POST MORTEM | Elizabeth Warner
Though her body had already accrued wear and scars beyond her years due to autoimmune disease, the woman who appeared before me in the evening on the transplant floor was younger than I was. I was thirty-one, a new mother and a fourth-year resident on the transplant service. She was not healthy — people on the transplant list are not in their best health — but she had a relatively normal, independent life outside of the hospital. Friends and parents who loved her.
She had been summoned to the hospital when the team received word of a donor match. Somewhere in the region, a person well enough to leave behind healthy organs had suddenly died. Their blood type had been checked, and their organs screened for various antigens, biological markers that determine how likely the organ is to be accepted by a different body. The woman had been put through a last-minute battery of tests to ensure she was well enough to undergo the transplant, free of any smoldering infection that could ignite like a forest fire once immunosuppressive drugs were begun, and confirming this kidney was a suitable match. The organ was harvested late that night and brought back to our hospital where it would be nestled into her pelvis and sewn to her artery, vein and ureter. With luck, it would return to its prior function, cleaning her blood and producing glorious, clear yellow urine in abundance, releasing her from reliance on dialysis.
Kidney transplants are done thousands of times a year all over the country. With the protocols that have been developed to ensure safety, they are not considered an unusually risky undertaking.
Late that night, the intern and I rolled her down to the operating room. We covered her in thin, scratchy blankets from the warmer, and their yeast-and-bleach smell wafted up in the temporarily warm air. “Ooh! Thank you,” she murmured as she blinked up at the bright ceiling lights.
Sometimes, particularly in the middle of the night, when hours of being awake left my body temperature dysregulated, I would unfold one of these threadbare blankets and wrap it around my shoulders for a few minutes before returning to my lab coat, stuffed with alcohol swabs and pens and patient lists. The warmth was a bit of reprieve during nights of rounding, writing orders and answering the ever-beeping pager.
The anesthesiologist moved busily in concert with the charge nurse, discreetly lifting the patient’s gown to apply sticky pads for the EKG leads, removing one IV bag and replacing it with another. Once Dr. Johnson, the head of transplant surgery, entered the room with a red and white Igloo cooler containing the new kidney, it was time to begin.
A few years later, when I was the attending surgeon and my own patients were being put under anesthesia, I would hold their hands and reassure them as they went to sleep, but as a resident, I did not. There were other details needing my attention. I supervised the intern placing the urinary catheter, heaving our patient’s legs into a splayed butterfly and watching for any break in sterile technique as the intern swiped her urethra with cold antiseptic cleaner and slid the catheter into place. Her belly was widely prepped — scrubbed in concentric circles, spiraling outward — with betadine, three times, leaving a metallic smell and a deep mustard stain on the skin and on the gloves of the one prepping. As we stepped out to the scrub sink to lather and scrub our fingers, hands and arms to the elbow, the anesthesiologist placed a central line in the jugular vein in her neck and an arterial line in her wrist.
The surgery itself was uneventful. The kidney began making urine, each drop golden and precious, when the vascular anastomoses were completed. Though she had signs of volume overload, she was extubated in the operating room. The promise of more urine made the team hopeful her new kidney would wake up and take over its job in its new body, ridding her of all the excess fluid circulating in her system.
Fatigue makes one perform executive functions as if drunk. Balance is thrown off, judgment suffers, reflexes become sluggish. I once watched an attending sit in a lounge chair on the ward to write a progress note and fall asleep with her pen mid-sentence. The ability to modulate temperature also suffers. After a night in the OR or tending to a sick patient, we would round with fleece jackets under our white coats, trembling, our noses cold at the tips. We joked about gut rot — cramps and diarrhea that come with a sleepless night. Still, we rounded and wrote progress notes, ordered CT scans and checked drug levels so that immunosuppressants could be adjusted, recorded bilirubin and creatinine levels and manipulated foley tubes in an effort to coax out any urine that might be sluggish to appear.
