Margaret Wacker, MD

War and medicine have always been linked, beginning with healthcare providers who could offer little more than solace to the injured and continuing to the modern day military hospital where physicians have access to specialty ORs.

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As a surgeon, perhaps I see more of the linkage, since surgery is so necessary to care for the injured and many surgical inventions come about due to necessity in time of war: Army/Navy retractors, Russian forceps, Jackson-Pratt drains, to name just a few.

Similarly, there have been medical advances, such as BAL, British anti-Lewisite, a heavy metal chelating agent, developed in reaction to the threat of arsenic-based chemical warfare agents during World War II. That war also showed many physicians the benefits of penicillin, since it was used on a large scale for the first time.

But as much as war has helped with the development of medicine, especially surgery, medicine has struggled to cope with the devastation of war. And physicians have at times been involved in development of "better ways to kill." Now, we have weapons that cause injuries that the best medical care cannot treat.

I must make a disclosure: I have never been in a war. The closest I have come was working in inner-city hospitals while drug cartels were fighting for "turf." But, I could return home to the safety of a middle-class community where shootings were rare.

Even so, I saw the toll such violence took on young lives. This has caused me to become involved with Physicians for Social Responsibility and EMERGENCY to try to help prevent war and care for the civilian victims of war.

The shooting down of the Malaysian Airlines jet in Ukraine shows of another way war has affected medicine. It's been reported that about 

The researchers likely thought that they were heading to a convention in a peaceful part of the world, Australia. The researchers likely had taken many flights before, and so were not worried about the risks of flying.

At 30,000 feet, they didn't think about what they were flying over. Just as many pilots in bombers have not seen the destruction they wreak below.

It may have been a case of mistaken identity. Even so, the shooting down of the Malaysian Airlines jet over Ukraine may have an effect on the health of the world's citizens for years to come.

This war has not produced new devices, invented out of necessity. It has, instead, destroyed some of the minds that might have thought up new treatments for AIDS.

As physicians, we must remain aware of the linkages between war and medicine. As ethical people, we must be sure that in the interaction, we do what we can to help all people. We cannot simply see it as not affecting us.

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The shooting down of the Malaysian Airlines jet over Ukraine may have an effect on the health of the world's citizens for years to come.

When War and Medicine Combine: A Physician Reflects

I can recall several patients who suffered because no one thought of the diagnosis. And so they were treated for the wrong diagnosis.

The first time I remember seeing this was in medical school. A patient described the onset of Jacksonian march seizures, sometimes losing consciousness due to secondary generalization. It was one of the clearest descriptions of Jacksonian march seizures I have ever heard from a patient.

But this patient had for years been labeled a schizophrenic because doctors and therapists only listened to the first part of her description of her “crazy spells.” These episodes had made her afraid to go out, since she never knew when they would occur. And her manner of speaking came across as odd, to say the least, to her middle class, West Coast providers. She reminded me of people I had met on a bus in Appalachia as a child. She had never completed grade school and spoke an unusual patois.

Despite undergoing years of incorrect and inappropriate treatment, this patient was more fortunate than another patient I can never forget. She was an 18-year-old honors student at a local college. Suddenly, she began to act strangely, and the police were called. Because her behavior was strange, she was taken to the local mental hospital and started on anti-psychotics. The nurses noted some high fevers and called the psychiatrist on call, who thought it was a drug reaction and treated the patient for that. But the patient didn’t get better. In fact, she died.

I met her on an autopsy slab. A beautiful young girl, whose life was cut short. When we opened her head, it was obvious. A thick coating of grayish yellow pus covered every surface of her brain. And, when we did the microscopic study, the pus was encasing perforating vessels, and there were numerous microinfarcts, throughout the brain and brainstem. She had died of meningitis.

A third patient had been a bank manager, when she started acting strangely. Her behavior became so extreme that she lost her job, and then her husband divorced her and her grown children became estranged. She deteriorated to the point that she was homeless. Finally she, too, was brought to a psych hospital. She too, was diagnosed as schizophrenic, even though the onset was in her 40s. But, on her second or third hospitalization, someone ordered a CT, and then an MRI and found a meningioma. I operated on it. The patient gradually improved. She got a job, though not at the level she was used to. She tried to make amends with her family. They had a hard time, because they remembered all she had put them through.

With my own illness, I first thought it was gallbladder, appropriate for my age and gender. But it wasn’t. Then, I had to go to the hospital due to the pain of a ruptured viscus. It seemed to be appendicitis, but wasn’t quite that simple. Finally, I was on my way to the necessary treatment four months after my first hospital visit, but nearly eight months after my first symptoms. Would it have made a difference? Will it make a difference? I don’t know, but hope for the best.

