'My Toughest Decision as a Doctor'

The toughest decision I have ever made as a physician involved my own mother (although I was technically still a few months from graduating from medical school).

Although I was young, I knew that whatever I chose would scar me permanently.

I had a couple months off from medical school, so decided to go to Europe to visit my parents. My father was at the time a visiting professor in Belgium.

I flew to visit in January. It was cold and gray. After traveling a bit around Belgium, my mother suggested we go south to get to some warmer weather. My father couldn't afford to take time off at that point, so my mother and I flew to Madrid, planning to spend a couple weeks traveling around Spain. After several days touring central Spain, Mom found a deal for a hotel on the beach near Torremolinos. Though warmer than Belgium, it was not yet beach weather. Nevertheless, there were many places to visit in the area. It was beautiful country.

But, at least where we were staying, the food was very rich. Lots of creamy sauces. My mother partook of all the rich food, saying that she was on vacation, even though she had recently had a CAT scan showing gall stones. She had thought that it wasn't much of a problem, and I was going to be visiting, so she thought that she would wait to have her gallbladder out.

One day, she had right upper quadrant pain. We stayed in the hotel instead of touring. When she didn't improve, we called a doctor, who came and suggested that she be admitted to the local hospital. I thought that maybe some fluids and avoidance of rich foods might quiet down the symptoms until we got back to Belgium. I called my father and asked for his help in arranging a return flight. I couldn't convince him of the seriousness of the situation. I became even more concerned once I saw the hospital and the treatment rendered. She was kept with her IV TKO, and was served soups with a layer of fat floating on the surface. I encouraged her to drink a bit of water, and would increase the IV rate when the nurses would leave, but knew that serving fat to someone with gall bladder problems was not a good idea. I even questioned the doctor. In the evening, my mother encouraged me to go back to the hotel to sleep, which I did, fitfully. The next day was much the same. After a couple days of minimal fluids, I noticed that my mother hadn't urinated for hours. I suggested a catheter be placed. The nurse returned, saying that she had permission, but asked, "Do you know where the catheter goes? Do you really want that in your mother?"

My mother was a nurse, so she understood. I responded that both she and I knew where the catheter went, and it would not even be a problem for me to place it, if the nurse was uncomfortable. Due to language issues, the conversation went through me. As a result, the nurses commented that my mother was "demented." By now, her gray hair was disheveled.

Finally, the catheter was placed, and she had minimal urine. I suggested fluids possibly followed by Lasix to get her kidneys started again. I was very concerned and called my father to see if he could help to get her out of Torremolinos. The insurance company was of no help, since they thought that gall bladder problems could be handled in the regional hospital. Again, I was encouraged to go back to the hotel.

I was awakened at about three in the morning and told to come back to the hospital. My mother had been transferred to the ICU. She had been flooded with fluids, but was not making urine. I suggested more Lasix, but they said that it was a dangerous drug and they would only give 20 mg/day. I tried to explain how to chase electrolytes if that became a problem. Finally my mother's breathing became irregular and gurgly. I looked up at the monitor, she was having some PVCs as well. For a few months before coming to Europe, I'd had dreams of running a code on a relative. I never knew who the person in my dreams was, only knew that we were related. I had interpreted this as telling me that I needed a vacation. I did not imagine that it was a foreshadowing of the future.

I started mouth-to-mouth on my mother, all the while watching the monitor. I yelled at the nurses to get the crash cart. They brought a defibrillator, which wasn't charged and had no crash cart with medications or an intubation set. I continued CPR alone while begging them to bring me the resuscitation medication she needed. Fortunately, there was a Dutch nurse there who helped as much as she could. She said that she had not seen a code run since she had been in Spain. We tried for over an hour. I felt her ribs crack as I gave her chest compressions. I saw the bruising on her chest. I had to keep going. I couldn't bear to lose my mother. My mother, who had been up for a vacation and could walk all day on cobblestone streets to see the sights only days earlier.

Finally, it was clear, that we couldn't get medications in time from the pharmacy. I couldn't get intubation equipment until morning when the anesthesiologists came to open the OR. I finally realized that was still nearly two hours away. I knew it was futile. She still didn't have a pulse on her own. I kissed her, and started to cry. The on-call doctor came and pronounced her dead. He then told me that I had to leave the hospital. I was shown the door and called for a taxi from a pay phone outside. I went back to the hotel and called my father. He flew down later that day. We made arrangements to have a funeral in Chicago where much of her family lived. I didn't know where I would be for residency. He didn't know where he would return after he finished his appointment as a visiting professor.

The two hardest decisions I have ever made were to start the code and to end the code. I made the only decisions that I thought I could live with.

Margaret R. Wacker, MD, grew up in Colorado and attended graduate and medical school in Washington state. She has spent much of her adult life in California, where she is a neurosurgeon. While she has published medical articles, she has recently begun to write more personal stories and is currently studying creative writing at UCLA. She can be reached at editor@physicianspractice.com.

This article originally appeared in the March 2012 issue of Physicians Practice.