It was late morning when the ICU nurse paged about our patient. Her central venous pressure was still very high, and she was feeling short of breath. Her blood oxygen level was at a safe level on moderate support, but she wasn’t making much urine — twenty milliliters one hour, twenty-five the next. Some, but not enough to quickly rid herself of all of the IV fluid she’d been given during surgery. The transplant fellow, Jamal, and I spoke with Dr. Johnson, who said, “Start her on a Lasix drip.”
We went to the unit to see her for ourselves, and, good news — her urine output had come up a bit over the last hour, to fifty milliliters. This was progress. More urine was visible in the foley tube. Jamal said, “I don’t think she needs the Lasix drip after all. What do you think?”
That sounded reasonable to me. “I guess,” I said. “Seems like the kidney is starting work.” We told the nurse things seemed to be looking better, and to tell us if things changed for the worse.
An hour later, the nurse paged again. She told me in a harried tone our patient was requiring more oxygen, breathing with great difficulty, and gasping that she could not breathe. “She says she thinks she’s going to die,” the nurse said. I ran to the ICU, because when patients sense they are dying, they are often right.
I entered a scene of action bordering on chaos. Bedside monitors were chiming and beeping, flashing ominous red numbers. One nurse administered Lasix through an IV while another raised the head of the bed to take pressure off the patient’s lungs. The respiratory therapist strapped a nonrebreather mask to her face to administer high-flow oxygen. The patient, writhing in her bed and clawing at the mask, was grunting, crying, voice thick and wet, coughing a fine pink spray. She gasped, “I can’t breathe. I can’t breathe.”
A code blue was called, bringing more staff to the bedside. The already warm and noisy room became hot with bodies and tense with voices speaking over one another. As I struggled to intubate her while another resident suctioned froth from the back of her throat, it was clear to me it was too late, that all of the delays and poor decisions would add up to be more than her body could bear, and I knew with a sickening certainty it was partially my fault.
Her heart collapsed into a useless, fluttering rhythm. She lost her pulse. A resident did chest compressions. There were rhythmic sounds of cracking as our patient’s ribs were broken. Drugs were pushed through her IV in an effort to restore her blood pressure, to force the blood to flow and command her heart to get back to work. Paddles were used to shock her heart back into rhythm as we all stood clear of the bed, our collective breath held. Her heart rhythm returned, her heart pumped, but only with the addition of medications to keep it cooperating. We forced air into her lungs through the endotracheal tube, and some oxygen pushed its way through the fluid in her alveoli to her bloodstream, but not enough. It would not be enough to support her brain, her organs, her new kidney. She was dangerously overloaded with IV fluid. She was drowning in her own blood.
I went out to speak with Dr. Johnson, who looked into my eyes and said, quietly, “When I say to start a Lasix drip, you start a Lasix drip.” He did not raise his voice; he did not tell me where I had gone wrong. He didn’t need to.
“Her family is in the waiting room,” a nurse said. “Can you go talk to them?”
I found the family and the chaplain in a tired-looking conference room with molded plastic chairs around prefabricated tables under mismatched fluorescent tube lights. I sat down and told them what had happened: the kidney had not worked as quickly or as well as we had hoped; the excess fluid in her circulation had stressed her heart and lungs, which had stopped, and we had restarted them with a breathing tube and ventilator and multiple medications. I told them she was gravely ill, that we were making sure she was not in pain and we would do everything we could to bring her through this terrible turn of events, but her condition was very serious.
Her parents nodded their heads, their shoulders slumped forward, their foreheads creased and brows peaked, like the disciples in Renaissance portraits of Christ’s passion. Their voices were low, soft and hoarse, as they thanked me for my dedication to their daughter, for my team’s work and expertise. I held their hands, sick with guilt.
I thought of my infant son at home, who I had not seen since leaving for work the previous day, for whom I pumped breast milk whenever I could find ten minutes to spare and had enough calm for my milk to let down. I thought of my raw love for him — wordless, savage, beyond explanation or my control — and I knew this was the same love they had for their daughter, a love that is vast and helpless and, like placenta accreta or a cancer, winds its way into your own body until separating it is an act that hastens your own death. I knew what our carelessness and exhaustion and hubris had wrought. We had functioned not as a team, but as a disjointed and bone-tired bunch of amateurs. Well-meaning but fumbling, with the worst possible consequence now inevitable.
