Written by Dr. Geeta Sundar

T/W: Death, blood, depictions of medical duress, loss of a loved one

The neuroanesthetist pokes around the green curtain bordering his field and our operating region. I’m closest to him, and see the concern of expression on his mask laden face. I am tired, exhausted – the case took far longer than anticipated and as my toes alternatively twitch on and off at the bipolar foot pedal, the rest of me is in zombie mode.

“BP dropping. Have given enough and more blood products.” His voice is alarmed, a contrary feel to his usual calming monotones.

The operating surgeon looks around, his beautiful, long eye lashes flickering from the microscope, his steady hands pause from the continuous bleed on the operating area and he shakes at his mask, before he asks. “How bad?”

“Bad, like she may crash, bad. Dual vasopressors full support.”

And that is enough to get everyone up. Me – I am alert in a second, the exhaustion is pushed to the side, my body on high adrenaline, the cold of the OR no longer a concern and nor is the rumbling in my tummy. The operating surgeon and his assistant change gears, the microscope is adjusted, arms moved, instruments changed and the atmosphere in the quiet, still, tranquil OR is now spontaneously combustible.

“How much time do I have?”

“Maybe 5 minutes. Max.”

“Give me another 5-10 minutes. I am trying to control the constant bleed in the surgical bed.” The operating surgeon’s steady voice carries in it a hint of pain and despair. But never once does he let it manifest on his face. Everyone hearing him in the OR knows that he is repeating himself, like the 10 minutes before, or the half hour, or hours before, but in the current situation, a reaffirmation is warranted.

The neuroanesthetist gives a half shake of his head, and then reluctantly nods. He goes back to his station, and I hear him order another PRBC. I think this PRBC was probably the 5th one. I am sure we crossed over a massive transfusion protocol about 2 hours ago anyway. The surgery appears more and more horrifying – for a blatant atypical meningioma, the bleed did not cease, irrespective of the cautery, the bipolar, the compression, the hemostatic agents. There was just blood. Blood. And blood. And everywhere. Drop and drop. Spurt and spurt. Each vessel poured out its heart content, damning the consequences, stubborn, irritating and needless.

I could feel the operating surgeon’s pressure. The stress. The looming reality checking itself every few minutes as illustrated by the vitals on that sats monitor. He had been at the surgery and hemostasis for over 4 hours now, calm, poised, persistent and I whilst I admired his strength, patience and energy, I could predict the harsh prognosis to befall us. True to his word, the neuroanesthetist gave the surgeon 5 minutes and then beeped over in a terrified manner. “I am unable to maintain BP. Bradycardia settled in. Let’s get ready to start compressions if required!”

This was it. We mobilize in the blink of an eye. The drapes were pulled off, few extra pair of hands scrubbed in, the chest was exposed, adrenaline loading somewhere off the counter, the operating surgeon had the craniotome ready to burr, the assistant and I were peeling another incision on the scalp dripping blood onto our cloaked soles, converting to a decompressive craniectomy, the nurse getting another surgical table ready with required instruments, chaos and sounds, bleeping monitors, people rushing in, OR door lost in its dwindling push and pulls, sterility – a questionable offense now, the neuroanesthetist shuddering as we almost came to declare a D-OT (layman language – death on table).

But in a minute, in the preparation to this very D-OT, the patient’s vitals stabilized to a barely revived state and we stopped the need for the chest compressions. But the damage was done, I am sure, with the brain exposed, the decompressive craniectomy done, the constant continuous bleeding, the transfusion requirement and vasopressors, she was gone to a place of no return and far, far away from her old life, her young kid and loving husband.

As we closed the skin and galea en masse, fighting the bleed, and the enlarged edematous, fiery red, bulging brain, with a tension laden suturing, and as everyone in the OR made plans to get ready to shift her out of the theatre to the ICU and stabilize her further, all I could think of was fate and fear.

Fate – what was my role in this woman’s life? Had she met me just so I could push her to the end? Was I involved to that extent where this would pertain to irreplaceable bad karma in my life? Was I ultimately responsible for her demise? I was the one who had stood, taken consent, explained the consequences, partly about D-OT and would I remain the face her husband would always recollect? What of then when we gave him the bad news and let him know that she would never return? This intertwined fate of hers and mine…was this already destined, was it fated?

Fear – A surgeon can’t be afraid of blood. I am not. But I am terrified beyond my limits (trust me, I am usually very fearless in all other aspects of life) of incessant bleeding from the brain. It’s not like I can cut off whatever is bleeding, or burn it off, or ligate it or transfix it, now can I? It’s not the skin/bone/soft tissue on the limb! Not even is it an extra bowel I can squander off! It’s the mighty brain and each millimeter is mapped to the important areas, I can’t sacrifice on just a whim! When you stand as the operating surgeon, in that operating room, on that operating table, a bleed like this is beyond comprehension, its beyond God, its beyond life/death and its beyond explanation. In that minute, in that second, you are just emotions, feelings, a blubbering mass of your training/experience/and knowledge and nothing hits you right, nothing makes sense and its all about how much luck/circumstances can favor you, about how many resources are available at your disposal, including the availability of a senior surgeon/mentor/consultant.

The lay public knows NOT of that fear. They know not of what that fear can threaten you to do. Or how that fear can affect every single other case/patient you touch and operate. They know not of that fear that can bring you to your knees and shackle you in muted confidence and self-neglect.

The majority of that public will only know to stand in front of you, blame you, throw things at you, scold or yell, and shout, hit/be violent with you, just because they think you didn’t achieve what you set out to do. They will brandish your name, your fame, your ability to continue on. They will thrash your image. Render you defenseless. They will call you names and say you did this for the money. They will not remember the detailed consent you took, the illustration of complications you drew out, but call you a cheat, a criminal and hate on everything you offer as compensatory explanation. They will think you did this on purpose and you are undeserving of everything life offers. They will be limitless in their candor to throw you to the dogs.

If only we could exchange places with them in that situation…maybe then, they would realize the harsh reality we face, and how helpless, and impossible it is at times to prevent a scenario like that despite better than adequate preparation and team efforts.

You really know NOT of what we face, of what we endure, of what we must maintain to allow every tiny bit of recovery in our patients.

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