ethics


I really had better not talk. I wrote a very bitter post about how angry I am at the hospital administration, but it was too nasty too publish. I’m so stressed out, between the administration’s actions, and just the ICU and trauma craziness, I’m making myself sick, which isn’t smart, because there’s absolutely no one to cover for me, so I’m not about to try to find out what happens if a resident takes a sick day (although I’m tempted to try it, just to pay some people back).

Today wasn’t so awful, I’m learning to just not talk to the attendings and then things go smoother. Tomorrow, I think the seniors have arranged things so that I get to cover the entire trauma ICU, and go to all the trauma alerts in the ER, by myself. I’m so thrilled, I can’t find words for it. I feel like the system, and people that I’ve built trust in for twelve months, are at the end of the year failing me so badly (not just tomorrow’s schedule, but other things), and I’m angry with myself for ever trusting people this much. But what can I do? I’m a surgery intern, and I have no control over my life. I have no bargaining capacity at all, nothing to stand on, nothing valuable that I hold. I belong to “the man,” and there’s nothing I can change at all. I have life and death responsibilities for my patients, but for myself I have nothing.

Ok, that’s enough bitterness for one night. Hopefully my patients all survive tomorrow, and you might hear from me later. And even if I manage it all ok, no one is going to care about that either.

Never trust administrators, they screw you every chance they get.

(For the last week, I was telling myself, at least if I have to work crazy hours and places, it’s this kind of work I want to be doing, and with these people. Silly of me. I don’t matter to these people, I’m just a number to fit into a slot. If I ever get to be a senior resident, which I’m starting to question, I know what kind of senior not to be.)

The only resident I met in medical school who made me seriously reconsider my interest in surgery was rotating on trauma. In fact, he seemed to have stopped rotating, and have come to rest in the trauma unit. Between the summer transition, and the vagaries of scheduling, he was spending three or four months consecutively on trauma, either days or nights. He was not happy at all. In fact, he was downright bitter. I think his wife was giving him grief about never seeing him, but he also hated the trauma unit in itself.

“Do anything else at all, just don’t do surgery.” “I would never do this again.” “If there’s anything else you could be happy doing, don’t do surgery.”

I remember watching him walk around the unit, running from one disaster to another, placing one feeding tube after another, changing central lines all night long, his face growing longer and grimmer the whole time I knew him. He was pleasant enough to the medical students when he remembered our existence, but most of the time he was too morose to even acknowledge our presence. He was a good teacher, when he had the time, but mostly he was too overwhelmed with work to explain anything about critical care.

I remember wondering what exactly was bothering him so much. To me, it looked he was doing a lot of procedures, was saving the lives of some critically ill patients, and was perfectly at home with pressors and complicated ventilator arrangements.

Now I understand that lines aren’t as much fun when you’ve got five of them to do, and only enough time for three or four, or when they keep going bad on you the day after you struggled to get them in, or when the attending comes in the next morning, criticizes your choice of location, and insists on it being pulled out and replaced elsewhere immediately. Feeding tubes are no fun when you’re going to spend three hours walking around the unit in circles putting them in, waiting for an xray to show that you’re in the wrong place, and trying again, while the patients complain. Disasters are no fun when they keep on coming, and for most of them (folks, if you’ve got to ride motorcycles, please wear helmets) success means you’ve saved someone to live without word or motion for another five or ten years.

Most of all, I understand the frustration of having every day a different attending come through the unit, require you to defend your reasons for doing xyz to any patient, rip you apart, and insist on doing the opposite (ie, the opposite of what the attending yesterday told you to do).

All I’m hoping for is to be a little more cheerful, at the end, than that resident. I know I’ve got the long face, and I’m snapping at people, and I’ve given up on being nice to the medical student; now I just use him as another pair of hands to get the interminable amount of work done. (He’s gone at the end of the week, and from there on the work force shrinks and shrinks, till I’ll be completely alone at the end of the month. It keeps getting worse.) It’s a good thing this is the last rotation of the year, otherwise, like that other resident, I would be seriously thinking about quitting. As it is, I can’t throw away a whole year’s work just to escape another two weeks of this; but the prospect is attractive – just to walk away from this whole game, and leave the attendings to deal with it by themselves.

