IT was 07:50 am. I had just changed into my scrubs when the phone rang – private number, probably work, I thought.

“Hello, this is Andrew,” I answered with my standard greeting to private phone numbers. (I hoped desperately that my gamble in answering was not another loss at the roulette wheel of telemarketers, or criminals armed with another way to scam me.)

“Hello Andrew, welcome back!” said the familiar voice of the department secretary, much to my relief. “I’m just calling to let you know that your theatre has been moved from theatre 11 to theatre one. Thanks!”

“Theatre one?” I thought to myself. “That is normally the neurosurgery theatre. I wonder what is going on?” I put my phone back into my pocket and made my way to the change room door.

“Hi, are you Andrew? … Oh good, I’m one of the registrars. I just want to let you know that you’re doing an organ transplant retrieval …” And off she rattled, relaying the patient’s medical history. She concluded by telling me the donor was a health professional who had spent some of their life caring for others. More details emerged — the donor had collapsed at work while providing healthcare to the community. They had met death in the line of duty.

My heart sank, and both of us frowned a little behind our COVID-19-mandated masks because this case now cut a little closer to home. The organ donor may not have been a doctor or someone who worked in theatre, but they were from the broader health care worker tribe. These cases can cause us to be a bit more introspective. Possibly it’s the psychology – why do we not bat an eyelid when hundreds or thousands of people die in a disaster on the other side of the world, but when tragedy befalls a stranger in our city (think Jill Meagher in Melbourne), why do we go into collective mourning?

I was also unsettled because I had no experience in organ retrieval, and recognised I was outside my comfort zone. I had not avoided these cases in my career, but I had trained in centres where organ retrievals were uncommon. I would need to revert to first principles: “What exactly is my role in all of this?”

Pondering this question furthered my unease as ideas whizzed through my mind. Our role in anaesthesia is to facilitate surgery or medical procedures. Our aim is to keep the patient anaesthetised during surgery and have them alive at the end of it (hopefully in better condition for having had the surgery).

Organ donor cases overturn these norms: I would be facilitating surgery on a patient who was no longer alive. Is an anaesthetic necessary when the patient is brain dead? Do you take the body back to the intensive care unit (ICU) when it’s finished, or does the body go straight to the morgue? Has the death certificate already been signed, and if not, whose responsibility is it? My helpful anaesthetic nurse was new to this too. She, of course, was sensible and looked up the institutional policy. When you don’t know what you’re doing, you should probably read the manual.

The organ retrieval team from another hospital came, and, to my relief, included a fellow anaesthetist. After introductions, I told him that I had zero transplant experience and that I would be most grateful for his guidance. Perhaps disarmed by my candour and willingness to learn, he asked me what year of training I was in. I told him I was in my eighth year as a consultant. In truth, I was simply chuffed that my youthful looks had deceived him.

When it was time, we made our way to the ICU. There, awaiting us was the transplant coordinator and the patient who had been prepared to make their final journey to theatre.

So it began.

Over my career, I have transported countless ICU patients within and between hospitals, as an ICU registrar, as an aeromedical retrieval registrar, and as an anaesthetist. However, the experience of wheeling this patient to theatre was unlike any I had experienced before. As we passed each bed in the ICU, the nurses, without a murmur, moved the chairs and equipment out of our way. A curtain of silence fell as we passed each room, making this short journey feel like a sacred procession. We were pall bearers marching through an avenue of mourners. The beeps of the monitors were the organ music, and the soft hiss of the portable ventilator set the pace of our slow march.

In theatre everything went smoothly. We ran no anaesthesia or sedation, which, while seemingly logical, felt so disconcerting. In medicine, where the double-blinded randomised control trial and meta-analyses are king, we like to think of ourselves as objective, rational scientists. But there will never be a randomised trial to explain my emotions.

For we doctors are human too, and I wonder sometimes whether this gets lost under the white coat’s façade, to the detriment of our own mental health.

The surgeons went about their business, and then the moment of finality arrived – the aorta was cross-clamped, the familiar clicks of the closing ratchet signalling the end. We turned off the electrocardiogram and blood pressure alarms. Only the breath of the mechanical ventilator remained. As the machine’s bellows slowly rose and fell in those last moments, I imagined the patient’s spirit slowly exiting the body.

On reflection, my disquiet throughout this case highlighted how unnatural this process felt. Clinical medicine was superimposing itself on death, that most natural and inevitable consequence of life. It also demonstrated my own discomfort with death, or at least that grey, Stygian realm separating Hades and the living world where brain death with a beating heart seems to linger.

Some say that doctors see themselves as gods, as final arbiters of life and death. Yet perhaps because of medicine’s influence on today’s technological society, people and doctors have forgotten how to die and let nature take its course. For in medicine death is often an outcome to be avoided. And in anaesthesia, our safety culture has made death on the operating table a shocking and rare occurrence.

