That Uneasy Feeling of Knowing All Effort Was Futile

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.

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19 comments

  1. nakakaiyak naman :'(
    sometimes, as doctors, we tend to lose our hearts.
    i’m glad you didn’t

    • It’s easy to lose compassion in a hospital such as ours. But as you stay longer and get older, you begin to realize that our patients and their families need much more than the medicines we prescribe and the surgeries that we do.

      I guess tumatanda na talaga ako. Haha! Thanks for reading, Ana! 😀

  2. Genevieve Yap

    Ronnie, It only shows what kind of doctor you are. 🙂
    I believe there’s more regret that comes with not doing anything than giving it all you’ve got. We are not gods, but sometimes when He thinks it right, we might just become extensions of His healing grace. Each doctor has the potential to be. And we won’t know unless we try. Just so you’ll know, a similar case came to us around 2 years ago, one of your seniors operated on him too, despite an initial poor prognosis. He went home, that one… 🙂 The point is, you never really know sometimes..despite all the stats you’ve studied and how illogical it may seem at the time.

    • Hi Gen! I agree, you never know. These life and death decisions are a tough responsibility, more tiring than actually having to do the surgery. As long as the parents know what the expect and as long as they are willing to do their part, I definitely would operate still. Wag lang GCS3. Hehe.

      Thanks for reading, always 😀

  3. Im glad you did it ronnie. As a parent who went through tough times with my son, i realized that one of the most important things that a doctor can do sometimes is give a bit of hope against all odds and to let them know that you did your best. You have the makings of a great doctor, dont lose your heart in the process ! 🙂

    • Thanks Ma’am Edhel! I should say that it always overwhelms me to find out that my former RICs get to read what I write. Having been inspired by my residents then when I was a student, I’d like to think that I am now just paying it forward. 😀 Good health to you and your lion baby 😀

  4. gilly santiago

    this is an inspiring story sir.i hope that when i go through my residency training, ill still keep the attitude.salamat po 😉

  5. I can say that most of us have experienced such cases when we have to decide whether to be aggressive or not. It’s a hard decision and personally, it’s difficult to give up, because I’d always be hunted by what ifs. If you have not operated on him, he’ll surely die. But by deciding to do the surgery, he had a chance to survive, even if it’s just 10% or 1%. And for me, that thought would be easier to bear by my conscience.
    You’ve done a good job with your patient and I hope you won’t lose that spirit, even if you’re already a consultant. ^_^

    • JenSan, we need to ask ourselves, “Am I doing this just so I’d have a clear conscience? Am I doing this because this is the easiest way out of the clinical dilemma?” Every patient is different. The circumstances change as well. In the end, we can only hope that we are doing what is right for the patient and his or her family.

  6. Thank you for finding the time to write these inspirational stories. That kid really deserved the chance and good thing he and his family had you as their doctor. Continue being the doctor with a big heart.

    • JenniPepper, truth is, the heart and the brain do not necessarily agree all the time. Thanks for reading 🙂

  7. I think there was a similar case when I was rotating in NSS last year. I was the intern on duty and you were the ROD. I believe you did not even got the chance to call me for that referral because you had to rush the patient to the OR. During the Friday conference I distinctly remember that you were asked if you would perform the surgery if you had the chance to do it over, and after you said yes, you were sort of mockingly asked by the consultant what your religion was.

    As an intern, I was really inspired that time because even though you already knew that you were going to be chastised, you still took the high road and did what you thought what was best for the patient.

    • Hi intern! No, this isn’t a similar case. This was the patient you never saw in the ER because I had to operate on him right away. Thank you for reading, and for listening while I was being chastised. Hehe. 🙂

  8. good day doc. i’m a nurse and currently an ERVP in the er. i have seen you in the hospital many times and i admit that your blogs are wonderul. i have recently read your 2nd to last blog and i was moved by your story. it’s the mind that decides whether to cross the boundaries of what needed to be done, but it’s the passion of the heart that pushes us to cross that boundary. in the er, i can see many pts neglected by doctors, i cant blame them because i know the er is a toic place. but it is like under serving the underserved. so it’s good to know that there are still doctors who pushes through their limit to fulfill their oath. that there are still doctors who still takes risk for the sake of their patients and not caring if they will be chastised or not. may you forever be brave to fight for what is needed. Kudos to all the brave doctors out there, including yourself doc.

  9. doc napanood nio na po ba ung Gifted Hands…..?yung story ni Dr.Ben Carson…?…..its a good movie pwedeng irelate dito sa story…nalungkot naman ako sa part na ng- ambu bag tatay tapos wala laman oxy……at least youve done everything you could..that’s great enough.God bless:)

    • No, I haven’t seen the movie. Pero may nagbanggit na sa akin dati. Wala lang oras mag-download at manood. Hehe.

  10. You are such an inspiration. You’re the kind of person I’d like to be. Thank you. Please write more.

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Names, dates, and events may have been changed to protect the identity of patients. The stories are not meant to provide medical advice for specific illnesses. The author neither accepts online consults nor gives medical advice online. Please consult your trusted physician.