Pursuing the issue of work hours: suppose a patient dies right before change of shift. The family has been notified briefly on the phone (via a message, because no one is answering, or perhaps a conversation cut short by grief and shock), but won’t arrive for at least a couple of hours. If the day team goes home as planned, the only person there to talk to the family will be the night float junior resident, who, with all the good will in the world, is overworked. Even if he gets time to talk to the family, they’ve met him maybe once or twice before, and have discussed little of their loved one’s situation with him. The attending and chief who did most of the interaction with them will be gone. As residents, we’re not about to ask our attending his plans, but we doubt that he’ll come in from home, on a night he’s not on call, to discuss how one of his cases went bad.

Your initial response, and our instinct, would be for at least the chief to stay in the hospital (trying to use the time to study or do something else productive) or perhaps arrange to come in from home when the family arrives.

But the chief has been operating late into the night for the last several days, and was in the hospital almost the entire last weekend. Staying a few extra hours to wait for the family, or even coming back for an hour later on, will push him over the 80hr limit, and hinder him from fulfilling his responsibilities later in the week. He can either stick with the rules, and satisfy himself with having spoken on the phone, or ignore the rules, misreport his hours, and stay around to fulfill this last ultimate duty to a patient and family, to talk with them personally about the death.

This is an extreme but very plausible scenario which illustrates the basic problem with the 80hr rule: an outside agency (government, and the ACGME, which is not surgery-specific) imposes an iron-bound rule which sets our regard for the law and for honesty in our reporting at odds with all professional instincts and obligations, and leaves us feeling guilty no matter which we end up following.

Somewhere in the last couple of years, I was near a city where the Body Worlds display (or one of the copy-cat shows) was stopping. After thinking about this for years, I’ve had enough of the ads (as it keeps travelling around the country), so here you go.

There are two primary ethical objections to these displays:

1) Our common humanity is denigrated by dissected bodies being displayed to public view as a matter of entertainment and moneymaking.

From a Christian perspective, the body is an integral part of what it means to be human. The Bible describes God forming Adam’s body and breathing life into it, and says that Adam was made “in the image of God.” To turn the human body into an object to be displayed for the enjoyment of crowds makes this crowning miracle of creation nothing more than any other animal displayed in a zoo.

But even if you wish to avoid a religious rationale, surely we can agree that the concept of Body World is of a piece with the modern entertainment culture, where horror films like Saw, Saw II, and Saw III (not to mention all the rest of their ilk) are viewed as acceptable amusements. Violence perpetrated on human bodies is now just a way to pass the time, not something revulsive. Similarly, Body World teaches us to accept the image of human bodies dissected, distorted, displayed – for our entertainment.

One of the greatest nightmares of medical school, gross anatomy, for centuries an illegal secret, and until recently at least a private activity, has been turned into mass entertainment for the crowds. I cannot express to you what it was like to cut up a human body, to destroy what another human person had used to live in, to love with, to see the sky from, the feel the ground by. . . At least I had the comfort, the excuse, that I was doing it for a reason – to be able to help hundreds of other people live, love, see, feel, a little longer, a little more comfortably. And it was, at times, a paltry excuse. To saw a skull open? To split a pelvis in half? To peel the skin off a face? To split a hand into useless threads? Who can do that calmly and claim to be still human himself? These phrases are the description of a monster’s activity. At least we had a reason; and I think our humanity survived. 

But what excuse is there, for the general public, to go and stare at bodies split open, splayed apart -amusingly posed? If you want to know what your inside is like, read Grey’s Anatomy; get a plastic model from the school supply stores; read Netter’s, if you prefer color. If you want to know how the thing works, there is no scarcity of physiology books, in all ranges of readability. The craze about Body World has nothing to do with a sudden hunger for anatomical knowledge. It stems from a fascination with the forbidden, the weird, the indecent.

Like the rest of the violence and indecency which is now commonplace in our society, the Body World displays serve the purpose of destroying our conscience and filching our reverence for humanity as something separate from the animal kingdom.

2) These particular humans almost certainly had no say in the disposition of their bodies; and even if you allow that it might be all right to use bodies this way, if their owners had knowingly and completely consented, it is wrong to participate in the exploitation of individuals who in their lifetimes were the victims of a cruel state.

