Complications (30 page)

When she called back, I filled her in on the details. I think he’s septic, I said. Sometimes a bacterial infection gets into the bloodstream and triggers a massive, system-wide response: high fevers and dilation of the body’s peripheral blood vessels, causing the skin to flush, the blood pressure to drop, and the heart to speed up. After abdominal surgery, a common cause of this is an infection of the surgical wound. But his incision was not red or hot or tender, and he had no pain in his belly. His lungs, however, had sounded like a washing machine when I listened with my stethoscope. Perhaps a pneumonia had started this disaster.

K. came right over. She was just past thirty, almost six feet tall, with short blond hair, athletic, exhaustingly energetic, and relentlessly can-do. She took one look at Howe and then murmured to the nurse to keep an intubation kit available at the bedside. I had started antibiotics, and the fluids had improved his blood pressure a bit, but he was still on maximal oxygen and working hard to maintain his breathing. She went over to him, put a hand on his shoulder, and asked how he was doing. It took a moment before he managed to reply. “Fine,” he said—a silly answer to a silly question, but a conversation starter. She explained the situation: the sepsis, the likely pneumonia, and the probability that he would get worse before he got better. The antibiotics would fix the problem, but not instantly, she said, and he was tiring out quickly. To get him through it, she would need to put him to sleep, intubate him, and place him on a breathing machine.

“No,” he gasped, and sat straight up. “Don’t . . . put me . . . on a . . . machine.”

It would not be for long, she said. Maybe a couple of days. We’d give him sedatives so he’d be as comfortable as possible the whole time. And—she wanted to be sure he understood—without the ventilator he would die.

He shook his head. “No . . . machine!”

He was, we believed, making a bad decision—out of fear, maybe incomprehension. With antibiotics and some high-tech support, we had every reason to believe, he’d recover fully. Howe had a lot to live for—he was young and otherwise healthy, and he had a wife and a child. Apparently, he thought so, too, for he had cared enough about his well-being to accept the initial operation. If not for the terror of the moment, we thought, he would have accepted the treatment. Could we be certain we were right? No, but if we were right could we really just let him die?

K. looked over at Howe’s wife, who was stricken with fear and, in an effort to enlist her in the cause, asked what she thought her husband should do. She burst into tears. “I don’t know, I don’t know,” she cried. “Can’t you save him?” She couldn’t take it anymore, and left the room. For the next few minutes, K. kept trying to persuade Howe. When it was clear that she was making no headway, she left to phone his attending surgeon at home, and then returned to the bedside. Soon Howe did tire out. He leaned back in his bed, pale, sweaty strands of hair sticking to his pate, oxygen levels dropping on the monitor. He closed his eyes, and he gradually fell into unconsciousness.

That was when K. went into action. She lowered the head of Howe’s bed until he lay flat. She had a nurse draw up a tranquilizing agent and administer it in his IV. She pressed a bag mask to his face and squeezed breaths of oxygen down into his lungs. Then I handed her the intubation equipment, and she slipped a long, clear plastic breathing tube down into his trachea on the first try. We wheeled Howe in his bed to the elevator and took him down a few floors to the intensive care unit.

Later, I found his wife and explained that he was now on a ventilator in the ICU. She said nothing and went to see him.

Over the next twenty-four hours, his lungs improved markedly. We lightened up on the sedation and let him take over breathing
from the machine. He woke up and opened his eyes, the breathing tube sticking out of his mouth. He did not struggle.

“I’m going to take this tube out of your mouth now, OK?” I said. He nodded. I cut the ties and deflated the balloon cuff holding the tube in place. Then I pulled it out, and he coughed violently a few times. “You had pneumonia,” I told him, “but you’re doing just fine now.”

I stood there silent and anxious for a moment, waiting to see what he would say. He swallowed hard, wincing from the soreness. Then he looked at me, and, in a hoarse but steady voice, he said, “Thank you.”

S
eeing patients with one of the surgery professors in his clinic one afternoon, I was struck by how often he had to answer his patients’ questions, “I do not know.” These are four little words a doctor tends to be reluctant to utter. We’re supposed to have the answers. We want to have the answers. But there was not a single person he did not have to say those four little words to that day.

