The ethical dilemma of a heart surgeon | Ferdinand R. Waldenberger | TEDxKlagenfurt

good afternoon I'm gonna tell you now a story about a young man young man came to our Hospital thirty years old with some knee problems and he went in the operating room and they planned a kind of a trois copy for him you know you make a small incision in your knee and then you put in this fiber-optic cable in his knee then you look around see what's wrong perhaps fix it let the patient wake up walk home during the operation suddenly things go wrong her heart starts speeding in an irregular fashion then it stops the anesthesiologist has to give major drugs then they start pounding on his chest to get some pressure done like for 30 minutes 45 minutes no big effect then they bring the patient to the x-ray room to see if we can do some diagnostics and they call the heart surgeon excellently I was on call at a time and I went into this x-ray room there was this standardized turmoil of 10 or 12 people some of them pounding on the chest of this young patient and you saw some pressure waves on the screen and you realized this young patient was dying and then you're in this situation which is and that was 28 years then which is a little uncomfortable because at that time we didn't have emergency room we didn't have Grey's Anatomy to tell us what to do in these situations so I'm a cardiac surgeon I need an operating room and need equipment I need a team that was there and in x-ray room no equipment no team there was just one small plate there plate perhaps I bring it like this and some of the nurses had some scissors in her coat like this and what could I do so I took this knife and cut the skin of the patient down to the sternum took the scissors and cut open the sternum spread sternum and there was the heart not doing anything so I started squeezing the heart and pumping and unfortunately you never had the feeling of a heart in your hands the feeling if some something happens and certainly this is the feeling you should experience but you probably never do and the heart certainly and some and the heart suddenly starts contracting again very slowly and more and more vigorous and it comes back and you see the unbelievable hopeful eyes of your team and you see also the pressure wave coming back on the screen this patient went home a week later was a big scar in the front of his chest the small one centimeter scar in his knee and he was wandering a little we told him well in medicine in heart surgery we sometimes have to make decisions within minutes within second not more and this is imminent in heart surgery it's it's always there even if you don't expect it if you don't calculate it we calculate probabilities before every operation we put in risk scores and computers and calculate risk we have these risk calculations on the back of our minds with experience and then after these calculations we go on and follow our plan very rational then sometimes that is gut decisions out of your belly within seconds and you need actually both of these ways of deciding because the ones are calculated the other ones are not and not calculated this are probably bravery what you call bravery or courage and thing which we did in the first in this young man probably would call as brave but think about if it doesn't come to a good end if the patient will die then they will tell you you stupid you're irresponsible so the small line between stupidity and bravery sometimes it's very small and there's this tightrope act between death and life in our professional only know that you have crossed this crossed it when the patient's dead so I was brought up in times between the life at the age of pioneers in heart surgery some of them my famous teachers and my times modern times standardized operating procedures calculated risks very low risk low risk the in the times of these pioneers survival was good luck 50% survival zone in our times survive is normal so bravery does it still have time or is that time for trade bravery I think bravery encourage always connected with some other things like conscience for instance conscience always has to be there and conscience makes us aware alert and it helps you in seeing all these pop ups in the back of our brain and popping up solutions how you could do it the alternative pops up also but it helps you and what you also need is you need values if you decide in such situation without being based on values it's foolishness so connecting bravery with referees well values then you could not think I'm on the right way I think if you think about what you could do and what's the cost the outcome and you do it anyway then its bravery if you don't calculate it and you just do it perhaps for self interest or for fame then it's foolishness so I'm actually an expert in the Artic surgery the artist is big vessel coming out of the heart making here an orange going down to the rest of the body and bringing blood down to the body in the aortic arch three vessels go up to the brain to the arms and to the spinal cord and sometimes we have aneurysms their aneurysms are enlarged arteries sometimes the order which is normally three centimeters big it's like eight nine ten centimeters wide and this aneurysms tend to rupture in the rupture the patient drops dead immediately that's what we want to avoid and then we operate on these patients and the usual procedure like 10 15 20 years ago we put the patient on a heart-lung machine and cooled the patients down to 18 degrees 18 degrees centigrade then we stop the heart we stop the sink relation and that mean we stop the circulation there was no blood running to the body for one hour and then you you can imagine this is kind of a challenge because you kind of have to rush to finish your operation and this is really a challenging operation so some people in the world and I was one of them developed new methods in avoiding this stopping the circulation and one day I performed one of these operations and an older man with a big aneurysm tended to rupture I informed him about this new type procedure informed the family we performed the operation it was success great you think well I almost got fired because because I didn't inform my boss who was out of town I didn't inform the system and there was my mistake that was foolish because I should have known it that I will get in conflict with the system and by not doing so I saved the patient's life but I almost got fired so I think there should be a third way besides bravery and fool it should be a kind of skilled or educated courage I think you should do you should know everything what is possible in in the way you decide in a couraged way so on another occasion I was on my mountain bike not in the operating room in the Alps with some friends and we were already travelling for a few days and was really tough I got some gastrointestinal problems vomiting and all this very unpleasant stuff and we came to the foothills of the Alps and we wanted to go up to a hut thousand meters of altitude higher ten kilometers away on the border between Austria and Italy so my friends were already far away and it started raining and as I'd wanting again and I knew I had to go up there and didn't want to because I was tired and it started snowing and I couldn't go back because on the next day we all would