We all ought to have known better than to think that Chinese bodies were come by honestly (and you had only to look at their faces to know they were Chinese). Recently ABC’s 20/20 removed the possibility of further self-deception by investigating the body-selling trade in China. Protest as he may, the inventor of plastination cannot deny that his original bodies came from a shady source, as he is now loudly promising not to use unethically obtained bodies anymore. The news stories mention thousands of people currently offering their bodies to be used in these displays, but the fact remains that there is no good documentation of the origin of the bodies that are currently touring the country. And for anybody who thinks any Chinese person whose body is being used actually freely consented to this arrangement, I have a bridge in Brooklyn to sell you.

But, even if all the unethically obtained bodies were cremated, the objections in my first point would still be reason enough not to see these exhibits.

For a much better-written exposition of the moral objections, please see Thomas Hibbs’ essay, “Dead Body Porn”.

I’ve learned the geography for maybe 120 miles around my new city by dint of making polite conversation with my patients, and hearing that they live in such-and-such a city, ten miles east of X small country hospital, and two hours north of our place; and so on. Thus, my picture of the surrounding territory consists of outcroppings of towns labeled predominantly with the names of our referring hospitals.

The attendings and chiefs are a step ahead of me. They know not merely the hospitals, but the physicians who transfer patients to us regularly. In fact, they know them too well for their own happiness.

There’s one doctor in particular, I’m not sure yet whether he’s ER or a surgeon, but when the attendings hear his name (“Dr. Smith called about transferring a patient to your service”) an expression of disgust comes over their face, usually accompanied by several unprintable words. We’ve figured out, through too much experience, that when he bills a patient as stable and ok for a regular floor, we’d better prepare an ICU bed, and maybe have the OR on standby. Whereas when he describes a patient as septic, on death’s door, requiring urgent operation, we can safely order a regular floor bed, and consider whether a CT scan might suggest the need for surgery, or simply send the OR staff to bed. If he describes right upper quadrant pain, it’s invariably in the left lower quadrant. If he says the patient has no cardiac problems, they’re most likely in decompensated heart failure and/or infectious endocarditis. If he says a patient has necrotizing fasciitis, we can safely conclude that it’s simple cellulitis. If he says there’s a rigid abdomen, it’s sure to be as soft as a kitten.

The real problem is when he says he’s not sure what’s going on. Then we have nothing whasoever to base our conclusions on.

So my question is: was he always this poor of a doctor, or did he change after he left residency? If I’m a conscientious, careful resident, and learn how to accurately assess my patients, will that protect me from becoming this kind of terror to my colleagues? Or is it that once you leave the demanding academic environment, where there’s always someone looking over your shoulder and evaluating you, it’s just as easy to slip into this lackadaisical, “we’ll let the big hospital handle it,” mode? What can I do to keep myself from becoming this doctor?

You know the reason everyone is really so rabid about the polygamists? It’s not just the matter of teenage mothers (who, after all, are a common enough phenomenon in this society; here, at least, they’re respected as legitimate, and the fathers are involved with their children).

No, it’s the women’s clothes. Modern Americans take one look at their appearance – which I would describe as graceful, elegant, sweeping, modest dresses and beautiful swept-up hair – and react viscerally, I believe because they’re convicted by this total contravention of modern society’s flagrant embrace of everything vulgar and obscene. It’s almost as though men think they have a right to see barely-clothed women, and are affronted by these women denying them that privilege; as though women think that they earn respect by flaunting their beauty in the eyes of all, and are defied by these women’s refusal to do that.

That, and the large families. In a society where a single child is pondered before years before being accepted, and where two children are an imposition, three unheard of (in the professional circles I seem to be in these days), the idea of having many children is shocking – the 400 kidnapped children (since I don’t see where the government gets the right to take all of them without specific evidence against everyone’s fathers) are described as a crowd of toddlers and 4-5 year olds running around under foot.

Plus, their rejection of the modern world. My friends talk as though it’s evil not to have TV and internet and cell phones. Who am I to talk, of course; but I think I can at least recognize the beauty and possible desirability of such a lifestyle (the Amish, for instance), while still choosing to use some of modern technology myself. So far, I’ve refrained from pointing out to my colleagues that I was raised without TV (although they may have figured that out from my profound pop culture illiteracy), and regard my cell phone as a necessary evil.

(I have previously described Mormonism as a heresy. But I respect the FLDS people for being consistent and true to the original spirit of Mormonism in spite of intense persecution.)

