Narrator

Oh good, I see you’ve made it to the cardio-thoracic wing of Seattle Grace Hospital. How are you? Most of you, I presume, are aspiring surgeons, anxious to get your first operating gig and  get in on some of the bloody action. You will see your textbook material manifest itself into a human life form that will become your responsibility. As you make your very first incision, you’ll energetically start pointing out all the vessels and tissues you were forced to memorize in medical school. A rush of adrenaline will come over you; you won’t have to pee, eat, anything, and you will only be aware of the delicate work of your hands. Sounds great, right? I want to show you something before we begin. In short, this patient you’re about to see died from a complication during a mitral valve replacement surgery. Yes, former star tennis player Mrs. Quinn Z was quick on the courts but slow to treat a streptococcal infection, leading to an infection of the heart valves that later manifested itself into a leaky mitral valve. Unfortunately, a blood clot during the surgery caused cardiac arrest, and she died. Due to her previous heart conditions, she was more likely to succumb to this cascade of events. I’ll spare you the details for now. Let’s begin. Take a seat. Grab some popcorn. Actually, don’t. It smells like blood and guts here. 

Patient (1 hour before the surgery)

Life is a tennis match. Throughout the course of your life, you play many sets and within those sets, games. And within those games, individual points. Now, just like in tennis, you don’t need to win every point to win a game. Nor do you need to win every game to win a set, or every set to win the match. The main idea I’m trying to get across is that life is a constant fight, and I believe that one can have an incredible come back if he or she gives fighting a chance. My name is Quinn Z. I am a former professional tennis player. 40 now, I sit back thinking about all the times I came back to win matches where I was down a set. It’s all about the struggle and fight. I was at my prime,but now I have been reduced to a mere lump of floppy skin and bones, facing my next opponent: a mitral valve replacement surgery. This old thing used to fly around the court, chasing tennis balls for hours on end. Tired? I didn’t even know the meaning of tired back then. Now, I can barely run a 12-minute mile, and every ounce of my breath is squeezed out of me. I feel fatigued and weak. Forget down one set. I’m down three sets. I’m now this decaying problem that is hauled from doctor to doctor by my family. Nevertheless, I’m a fighter. Therefore, I sit here, writing and keeping track of my progress in my diary, about to have my chest ripped open and have my mitral valve replaced. 

It’s a risky surgery, the doctor explained. I am more prone to develop a blood clot during the procedure - one that can ultimately cause cardiac arrest and death. Given my recent infection of the heart valves, I have an even greater chance of this little incident occurring. My husband pleaded me to reconsider; even if the leaky valve ultimately causes heart failure, I’ll have a 50% chance of living for five more years and 10% for 10 more years. Oh wait, there’s more! I can exercise and eat healthy to give myself another year or two! Now isn’t that great? No. No, I cannot succumb to this disease eating away at me. No, I can’t stand to see myself absentt from my weekly tennis practices, my healthy girlfriends flying around the court as I sit here in isolation, deteriorating. No, I will have the surgery. No, I will put up the fight. This match isn’t over.

“Ready?” The cardio-thoracic surgeon asks, walking over in her sky-blue scrubs, scrubs soon-to-be splattered in my blood.

Surgeon

Dan, the anesthesiologist, and I wheel Mrs. Z down to the operating theater, a place where eager interns and residents observe my work, hungry for their first cut. 

“Just to verify again, how long is the surgery?” the patient asks. 

“About two to four hours” I reply, trying to remember how long my last valve replacement took. Images of previous surgeries start flashing through my mind as I scroll through my mental library. 

“And how long did you say the recovery time is? I want to be able to get back out on the courts.”

