University of Minnesota

“If It Isn’t Fun.” – Heroic Surgery

Hospital residency molds not only the young specialist’s skills but also his attitudes. I confess to have developed “attitude” about heroic experimental surgery in my junior residency. It started with the case of veteran Mr. O, sixtyish, who entered our medical service complaining of devastating syncopal attacks or black-outs. I worked him up to find severe valvular heart disease, a high-grade aortic stenosis, with heart enlargement or left ventricular hypertrophy. Under my primary charge, I prepared to present his case properly to our Medical-Surgical Conference for consultation at the end of his first week.

But Mr. O’s fate was to enter our academic setting at the very moment in history when a daring, perhaps brilliant, and certainly aggressive young chest surgeon, Ivan B., was primed to do his first mechanical fracture of a stenosed aortic valve. He had, of course, carried out the necessary preliminary dog surgery, perfected the dilator instrument, plotted the course, and calculated the odds. He thought he was ready.

Dr. B’s surgical resident spies had somehow got wind of my case, and without my knowledge had, in the night, secured the patient’s consent to a highly experimental valvuloplasty, quite without discussion with me. They had promised the candidate the moon, of course, with the usual (in those days) surgeons’ downplaying of the experimental nature of the procedure or of its unacceptable risk (that is, the risk for any given first experimental attempt). I later maintained that this was not informed consent.

As I came in early for rounds the particular morning, I encountered my patient on a gurney being trundled off to surgery. Flying to the Medicine office, I learned that they and my attending physician had, in fact, given tacit approval for the surgery in a phone call with the surgeons the night before! The new junior resident (me) had been forgotten about in their exchange.

Having no other recourse, I gowned and entered the amphitheater and watched the carnage.

In a ghastly procedure, the medieval valvotomy tome was introduced directly through the heart’s wall into the high-pressure, thickened ventricle through its muscular apex. There followed a rapid, desperate positioning of the tome in the gravely obstructed aortic valve, with blood spewing in an angry jet around the apical wound. Then came the awful crunching sound of the dilator opening inside the heavily calcified valve, followed by the immediate and precipitous decline of vital signs and the rapid demise — on the table — of Veteran O., my patient.

Standing in the shambles of the theater, the grotesque dilator hanging limply at his side, the crocodile tears of the defeated warrior surgeon could never make up, in my view, for the loss of good days and companionship that my patient had suffered, nor for the fundamental deception of his “informed consent” for this surgical “first.” I was sickened and I was furious.

Now, years later, I grudgingly admire the ability of pioneer surgeons to enter situations with such terrible risk of killing people to achieve progress. But now, at least, an improved consent process and institutional approval relieve some of the onus from the shoulders and conscience of the innovative, ambitious surgeon.

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