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What Should A Surgeon Do With An Impossible Case?

Mon, 06/17/2013 - 9:12am
David Gelber, M.D.

For the first time in my career I asked myself that question. Over the years, I’ve had more than my share of difficult cases. I’ve had patients with life threatening conditions whom I wished I could offer more than to just shake my head and speak empty words of encouragement. They stare back at me and I see their eyes full of hope. How many times have been forced to say: “I’m sorry, there’s nothing I can do that will make you better, or cure you, or ease your pain.”

I hate moments like those.

A patient comes to me with cancer of the stomach. Major surgery is scheduled. All the preoperative testing indicates that there is a good chance for the surgery to be curative. An incision is made and the abdomen is explored. My heart sinks with the first glance.

Grayish white nodules stud the abdomen. The normal yellow fat of my trusted friend, the omentum, is caked with an ugly gray mass of cancer. Nothing can be done.

“Maybe chemotherapy will shrink the tumor,” I say, although I know that this cancer rarely responds.

The tumor was there before the operation. The surgery offered hope and no harm was done. And, the patient thanks me.

Irony.

Another patient comes with pain in his legs and black patches on his feet. He smokes two packs of cigarettes a day, has been hypertensive for years and sporadically takes his medication. My exam reveals areas of dry (not infected) gangrene on his feet, bluish discoloration of his toes and no pulses can be felt in the groins or feet. The patient is sent off for a battery of tests which confirm my suspicions. All of his major arteries from just below the aorta and throughout his legs are occluded. In this case there is no reason to try to do any surgery. Any operation will surely fail and probably leave the patient worse than he is now.

The two cases above are difficult, no question. But they were handled in the best way possible and in neither case was the patient harmed; Hippocrates fulfilled. They were difficult, but not impossible.

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