Larry Zaroff, MD, PhD

Stanford University, Palo Alto, California, United States

Every death is replayed. As if the film were reversed, death would give back a pulse. But the clock is stubborn, unwilling to turn. The operating room is not a time machine. The dead need editing. We want to change things, even small things. Let the final scene play out differently. Unfortunately, Lazarus will not arise. We plead silently to at least change the beginning or the middle. At death we wish for time to say how much we admired, respected the accomplishments, and forgave the nastiness, the inconsideration, the unawareness of the deceased. Time more for love. If we talk enough, review enough, remember enough, conjure up details, the body might change its mind. Or if the death can be attributed to someone else, a drunk driver, carelessness near a construction site, a poorly monitored pool, the play has a villain. Villains can be helpful. Assuage our own guilt.

The unexpected death in the hospital raises red questions. Was anyone at fault? Was everything done right? Was there malpractice? A death in the operating room is especially disturbing. Everything in surgery is beyond the subcutaneous, deep to the organs. Even a relative, friend, or lover without guilt will find questions to equal the mourning, qualify the tears.

Why is this? Why is a death in the operating room unacceptable?
The stage: A theatre, bright lights, action, blood on the floor. The drama is so concentrated. A two-person show, a dialogue, but the patient like Godot is silent, waits to be acted on. A single person is center stage, the surgeon. Can he be absolved—“he did his best” or blamed—“what went wrong?”

Always that question remains. How can someone die in the operating room, where people, facilities, and equipment focus completely on one patient? Why not a different ending? But as with every death, the play ends, never to be repeated with the same actors, though the script is similar.

I remove my scrubs and change into clean clothes; never have I dressed so slowly. I peek into the now deserted operating room, stage reset, props in place, the scene sterile, in order. As I tread slowly to the waiting room, I review the operation. I did everything right, efficiently, no blood loss, no technical errors. The anesthesia was smooth. Yet I feel guilt. My gut churns. I could ask no one else to bring the news, the death note. Not the resident or the student, the nurses or the anesthesiologist. Where the hell is the robot that makes life easier? I am ultimately responsible. No one wants to, can deliver, this message but I. I picked up the knife. No matter my innocence, deaths add up, the burden cumulative. If only I could phone, send a telegram. I hate the telling. This part has no rehearsal, no lines to memorize.

I am about to open a door, never before for this family. This sad room, strewn with at least fifteen. Waiting for me. Not the quiet, intact operating room, where I rule, am obeyed. Here I too am a patient, a victim, a fellow sufferer. A large family, wife, sons, daughters, aunts, uncles, nieces, nephews, and friends. No preliminaries. I am on another stage, a monologue proclaiming tragedy. The light is too bright, focused on me; I feel the heat from a naked sun. I have acted, but expect no applause. I brace for criticism. For a moment I don’t speak, better not to start yet. I don’t have to. Slow to allow for absorption. They can smell me – I, like Lear, reek of mortality.

The audience could be encased in blocks of marble, organic stones. They are rigid but for their eyes. Their eyes follow me like the tail of a comet hanging to my body, fiery. I am in now, I feel, over my head. I have to squeeze the words out of my poison glands. Nothing is harder than, “He’s gone.” No one asks, “Where to?” Everyone gets it. “Dominic died in the operating room,” I choke, and another knife slices the room. A younger man screams, curses, and accuses, “What was the rush? Why didn’t you wait?” “Listen,” I counter, feeling defensive, “I did, I waited. I postponed for two weeks because of his severe heart disease.” The elders quiet the young man, “Let him explain.” The deceased was a sixty-eight year old man who had survived three heart attacks; he came to me because of a large cancer in the left lung. I say again that in the preoperative conference I told of the high risk. I was not eager to operate. The family doctor insisted; it was “his only chance.” I had hoped the patient, given the options, would decide on palliative radiation. But he made the decision for surgery.

I give details, feeling the family’s sadness, understanding their loss as if the patient was more, a friend, a relative, “The cancer was localized, easy to remove with the lower part of the left lung. Then the blood pressure went down. I could see the heart striving, but weak. I gave medicines, compressed the heart, forced blood around. I tried for an hour. “He must have had a massive” I pause, “another heart attack.” I hated to give up but nothing else could be done.” Where is the weeping? Their tear ducts are occluded, stunned. Finally someone, a brother, I think, says, “Thank you, doctor.” Then in the quiet, I ask for permission for an autopsy. Another hard moment for me and the family. I push forward, “We may learn something that will help someone else, maybe someone in this family.” A second storm, an aftershock. Disputes. But the wife agrees, signs. The last scene of the last act: “I want to meet you, the family in two weeks when we will have the results of the postmortem exam.” An epilogue will serve to assuage their guilt and ameliorate mine. I will emphasize that the death was no one’s fault; he had excellent care, and his suffering ended without pain. They will ask more questions and be satisfied with my answers. I will feel better.

 


LARRY ZAROFF, MD, PhD has had five careers following his residency and two years in the U.S. Army Surgical Research Unit. He focused for 29 years on cardiac surgery, including a stint as director of the cardiac surgical research laboratory at Harvard. There his work centered on the development of the demand pacemaker. He spent the next 10 years concentrating on climbing and did a first ascent of Chulu West, a 22,000-foot peak on the Nepal-Tibet border. His third life has been at Stanford, where he received a Ph.D. in 2000, and where he teaches courses in medical humanities. His fourth career has been as a writer for the New York Times science section. He now works one day a week as a volunteer family doctor. He has received awards as the outstanding faculty advisor for the Human Biology program and in 2006 was honored as Stanford's Teacher of the Year.