Twelve Patients: Life and Death at Bellevue Hospital (25 page)

After dealing with my office stuff, I went up to check on Marta’s mother. Omar Bholat waved me over to join rounds with his team as they were wrapping up a case discussion with a family whose young adult daughter had a close call with an extreme case of ulcerative colitis. When the discussion of what to do next closed, the group moved amoeba-like fifteen feet down the corridor, parking in front of Olimpia Gutierrez’s room number 1024.

Through the sliding glass doors I could see an overweight elderly woman on a respirator. A technician was changing some tubing and settings on the ventilator while a nurse was finishing recording her vital signs and changing a dressing on a clear plastic tube that snaked from four different clear solutions in plastic bags, feeding medications slowly via computerized pumps hanging from a single pole like post-modern stoplights in a futuristic Gotham out of a Batman movie. A heavyset woman with jet-black hair was tidying up two chairs in the corner covered in sheets and blankets where she had clearly spent the night. I recognized Marta when she turned and spotted me through the glass doors.

The chief resident, a sturdy Chinese woman around thirty in scrubs and black clogs, who had been up all night in the OR, began her summary, “This is day number seventeen in the unit for Mrs. G, a seventy-two-year-old woman who presented by ambulance to the Bellevue emergency room in severe congestive heart failure. She felt nauseous and was slightly uncomfortable and had gone to the bathroom. Within minutes she was finding it difficult to breathe. Her banging brought her daughter to her side, and a 911 call brought an FDNY ambulance to their apartment. The family lives on the edge of Greenpoint in Brooklyn, and there are two hospitals within minutes nearby. The family insisted on Bellevue. All of the family’s doctors are here, and
her daughter is an employee here.” She looked into the darkened room at Marta. The group’s eyes moved with her.

What had brought her to the hospital in the middle of the night were the effects of long-standing coronary artery disease, the accumulation of fatty deposits in the blood vessels supplying her heart muscle. The rupture of a cholesterol-filled “plaque” triggered a cascade that clotted off the vessel. A heart attack was in progress. She was sitting bolt-upright in the ambulance while hacking up frothy white pulmonary edema fluid. Her heart was barely squeezing, and the backup pressures in her lungs were literally pushing fluid from the vessels into her air spaces. The EMT crew radioed in that she was within minutes of a cardiac arrest.

It took only a few seconds to give her some morphine when the gurney came to a halt in the treatment room. Her wild-eyed look calmed down. The anesthesiologist rubbed her arm and told her he was going to put in a breathing tube as he pushed in another intravenous medication. The lines on the EKG electrically sampling different parts of the heart muscle showed an evolving heart attack. A trip to the cath lab, five minutes away, would have to be delayed until she was hooked up to a dialysis machine to filter her blood and to get some fluid out of her system. She was in a no-win situation. With kidneys that had failed two years earlier, there was no room to maneuver.

Several hours later, the cardiologist came out of a heavy metal side door directly from the cath lab into the side corridor where Marta, her daughter Irene, and friends were seated on a wooden bench. Dr. Pamuk was all business but quickly recognized the family’s distress. “Mrs. Gutierrez did well with the procedure. There were no complications.” She got the most important news out right away and then settled into the decisions that had to be made. These would be hard ones for everyone involved.

“Your mom,” she continued, “has several blockages in her coronary arteries. We can’t get to them with our catheters. All we could do safely was get in, make a diagnosis, and get out quickly.” At this point she was joined by Denise Collachio, a young heart surgeon, who introduced herself and stood quietly while Dr. Pamuk finished. “There
is too much disease, and the locations of the blockages make it impossible to treat her in the cath lab. Plus, she needs to settle down from her heart failure and get another dialysis treatment.” The cath lab had sophisticated radiology equipment that would assist the cardiologist in threading in tiny plastic tubes to investigate the integrity of the most important blood vessels supplying the heart itself—and many times to treat blockages with small balloons at the same time.

“So there is nothing that you can do for my mother?”