After I had completed rounding on the rest of the patients that evening, I stopped back at my patient’s bedside. She was bloated beyond recognition with edema, lips and teeth parted around the ET tube forcing air into her heavy, wet lungs, limbs splayed dumbly into a five-point star, mottled purple skin at the apices of her ashy knees. The chaplain approached me: would I be willing to pray over her, with her parents? I paused. I hadn’t seen my baby in nearly 36 hours. My breasts ached. My body ached. I would be back here again in twelve hours. “I’m not sure I have time to pray right now,” I said, the words dropping out of my mouth like turds, like rot. The chaplain paused. “Alright,” she said. I fled for home. My patient died that evening.
My preparation for M&M — morbidity and mortality conference — was meticulous. I knew every detail of what had led to her death. The early, risky extubation before her kidney had proven itself. Ignoring the order to start a Lasix drip when her kidney seemed to be perking up. Failure to act, again and again, by all of us, had killed this young woman. I stood at the lectern and described her hospital course while my colleagues ate bagels and drank coffee. At the end of my recitation, Dr. Johnson asked, “What ultimately caused her death?”
“Inertia,” I said. “There were so many warning signs along the way, and we failed to recognize them or to act on them.” I enumerated them. The department of surgery was satisfied. I had demonstrated understanding of the physiology, an accurate analysis of the systems-level errors, and contrition for my role in this disaster.
What we never discussed as a group, what we grappled with and choked on in our own private spheres, was what it did to us. A seed of fear had been planted in me at the beginning of residency — that I was unworthy, unable, lacking in skill, nerve, and stamina — and those feelings took root and poisoned me, because I buried them so deep under layers of shame. If only I’d found a way to name those fears aloud, to expose them and get some help rooting them out. But for a surgeon, there is nothing more shameful or foreign than fear. Real surgeons do not worry, do not let failure crack the veneer of bravery. We admitted missteps, but we absolutely did not discuss the emotional fallout of those missteps.
So I started to confuse transparency about outcomes with true honesty. I could stand at a lectern and say miscommunication and subsequent medical mismanagement of a young kidney recipient led to her death. But there was no place to talk about how I felt when I spoke with her mother about her grave prognosis and her mother asked me to pray with her. There was no way to ask my team members or my attending how they were dealing with the fact that we had collectively hastened that young woman’s death, that we were responsible for that mother losing her daughter. What if we had sat down together and offered a modicum of tenderness to each other? What if we had shown each other some grace, some mercy for each other and ourselves in the face of our terrible mistakes? If we had discussed our shared loss, what it did to us as people, would I be a different person now? Would they? Would we all have trusted each other more, and would subsequent patients be safer? Would it have saved lives — theirs, ours?
I wish I had gone back to pray with that family over their daughter. I wish I had looked Dr. Johnson, Jamal and the rest of the team in their eyes, and asked for a few minutes to sit together, as a group — as the team we called ourselves — so that we might acknowledge not only our errors in judgment and failure to act, but our private and shared loss, and shame at what our mistakes had wrought. At that time, I had neither the words nor the courage to speak about my grief aloud. I wish I had. I wish I had cried with them, instead of alone in my car on the ride home to my son.
Elizabeth Warner is a mother, wife and Vermonter of almost two decades. Until a year ago, Warner was the chief medical officer at a regional health plan. Before that, she was a general surgeon. An avid writer during her youth, she returned to writing in 2021 after many fallow years. Her first essay was about a patient who died during her residency training. More stories from her training followed. Warner’s goal is to complete a book-length memoir about general surgery residency. She is often asked, “Why did you leave your job as a surgeon?” and would love to have an answer to that question that rings true. She hopes that writing down the stories will bring her closer to the answer.