go together to Italy and further on so I decided well if I just go step by step if I have to push my bike all the way up if I take hundred rest at a certain time after few hours it will come up there and so I started I was shivering and it was really miserable but after a while then I came around the corner and I saw the hut in 30 minutes I was up there and hit my shower at my food and after some recuperation time it was great and it was this feeling of success that you did it despite all the obstacles a few weeks later I was operating on a very old man very fragile tissues very challenging operation and it was technically really difficult also aortic arch and then we let the blood flow through the arteries again was a disaster blood everywhere sutures torn out everything fell apart and it was already after 6 or 7 hours operation so then you're in a kind of a miserable situation because you know actually this patient has to die and everything was in vain because if you would go on you would have to redo everything and in an old patient redoing everything doubles the operation time and the risk will go up sky-high so your only intention is just leave go home drink a beer or two or even more anyway it's not possible because it's a patient's life so I sat down and thought about the situation for a few minutes then I recalled the situation at the foothills of this mountain and the thought about the hut up in the mountains and they thought about the feeling which I had when I came up there and on the way up there and then I knew I had to do it again and they can do it even if I make stitch by stitch the whole procedure again and the patient came out of the operation room a life and went home there was a lot of luck and it was not foreseeable but without doing that he would never had the chance not a patient 40 years old now that guy had operated on this patient and the evening I was on duty I was called in patient had a dying heart massive infarction they we made some diagnostics and looked in and we saw that these new valve blocked the arteries which supported the heart with blood so I went back in made some bypass surgery to bring in some new blood but it was too late the infraction was ever really done and there was no more help for his heart so this 40-year old man dying if we would say okay and go out of the operating room you would have been dead but at time I already had quite a lot of experience with the development of artificial hearts and we've developed our own artificial heart but it was relatively new so I had this decision to make either employ this new procedure or let the patient time operate till midnight or later or let the patient died so we implanted this new heart patient went home with his artificial heart and became transplant a few weeks later so it's always a matter of knowledge skills and decision and courage and I think especially in science courage and decision and risk making is always connected with the risk of the patient also because if you compare 1969 the first drop the first trip to the moon and the same year the first heart transplant these guys these three guys went to the moon they took their own risk they went up there and knew exactly what they were doing and they were doing on their own risk the team who made the first heart transplant had no risk they just when they knew if they would succeed they had the fame but the guy which they transplanted had the risk so that's what we always need to know and especially if we know that we get into conflict with the interest of the patient because nowadays we can almost do everything in heart surgery but sometimes the patient wouldn't stand it because it's too older too fragile so if we go for the optimum the state-of-the-art the maximum procedure it doesn't necessarily mean that this is for the benefit of the patient we have to go for the minimal harm for a maximal benefit of the patient and sometimes it takes courage to say okay we just to a minimum or okay we just don't do every anything we let the patient die or we treat the patient in a conservative way to give you an example for them a few few months ago my mother called me and she had had very bad times the last months she was like 80 years old and she on the phone she had terrible voice almost no breasts short of breath in the last months before had several episodes of the shortness of breath and kidney failures and she told me you've saved my life twice during the last three months please do it again and I said okay called the hospital called the ambulance she was brought in the hospital next morning they called me it's getting worse which was expected we have to intubate her put on the respirator but perhaps she's gonna die if we do it and that's a okay do it because otherwise she will suffocate and if she dies on the respirator it's a test which is okay but if you suffocate that's terrible and if you just proceed and go on and give you any medication you can give that's not fair so they put it on the respirator I put in I went into the car and started driving for the next 400 kilometers and after one hour they called me that she has died I think this was the right disposition to stop at a certain point we have to stop and I think we have to be decent over the years if I look back at all my years over the last 20 30 years I would sometimes wonder how aggressive was it the first time because now now I'm capable of doing a lot of things now I'm expert in in some fields and I can do a lot but now I'm much more decent than that no there's also destiny and we sometimes can't beat nature and sometimes we can be destiny and it gives you a feeling of of pride and satisfaction and then very thankful then I can I could have this feeling quite often but then sometimes you have to admit victory of nature but to have to make the right decisions I think we can train things we can acquire skills to make the right decisions not to make foolish decisions or brave decisions I think you can make educated courage decisions and for that you can acquire algorithms to make the right decisions you can make team training you can do mental training sometimes you even have to stay and say okay it's too hard for me now I had so many complications so many loss of lives I have to make a pause and then I go into the woods do some training get some mental strength and then I go back to the operating room do some easy cases and then I get the friend and say okay let's do a tough case again and I think with this approach you get more safe you get a lot of risk out of it and if I ask you a question or how would you do in a situation we have decide between life and death and you know if you have if you would take time to make the decision it would mean death how would you decide I think it's very important to ask for forgiveness or not for permission then you could have success like ahead in this operation where I almost got fired but I had a safety human's life and I think if you could acquire this educated courage for you it will help you in your life and I would invite you to follow this path and I thank you very much for attention you

Channel: TEDx Talks

Views: 103,955

Keywords: TEDxTalks, English, Austria, Health, Ethics, Heart health, Medicine, Surgery

Id: ZScCiXNyD6M

Length: 19min 19sec (1159 seconds)

Published: Tue Oct 27 2015