Schwab: How closely should a doctor follow patient’s demands?

If you were the surgeon would you take a young man’s leg or risk his death to a spreading infection?

By Sid Schwab

Herald Columnist

Taking a break from Trump’s ethical failings, here’s a story of an ethical dilemma I faced early in my surgery training, involving necrotizing fasciitis, aka “flesh-eating disease.” Excerpted and revised from my book about those times, it’s graphic. And I’m unsure what the lesson is.

Playing softball in Golden Gate Park, Eric A. took a knee to his thigh as he slid into second base. By that evening, it hurt too much to walk, so he lay on his couch for a couple of days until he started to feel ill, at which point a friend brought him to San Francisco General Hospital, where, only three years into surgery residency, I was in charge of the “Extremity Service.” Given his story, there was little urgency in the call I got from the Emergency Department. It figured to be an infected blood clot, needing routine drainage.

As expected, his thigh was red and swollen, but I wasn’t alarmed until, palpating it, I felt the crunch of gas bubbles under his skin. Then, for the first of countless times in my career, I called to request an operating room ASAP; and, unready to be on my own, I called Dr. Blaisdell (rightfully known as “Blazer”), chief of surgery.

You expect fat to be bright yellow and to bleed a bit as you cut through it. When it’s gray and fizzes, a thudding sickness arises in your gut. Even worse when it’s muscle, liquefying, frothy. The treatment for necrotizing fasciitis is aggressive, wide removal of all the involved tissues, and big doses of antibiotics. And going back to the OR as often as it takes, to do it all again. It doesn’t always work. Gas-forming infection moves so fast, you can see it.

We cut away most of the muscles of Eric’s thigh, and the skin over them. Preserving his leg seemed impossible, but at that point we’d removed everything that looked infected; and since, in my inexperience, I hadn’t considered discussing amputation with him, I took him to the Intensive Care Unit to wake him up and talk things over before the next operation. He was lucid, and adamant: no amputation. He’d rather die, he said, than lose a leg. I was as persuasive as I could be. So was he. When his pulse and temperature began to rise, I took him back to the OR.

Within minutes it was obvious: There was no way to save Eric’s leg, and it was unlikely we’d save his life. The infection now involved the remaining muscles of his leg, had forced itself around the buttocks, and, portentously, the fascia of the psoas muscle — a core muscle connecting the lumbar vertebrae to the femur — heading up into the belly along its back side, all the way to the kidneys.

“He needs disarticulation,” Blazer said, meaning taking the whole leg out of the hip joint, the worst kind of amputation. Without a stump, it’s hard to control a prosthesis, let alone attach one.

“Dr. Blaisdell,” I said, “he was very clear: he refuses amputation. He said he’d rather die.”

“He’s septic. I’ll testify he’s mentally impaired if I have to. No 20-year-old is going to die here for lack of an amputation.”

“Really,” I repeated, by now not at all sure what was right. “He was very clear.”

“Then I’ll do it.”

So I did it.

When we finished, Eric’s hip socket was empty, his buttocks denuded to the middle of his back. His lower belly was skinned, his left testicle, denuded, was hanging like an egg on a string. We’d reached into his retro-abdominal area as far as we could, stripping the psoas muscle’s surface and leaving a bunch of rubber drains. It was going to be hard to face him when he awoke, as clear as his demands had been. On the other hand, I was certain he was going to die.

Embarrassingly, Blazer was already leaving the ICU when I got there at 5 the next morning. “Your patient just wrote a note,” he told me. “You’d better go read it.” (Still intubated, Eric couldn’t talk.) “Get me a lawyer,” was what I expected, and my stomach tightened as I reached for the clipboard.

“I’d like information on prostheses, please,” is what it said.

After some late-night hilarity featuring too much soap in a jetted tub (it’s in the book), and several skin grafts later, Eric returned home to Boston. For years, he sent Christmas cards.

Email Sid Schwab at columnsid@gmail.com.

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