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Miri

Ein Hod is an artists colony in the north of Israel famous for its bohemian lifestyle and its near total destruction during the Carmel Mountain fire of 2010. Ein Hod fit Miri like a glove. By the ripe old age of 14, she had already lived an eclectic life. Born in New York City, her family moved to India for several years before settling in Israel. Her father was a psychologist who specialized in organizational training and played the harmonica in a jazz band every Tuesday night. Miri’s mother, a native Israeli, was the artist in the family. Her parents were divorced now, but they were both actively involved in Miri’s life. Ein Hod was their home. Miri loved to dance and sing with her classmates.

One day Miri noticed a little blood in her urine. She didn’t think much of it when she told her mother. They went to see her doctor a few days later but the blood had cleared by that time.

“Maybe she is starting to get her period?”

The blood came and went over the next few weeks.   When the doctor finally saw it she sent Miri to the emergency room for some more tests and an ultrasound

“It will be faster this way, I’m sure there is nothing to worry about”

An hour later Miri’s abdomen was covered in cold ultrasound gel while a technician probed every inch of her body between her ribs and pubis.   She stopped when she got to Miri’s left flank and kept it there for 5 minutes moving it back and forth slowly.

“What is it?” Israelis aren’t known for their patience in general, certainly not at a time like this.

“ The radiologist will review it and talk to you.”

30 minutes later Miri’s mom was sitting with the head of the pediatric emergency room.

“There is a large tumor in Miri’s left kidney.”

“I’ve already spoken with the head of the pediatric oncology unit at the children’s hospital. You should go there now so they can start treatment”.

Miri spent the night on the pediatric unit and had a CT scan the next day. It was only after she was admitted to the hospital that she complained of a little shortness of breath and abdominal pain.

The tumor had destroyed most of Miri’s left kidney and was growing through the renal vein into the inferior vena cava, filling it with tumor and clogging it, almost completely. Miri’s tumor extended up the inferior vena cava and through the liver, stopping just below the diaphragm.

In addition, there were 2 large clots in the right and left pulmonary arteries, the blood vessels that bring blood from the heart to the lungs. Now we knew why she was short of breath. Pieces of the tumor in the vena cava had broken off, travelled through the heart and lodged in the pulmonary arteries.

A biopsy the next day confirmed our worst suspicions. She had a rare tumor in her kidney with a particularly poor prognosis. After consultation with the chief of vascular surgery we decided Miri needed an operation as soon as possible. She was started on heparin to thin her blood and prevent her from developing any clots due to the clog in her vena cava.

Our discussion with Miri’s parents was difficult. Two weeks ago Miri had a little blood in her urine, now they were hearing a discussion about a very dangerous operation and a life threatening tumor with a poor prognosis. I am not sure how much they actually heard.   Her parents had been divorced for a number of years and it obviously wasn’t an amicable split. They each spoke to us but didn’t really speak to each other. What they did say to each other was terse and tense. They asked if she should be transferred to another hospital, maybe one in the States.   I generally encourage patients to seek second opinions, it’s good for them and I am always open to other options or suggestions. In this case I discouraged it. The tumor in Miri’s vena cava could break off and clog her lungs anytime. Flying or even traveling by car was, in my opinion, too dangerous.

Two hours before Miri’s operation I visited her to make sure she was okay. She sang me a Passover song she had recently learned; the same song I have heard every year at the Passover Seder. To look at her you would never guess she was sick. She wasn’t thin or pale, she hadn’t lost her hair yet. She had none of the “usual” signs of a cancer patient. She was just a young, energetic 14 year old girl playing with her iPhone. She showed no fear at all until she kissed her mother goodbye and was wheeled into the operating room, alone. Then she started to cry.

About 30 minutes after we opened her abdomen Miri’s blood pressure dropped precipitously and didn’t respond to any of the treatments the anesthesiologist tried. We were pretty sure Miri had just suffered from a pulmonary embolus from another piece of tumor. The vascular surgeon left to consult with a heart surgeon about opening her chest to try and remove the clot. While he was out of the room Miri’s blood pressure was so low we couldn’t measure it. We started CPR while I cut open her sternum with a pair of scissors and started massaging her heart with my hands. A minute later the heart surgeon was in the room putting her on heart lung bypass.   Once on, he opened her pulmonary artery and pulled out a massive piece of tumor.   The surgeon irrigated the arteries and pulled out several more chunks of tumor. All the time Miri was borderline stable requiring large amounts of medicine to help keep her blood pressure up.

Miri’s father stayed in the waiting room all the time Miri was in the OR. We spoke to him several times and let him know how we were progressing.   We explained that Miri was still in quite a bit of danger. He understood but didn’t say much.

