Ethics and Technology
Shortly after I arrived in Jeddah I was faced with an extremely difficult medical case. By difficult I do not refer to the technical part of surgery. Right now great technology is a given in neurosurgery. But it is the ethical decision making that is involved in whether or not to recommend surgical care. A young 29 year old ICU nurse suffered a major stroke of the left brain hemisphere which is ordinarily a devastating brain injury. Recovery is poor and usually associated with major neurological impairment (speech and paralysis) and a good possibility to remain in a vegetative (unaware) state permanently. There was no family available for consent and her nursing colleagues became her health care proxies. In the glare of this discerning audience I would have to make some tough decisions and the outcome would affect my very reputation within the hospital medical community.
Many of my colleagues here in Jeddah have counseled me to be very conservative and not to take any medical risks. This has been a mantra for care since I have been here. It puzzles me because there are inherent risks in any neurosurgery decisions and the results are never guaranteed to go exactly as you plan. Balancing failure and success has never been more difficult than in the past two years. One thing that I have noted is that there is a definite tendency toward unrealistic expectation by patients/families that everything done must be successful.
Our young nurse had deteriorated neurologically and brain death seemed imminent. So a split second decision was made based on my gut feeling and medical experience; the plunge was made. We took her to surgery and in a series of operations proceeded to remove her skull bone, evacuate the blood clot, remove dead brain in order to preserve the brain that would survive, reconstruct her skull, and finally insert a ventricular shunt. I summarized about six months of hard care in that previous sentence. There were many times that I questioned myself as to whether it was the right decision that I made to try to save her life. My questions came because for many months she was completely neurologically severely impaired, unable to speak or care for herself. Mom arrived more than two months later. She had been unable to obtain a travel visa from the Saudi government.
The hospital and the nursing staff were wonderful in supporting a nursing colleague. And day by day my patient became more and more responsive to her environment.
I received this thank you text from her mom at the airport just before they departed for home in the Philippines. My patient, her daughter, was now communicating, not yet speaking, feeding herself, and walking with assistance. She needed help to take care of herself. Her mother was happy for her recovery. And knowing what I knew as she left for home I have no regret in pouring out a maximum effort to save her life despite the tremendous odds against even a fraction of the recovery she made so far. Some days it’s worth being able to think back that we did something that no one thought we could do.
No one likes an unhappy ending. Some years ago it was noted that movies with unhappy endings are not popular. Really, think about it. At the time, it was said to me, Robert Redford in “The Natural” hit a home run to win the game to end the movie. But in the book David Mamet wrote, the character strikes out to end the story.
I have experienced my share of unhappy endings. It can’t be helped. But there are those times when a decision and good skill will touch a life in ways that everything was worth all the hours and work you put into your profession.