Job

A Story for Veterans' Day

A Confederate Veteran and a Union Veteran at the 50th anniversary of the Battle of Gettysburg.

Not long ago when one of the morning surgical cases was cancelled, several members of the O.R. staff gathered in the break room for a little breakfast, coffee, story-telling, and laughter. It was a nice change from the usual pressures of a day in the O.R., but soon enough the time came to get back to work.

My friend Caroline, one of my favorite surgeons to work with, lingered after the nurses cleared their coffee cups and left the room. "I wanted to talk to you about an add-on case for this afternoon. It's not up on the board yet."

"Who is it?" I asked.

"59-year-old guy, Vietnam veteran, PTSD, schizophrenia, intermittently agitated. Gave Hilda in the O.R. a pretty bad scratch last week."

"Whew."

"Last week he had a perforated appendix, which was discovered pretty late because it took a while for him to seek medical attention. We operated and took it out. Now he has an angry-looking, infected fistula in his lower right quadrant that's draining some bad stuff out of it. A fecal fistula."

"What's the catch?"

"He's combattive. Stressed out and a potential danger to himself and others. And he refused to consent to the surgery."

"And if he doesn't have it, he'll be septic by tomorrow and possibly drop dead."

"Frankly I thought he'd go septic last week. Now we have a court-appointed lawyer as his legal guardian giving consent."

"So, we basically have to commit assault and battery to protect this guy from going into septic shock."

"Basically. But with legal permission. He doesn't want to be here, but he's also rescinded his consent to be transferred to the VA hospital - not that they'd have a bed for him right now. He wants to go to the psychiatric VA hospital, but they don't do medical things over there. So he's stuck. "

"Can't the lawyer guy give consent for the transfer?"

"No, because the judge says the patient has SOME capacity to make decisions, and the transfer is not a medical decision. Go figure. And after the surgery, they all wash their hands of him - the guardianship's only valid for the surgical part."

"How nice."

"My question for you is, from an anesthesia standpoint, is there any reason you might feel this guy would be better off transferred?"

"Not from what you've told me. Especially considering the urgency of the situation - it doesn't sound like we should be sitting on this for too long. Although if he's that belligerent with the staff, I wish I could convince myself that I felt uncomfortable treating him here. But the truth is I don't. We can take care of him. It's just not going to be easy."

Caroline nodded. I told her I would go and see the patient. She gave me his room number and warned, "Don't be surprised if he closes his eyes and shuts you out when you start talking to him. That, or takes a swing at you. Or tries to rip out his IV - he's ripped out four already."

***

I'll call him Job, after the Biblical figure smitten with all kinds of pain and suffering. I peered into Job's room from the corridor and saw a bearded, disheveled man sitting on a chair in the corner of the room, at the foot of his bed, hands in his lap, gaze to the floor. His nurse was in the room informing him that she would return soon to change the dressing on his abdominal fistula. When she came out into the corridor I asked if I could introduce myself to him and examine the area while she was doing the dressing change. I followed her to the supply area and tried to get a better idea of any problems he had been having. His chart was not a helpful source of information.

When I accompanied the nurse back into Job's room he was lying on the bed with his hands folded across his belly, ready for the dressing change. Approaching from the right side of the bed, she began removing tape from the old dressing. I stood on the left side and tried to talk to him.

"Hi. I'm Dr. T. I work with Dr. Caroline Walsh. I wanted to introduce myself so you would know who I was. We'll be taking care of you together today."

He gave a sidelong glance in my direction, then resolutely closed his eyes.

"Dr. Walsh and I are very concerned about the infection in your belly. We'd like to help you get rid of it. Do you have any medical conditions I should know about in order to be able to take care of you?...Asthma?"

He shook his head.

"Pain in your chest or trouble breathing?"

He opened his eyes a crack and again shifted them toward the sound of my voice. "Why do you want to know?"

"Knowing your medical problems helps us take care of you as best we can. Have you had trouble with your heart and lungs at all, or with diabetes?"

Job shut his eyes. "You're not going to operate on me, are you?"

"I'm not, no. But Dr. Walsh feels that you do need an operation for this, and my job is to help keep you comfortable and safe for it."

"I don't need an operation. It's better already."

The nurse then interjected, "No, Job, this looks worse now than it did yesterday. It's a lot redder and it's draining a lot more. You need to have this surgery, or you'll get very, very sick."

"No I don't. I don't want to be here. It'll get better on its own."

We went around in circles for a bit discussing the issue. At one point I found an opportunity to ask if I could listen to his heart and lungs. At that, Job started, and his eyes opened quickly and he said, "I won't have none' a that. I know what you're trying to do. I don't want to talk to any of you any more." Then he shut his eyes firmly once again, and the conversation was over.

