A Trained Eye

A Life Worth Living

By Claire Panosian Dunavan
Special to The Washington Post
Tuesday, April 22, 2008

Recently, I've been dwelling on death. Not death with a capital D, but patients who died on my watch during my early years as a doctor. Some of them will haunt me for the rest of my life, I suspect, especially those who died young.

Of course, when I met them, I, too, was young. And naive. Could this be me, a tiny voice whispered after I met a desperately ill contemporary who -- in an ideal world -- would have been playing tennis or making love or downing a beer after a long day at work. But the tiny voice was soon drowned out by the next patient, the next page, the next night on call. After all, we interns and residents weren't there to indulge our emotions, but to work hard and heal the sick.

Once in a while, however, I would meet someone whose problems were so dire that my tiny voice screamed: This is hopeless! I still did my best to keep them going. Deep down, however, I wondered: If I were in their shoes, would I want to live? (Here's a secret: When you're a tired young doctor who hasn't yet witnessed certain patients doggedly overcome catastrophe, thoughts like these are not uncommon.) Then again, perhaps the pain in some patients' eyes was more than I could bear at any age -- or the challenges they faced were simply beyond my ken. In either case, this is a story about a patient in whom my private death wish came true -- and how I feel about it now.

The year was 1978, the place a major Midwestern medical center. Down the block was a rehabilitation institute that specialized in spinal cord injuries. The spinal cord patients -- whose paralysis stemmed from a bad dive in a shallow stream or a shootout in a city street -- were often in their 20s or 30s. Before their accidents, they had been in peak condition. After their accidents, they needed intensive hospital care before being transferred to "the rehab" to spend months launching their lives anew.

And so, one steamy summer night, a 23-year-old with a fresh cervical spine injury arrived on my medical ward with nurse, respiratory therapist and husband in tow. With her sculpted cheeks and sea-green eyes, she could have been a cover girl for a magazine. Except that she would never again mug for the camera or swim or move or feel below her chin. So extreme was her cervical damage that her previous doctors feared for her breathing. As a result, in addition to a padded halo and back brace immobilizing her head and spine, they performed a tracheostomy, just in case she needed emergency ventilation. The tube sewn in her neck was slightly askew, but it worked fine.

Over the next several days, I checked my new patient frequently, each time following the same routine. Knock, knock. Enter. Politely converse (one-way). Listen to lungs to rule out pneumonia, examine legs for telltale streaks of phlebitis, gently probe abdomen to make sure bowels aren't blocked. Finally, I would simply watch my patient's chest rise and fall and feel her moist breath float onto my hand from the oddly angled aperture in her neck. Because the trach tube prevented her from speaking, I never heard her voice, but I knew her eyes. When awake, they were gracious, weary, opaque. When closed, they reminded me of a fairy-tale princess under a spell.

Then, one night, the spell was broken. My beeper blared and flashed my patient's room number. When I got there, the scene was awash in blood. The ill-positioned tracheostomy had eroded into a major vessel. After 30 minutes of fruitless effort, it was my job to tell the cardiac arrest team to call it quits.

I stopped the code and declared my patient dead. Then it really hit me: All alone -- and most likely wide awake -- she had silently exsanguinated -- bled to death. I was horrified, spent -- and relieved.

Today, of course, this drama would end differently. No university hospital worth its salt would allow a fresh cervical spine patient to lie unmonitored on a general ward. Within a day or two of admission, a surgical team would have repositioned her tracheostomy. Finally, thanks to tremendous advances in the care of quadriplegia, perhaps she (and we) would have viewed her next chapter with more hope.

On the other hand, you could argue, in 1978, it was a miracle she had made it to our hospital at all.

But that begs the point. In the 30 years since we lost the beautiful, paralyzed girl, what haunts me most is not her tragic end but my callow assumption that her life was no longer worth living. At age 27, I knew a lot about death and broken wings -- but very little of the human spirit's power to survive, rebuild and soar. ยท

Claire Panosian Dunavan is a professor of medicine and infectious diseases in the David Geffen School of Medicine at UCLA. Comments:health@washpost.com.

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