She was dead when we walked in the room. Lungs ventilated, kidneys dialyzed, on pressors to maintain enough tension within her blood vessels to keep blood traveling to her brain and with a tentatively beating heart, but dead, nonetheless. The microbes had done their damage. Necrotic fingertips and toes curling and black, contractures sharply flexing her wrists and ankles from edematous compartments, damage to organs both known and yet to be made apparent. Wicks in her ears and vagina drained thick pus. She had multiple large-bore intravenous lines in place centrally at the groin and clavicles, all properly secured and marked for timely change so no hospital-introduced infection would add to her already overwhelming burden.
The initially spacious critical care unit room felt smaller and smaller as we created a makeshift operating room with help from the on-call weekend OR staff. They discussed and worried a bit about their jobs and licenses, since we were acting outside the operative suite’s confines. Intensivists and surgical personnel questioned whether the pain and risk that would be inflicted were justified in a patient who likely would not survive and could not be kept completely comfortable. Convoluted conversations took place with the patient’s estranged husband, a translator, and her parents, for whom English is a cold and foreign language. Ultimately, the slim chance that this could help won out, though at no time did preparations for the procedures cease as the conversations and questions were voiced. Discussions of timing, of moving her to the surgical suite downstairs, of whether or not to surgically release the swollen and tense compartments. We would be creating additional wounds in a body already decimated by disease with no guarantee of success. A moot exercise in the debate, but undertaken, nonetheless. All stops out, in our very modern, brick and mortar M*A*S*H unit, we proceeded, the Critical Care Unit nurse administering as much anesthesia as would not kill the patient and keeping us apprised of her status.
Colleagues from various -ologies involved in her care gathered outside the glass wall, all serious eyes and somber demeanor as they played voyeur to a portion of care they did not usually witness, maybe had not seen since medical school or residency. Her father tried to see in, and we closed our bodies in a line to shield the shocking view from him and asked a nurse to usher him away from the scene. We would perform compartment releases on three of four limbs that day, one immediately and the final two eight hours after our hushed conversations. We opened the skin and underlying tissue, slicing open the thick, paper-like fascia that normally kept the muscle in a mobile pink bundle, but now was strangulating the muscle tissue in the high-pressure chamber as fluid and pus gathered faster than the body could siphon it out. Muscle crushed and robbed of blood supply was grey and still rather than pink and responsive. An attempt to salvage limbs, to at least leave a base for prostheses should a miracle happen.
I felt numb. I reminded myself that the limbs we were operating on belonged to a person. I held retractors and looked in vain for blood to wipe or, even better, enough blood that I would have to suction it out of the field. That blood would be an indicator that the muscles would revive. That blood was not there.
As I left her side for the final time, my patient lay still and silent with gaping, intentional open shark bite wounds on her limbs and tubes snaking from nearly every orifice. The surgeon approached the family. He told them we would not know whether the release of tissues would help until/unless she survived, and survival was not a likely prospect. Maintaining a strong countenance, her father could only nod his head, trying to reject the information. I saw her mother collapse into a sobbing heap of grief in the hallway. The charge nurse professionally issued orders, and the staff kindly and safely moved her mother out of the hallway so the automatic door would not batter her as it opened.
Overnight, more of her organs failed, and her reactions showed that even moving her gently for sanitary care caused her pain. It was time. The family made the agonizing decision to let her go. They would free her from all the tubes and lines and medicines and allow the battle-scarred shell of her body to perish. I thought of her parents, her young children. Her estranged husband, learning that he was facing a future as not just a single parent, but as the only parent. I wondered, had she been aware in those hours of trial? Did we do right by her? Did we do right by her family?
Tamara E. Jackson is a physician assistant.
Image credit: Shutterstock.com
