euthanasia

"The pain started suddenly at 4 o'clock this morning." The man stretched out before me on the gurney is in obvious distress. His abdomen is swollen and he's gasping for air. I look at his carnet. His name is Gaouna.

"How was he yesterday? Was he sick at all?" I ask through his brother who interprets from French to Ngambai and back again.

"Yeah, yesterday he was fine, but this morning, the pain started right here," he points to the epigastric region of the patient.

I examine the belly. It's firm but not tense. When I tap with my fingers it sounds hollow, full of air. Gaouna winces in pain with each touch: peritoneal signs. His breathing is shallow and his heart is rapid and his pulse weak. It sounds like a perforated ulcer. The ER had started an IV so I tell Abel to give Gaouna triple antibiotics, call in Samedi from home and go see the last of the ER patients while the OR staff preps for an immediate laparotomy.

The family doesn't have money to pay but they are well to do and leave their motorcycle at the hospital as collateral for future payment.

I finish in the ER and come back to the operating theater. I enter the room. Gaouna is lying on the OR table. Two IVs of Ringer's Lactate are raised high on IV poles running in fast into both arms. A foley catheter has about 300 cc of dark urine. His arms are stretched out on the arm boards and tied down as if he's about to be crucified. Gaouna's eyes are closed and his breathing is even shallower and more rapid. The beep of the pulse oximeter tells me instantly he's not getting enough oxygen. I glance at the numbers. He's at 60% saturation, way below the accepted norm. I'm afraid Gaouna is not going to make it. Maybe we're too late.

We have no oxygen, so I decide to intubate him. I grab a cardboard box off a top shelf. Inside is a mix of all our endotracheal tubes. I select one I think will work. I test the cuff with a 10cc syringe of air while Abel pulls out the laryngoscopes. In my hurry I forget to prepare suction or put in a stylet. I check the laryngoscope and the light works. Abel injects 2mL of ketamine and I insert the blade in the patients mouth. The light isn't working. I pull it out tap it a little, take the blade off and put it back on the laryngoscope handle. It works again. I put the instrument back in his mouth and lift up the tongue. I briefly see the vocal cords before a mass of saliva obscures my view. I call for suction and try to put in the breathing tube anyway. It bends down away from the vocal cords. I reach behind me and quickly leaf through a drawer in the anesthesia cart to find a stylet for the tube. I put it in and bend it into a distal hook to help me put the tube into the trachea. I try again and this time am successful. I put on a bag to the tube after blowing up the cuff and start to breathe for our dying patient. His saturation comes up to 85%. I give the bagging over to Samuel and go scrub. Samedi and Abel have already prepped and draped the abdomen. I'm sure that with release of the abdominal tension, Gaouna's breathing will improve.

I take the large scalpel and am quickly in the abdomen as a surge of dark red, slimy fluid surges out. We quickly suction out over 3 liters of fluid. The intestines look injected and angry but don't seem to be gangrenous. I start to explore and soon discover the real problem. As I cut up the abdominal wall to expose more of the contents a purplish, lumpy, alien-looking mass pops out of the right upper quadrant. Gaouna has end-stage liver cancer. Inside I'm furious. As I quickly try to close up the useless operation, many thoughts whirl through my head. How could the family deceive us? Of course, Gaouna's been sick for months if not years. Without CAT scans and other diagnostic equipment we base so much of our diagnosis on history and physical exam. This surgery could've been avoided. Now in all likelihood he'll die before making it out of surgery. How could God have let me make such a big mistake costing so much money for Gaouna's family and so much time and personnel resources for the hospital?

I've never closed up a surgery quicker. I take over from Samuel and take the bag off the breathing tube. Gaouna's sats go down to 57% but stabilize as he starts breathing on his own. I just want to get him out of here alive. I take out the ET tube and we transfer Gaouna to the gurney and wheel him out to the wards. I explain to the one family member who's there but it's not the same one who gave me false information.

An hour later, Pierre comes to inform me that Gaouna has "rendu l'ame" (given up his spirit). I'm not surprised. By this time, I've had more time to reflect. What if we wouldn't have operated? Gaouna may have lived several more days or even weeks. But he would've suffered. We have no real good pain medication. In hospital, we can give some pentazocine which is OK but not great. As far as pills, we only have Ibuprofen and Paracetamol (a medication like Tylenol). Instead of a slow, painful death, but operating on him we let him slip away in a Ketamine coma without any suffering. Sure, the operation didn't save his life, it just saved him from a torturous death. So maybe it was the right decision after all.

James