There was the patient who had come in two weeks after an abdominal hernia repair: “What’s this pain I feel next to the wound?”

There was the patient one month after a gastric-bypass operation: “Why haven’t I lost weight yet?”

There was the patient with a large pancreatic cancer: “Can you get it out?”

And to all, the attending gave the same reply: “I do not know.”

A doctor still must have a plan, though. So to the hernia patient, he said, “Come back in a week and let’s see how the pain’s doing.” To the gastric-bypass patient, “It’ll be all right,” and asked her to come back
in a
month. To the cancer patient, “We can try to get it out”—and although another surgeon thought he shouldn’t (given the tumor’s appearance on a scan, operation would be futile and risky, the colleague said), and he himself thought the odds of success were
slim at best, he and the patient (who was only in her forties, with still-young children at home) decided to go ahead.

The core predicament of medicine—the thing that makes being a patient so wrenching, being a doctor so difficult, and being a part of a society that pays the bills they run up so vexing—is uncertainty. With all that we know nowadays about people and diseases and how to diagnose and treat them, it can be hard to see this, hard to grasp how deeply uncertainty runs. As a doctor, you come to find, however, that the struggle in caring for people is more often with what you do not know than what you do. Medicine’s ground state is uncertainty. And wisdom—for both patients and doctors—is defined by how one copes with it.

This is the story of one decision under uncertainty.

It was two o’clock on a Tuesday afternoon in June. I was in the middle of a seven-week stint as the senior surgical resident in the emergency room. I had just finished admitting someone with a gallbladder infection and was attempting to sneak out for a bite to eat when one of the emergency room physicians stopped me with yet another patient to see: a twenty-three-year-old, Eleanor Bratton, with a red and swollen leg. (The names of patients and colleagues have been changed.) “It’s probably only a cellulitis”—a simple skin infection—“but it’s a bad one,” he said. He had started her on some intravenous antibiotics and admitted her to the medical service. But he wanted me to make sure there wasn’t anything “surgical” going on—an abscess that needed draining or some such. “Would you mind taking a quick look?” Groan. No. Of course not.

She was in the observation unit, a separate, quieter ward within the ER where she could get antibiotics pumped into her arm and wait for admitting to find her a bed upstairs. The unit’s nine beds are arrayed in a semicircle, each separated by a thin blue curtain, and I found her in Bed 1. She looked fit, athletic, and almost teenage, with blond hair tight in a ponytail, nails painted gold, and her eyes fixed on a television. There did not seem anything seriously ill about her.
She was lying comfortably, a sheet pulled up to her waist, the head of the bed raised. I glanced at her chart and saw that she had good vital signs, no fever, and no past medical problems. I walked up and introduced myself: “Hi, I’m Dr. Gawande. I’m the senior surgical resident down here. How are you doing?”

“You’re from surgery?” she said, with a look that was part puzzlement and part alarm. I tried to reassure her. The emergency physician was “only being cautious,” I said, and having me see her to make sure it was nothing more than a cellulitis. All I wanted to do was ask a few questions and look at her leg. Could she tell me what had been going on? For a moment she said nothing, still trying to compute what to think about all this. Then she let out a sigh and told me the story.

That weekend she had gone back home to Hartford, Connecticut, to attend a wedding. (She had moved to Boston with some girlfriends the year before, after graduating from Ithaca College, and landed work planning conferences for a downtown law firm.) The wedding had been grand and she had kicked off her shoes and danced the whole night. The morning after, however, she woke up with her left foot feeling sore. She had a week-old blister on the top of her foot from some cruddy sandals she had worn, and now the skin surrounding the blister was red and puffy. She didn’t think too much of this at first. When she showed her foot to her father, he said he thought it looked like a bee sting or maybe like she’d gotten stepped on dancing the night before. By late that afternoon, however, riding back to Boston with her boyfriend, “my foot really began killing me,” she said. The redness spread, and during the night she got chills and sweats and a fever of one hundred and three degrees. She took ibuprofen every few hours, which got her temperature down but did nothing for the mounting pain. By morning, the redness reached halfway up her calf, and her foot had swelled to the point that she could barely fit it into a sneaker.