“Well, recovery is usually four to eight weeks, but it also depends on a number of factors, such as your diet post-surgery,” I respond. As I’m scrolling through all my previous surgeries, I start matching them with the patients. Each surgery is like a baseball card that I collect and store; each one is filled with its associated statistics. I stop scrolling at one particular case from a few years ago: an aortic valve surgery. The player: one-year old Jimmy. Open-heart surgery. Mechanical valve. Three-hour procedure. Recovery time: Five weeks. Jimmy continues getting checkups as he gets older. The modified valve is expanded by threading a balloon catheter into his heart, prolonging its function. I continue scrolling.

I also take note on the personality of the patient. Mrs. Z right here is one of the hopeful patients, ready to undergo a very risky surgery in her condition. Despite the risks at stake, Mrs. Z would rather die struggling instead of living a few more years in regret. She believes that’s where the courage lies. Dan and I pass the waiting room, a surgeon’s best and worst place to be. I’ve walked there with pride, as if I was the last one standing from a gory war, receiving hugs from sons, daughters, and husbands. However, there have been too many times in which I had trudged in there, only to witness the first gasp of a family member when they realize their loved one did not pull through. It’s never easy to hold myself together. I find myself crying in my car after a waiting-room event. 

Dan and I wheel Mrs. Z into the theater. Dan starts inserting the anesthetic through the IV and the nurses start inserting a multitude of things into the patient for vital-sign monitoring: small wires placed on the chest attached to an electrocardiogram, a pulse oximeter attached to the patient’s finger, and a temperature probe connected to the skin. I glance at the residents assisting me and then at the patient: her eyes are becoming loopy andslowly shutting. She cannot wait to get out of here. Lord, please let me be able to get her out of here.  

“Ok everybody, let’s begin,” I say, careful not to reveal the quiver in my voice. One of the nurses begins to disinfect the patient’s skin with chlorhexidine before I make the first incision in the patient’s sternum. I start scrolling again, reminding myself of the exact steps I took in my last mitral valve replacement.

“We’re ready for you, Dr. Carmen,” the nurse says, jolting me out of my flashbacks. I grab the knife used specifically for cutting the sternum. I place my hand over the upper chest area and slowly insert the knife and glide it symmetrically down the sternum. I turn to face the residents, who are staring intensely at the incision I just made.

“Once you perform the sternotomy, you dissect through the internal tissue to get to the heart,” I explain. I start cutting through the pericardial sac to expose the heart. After a few cuts, I decide it’s time for one of the residents to finish opening the pericardial sac.

“Dr. Marx, let me see you finish opening the pericardial sac,” I say. Dr. Marx looks at me; I can see a mixture of excitement and fear twinkle in his eyes, causing him to freeze for an instant.

“Dr. Marx, we don’t have all day,” I add.

“Yes, Dr. Carmen,” Dr. Marx utters. I can see his hands are shaking.

“Nice and easy, take your time.” Dr. Marx continues the cuts, hands still shaking, but making the appropriate incisions. I take a quick glance at the hanging clock. Perception of time is completely distorted during a surgery. Suddenly, I hear the slow, calm beeping of the vital monitoring screen accelerate, one of the most dreaded sounds a surgeon can hear. Her heart rate becomes fast and irregular. 

“What the hell did you do?” I exclaim, staring directly at Marx

“I accidentally damaged the SA node. I don’t know what happened, I-”

“Oh, shut up! I don’t need your fucking life story,” I yell anxiously. And then, another sound surgeons dread: the sustained, one long beep.

“Someone call a code blue!” I shout, grabbing the defibrillator. “Get out of the fucking way Marx, you’ve done enough today.” Come on, come on, fight, fight, fight. 

