One Final Goodbye

“Can we run through the risks of the surgery again, doctor?” she inquired, not understanding the medical terms the surgeon was spouting off rapidly. Something about the fracture of a femoral head, the need to replace her entire hip in a total arthroplasty, words of those sorts. She was finding it rather hard to follow, and the speed of his speech was doing nothing to help.

”You’ve broken your hip. We can reconstruct it for you, but that will mean replacing the entire joint, and putting a new ball in your hip. It’s a pretty routine surgery, it's one of the most common surgeries I do.” The orthopedic surgeon started explaining. “Pre-surgical testing looks good: clear chest x-ray, normal EKG, labs look fantastic. But with that being said, there are always risks with surgery. The risk of infection is present anytime we break the skin barrier, as well as the risk of bleeding. Typical risks of any surgery.”

She took a second to think it over before signing the informed consent papers, her family nearby, rubbing her shoulder in an act of sympathy and comfort. She had never had any major health crisis: no allergies, no chronic illness, and no accidents. She was a woman, seventy-three years old, and had managed to skate through with no incident. Just the day before, she had her first. A slip on acorns from a yard, a massive accident brought on from being late tending to the yardwork. She knew what had happened the second her hip hit the ground.

Her husband brought her to the emergency room, where they broke the news, leading her to now. They wheeled her into the holding room, got her changed into a hospital-issue gown and a bonnet to keep the surgery suites sterile. Things were moving fast in the operating room. The nurse anesthetist put an oxygen mask over her mouth and nose briefly before injecting the sedative into her IV. She witnessed her consciousness fade, before falling into a deep, propofol induced sleep.

The surgery room was filling up with all the essential staff: the X-Ray Technologist with the C Arm for real time fluoroscopy, the Registered Nurse that controls the madness with frightening accuracy, the two Surgical Scrub Technologists that know the instruments and the surgeons’ brain like the back of their hand, the Physician Assistant that can somehow predict each move of the doctor, and finally the Surgeon, the ringleader of the operation, clad in his lead vest and surgical headlight. Everyone gets into their places after the doctor gowns up, and after the first count, the surgeon begins with one word, ”Opening.”

Surgery is going well and underway, the controlled chaos of the room going according to preset protocols. The surgeon is forty-three minutes into the procedure, sawing and pulling the ball out of the joint all while a pop-punk playlist shuffles on in the background. The nurse anesthetist keeps a careful watch on the patients vitals while the x-ray tech snaps another picture of the joint. The registered nurse charts equipment and materials that have been used in the surgery so far, her stack of sterile material wrappers slowly dwindling. A soft thud barely makes it through the music as one of the scrub techs grab the bone saw, cleans the blade of tissue, and places it onto the back sterile table, possibly for later. Weekend to-do chatter slowly starts filling the surgery suite, the doctor causually commenting about how he was able to score some tickets to a sporting event, the PA retorting that he must have been queued up in line before him. The nurse anethetist fiddles with the pulse oximeter on the sedated patient while the doctor inserts the reamer, ready to widen the socket.

The monitors by the anesthetist start beeping, indicating a drop in oxygenation and blood pressure in the patient. He pulls out a vial of a vasoconstrictor and draws up the medication in a syringe. Capping the needle and twisting it off, he twists the syringe onto the IV catheter cap and slowly depresses the plunger, silently praying the medication takes effect while watching the monitor for signs of improvement—they do not.

Minute 45: The patient’s heart rate starts dropping rapidly, faster than the anesthetist can react. Instead of reaching for a new medication, he shrieked for the nurse to page the anesthesiologist over the private, room to room intercom system.

Minute 45: Chaos ensues in a show of calculated, controlled protocol and muscle memory jolts through every medical care provider in the operation room, desperate to start this woman’s heart again, all while Coldplay’s “Yellow” plays in the background. In the anesthesiologist rushes, with two nurses hot on his heels with a crash cart as the patients heart hits a flatline. All at once, the surgeon takes the reamer out of the hip socket while the anethetist is already dropping the bed, preparing for resuscitation attempts. The x-ray tech lurches the c-arm backwards, and rushes it up against the back wall, out of the way so more personnel may come in as needed.

