Practicing Art on Medicine's Front Lines: Tales From the OR and the Bedside

Science takes doctors only so far. Then treatment becomes a judgment call.

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Photo Gallery: One Cancer Patient's Journey

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About 45 minutes after speaking with Rhonda, Hanna realized the kidney had to go; the tumor was attached to the kidney wall. Even so, it wasn't an easy call. "If Bart's cancer comes back anyway in three months, his quality of life might be impaired more from taking the kidney out," Hanna admitted later. "But I think this will give him the best chance he has at survival."

Before starting chemo, Hanna called a colleague and asked him to research what dose of the drug, which normally is cleared by the kidneys and thus could be toxic for Simmons, could be safely administered to a patient in renal failure. Hanna calculated that he should lower the dose by one quarter and administer the drugs for one hour instead of 90 minutes—and monitor Simmons carefully in the days following surgery.

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While unclear and painful decisions occur in all areas of medicine, the choice to end a new life is among the most agonizing. These discussions commonly occur when fetuses are diagnosed with genetic problems or severe organ abnormalities, but they also happen in about 30 percent of identical-twin pregnancies, when a blood-flow problem endangers the placenta-sharing twins. All too often, couples must decide whether to terminate one twin to improve the survival odds of the other. "Sometimes one baby has so little flow that it can't make it," explains Ahmet Baschat, a fetal medicine specialist at UMMC. "If that baby dies, the surviving baby can be hurt as well, since they share the same connections for oxygen and nutrients." In many pregnancies that he monitors, the blood flow improves, and the babies are fine. In some, though, things quickly change, and one or both babies are born severely prematurely or die in the womb.

Vera Mednikova, 32, of Vienna, Va., consulted Baschat last fall after being told she might need to terminate her pregnancy (her first) or abort the twin that was abnormally small. She and her husband decided to keep both babies after Baschat said that they could be monitored via weekly ultrasounds; termination of the smaller fetus would be an option up until the 21st week. After that, "we knew if something happened we could lose both babies," Mednikova recalls. The couple's twin girls were born six weeks early in May, and both are doing fine.

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A month after being released from the hospital, Simmons, back at his home in Florida, was upbeat but introspective, hopeful about returning to work part time in a few weeks and doubtful that he'd try any more cancer treatments. "This is the third time I've had to rebuild my life," he says. "There's only so many times you can punch me before I say that's it, I'm not going in the ring again."

The experience of Thomas Scalea, head of UMMC's shock trauma center, illustrates why doctors hate to be the ones to call anyone down for the count. In his work with young people whose severe head injuries have left them comatose, though not brain dead, he knows that even the best imaging scan can't tell him if they'll wake up or how much of their old selves will remain. "A few years ago, I saw a man in his 30s who had nearly drowned after being struck in the head," he recalls. Through heroic efforts, he'd managed to save the man, who had suffered "the worst brain injury I'd ever seen in a living person." After weeks of heart-wrenching conversations with the family, Scalea advised them to withdraw treatment, since he'd seen so many loved ones bankrupt themselves with years of futile efforts. The family decided to hold off. Six months later, the man, fully recovered, walked into Scalea's office and thanked him for saving his life.