Out in the corridor the nurse said, "Well, at least he didn't yank his IV out that time."

***

At 13:30 we had a team meeting to discuss Job's care and safety - social workers, nursing care coordinators, the pulmonologist in charge of the ICU, Caroline, and I. I learned that Job lived in a group home for veterans, similar to foster care but for adults. We came up with a plan to give him enough sedation pre-op to ensure the staff's safety, but not so much that he was too "snowed" to breathe on his own. We would treat him like a trauma patient with unknown medical history and try to keep his vital signs as stable as possible during the induction of anesthesia. We discussed ventilation issues back and forth and decided my goal would be to remove the breathing tube at the end of the surgery, unless the long-acting narcotics I had to give him to diminish the pain of the surgery disabled his breathing too much. We agonized over what would happen if he decided to sign himself out "AMA" - against medical advice - after the operation.


***

After receiving a dose of a valium-like drug that would have rendered the average person totally unconscious, Job was still talking to us as we wheeled his bed toward the O.R., but he was also calm. I placed monitors on him and gave him oxygen, talking to him as gently as I could about what I was doing at every step. I injected the anesthetic into his IV and watched as his eyelids fluttered closed and remained motionless when I brushed my fingertips against his eyelashes. I placed the breathing tube, put a warming blanket on him, relaxed his abdominal muscles, measured his temperature, and gave him anti-nausea medication as well as a large dose of long-acting narcotic to blunt his response to painful stimuli. Throughout the surgery I watched over his ventilation, heart rate, heart rhythm, and blood pressure, made sure he was receiving what I thought was the right amount of fluid, checked his urine output, made sure his abdomen stayed relaxed enough to allow Caroline to do what she needed to do, and gave more pain and anti-nausea medicine.

A couple of hours later the surgery was over. I removed the breathing tube and most of the monitors, and as his eyelids slowly opened I spoke to him, again as gently as I could, reassuring him that all was well, that he was safe and not alone and that we were about to bring him to the recovery area. His eyes were large, like those of a child waking up in unfamiliar surroundings, but he wasn't queasy or experiencing significant pain. He didn't wake up violently, wildly flailing about as so many anxious or very young or very old people do. In fact, his eyes drifted shut again and he was completely peaceful as we wheeled him to recovery.

***

Veterans are invisible. Unless people know one, my impression is most people don't think about them. They suffer unimaginable trauma to serve their country, then come home and find everyone going about their business, blithely going to the grocery and playing soccer and hanging holiday decorations, oblivious to and, for the most part, untouched by the pain their soldiers, fellow-citizens, have seen and experienced. Then veterans disappear into an underfunded system that is backlogged beyond belief, into squalid hospitals that are stretched to their limit, ofen receiving what has been described in the press on more than one occasion as "substandard care" for their amputated limbs and nightmare-laden minds, all the while trapped in a vast societal blind-spot. No one wants to see their pain or hear their cries, or even look their way, after they volunteer to fight in the name of our own peace and freedom - sometimes against their will, in causes that they feel are unjust, in the midst of atrocities that warp and disfigure and dismember them forever. No one wants to hear or to see or to think of these very bad things. And so invisible they stay, among us but lost to us, because of our own need to protect our minds from horrible truths.

Joseph Ambrose, an 86-year-old World War I veteran, attends the dedication day parade for the Vietnam Veterans Memorial. He is holding the flag that covered the casket of his son, who was killed in the Korean War. Photo credit: U.S. Census Bureau. (I'm sorry, I don't know who took the picture above this one, and I don't know if it's copyrighted, but I thought it was such an important photo - found on http://www.freerepublic.com/focus/f-news/1146118/posts. It's of marine Cpl. James Wright, who received the Bronze Star for valor, and it may have been taken by Cpl. Richard Stevens of the USMC. I'm hoping it comes under the U.S.-federal-government-public-domain rule.)

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Addendum, Tuesday, November 13, 2007: A report in the CBS evening news tonight described the alarming rate of suicides among Iraq war veterans - numbering about 120 per week in 2005 alone, and by some calculations more than double the civilian rate - yet reporters had to dig for and do the math themselves to find the statistics. The responses from the VA and government agencies ranged from "This research is ongoing" to "We just don't have those numbers at the moment." They should be publicly held accountable - tarred with families' stories and feathered with questions demanding accountability. Again, there's a recurring evil here: no one wants to look at what's happening to these vets who survive the violence but return home and cannot survive the aftermath. Why? Because looking means finding - finding enormous trouble, corruption, and indifference in the system, and with that trouble, the need to be accountable for the evils perpetuated. The United States should be ashamed of the way these soldiers are used, abused, then abandoned and forgotten.