Death

Let’s see, who do we have here, looking over my checklist. Mrs. Quinn Z. Former tennis player. Valve infection. Leaky valve. Vein rupture during surgery. Ah, she’s one of those who really tries to avoid me. It’s your time Quinn, and I am here. I-

Surgeon

The staccato beeping comes back on. The patient’s heart rate returns to normal. What a relief.  I let one of the other residents finish opening the pericardial sac. The heart is now exposed. I can never get enough of the beauty that resides within that muscle. At this time of the surgery, the patient is usually placed on cardiopulmonary bypass to stop the heart during the valve replacement. I make a small incision to gain access to the leaky valve and stare at it. The mitral valve is located in between the left atrium and left ventricle. When oxygen-rich blood collects in the left atrium, the mitral valve opens and allows some of the blood to flow from the left atrium into the left ventricle, which then contracts and allows the blood to flow into the aorta. This flow of blood is essential to the function of the circulatory system. However, a leaky mitral valve causes some of the blood to flow backward into the left atrium. This is ultimately what causes the shortness of breath and fatigue. I can see the mitral valve leaflets are failing to meet, the root cause of backflow of blood. 

“Dr. Carmen, the echocardiogram is showing fast irregular heartbeats,” Dan exclaims.

“Unfortunately, the damage to the SA node is too severe,” I reply, taking a closer look at the mess Marx made. “We’ll probably have to place a pacemaker in after taking her off the pulmonary bypass. Ok, we are ready to take out this valve,” I say, turning toward my team. I carefully start removing the damaged mitral valve tissue. When the valves become infected they have the potential to manifest into other sets of problems; in this case, they manifested as a leaky valve. I finish removing all the damaged mitral tissue with a couple of residents.

“I think we can place the mechanical valve in now,” I say. The primary benefit of implementing a mechanical valve instead of a tissue valve is that it gives a greater chance of prolonging the patient’s lifetime. However, mechanical valves can cause blood clots, so the patient will have to take Warfarin for the rest of her life. Still, let’s hope she pulls through this operation in her condition. I start sweating, thinking of how I will walk to the waiting room tonight. Will I walk with pride and confidence or will I be dragging myself there?

It is now time to stitch up the mechanical valve. Under my watchful eye, a resident carefully attaches the new valve into its place; a total of 12 stitches are put in. I test the valve to make sure it works and is fully secured. Thankfully, it’s working just beautifully. I don’t know how long we’ve been operating. Time doesn’t exist when you’re operating. My own heart is pounding as we take Mrs. Z off the pulmonary bypass. The final test: can the heart beat on its own? 

“How are the vital signs?” I ask.

“Stable, but the heart beat is still irregular and elevated,” Dan replies. The heart is still beating, though, on its own. The waves of adrenaline slowly start ceasing. I’m about to give one final check over before placing the pacemaker when the beeping on the electrocardiogram starts to accelerate.

“Damn it!” I exclaim. I see the culprit: an unnoticed blood clot, also due to the damage to the SA node earlier, and on its way to cause cardiac arrest. “Someone hand me the damn defibrillator!” This time, I am not surprised when I hear the dreaded sound of the flat line. I start applying the shock, hoping the electrical impulses jump-start the heart. No luck. Come on, fight, fight, fight. 

“Push to 300!” I order one of the nurses. 

“Doctor, I think the patient is done,” one of the residents calls out. I let go of the defibrillator and move on to administering manual resuscitation.

“Damn it!” I shout, pushing with all my might, holding back the tears behind my eyes. Quinn Z was one of my favorite tennis players. I was not going to let her die under my hands tonight.

“Doc, she’s gone,” Dan says, apologetically. I’m breathing heavily as if I had just finished a race, sweat pouring down my face and seeping through my blood-stained scrubs.

“Time of death 20:27,” I pronounce. 

I head towards the dressing room, disposing of my bloody scrubs and sweaty cap. As I wash my hands, I stare out into the theater. The blood on the floor is being mopped away, the table is being tidied up for the next patient, new surgical instruments are being laid out on the tables. Just like a hotel room. One tourist leaves, and the room is cleaned up for the next one. Watching the cleaning crew, it is hard to believe that just an hour ago there was a fight between life and death. They’re going about their usual day. So why can’t I?

I throw my scrubs and cap into the bio-hazard disposal bin and step out of the dim theater, not prepared – but when am I ever? - to trudge back to the waiting room. 

