I watched Mrs Fox wheel her husband into the exam room. As most of you have figured, the people I write about are real, their names are not. It was years since I had last seen them. In the five years since, he had undergone a renal and pancreatic transplant and coronary bypass surgery. He looked frail and old. "You look like hell," I said as I walked in behind them. "You should have seen the other guy," he retorted, as we shook hands. Mrs Fox gave me a hug, then looked at me and said, "We hear you are a big shot now, you were a baby when we last saw you." "I was forty," I said, smiling back.
We got into it. He needed a new valve and was too sick for open surgery. He did not qualify for the standard method of getting the prosthetic valve up to the heart from the leg arteries. I suggested he go to one of the more experienced centres. "I just got back from two of them, sick and tired of different doctors giving different opinions," he said. "That's why I am here," he continued. I thought he was too much of a risk. I told him we needed to wait. He wasn't happy, but agreed. Over the next few months he continued to deteriorate. I had found one excuse or the other to avoid doing his case. Finally, one day he pinned me down, "I can't go on like this," he said. "This quality of life is not worth it."
I reviewed his case with the rest of the team. We all concurred that it was tough, but we thought we should be able to get him through. The main artery to his left arm was remarkably healthy, and we decided to use it to track the new valve to his heart. We ran all types of scenarios multiple times. We felt ready and thought this was the next step to our now established programme.
Game day, he was our first case. My colleague and friend did a remarkable job cutting down to the artery with a minimal incision. In the next 15 minutes, we had the valve ready and deployed. He was rock stable throughout. We were done, and hadn't broken a sweat. I scrubbed out as the surgeons were putting the final stitches, and went out to meet the family. "That went remarkably well," I told them. I could already hear him giving me grief for making such a big deal out of it.
I was drinking coffee, when the anaesthetist called me. "He isn't waking up," he said. I went back into the OR, he seemed stable, and the oxygen levels to his brain hadn't changed. It is probably the anaesthesia, I said, with his kidney and pancreatic issues. "Let's get him to the ICU and wake him up there."
We finished our next case, and went back to the ICU. Still no response. The two surgeons and I were discussing the possible reasons, but I was getting that strange sensation in my gut, telling me something was very wrong. 'Stroke', was the dreaded word. It was possible we had broken off some debris from the old valve, which went up to his brain. It still didn’t make sense, because we were monitoring the oxygenation to the brain throughout, and there were no significant shifts. I went back and spoke with the family; the roller coaster of emotions from hope to despair had begun. We ordered the CT scan of the brain and scrubbed into the next case.
The radiology call came in 30 mins into the next case. My colleague and I exchanged glances. “Never good news when a radiologist calls,” he said. He was patched to the speaker system as we were scrubbed. "There is a large bleed,” he said. It was over, and I knew it. I went through the motions of calling the neurologist and neurosurgeon. The neurosurgeon was sympathetic, “Nothing you guys could have done, there was an aneurysm there and he decided to rupture.” The neurologist said that he was already brain dead.
I broke the news to the wife. We waited till the next day to have the rest of the family come in to withdraw support. I normally don’t stay in the room during withdrawal, but wanted to be with him till the end. The nurse removed the breathing tube, and turned off the ventilator. It was as if the rest of the body was unaware that he was no more. The heart kept pumping and his oxygen levels remained stable for a good two minutes as his organs kept sucking up the oxygen already present. Without the brain, there was more oxygen for the rest of his body, but after that the oxygenation started dropping. The heart, refusing to quit, kept fighting for another minute, but began fatiguing and slowing down. The oxygen levels fell even further and the line went flat. The nurse turned the monitor off.