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A Lifesaving Decision

2015-09-01

 

At one time I was the doctor at a small hospital in rural South Dakota; we had ten or twelve beds and we were attached to a nursing home with thirty or forty patients. I had just gotten out of my first year of residency the year before and I was still green.
In the wintertime we had a hard time getting IV supplies because the fluids would freeze in the delivery vans when the outside temperature got down to zero or below; sometimes, in December and January especially, it would get down to forty below. The hospital pharmacist would lay in a supply of IV fluids in the fall that had to last until March or April.
We were ninety miles from Rapid City, the nearest large hospital; any surgery beyond the most basic procedures would have to be done there. I tried to transfer patients with serious illnesses that would be helped to the hospital in Rapid City, but sometimes it was difficult when the weather was bad. Not so much cold, since a vehicle could usually be coaxed to function in forty below temperatures. The problem was usually wind and snow; sometimes winds exceeded eighty miles an hour, mostly from the north. With heavy wind and snow, visibility would drop to less than a hundred feet, and your vehicle would crawl along at twenty miles an hour through blinding white; it was like being on the inside of a ping pong ball.

One night when the weather was particularly bad I had two patients admitted around the same time; one was a young woman with abdominal sepsis and the other a middle-aged man with lung cancer and pneumonia. I only had enough gentamicin to give it to one of the two patients, although according to the book I was supposed to give it to both of them.

On evaluation, the young woman with abdominal sepsis turned out to have a treatable problem and a number of years left to live. The man with lung cancer had been treated already with radiation and a partial pneumonectomy. He had a recurrent metastasis to the liver. He had developed pneumonia, which was to prove growth of Pseudomonas aeruginosa after a couple of days of culture, although I didn’t know that the first night. The young woman grew gonococcus on her cervical culture; with rebound tenderness, she had clinical symptoms of peritonitis and needed gentamicin. The old man, likewise, needed gentamicin for his lungs.

I made a decision, based on the limited quantity of gentamicin on hand, that I would administer it to the young woman with peritonitis. The old man got penicillin although he did not have pneumococcal pneumonia; I made a chart entry that suggested that he did have a pneumococcus, or at least I thought he was going to have a pneumococcus. In fact, he did not have, and I did not suspect him of having anything other than gram-negative pneumonia, which was much more likely in an enfeebled patient dying of lung cancer.

I made a decision that the young woman needed the gentamicin and the old man did not. I decided that giving gentamicin to the old man would be futile because he was going to die soon anyway, and the gentamicin wouldn’t buy him any more life. Even if the Pseudomonas bacteria proved to be sensitive to gentamicin, the patient’s body would not be able to fight off the infection.

The next day, the old man died. I happened to be in the room when he breathed his last breath. He croaked like a frog. It was the most incongruous thing I had ever heard. The man’s son and his wife were also in the room; I asked them to step out for a minute while I confirmed that he was not going to start breathing again. His pupils quickly dilated and became unresponsive to light. It was then that I knew I had made a life-saving decision. I had allowed the man to die, with his family present, quietly and without any fuss, while another person was saved and restored to health.

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