I have been shocked twice by death under anaesthesia – both times as a trainee: one a gunshot wound through the vertebral artery, the other a left ventricular rupture following elective mitral valve repair (a heart broken and unable to be knit together, both literally and metaphorically). In each case, the patient was left to “bleed out” from uncontrollable haemorrhage when the surgeons surrendered to the inevitable, crimson spattered on their gowns and dripping onto the floor.

Both of those cases were wild and chaotic, but this case was deliberate and controlled, and strangely felt more unnerving. But why? Perhaps it’s because during the mayhem of those two earlier cases I was a heroic Orpheus attempting to rescue Eurydice. And now, for the first time in my career I had switched sides. No longer Orpheus, I had become Charon the ferryman, rowing this unfortunate patient to their fate on the other side.

Acknowledgements:

Thanks to Dr Ferghal Armstrong (Consultant Addiction Specialist), Dr Vanessa Andean (Consultant Anaesthetist) and Ms Michele Gaca (Chief Librarian, Austin Health) for reviewing and providing feedback on the manuscript.

Dr Andrew Yanqi Huang is an Anaesthetist and Specialist Pain Medicine Physician working at Austin Health and Eastern Health, and is a PhD candidate in the Department of Medical Education at the University of Melbourne.

 

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.


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7 thoughts on “Ethics and emotion while navigating the River Styx

  1. B Cochrane says:

    Thank you for sharing the experience

  2. Anonymous says:

    I was deeply moved by this.. it was beautiful to read about the deep sense of community felt within the medical tribe. Thank you.

  3. Ian Hargreaves says:

    Just as grim being the orthopaedic registrar harvesting the femora or maybe a hemipelvis.

    The cardiac team have been, liver and kidneys gone, anaesthetists packed up.

    You and the cornea doctor are the last, no warm ischaemia time constraints.

    The lions have had their fill, the leopards and hyenas are sated, you are the final vultures picking the carcass.

    The scrub nurses, usually the cardiac team who have been forced to stay on after their organs are long gone, and swab counts are mandatory but meaningless, look at you like the mother zebra regards the last vultures over her foal’s corpse. You are Burke and Hare, Hannibal Lecter, Josef Mengele – it’s a travesty of ‘real’ surgery.

    The only thought that spurs you on in a theatre without music or bonhomie, is the 15 year old kid with osteosarcoma who needs this bone, which you pack aseptically for processing, to avoid an amputation.

    The theatre staff grimace further as you saw a broomstick to length, to fill the defect, in case the relatives view the corpse; while the eye registrar sutures the eyelids over the orbital packing.

    I always looked proudly at that little endorsement on my driver’s licence, ‘Donor – All’. Yes they could even have the eyes, any parts I was no longer using. Some poor bastard who had not been trained or prepared for this could come and flense my corpse, my last chance even post mortem to help maybe a few more suffering patients.

    Only last year did I discover I’m too tarnished, as a conversation with my anaesthetist and intraoperative Googling revealed. An English fellowship 30 years ago, my wife and I and our 2 oldest kids are mad cows. I knew they wouldn’t take my blood, but refusing a healthy heart for a minuscule risk of variant CJD? That’s a tragedy of Greek proportions.

  4. Dr Louis Fenelon says:

    Yes, this was a very emotive description and a good way to debrief I hope. It is sometimes too hard and too easy to deal with death on our watch.

  5. Anonymous says:

    I’ve been involved in organ retrievals over 25 years, both after brain death and cardiac death. They have always seemed macabre to me- Picking over the dead for “spare parts”. I was affected deeply by a young Korean woman who died accidentally. She was in Australia for a holiday after just finishing university. Her mother came from Korea. She didn’t speak English so I couldn’t tell her we would take care of her child. She was sobbing while we wheeled her away. Heartbreaking.

  6. Sue Ieraci says:

    Many years ago, as a junior doctor, I had to care for a donor overnight in the cardiothoracic ICU. The matched recipient (for the heart) had missed the last flight from interstate, so the surgery could not proceed until morning. Though this was decades ago, I recall that night vividly. The only instruction I remember being given was “don’t let the donor die”. Through that night, my patient (though certified as brain dead) had muscular tremors that rattled the space blanket, making crackling noises. He had polyuria, which I was chasing with IV fluids. I also remember the nurses asking “what if he wakes up?”. Another surreal situation – battling to keep the person “alive” in order to save another patient’s life.

    Of course, we all understood what it meant to be certified as a suitable donor. The surreal aspect was responding to signs of life, working to preserve them – a reminder that this was one person dying, but also helping another to live.

    Thanks, Andrew, for a reminder that the donor is not just a set of organs, but another human.

  7. Yvette McLean says:

    Too difficult to describe the surreal emotion after reading the above. All I can say, is that I felt that I was physically present whilst reading the article and watching the whole scene unravel.

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