Eleanor hobbled in on her roommate’s shoulder to see her internist that afternoon and was diagnosed with a cellulitis. Cellulitis is
your garden-variety skin infection, the result of perfectly ordinary bacteria in the environment getting past the barrier of your skin (through a cut, a puncture wound, a blister, whatever) and proliferating within it. Your skin becomes red, hot, swollen, and painful; you feel sick; fevers are common; and the infection can spread along your skin readily—precisely the findings Eleanor had. The doctor got an X ray to make sure the bone underneath was not infected. Satisfied that it was not, she gave Eleanor a dose of intravenous antibiotics in the office, a tetanus shot, and a prescription for a week’s worth of antibiotic pills. This was generally sufficient treatment for a cellulitis, but not always, the doctor warned. Using an indelible black marker, she traced the border of the redness on Eleanor’s calf. If the redness should extend beyond this line, the doctor instructed, she should call. And, regardless, she should return the next day for the infection to be checked.

The next morning, Eleanor said—this morning—she woke up with the rash beyond the black line, a portion stretching to her thigh, and the pain worse than ever. She phoned the doctor, who told her to go to the emergency room. She’d need to be admitted to the hospital for a full course of intravenous antibiotic treatment, the doctor explained.

I asked Eleanor if she had had any pus or drainage from her leg. No. Any ulcers open up in her skin? No. A foul smell or blackening of her skin? No. Any more fevers? Not since two days ago. I let the data roll around in my head. Everything was going for a cellulitis. But something was pricking at me, making me alert.

I asked Eleanor if I could see the rash. She pulled back the sheet. The right leg looked fine. The left leg was red—a beefy, uniform, angry red—from her forefoot, across her ankle, up her calf, past the black ink line from the day before, to her knee, with a further tongue of crimson extending to the inside of her thigh. The border was sharp. The skin was hot and tender to the touch. The blister on the top of her foot was tiny. Around it the skin was slightly bruised. Her
toes
were uninvolved, and she wiggled them for me
without difficulty. She had a harder time moving the foot itself—it was thick with edema up through the ankle. She had normal sensation and pulses throughout her leg. She had no ulcers or pus.

Objectively, the rash had the exact appearance of a cellulitis, something antibiotics would take care of. But another possibility lodged in my mind now, one that scared the hell out of me. It was not for logical reasons, though. And I knew this perfectly well.

Decisions in medicine are supposed to rest on concrete observations and hard evidence. But just a few weeks before, I had taken care of a patient I could not erase from my mind. He was a healthy fifty-eight-year-old man who had had three or four days of increasing pain in the left side of his chest, under his arm, where he had an abrasion from a fall. (For reasons of confidentiality, some identifying details have been changed.) He went to a community hospital near his home to get it checked out. He was found to have a small and very ordinary skin rash on his chest and was sent home with antibiotic pills for cellulitis. That night the rash spread eight inches. The following morning he spiked a fever of one hundred and two degrees. By the time he returned to the emergency room, the skin involved had become numb and widely blistered. Shortly after, he went into shock. He was transferred to my hospital and we quickly took him to the OR.

He didn’t have a cellulitis but instead an extremely rare and horrendously lethal type of infection known as necrotizing fasciitis (fashee-EYE-tiss). The tabloids have called it a disease of “flesh-eating bacteria” and the term is not an exaggeration. Opening the skin, we found a massive infection, far worse than what appeared from the outside. All the muscles of the left side of his chest, going around to his back, up to his shoulder, and down to his abdomen, had turned gray and soft and foul with invading bacteria and had to be removed. That first day in the OR, we had had to take even the muscles between his ribs, a procedure called a birdcage thoracotomy. The next day we had to remove his arm. For a while, we actually thought
we had saved him. His fevers went away and the plastic surgeons reconstructed his chest and abdominal wall with transfers of muscle and sheets of Gortex. One by one, however, his kidneys, lungs, liver, and heart went into failure, and then he died. It was among the most awful cases I have ever been involved in.