Another mistaken diagnosis that I personally experienced occurred during my stay in the recovery room. Despite having an epidural placed, I was in severe pain. I asked the nurse for more for pain. She told me that I shouldn’t be having any pain since I had an epidural. I suggested that she ask the doctors for more medication. After all, I’d just had a major surgery. I suggested some medications that I would give patients in similar situations.

Finally the doctor came over, a resident who had rotated through the hospital where I worked. The nurse told him that I had been asking for pain medication since I woke up, and even asking for drugs by name. He responded that, of course, I knew what drugs to use since I was an attending surgeon at a neighboring hospital. The nurse, who clearly had not read my record, turned 50 shades of red. It was clear that she had been convinced that I was a drug abuser.

Every patient encounter carries with it the possibility of error. And every error can cause problems for the patient. So what do we do as physicians?

We must remember our duty to do the best for the patient. And that means we must try to be our best. We must try to be informed, not just in a narrow part of our own specialty, but in neighboring ones. And, we must look harder when things don’t fit. We can’t try to force the patient to fit in the box of our preferred, or most common, or most lucrative diagnosis. If the patient doesn’t fit, there’s probably a reason.

Every patient encounter carries with it the possibility of error. And every error can cause problems for the patient. So what do we do as physicians?

A Physician's Recommendations for Avoiding Misdiagnosing Patients 

Even though I have had health insurance continuously since finishing physician training, I found the costs of my illness significant. So significant, in fact, that the costs of care canceled my income for working nearly half a year.

No wonder so many people have gone bankrupt due to healthcare expenditures.

Fortunately for me, my savings and those left to me by my parents allowed me to weather the costs fairly well. Yet, it has been a continual worry. Will I outlive my savings? Will I be able to afford education for my children?

These concerns have lingered since a return to the operating room still looks far off due to complications of chemotherapy.

Now, I am staged as no evidence of disease. A cause for celebration. But, my life is still disrupted by the fact that I have a neuropathy. My hands and feet are numb and tingling. I am sometimes unsteady when I walk. Fine motor skills are still more difficult. Will this get better or not? Will I need to find a new career?

I am too young to retire. And I still have two school-aged children. How much retraining should I consider? No one can answer these questions. I am simply told to "wait and see."

But, I must live while waiting. And if I am away from surgery for too long, hospitals will worry that I have lost my skills. Returning to the profession I have practiced for over 20 years will require retraining. And, then there is the issue of endurance. Neurosurgery, and most surgical specialties, are physically demanding. I know my endurance is not normal. I have heard from other patients that it may be decreased for years.

So, is it even reasonable to consider a return to full-time practice?

It is hard to struggle with these questions. And, yet I know that I have been fortunate to have the resources to have continued without major disruption for my children. Yet, they, too, worry about the future. They wonder what will become of them if I die. I have tried to reassure them that this has been taken care of. And, that I plan to live to see them grown and on their own.

Many cancer patients don't have the resources that I was fortunate to have. For many, it becomes a struggle to make ends meet. Fortunately, now there is a cap on medical expenses for nearly all Americans. But, that is only half the story. Expenses like rent, food and utilities continue. And without an understanding employer, a job may be lost, or pay cut, pushing families even closer to the edge. And, sometimes, this can make it difficult for a patient to continue with treatment.

Years ago, I had a patient, a child whose parents were unable to provide the care he needed. So he was bounced from relative to relative, missing or delaying his treatments. I remember wishing that I could just take in this child, so I could make sure he made it to his treatments. But, I knew that would become a full-time job.

That is what his relatives had struggled with. All of them were barely getting by financially. They couldn't afford to take the time off work to care for this relative.

So, I saw him dwindle and eventually die. He succumbed to a type of cancer that is often treatable with good success. I do think the lack of a social-support system cost that youngster his life.

Another child, through her treatment, caused her middle-class family to slip from a comfortable existence to needing public assistance. Only a part of this decline was due to direct medical care costs. It was also due to the costs of lost wages from her mother taking a leave of absence and her father cutting his schedule to part time.

Other patients, fearing that they might have cancer delay treatment because of the non-medical costs of treatment, and often shorten their lives.

These costs are one of the reasons cancer outcomes vary by socioeconomic status. The poor may not have the reserves or support system to fall back on to make it through treatment.

Fortunately, so far, I have had the resources. But, I must now plan for the future. I know I must return to work, but know that the work may have to be different. I wish writing could support my family, but know that we are a long way from that.

A long road to recovery leaves one physician concerned about healthcare costs, and wondering whether a return to work full time is realistic. 

After Serious Illness, a Physician Faces Questions about the Future 

The toughest decision I have ever made as a physician involved my own mother (although I was technically still a few months from graduating from medical school).

Although I was young, I knew that whatever I chose would scar me permanently.

I had a couple months off from medical school, so decided to go to Europe to visit my parents. My father was at the time a visiting professor in Belgium.