I betook myself to the Coptic Pascha evening service tonight after work. I missed Palm Sunday service through falling asleep post-call, and not being able to muster the energy to get myself out of bed after a 15min nap. So I felt bad about that, and I considered giving up on the enterprise of keeping Pascha and working 13-15hrs a day at the same time. But then there wouldn’t be an Easter that meant anything to me, and that would ruin the whole year, and that would be pretty bad.

So I dragged myself to church after work, not entirely thrilled about a 1hr round trip, and two hours of service (allowing for missing the first hour, and skipping the last 45min due to the sermon being entirely in Arabic).

Somebody please kick me the next time I consider missing Coptic church. I was so glad to be there. I didn’t know many of the people, and I didn’t have a service book. But we were praising God and commemorating Christ’s passion, and there is nothing better in the world.

Thine is the power, the glory, the blessing, and the majesty, forever, Amen.
       Emmanuel, our God and our King.
Thine is the power, the glory, the blessing, and the majesty, forever, Amen.
       My Lord Jesus Christ, my Good Savior.
           The Lord is my strength and my song, and has become my salvation.
Thine is the power, the glory, the blessing, and the majesty, forever, Amen.

The Copts are my identity, one of the only things about me that’s still the same at the end of this year. At that church, everything is right and in order.

(Man cannot live by bread alone; and neither can one get by entirely with Presbyterian church services, especially the strict ones. They’re missing something, like icons and incense and color and music. I should point that out to the elders of the church I’ve been going to. The reaction at least would be interesting.)

Once again, more studying got done than my brain can really stand. Learned all kinds of things about the biliary tract, including, in detail, what to do if you injure the common bile duct during a laparoscopic cholecystectomy. Which is actually fairly irrelevant, since although I’m afraid such an event may be in my future (incidence stable at 0.5% for the last several years), hepatobiliary surgery has never crossed my mind as a specialty, so I am sure I will not be in a position to repair the injury adequately. The general tenor of the lengthy textbook discussion was, interspersed with detailed instructions on how to repair every variety of injury, admonitions to refer such patients very early on to a major center and an experienced hepatobiliary surgeon. So mainly I learned something else to try very hard not to do; of which I already had a long list.

I’m still not happy with my moral position during conversations which I disapprove of. But at least I resolved, again, to try very hard not to say anything I wouldn’t say if the subject of the conversation were in the room. Maybe I can’t help what other people say; but I don’t want to contribute.

I really love this type of patient conversation:
Me: “. . . So basically everything that brought you in to the hospital has been corrected, and you are ready to go home, although you do need to continue taking these medications.”
Patient: “Great, I feel fine, I was ready to get out of here yesterday. Let’s go.”
Spouse (with the most suspicious tone of voice you can imagine): “You’re not kicking him out of here again, are you? I’m sure he was deathly ill with this xyz the last time you discharged him, because he was sick immediately [although we didn't come back to the hospital or talk to any office staff for a month].”
Me: “Ma’am, I understand your concern, but I assure you that there were no signs of this problem the last time he was discharged. And anyway, right now [laundry list of tests] have all been completed, and show that the problem is completely under control. The best thing is for him to get back home and on the road to recovery, and you just let us know immediately if anything concerning comes up.”
Spouse: “They should have listened to me the last time. . .”

Which is such a horrible note to close on if, as there’s a decent chance given his underlying disease, the poor fellow gets sick again and has to come back. But right now he’s fine, and he wants to go home, and I want him to go home, so please, try and give some credence to the long list of negative test results. Some people do seem to feel better after you explain it all in detail; but this lady had our negligence firmly in her head, and she wasn’t listening to reason. Ah well. I’m sure we can resume the discussion at the next admission.

I’m beginning to think there’s either something wrong with me doing what I’m doing, or with how I’m doing it.

I figured out today that the way the guys were talking about the attendings wasn’t bad at all. I know this, because today I was present when a fair number of the residents started to give their uninhibited opinion of a few other residents, and it was not pretty.

I didn’t know what to do, except try unsuccessfully not to laugh. Granted, the people they were discussing have some peculiar mannerisms, and some of them are not the brightest pennies. But only one of them would I call downright irresponsible. The others are trying to do well, and just don’t quite match the other residents’ ideas of normalcy or success. So the senior residents are mocking away, and it really was hilarious, between their imitations and made-up lines, and actual quotes from the residents in question. (For instance, on the subject of how to avoid adding consults to one’s list of patients to see in the morning, they stated that one resident quite surpassed their expectations, by flatly lying to the medicine service (or perhaps she was just confused on the subject) about whether her group would consider seeing a certain patient. The internists took her at her word, and consulted another service. The surgery residents considered this a desirable outcome, but by astonishingly unethical means.)

