ethics


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.

On the advice of my family, who have been a little concerned by recent interchanges on this blog, including my tone, which apparently comes across as much more cynical than I intend, even to my friends, I thought I would relate a couple of incidents from the last week:

Medicine attending in the hallway: “Alice, thanks for your help with that guy the other day. I appreciate how quickly you came by to do the procedure.” Me: “Any time, Dr. Smith; you can always get me interested in sharp objects.”

CRNA in the PACU: “By the way, Dr. Alice, after you left with the patient, the two OR nurses remarked how much they like to have you in the room. They said you’re the politest resident.” Me: “Oh, really? Mmm.”

ER resident: “Wow, Alice, you guys got here fast. I was planning to send labs and have them back before you came by.” Me: “It’s ok, we like to evaluate consults as soon as possible.”

ICU nurse to student: “Have you met Alice? She’s one of our favorites. We like to hear her answering our pages, because we know she’ll always come right away and help out.” Me, silently: “That’s because I don’t trust myself to deal with things over the phone.”

Medicine intern: “Boy, you got here quickly, Alice. I just put that consult in half an hour ago.” Me: “I came as soon as the secretary called me. It sounds like you have a really interesting case – a bit more intriguing than the usual gallstones.” Medicine intern: “Yeah, I know those are a nuisance. But this guy sure is puzzling.”

Okay? I guess I’ve been doing some stress relief on this blog; but I don’t talk like that in real life, and, although this is a lot of positive feedback for one week, as far as I can trust what people say to my face, I think I’m getting along smoothly with all but maybe three ER residents and one floor’s worth of medical nurses. Now don’t make me have to say nice things about myself on my own blog again.  ;)  And of course all these nice personal interactions don’t prove anything about my skills in the OR or my clinical acumen (I feel funny even putting those words together, because I don’t think there’s much of it yet).

I’m looking for opinions/advice on how to deal with people doing impressions of others. A lot of the guys here like to do “impressions” of various attendings. To me it feels like mocking them for being older than us, or for having a pet phrase or two, or for always approaching a problem in the same way. I’m not sure whether it’s mocking, though. They don’t do it as much about the attendings we don’t like as about the nice attendings. But of course they wouldn’t do it if the attending was around, and I’m pretty sure the attendings wouldn’t like it if they heard it. I wish I could stop these conversations, but I don’t know what to say.

Ok, that’s the Dear Abby section for today. Now, some stereotypes from another angle:

Another group that my colleagues like to do imitations of are medicine residents in general (not one in particular). At one point today I had decided that was really enough, and we were setting a bad example for the medical students, and I needed to do something to slow it down, or at least demonstrate that we do respect our colleagues. And then we got a consult from the medical ICU, and the medicine resident said, at various points in the conversation, “I know there’s nothing you can do for this guy, but my attending said, ‘He’s crashing, and I’m not sure what to do about it; consult surgery.’ . . . Yes, I’ve been here all morning; it took me four hours to put in a central line, that’s why I didn’t call you earlier. . . Sure, take the chart, I’m going to be writing a note here for quite a while longer [1hr, by my count]. . . We were going to get an ultrasound to evaluate the ascites. You guys don’t do that kind of thing, do you? You just touch it.”

That, my friends, is an admission I could not make up. Every single medicine stereotype that the other surgery residents had been quoting to the med students, in living color – from one of the smartest, most competent (except for lines) medicine residents. He knew the consult was ridiculous. At least he called us about it, and we had an intelligent conversation about the patient. (And as for the ascites, yes: we had a CT, and an abdominal exam. No need to be repetitious with the ultrasounds, except if you intend to tap it. At the beginning of this year, I was puzzled when called upon to say whether someone’s abdomen was distended or not. I couldn’t tell the difference between distention (which is usually pathological) and obesity (which is physiological – not an immediate surgical pathology). I’ve learned the difference now, though. Distention, even an obese person, gives a different texture, a different quality under the skin. It’s fluid, or air, that shouldn’t be there; and you can sense how the skin is stretched in an unusual way to accomodate it.)

And then finally, another group whom I have decided to abandon all scruples concerning, and make bitter and sarcastic remarks about without reserve: the ER, and especially the ER residents. I think, honestly, ER doctors with specialty residents in-house are obliged to do better than this, because they think a bit longer before calling an attending in from home, than before calling a resident down the stairs.

Today, ten minutes before sign-out, we got a page from the ER, for a young man who had arrived only 15 minutes before. (I know, because we were down there evaluating a genuine surgical issue when the fellow was brought back.) The consult was for appendicitis in a patient with no other medical problems. No labs had been done, and certainly no imaging. We went to see the patient, and a few moments later informed the ER resident that in our opinion, a young man with groin/testicular pain as well as right lower quadrant pain, who had a history of both kidney stones and Crohn’s disease, deserved a little investigation into other possible causes of pain (testicular torsion, kidney stones, Crohn’s disease) before being summarily dumped on the general surgery service as an appendicitis. (If it were one of those other causes, he should have been sent to urology, or colorectal surgery, or even plain medicine.) So I apologize to the excellent ER doctors in the blogosphere, but I’m giving up being polite about the ER for right now. From here on, I’m going to fight every call from them until it’s been properly – even exhaustively – worked up. And all stereotypical jokes are fair game. As my chief remarks, we’re not asking them to think like surgeons, just like doctors. Examine the patient and think for two minutes!

