Thirteen-year-old Eric Reyes only wanted to help his six-year-old neighbor cross the street. In an ironic turn of events, a tricycle hit Eric on his way back. The impact immediately rendered him unconscious. Bystanders took him to a local hospital where he partly awakened, vomiting relentlessly and moaning from severe headache. As suspected, on the cranial CT they found a rapidly enlarging blood clot occupying almost the entire left half of his brain.
Sixteen hours later, I received him in our emergency room. He was intubated and he would not open his eyes, no matter what stimulus I applied. He was Glasgow 5 with bilateral dilated pupils, both indicators of poor prognosis. In a desperate attempt at heroism, I operated on him to evacuate the massive acute subdural hematoma and relieve his brain of severe pressure. Two days after his surgery, he died just the same.
“‘Tay, ‘Nay, hindi pa rin po siya nagigising. Mukhang hanggang dito na lang po talaga ang anak ninyo. Pasensya na po.”
I was sleepless and frustrated, and though I had already said the same line to innumerable families hoping against hope for some good news, I attempted still to be as sincere as I could.
Eric’s mother lay her head on her husband’s chest and began to cry. Father and mother hugged each other, seeking mutual comfort in a desolate hospital as they faced the inevitable death of their son.
“Nag-iisang lalaki ko ‘yan, Dok, mawawala pa.”
I could not think of anything else to say, as both parents’ slow sobbing resonated throughout the damp operating room waiting area.
In retrospect, the odds were largely against Eric surviving his head injury. It took his family nine hours to get him a cranial CT scan. And when they finally got the scan, it took them another seven hours to get to our hospital. In an ideal setting, he should have been taken to the ER, then to radiology for the scan, and then straight to the operating room all in under an hour. That alone would have increased his chances of survival a hundredfold.
The delay could only be explained by their being poor. Eric’s father makes and peddles guitars on the national highway for a living; his mother is unemployed. They could not demand financial assistance from the injuring party, either. How could they, when it was a kababayan tricycle driver, whose meager income could not be expected to suffice for the health expenses of a severely injured patient?
“Dok, hindi namin kaya ‘yung hinihinging pera para sa operation sa provincial (hospital),” his father told me.
“Bakit hindi ho kayo lumipat agad dito?”
“Wala kasi kaming pambayad ng ambulansya, Dok. Hinintay pa namin ‘yung ambulansya ng barangay.”
Imagine my disbelief when the father recounted how he had to pump the Ambu-bag for eight straight hours, in the hospital and in the ambulance, just to keep his son breathing. I did not have the heart to tell him that the oxygen tank in their ambulance was empty when we received his son in the ER.
I gave them an honest assessment at the outset. Bilateral non-reactive pupils are associated with a 90% mortality rate, even in the best trauma centers in the world. If their son did survive, it was almost certain that he would end up in a vegetative state, fully dependent on others for daily care. Still, they agreed to push through with surgery, even if it meant that their son might die on the operating room table.
They had little money. Our service had to provide Eric’s operating room needs and medications, and pay for mechanical ventilator rental and blood transfusions. But these were not enough to see him through. The severe swelling of his brain would not subside even after adequate surgical decompression. His other organs began to fail one after the other. Face bloated and pupils remaining non-reactive, Eric Reyes never woke up.
I was prepared to be chastised during the Friday conference, where residents present to consultants all mortality cases for the week.
“Eh fixed dilated pupils na pala, bakit inoperahan mo pa?”
“What are the expected outcomes in this subgroup of patients?”
“What did you tell the parents?”
With the death of a patient comes a long-drawn-out period of introspection for any surgeon. You work out the different scenarios in your head, wondering if the outcome would have changed if you made a different decision at any point during the patient’s clinical course.
Did I really think I could save him? Yes, I did, else I would not have pushed for the surgery.
Was it realistic? At that time, it seemed it was. But now, I am not too sure.
Was it the right thing to do? Up to know, I do not know. I think I never will.
Was it out of pity? To some extent, yes. It was a child, and no ordinary child either. This was a child who only wanted to help. If it were a drunk, irresponsible, helmet-lacking, reckless motorcycle driver, perhaps I would have reconsidered my decision.
If I did not operate, could he have lived longer? No, he would have died sooner.
What was I thinking? Or was I “feeling” more than I was “thinking”? If tonight I get an identical patient in the same condition under the same circumstances, would I still operate, knowing that this patient died?
“Huwag ni’yo pong sisihin ang mga sarili ni’yo ‘Tay, ‘Nay. Wala naman pong may gustong mangyari ito sa anak ninyo. Ginawa naman po ninyo ang lahat ng makakaya ninyo. Dinala ni’yo po siya sa ospital. Pina-CT scan. Naghanap po kayo ng ambulansya. Inoperahan po natin siya nung kailangan siyang maoperahan. Pero wala pa rin po talaga. Ang mahalaga po, hindi ni’yo po siya pinabayaan.”
When all effort seems futile, sometimes, all that is left to do is to comfort the bereaved, in the hope that words and compassion will be enough to ease the suffering.
“Salamat po, Dok.”
My job was done.