So that was a bad thing to do, and fair to laugh at, I suppose. (Although really somebody ought to tell this resident how incredibly awful her performance is, and how horrified the rest of the residents and the attendings are by her either complete incompetence, or thorough dishonesty – no one is quite sure which it is. We’re hoping incompetence, which would make it funny, rather than dishonesty, which would make it reprehensible.)

But what about the other guys, who just have some unfortunate idiosyncrasies? I feel like I ought to say something along the lines of, “that’s not polite,” or “that’s not kind,” or “how would you like it if people talked that way about you?” (which indeed they sometimes do). But that would sound so completely schoolmarmish, and would only result in them not talking around me, and no doubt adding to the stories they tell about me. (I’m sure I’m shy and hesitant and socially inadequate enough to have plenty of jokes circulating about me.) Then that reminds me of Mark in That Hideous Strength, and what crimes he was led into by his desire to be part of a inner group; which is what the surgery residents have always been to me. Now nearly a proper resident, I’m getting closer and closer to being part of the inside group, and their pull on me is getting stronger.

Anyway. And then there’s the whole matter of women’s proper role in society (which the affair of the fundamentalist Mormon ranch brought up), on which I can’t say a single thing. I want to praise women who stay at home and take care of children, and I want to uphold a husband’s authority over his wife. But I can’t say a thing about what I really believe, and just have to listen to the conversation in silence, because if I open my mouth, I will instantly lose any chance of having equal dibs with the guys at the big cases, of being respected in the trauma bay or at ICU crises, of being listened to when I become more senior. I’ve never had to keep this quiet about my beliefs before. It makes me think I’m doing something wrong.

Lately we’ve been having some object lessons on the theme that just because you’ve closed the skin in the OR, the patient is not out of the woods.

The other day we had a patient give a few good coughs as the anesthesiologist started to wake them up. Shortly afterwards the surgery resident (not me) noticed a fair amount of swelling at the operative site. A few moments of consideration led him to conclude that this was probably not just normal fatty tissue. He called the attending back in (this is where I entered, seeing the attending heading back, and figuring if he was that interested, it was worth me seeing too), and the wound was opened up to disclose a large amount of fresh blood. After clearing their way in, they found a bleeding artery, which would have led to serious problems if the patient had gotten out of the OR or up to the floor with it.

Then there’s the story from neurosurgery making the rounds: a young woman involved in an ATV accident was brought into the ER with altered mental status, and developed a blown pupil (dilated, no contraction with light). CT showed a subdural on that side, so she was rushed to the OR. After the subdural hematoma had been evacuated, the skin was closed over the site. A junior neurosurgery resident then came in to take over for the senior who had done the case, just to get the patient back to the ICU so the senior resident could take care of some other issues. The junior flipped through the patient’s history, and then decided to take a look at the blown pupil for himself. His next remark was, “Which pupil did you say was blown?” This led to the realization that both pupils were now dilated and unresponsive. The patient was rushed to the CT scan, which revealed an epidural hematoma on the opposite side of the head. By the time they got her back to the OR, the patient was bradying down (Cushing’s triad, in response to increasing pressure on the brain: as the brainstem is forced down into the foramen magnum, you see bradycardia, hypertension, and irregular breathing). Her life was saved by the fact that the neurosurgeons were just in time to get the epidural hematoma out. Which was due to the attentiveness and inquisitiveness of the junior resident.

My takeaway lesson: I need to be more particular about investigating these details, particularly in postop patients. In vascular patients, I usually do check all the pulses just out of curiosity, whether postop or on new admissions. But just because you’re handed a postoperative patient, with the assumption that they’re all fixed, doesn’t mean that everything is necessarily ok. No time to relax till the patient is stable in the recovery room, and not quite even then. Verify all pertinent findings, and relevant negative findings, for yourself. For example, when getting signout on a patient in the ER, that their abdominal exam is benign – take the time to go down, say hello, and check for yourself before you let them be discharged or sent to the floor for simple observation.

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