Miri’s mother chose to stay by the sea during the operation.

Two hours later we were finally able to come off bypass and close Miris chest. She was now bleeding diffusely. Miri was so sick her body could not produce blood clots anymore and she was oozing from everywhere. When her chest was closed, we placed several lap pads in her abdomen and covered it with a large piece of adhesive sterile plastic.

Miri’s condition continued to deteriorate. Her blood pressure was so low a team of two anesthesiologists had trouble treating it. She was dying and there wasn’t much we could do. We decided it would be best if we could get her up to the pediatric intensive care unit so that her parents could say goodbye before she died. At 2 o’clock in the morning her heart stopped. Her mother and father were at her bedside but they both knew it had been over for some time already.

Surgery is a contact sport. That’s the simple truth. Occasionally, no matter how hard we try, no matter how much we plan, something terrible will happen to one of our patients.   If you are a pediatric surgeon, it means a child might die and a family will be destroyed.   It can happen in the blink of an eye.

I have seen complications like Miri’s devastate surgeons.

During my last months as a pediatric surgery fellow I assisted on a living related kidney transplant. This entails taking a kidney from a healthy family member and transplanting it into another with end stage renal failure. The procedure requires two surgical teams, one to remove the kidney from the donor and another to sew it into the recipient.   In this particular case, a mother was donating one of her kidneys to her 12 year old son. He had been in complete kidney failure for some time, the result of a congenital problem with his urinary system.   I was on the team transplanting the kidney into the young boy.

The surgeon in charge of removing the kidney from the mother was one of the senior attendings at our hospital and is the best surgeon I have ever met. During my training I watched with amazement as he did liver transplants, kidney transplants, complex thoracic procedures, vascular reconstructions and dozens of other complicated and varied operations all on tiny infants. His movements were swift, smooth and effortless. He also had a real commitment to his patients and their families and had an excellent bedside manner. Whenever there was a complicated patient in the hospital, his was the final word. All the other surgeons sought out his advice and expertise. He was the surgeon all the trainees wanted to emulate.  He was my mentor and still, to this day, I call him with questions when I have complicated patients.

The kidney was removed from the mother in one operating room without any difficulty and brought to us in an adjacent room.   It took about two hours to finish transplanting the kidney into the son. The operation went smoothly and the kidney started to produce urine immediately after it was connected.

A few minutes after we were done as we were transporting the boy to the recovery room, I was “stat” paged to the unit where the mother was recovering. She had suddenly become unresponsive and was in cardiac arrest.   She was pale as a sheet and had obviously bled to death.   We rushed her back to the operating room while doing CPR, opened her abdomen and found that it was full of blood and clot.

Harvesting a kidney requires that both the renal artery and vein be divided and tied closed. In this particular case the surgeon chose to close the renal artery with metal hemoclips instead of sewing it with a silk suture. In retrospect it may have been the wrong decision but at the time it seemed fine.

He didn’t close the artery with one clip; he closed it with three. All three came off.  And that, seems to me, is the hand of God.

We suctioned the blood, found the end of the renal artery and sewed it closed all the while doing chest compressions, shocking her with a defibrillator and giving large doses of medicine to try and jump start her heart.

She wasn’t responding.

We were about to pronounce her dead when the anesthesiologist decided to try one last move, shocking her with the defibrillator set to maximum.

She came back, miraculously, but was significantly injured. She required three more operations and lost part of her large intestine. Finally, after more than a month in the intensive care unit and several more in the hospital, she was discharged to a rehab facility, where she spent several more months. Her son was discharged one week after his transplant with a kidney that was working perfectly.

I went to Miri’s shiva. I don’t think I said anything. I couldn’t speak. Miri died a few weeks before Passover and we sang the same song she sang in her room before the operation at our seder. I visited Miri’s mom once again after the shiva. Her younger sister was there. I found it hard to say anything. I am sure I didn’t comfort them much.

I have reviewed Miri’s case in my mind over and over again; what I should have done, what I would do differently next time. The feelings of guilt subside from time to time but I don’t think there is a day that has gone by since her death that I haven’t thought of her.

I may never get over this. I am not sure I can. How do you?

My mentor stopped doing kidney transplants shortly after his complication. A little while later, he transitioned out of clinical surgery and into an administrative role at the hospital.

Decades of experience and now he shares it with virtually no one.

As a person of faith, I am supposed to believe that everything happens for a reason. Somehow I should believe that Miri was supposed to die like this. That this was meant to be. This was Miri’s time.

Maybe. But why did I have to be part of it?

About the Author
Marc Arkovitz is a pediatric surgeon living in Israel and an associate professor of surgery and pediatrics with more than 20 years experience working in both Israel and the US.
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