I flew to visit in January. It was cold and gray. After traveling a bit around Belgium, my mother suggested we go south to get to some warmer weather. My father couldn't afford to take time off at that point, so my mother and I flew to Madrid, planning to spend a couple weeks traveling around Spain. After several days touring central Spain, Mom found a deal for a hotel on the beach near Torremolinos. Though warmer than Belgium, it was not yet beach weather. Nevertheless, there were many places to visit in the area. It was beautiful country.

But, at least where we were staying, the food was very rich. Lots of creamy sauces. My mother partook of all the rich food, saying that she was on vacation, even though she had recently had a CAT scan showing gall stones. She had thought that it wasn't much of a problem, and I was going to be visiting, so she thought that she would wait to have her gallbladder out.

One day, she had right upper quadrant pain. We stayed in the hotel instead of touring. When she didn't improve, we called a doctor, who came and suggested that she be admitted to the local hospital. I thought that maybe some fluids and avoidance of rich foods might quiet down the symptoms until we got back to Belgium. I called my father and asked for his help in arranging a return flight. I couldn't convince him of the seriousness of the situation. I became even more concerned once I saw the hospital and the treatment rendered. She was kept with her IV TKO, and was served soups with a layer of fat floating on the surface. I encouraged her to drink a bit of water, and would increase the IV rate when the nurses would leave, but knew that serving fat to someone with gall bladder problems was not a good idea. I even questioned the doctor. In the evening, my mother encouraged me to go back to the hotel to sleep, which I did, fitfully. The next day was much the same. After a couple days of minimal fluids, I noticed that my mother hadn't urinated for hours. I suggested a catheter be placed. The nurse returned, saying that she had permission, but asked, "Do you know where the catheter goes? Do you really want that in your mother?"

My mother was a nurse, so she understood. I responded that both she and I knew where the catheter went, and it would not even be a problem for me to place it, if the nurse was uncomfortable. Due to language issues, the conversation went through me. As a result, the nurses commented that my mother was "demented." By now, her gray hair was disheveled.

Finally, the catheter was placed, and she had minimal urine. I suggested fluids possibly followed by Lasix to get her kidneys started again. I was very concerned and called my father to see if he could help to get her out of Torremolinos. The insurance company was of no help, since they thought that gall bladder problems could be handled in the regional hospital. Again, I was encouraged to go back to the hotel.

I was awakened at about three in the morning and told to come back to the hospital. My mother had been transferred to the ICU. She had been flooded with fluids, but was not making urine. I suggested more Lasix, but they said that it was a dangerous drug and they would only give 20 mg/day. I tried to explain how to chase electrolytes if that became a problem. Finally my mother's breathing became irregular and gurgly. I looked up at the monitor, she was having some PVCs as well. For a few months before coming to Europe, I'd had dreams of running a code on a relative. I never knew who the person in my dreams was, only knew that we were related. I had interpreted this as telling me that I needed a vacation. I did not imagine that it was a foreshadowing of the future.

I started mouth-to-mouth on my mother, all the while watching the monitor. I yelled at the nurses to get the crash cart. They brought a defibrillator, which wasn't charged and had no crash cart with medications or an intubation set. I continued CPR alone while begging them to bring me the resuscitation medication she needed. Fortunately, there was a Dutch nurse there who helped as much as she could. She said that she had not seen a code run since she had been in Spain. We tried for over an hour. I felt her ribs crack as I gave her chest compressions. I saw the bruising on her chest. I had to keep going. I couldn't bear to lose my mother. My mother, who had been up for a vacation and could walk all day on cobblestone streets to see the sights only days earlier.

Finally, it was clear, that we couldn't get medications in time from the pharmacy. I couldn't get intubation equipment until morning when the anesthesiologists came to open the OR. I finally realized that was still nearly two hours away. I knew it was futile. She still didn't have a pulse on her own. I kissed her, and started to cry. The on-call doctor came and pronounced her dead. He then told me that I had to leave the hospital. I was shown the door and called for a taxi from a pay phone outside. I went back to the hotel and called my father. He flew down later that day. We made arrangements to have a funeral in Chicago where much of her family lived. I didn't know where I would be for residency. He didn't know where he would return after he finished his appointment as a visiting professor.

The two hardest decisions I have ever made were to start the code and to end the code. I made the only decisions that I thought I could live with.

grew up in Colorado and attended graduate and medical school in Washington state. She has spent much of her adult life in California, where she is a neurosurgeon. While she has published medical articles, she has recently begun to write more personal stories and is currently studying creative writing at UCLA. She can be reached at 

This article originally appeared in the March 2012 issue of 

Neurosurgeon Margaret Wacker on being forced to run a code on her own mother.

Author | Margaret Wacker, MD

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