. Yet all of these, and more, would be considered standard practice. It seems that many of our solutions require things to get “worse” before they get better.
Perhaps what makes this whole concept so strange to me is the idea that it will not be long before any one of us in my class will be expected to do these things. I find myself wondering who am I to inflict this pain on someone? I am just one human in a room, hoping to have letters behind his name someday, trying to practice medicine on another human in the room. In any other context these incisions, maneuvers, and causing general psychological stress could be deemed illegal or at the very least unethical. In a hospital they are expected. Patients trust doctors to do what is best – even if that treatment comes at significant personal cost. That burden becomes even heavier when realizing that there will be suffering no matter what happens. The question is just how much will occur. The 4-year medical school curriculum and 3-year minimum residency training are both testament to the fact that these practices and procedures are anything but random. The gold standards are tried and true in improving people’s lives. We will all be highly skilled after our training is complete – a knowledge built on an infinite series of trials and errors. Still, despite the current triumphs in medicine, outcomes are not always predictable despite a physician’s best efforts.
I saw firsthand how extreme this iatrogenic suffering can be. Unfortunately, this liver transplant case was one of the rare instances where the patient did not survive the procedure. He tragically expired on the operating table despite enduring more than five hours of surgery and multiple rounds or brutal CPR. He did not even get to use his new liver since blood flow was never established. Seeing that chaotic scene will stick with me forever. No errors were made. Everyone involved was highly skilled and competent doing the things they have done hundreds of times before with great success. Seeing everything unfold opened my eyes to just how little a non-medical person knows about the almost violent nature of medicine at times; ignorance is bliss. Liver transplants have a high success rate. 75% survive the first five years after their operation. This is a marked improvement from the mere months this man had without this donor organ. As with any procedure though there are implicit risks that need to be balanced with any potential gain. There were high stakes with the procedure. The decision to proceed was the correct one; to get this new liver was to live for many years to come. Yet had the family known he would not survive, or had they seen the extent of the damage inflicted on his body from advanced cardiac life support, perhaps they would have simply chosen to enjoy those last few months with him instead. Hindsight is always 20/20. It may have been his alcoholic cirrhosis that brought him to the table, but it is hard to shake the feeling that it was medicine that killed him.
Stitching up a recently deceased person is a strange sensation. Perhaps stranger though was the sense of closure it offered with the situation. Medicine is not perfect and our means to achieve our goals can be savage. Yet, we are doing our best with the odds ever stacked against us. We work hard to ensure that people suffer to the least extent possible. Situations may go from bad to worse, but the intention is there and the knowledge and skills backup every decision that is made. Yes, suffering is inevitable, but surely it can be minimized. Just like with this man before me, the sutures were a feeble, but well-meaning attempt to make things better. Ultimately, it makes me think about the role of striving to do better as a physician and a person. At the very least, he will be presentable for his family to see him one last time.