Dr. Pamuk looked at Denise Collachio, who continued, “I have looked at the pictures, and it is clear that surgery is the only approach for the disease she has. However, this is a very high-risk situation. Given her weight, diabetes, dialysis, diffuse vascular disease, and poor heart function, her risk of dying from the surgery is 50 percent. Plus, there is a high rate of complications from infections to strokes.” Denise was direct and unflinching in her assessment, but she then spent a long time with the family drawing diagrams of the surgery until she was sure they understood what was at stake. Bypass surgery meant taking some veins from her legs and arteries from her chest wall to “jump” or bypass the diseased ones supplying her heart. “A lot of people would choose to do nothing. It is an okay decision. Sometimes doing nothing is the harder decision to make.”
True enough
, I thought.

“And if we do nothing?” Marta looked at Denise. The question said it all. This was always the hardest question to answer.

“Marta, this is a really tough question. Why don’t you talk with your mother? We can operate. Once you have all of the information and feel comfortable we have answered your questions, it is your decision. Different people will answer differently. We will go with your decision.” I was impressed with her neutrality, how she presented the case. I had seen so many misrepresentations of the odds and options to families. Physicians would buckle under the pressure, the guilt of not offering some treatment or hope. Genuine informed consent was harder and less common than most people assumed.

I remembered a high-volume altercation between our internists and surgeons over a patient who was an intravenous heroin addict with a
recurrent infection of a heart valve from shooting up with dirty needles. “But you have to operate on him, it is his only chance. He will die otherwise.” The internists were adamant. The surgeon responded just as adamantly: “We operated on him for a valve infection and heart abscess and put in a brand-new plastic valve eight months ago. He chose to inject himself again and reinfect his valve. Not me, I didn’t choose to reinfect him. He will die from the surgery. That is a near certainty. I don’t want to be his undertaker. I am just a surgeon.”

The 1 percent “solution” prevailed. I had seen it in action before. Any-chance philosophy meant an intervention. I had seen more than one woman with metastatic breast cancer in an ICU on another round of
let’s try this chemotherapy
. The impetus for that procedure came from the seemingly well-meaning oncologist who couldn’t accept the death of his patient. Who exactly was being treated in this situation?

The surgical team operated on the addict with the infected valve. The patient had a stroke and died a slow death in a nursing home. The surgeon never again let sentiment overwhelm his hard-earned experience. The internists learned that not everything could be fixed. A patient’s death is often experienced as a total failure or a narcissistic injury by most physicians. Better to keep treating or hand off to a waiting squadron of consultants.

Marta sat with her mother in the cath lab recovery room. The decision was a given. We could all see it coming. “
Mi mama
would like the surgery.” The surgeon went in to talk to Olimpia with Marta, and they reviewed everything again. The old, nearly blind woman was exhausted. “
Hija
, you decide. I am too tired. I trust the doctors. But you decide.” Marta stroked her mother’s hands gently and patted back a strand of her gray hair. She was not about to let her go.

The six-hour operation was a success—four bypasses and daily dialysis kept her alive and her lab numbers in order. The fact that Olimpia was obese, however, confounded her treatment and recovery by another order of magnitude. The team was indefatigable and kept pushing her to do more for herself. A special mechanical lift got her into a chair. A family member was always at her side. She was slathered
in cocoa butter, her hair was washed and combed, she was exercised gently and fed with food brought from home. The ship slowly turned around while the team held its breath.

When the team left, I stayed behind to talk to Marta. Despite everything that had happened with her mother, she was totally composed. She had gained a considerable amount of weight. The rhythm of illness, hospitalizations, surgery, complications, more treatments, testing, and conferences was to her part of the natural course of events. My secretary had graciously brought up some breakfast for the two of us as we used a small family conference room to talk about her letter. Marta Sahagún was effusive in her greeting. It had been at least three years since I had seen her.

“Dr. Eric—” She paused. “I wrote not about my mother, but about myself. I need your advice on what to do about my own health. I know my mother is getting the best care possible.” Despite two weeks sleeping on chairs in the ICU, she was animated and shrugged off the fatigue.