Minute 46: In the blink of an eye, the doctor rips off the sterile drapes and starts CPR while the crowd of nurses start drawing up doses of epinephrine and sodium bicarbonate to try to prompt her heart to start beating again on its own. Two minutes pass, and one of the nurses rotates with the tired physician to continue the possibly life-saving chest compressions. During the trade-off, a second nurse applies the defibrillator pads in the event of a shockable heart rhythm.

Minute 49: The defibrillator pads detect a shockable rhythm. All of the staff actively working on the patient step back when the machine prompts them to, then one hundred and fourth joules are set off. Everybody looks at the monitor with anticipation. A small, slow, thready pulse quivers. CPR ceases and injections stop, but monitoring and protocol do not. The nurses are already setting up to get another point of intravenous access for laboratory before the doctor can order it. The anesthetist set up an arterial line to collect a blood sample to check her oxygenation. A scrub tech “scrubs out” and dons another set of sterile gloves to set up for central access. The x-ray tech is scrambling for another mayo stand to try to keep everything organized and tidy. A respiratory therapist has wormed her way into the crowded scene, waiting patiently for an opportunity to snag a blood sample.

Minute 53: Cardiac arrest grips the patient again. CPR resumes in an attempt to receive any form of a rhythm in her heart. The laboratory tests have been sent off with an urgent, “stat” message, awaiting the valuable results they bring. A prior established “compressions, pulse check, switch” pattern has started again, this time with an increased duration. The doctor and the nurses flick their gaze at the heart monitor every so often, hoping the generated heartbeat from the chest compressions may sustain itself, but no such pattern arises.

Minute 67: No sign of life other than the rhythmic, mechanical ventilator breathing for her is noted by the physician. He performs his final exam on his patient, then calls the time of death. The patient who was getting a surgery he had executed near perfect a couple hundred times. The operating room falls silent for a short time: some people praying, some people stoic, some newly graduated healthcare personnel staring in shock. The nurse takes a fleeting second to steady her voice as tight as she can muster before calling the inpatient room she was going to be sent back to.

The call landed on the patient’s daughter like a landslide of mud and bricks. The brother took the phone from her and upon hearing the news, smashed a flower vase that had been waiting on her return from her procedure. Her sister didn’t even need to hear it from the landline phone—she knew her sister was gone. A dark cloud of grief settled upon the room, silence broken up periodically by strangled sobs and the sound of sniffling. Just over an hour ago, the family was together, smiling and joking around before the patient went back for surgery. No one knew that would be the final conscious moment of her life, but it was filled with love and life. Now, the room is quiet, with husks of family members grappling with memories and a somberness that does not pass the threshold of the door. Right outside, nurses pass out medication to smiling residents, their families unaware of the privilege they have being able to laugh and joke, and to cry but still hold their loved ones while they are still living. Right outside the room, patients are being discharged from the facility, striding free back home to pets, children, and relatives. The cloud inside the walls does not lift.

Little does the family know, even though she has departed their world, she has joined another. I see her in front of me, walking toward me, full of grace and uncertainty. Her hip restored, the signs of age and stress removed from her skin. The realization slowly materializes in her eyes. She knows exactly where she is and what has happened.

She speaks carefully, almost like she is checking to see if she still has a voice. “Is there any way I can speak to them one last time? I want to tell them something I didn’t say before I went under the knife.”

I nod. “You have one opportunity to speak directly to them from this point forward. Do you wish to speak now?”

“I do.”

She opens her mouth and she speaks one word with a slight, reverberant echo. A single word, encased with somberness but a core of love.

All of her close family members look at each other, tears in their eyes, making sure they all heard the voice in their heads. Her children look astonished, the sister is at peace.

“Goodbye.”