Death

Quinn Z you are back again. Oh, where are my manners, I should introduce myself to you all. I’m death, the entity that you will be fighting against for the rest of your life, both as life savers and as living beings yourselves, with a ticking life clock. As I was saying before, Quinn is someone who has been avoiding me for years, from her valve infection that nearly killed her, to the cardiac arrest she experienced in the middle of the surgery. I’ve taken away all sorts of people, but there have been too many times when I encountered souls that were completely drained of happiness and strength. Quinn Z was a fighter her whole entire life, and sometimes there is nothing better than winning the match after a setback. But sometimes winning the title doesn’t make for a meaningful match. Everyone is always trying to avoid me, fight me, trying to trip me over the obstacles they throw my way. Even if it means suffering and losing the meaning of life, people still try to resist me. But it’s inevitable, the life and death match is rigged by God, the universe, or whatever you believe in so that I always win the competition in the end. Still, it doesn’t mean I want to pick up humans in the state that they are often in: suffering. If people can acknowledge me, they can add life to their years because sometimes the match isn’t the most important, it’s the quality of the points you play.  

Summary 

The main illness explored in this paper is valve regurgitation, which is the backflow of blood in the backward direction due to improper functioning of one of the valves (“leaky” valve). Valves open and close to allow blood to flow through the four chambers of the heart and if they don’t open and close properly, blood is not pumped efficiently, which results in weakness, fatigue, and shortness of breath. The patient in this story has a leaky mitral valve, located in between the left atrium and left ventricle (see figure 1).The mitral valve opens to allow the blood to flow into the left ventricle from the left atrium, which then flows into the aorta and back out to the rest of the body. If the mitral valve is leaky, some of the blood will flow back into the left atrium.

A leaky valve can result from a valve infection. The patient in this story develops a valve infection when she does not treat her Streptococcal infection (infection of the throat). The valve infection, in turn, manifests into a leaky mitral valve. Given the earlier complication, the surgery to replace the mitral valve becomes even riskier for the patient. Additionally, open-heart surgeries and the placement of a mechanical valve make it even more likely that a blood clot can occur during the surgery and has a chance to cause cardiac arrest. The risks for continuing the surgery become even greater when the sinoatrial (SA) node is damaged. The SA node is responsible for sending out electrical impulses from the atrium, causing it to contract and pump blood into the bottom chamber. The SA node is crucial in maintaining the normal heart rate and can be replaced with an artificial pacemaker that takes on its role. A damaged SA node can also cause the formation of blood clots. Given all these factors, it makes sense the patient develops a blood clot during the surgery and goes into cardiac arrest, ultimately dying.

The story types included in this paper include a (in order) narration (inspired by The Plague), patient account (inspired by When Breath Becomes Air and Surgical Ward), physician account (inspired by Do No Harm), and personification of death. The different story types highlight a certain theme related to the nature of disease. For example, it is evident that Quinn Z feels separated from the rest of the world and perfectly illustrates the isolated patient: distinct from those who are healthy. However, she is also a fighter and refuses to make meaning in the face of mortality as a sick person when she opts to have a risky surgery. Likewise, Dr. Carmen’s relentless attitude during the critical moments during the surgery is another example of the constant avoidance of death society tends to have. Furthermore, it is evident that Dr. Carmen struggles to balance emotions and detachment in her waiting room scenes. Lastly, Death addresses the issue of making meaning in the face of mortality, rather than struggling against its coming. 

I thought about the job of a health professional and their role in the face of issues surrounding life, death and meaning. Perhaps a risky surgery shouldn’t always be the only option? Doctors should be more than just scientifically-driven professionals; they should be advisers to patients, giving patients advice on how to add life to their years. If the patient continued leading a healthy lifestyle, the quality of her life would have increased. Her set back wasn’t the leaky valve; it was the threat to her old life, forcing her to make some changes. She had the potential of changing her attitude, making a comeback, and winning the match.