The fact that her mother was not the main event caught me by surprise. I’d been sure there had been some miscommunication between the physicians and her family that needed intervention. Those were the usual calls from family or from frantic social workers brokering angry families who were living the horror of imminent losses.

We went on a few more minutes about her mother. Olimpia’s weight, her massiveness on a tiny frame, made everything more difficult, including her breathing. She was five foot four and weighed 270 pounds. She was enormous by any measure, and her inability to move around since she’d lost her eyesight a number of years ago, complicated by her dialysis regimen, resulted in another jump in weight and her diabetes ricocheting out of control—despite the steady attendance of visiting nurses and meticulous monitoring by her family. She had been progressively more depressed. She barely left her bedroom during non-dialysis days and expressed a lack of a will to live. She was ready to join her husband, who had died in an accident involving alcohol and stairs a decade earlier.

“Marta, it sounds like your mother has had every known complication
from diabetes related to her
obesidad
, obesity.” The Olimpias were filling our clinics and the hospitals around the city and country.

“
Sí, Doctor
. She has had every complication, and pitifully so have I.” She looked at me, embarrassed, and sat still. There was a fading resemblance to her mother as a young beautiful woman from the pictures in the intensive care unit room.

“Marta, tell me what I can do to help you. You know I will do what I can.”

“Doctor, I have some papers here outlining my medical problems and was hoping you would go through them and help me understand what is happening to my body and what direction or options I have. I am scared of all of it and do not want to end up like my poor mother, suffering for years at the end of her life, a lifeless life. Totally dependent. Like a child now.” She pushed across a manila folder with her name in Magic Marker, filled with twenty pages of computer printouts and a CD in a plastic case marked “CT scan Sra. Sahagún / Alfonso Reyes, MD.”

I pushed back in my chair and took out the papers, putting the CD to the side. They were a mix of office notes, a biopsy report, X-rays, and laboratory tests covering the last eighteen months. I read them carefully and made some notes on the manila folder, then took a moment to leave with the CD and review the scan on a computer down the hall.

“This is pretty heavy stuff, Marta,” I said to start the conversation. We spoke half in English and half in Spanish, as she always had in the hospital. The handful of medical information that she had given me had dire implications for her. “I will be totally honest with you. You came to me for a second opinion. But I cannot do that unless I can talk to you honestly and openly.”

“Doctor, that is all I want at this point. No time for fooling around. I fooled around for too long and now I want to see if I still have a chance at a life. I can see clearly with my own two eyes where I could end up.”

“Well,” I said, “the good news is that you have medical conditions that are still reversible. The bad news: What you have is in many ways as serious as cancer and in many ways as bad or worse.” I had Marta’s
attention completely. “Let’s start off with the simple stuff. You have inflammation in your esophagus, from acid reflux. There is a change in the cells lining your esophagus called Barrett’s. That will keep your GI doctor in business for a few more years.” I smiled to see if she had her old sense of humor. She did not.

I continued from Dr. Reyes’s records. “The biopsy shows a fatty liver with early cirrhosis. The inflammation from your weight has caused a reaction by the liver’s cells. This reaction causes micro-scars to form, like a million tiny cuts that heal with tiny scars. What your father, Andreas, did to his liver with alcohol is happening to your liver with fatty deposits that don’t belong there.” I could not have put it more graphically or directly to Marta. She had such ambivalence toward her long-deceased father. The shame from his drinking was only overwhelmed by the time he hit Irene, his granddaughter. Neither Irene nor Marta ever forgave him. He was dead to them before he died.

“It is like a giant map of New York City with all of the streets laid out—then little by little, a few here and there are blocked off, and over many years more tiny blockages appear. Then after a while there is no place for the traffic to go. There is huge congestion for miles and miles until people can’t even pull out of their driveways.”

I flipped over a page of paper and sketched out a cartoon liver, half of it a normal liver, half cirrhotic. “Your blood tests show that there is inflammation, the liver enzymes are elevated. It is like what you would see with a viral infection. But the good news is that your liver is able to make all the key proteins to prevent bleeding. It’s like a factory, and so far it is continuing to do its work. You have not crossed a point of no return.” I paused and she interrupted.