(My patient is dying of cancer, and I can’t fix him, I can’t help him, I can’t even make him comfortable. Every time I go to see him, he holds my hand and cries. I hate cancer. My patients are all sick, and I can’t fix them. I’m tired of sick people. Did you know everyone in the hospital is sick? I forget what healthy people look like. All my patients end up in the ICU. The world is broken and I can’t mend it. . . The creation also shall be delivered from the bondage of corruption into the glorious liberty of the children of God. The whole creation groans and travails in pain together until now; and not only they, but we also, who have the first fruits of the Spirit, groan within ourselves, waiting for the adoption, to wit, the redemption of our bodies. And we are saved by hope, but hope that is seen is not hope, for what a man sees, why does he yet hope for? Likewise the Spirit also helps our infirmities. . .)

That was a busy night. Spent a lot of time shepherding a patient who ended up going back to the OR in the middle of the night. Although too bad for the patient, it was kind of nice to have been right about what needed to happen. Then, it seemed like every drug dealer in the city decided to shoot or stab himself in the hand, and come to our ER to see about it. Such babies. For big guys who were playing with dangerous weapons in dangerous situations, they were pretty wimpy about the results. On the other hand, they were also fairly polite about it, and quite willing to explain all the circumstances surrounding their misadventure. Made the time pass while I was suturing.

Maybe surgery residency was like this before the 80hr rule, but we seem to have a very stiff ethic about responsibility for one’s own jobs now. If something is assigned to you, you’re expected to get it done somehow, without asking other people to share the work. (This applies to tasks, not to asking for help if you don’t know what to do.) We’re pretty touchy about making it clear that we can do all of our own work. It would be lazy to ask, or allow, another resident to help out; and laziness is regarded by residents and attendings alike as most of the seven deadly sins.

This was brought up because of the [rare] episode of a surgery resident and medicine resident being on the same team. The medicine resident offered to help fill out some paperwork for the surgery resident, who was shocked. They were his charts, and he had every intention of taking care of them himself – somehow, no matter how late he had to stay for it. The whole group of us then spent an entire lunch time dissecting this difference between the medicine and surgery cultures. I think the point, for us, is that we want to prove to ourselves (and to our attendings, if they’re noticing) that we’re not slacking off just because there are relief shifts.

So I’m trying to figure out the subtle line where, without implying laziness in someone else, I can still offer to help when another resident is truly overloaded. Especially when one resident is being pretty frankly abused by one of our worst seniors/chiefs. There’s no shame in accepting help when you shouldn’t have been given such an assignment anyway. On the other hand, this is also the attitude that lands me with cleaning up constantly after the weakest interns in the program.

If you’re wondering about the lack of Easter posts, it’s because the Orthodox Easter, which is the one I plan on celebrating, is not until April 27th. Our Lent just started two weeks ago. So Happy Easter to you Westerners (and Protestants – meditate on the fact that the date you celebrate Easter is still determined by the Catholic Church ;) ), and if you want some Easter programming, go back to April 2007, when I had the time to blog pretty extensively about Passion and Resurrection.

Not a fun night. One of the services I cover did its usual crazy thing, admitting three patients right at sign-out, and spending five hours in the OR with one of them. I’m getting a little tired of working with the intern on this service. He means well, and I don’t think he’s deliberately neglecting things; but it’s getting to the point where I feel I have to double-check every point he tells me in sign-out, otherwise the nurses will be calling me at 2am: “this patient is for the OR today, did you mean him to be NPO?” “this patient just started coumadin, do you perhaps want an INR drawn this morning?” “this patient got a transfusion, would you like to check the hemoglobin count?” “this patient was admitted the other day, would you maybe like to write an H&P for him?” and so on.

Then, the ER called us with the most outrageous consult. There was no imminent surgical issue – maybe in a few days, maybe – and the patient was to be admitted to another service, but somehow we were called to see the patient in the ER before the admitting service was called. I and the senior resident got so frustrated we actually started arguing with the ER attending, who is a frequent offender on such points. Usually as a resident you try not to get into it too much with attendings; but still. And then there’s this other ER resident who is making a habit of calling me the minute a surgically-related patient hits the door, without having even labs, let alone basic imaging (I mean xrays; I support the idea of not scanning people unless the surgeon asks for it), sometimes without a complete history or physical. I mean, he’ll call me about vascular issues without bothering to check pulses, based simply on the report he was given. I keep meaning to make an issue out of it, because all it does is make me wait in the ER for an hour before I can call anyone (because you bet I’m not calling my attending without a white count and a creatinine), instead of him waiting for an hour before calling me (because once he’s called me, I don’t dare to simply wait for the labs to come back before looking at the patient; maybe the patient is acutely ill and requires emergent intervention without labs; hasn’t happened yet, but it might). But then every so often there’s a delicate patient who I am happy to hear about quickly, so I haven’t managed to argue about it yet. And he’s senior to me, and thinks he’s being efficient, which also makes it difficult.

Finally, and this is the real reason that I am fed up with the day intern, I had to manually disimpact a patient, for the first time in my career. (Yes, I know, you’re not allowed to be done with internship, especially surgery internship, without doing this; and it so serves me right for the time I was a medical student, and ran away from helping a resident do this.) I’m not completely sure how this is the day intern’s fault, but I’m sure it connects somehow, so I’m blaming him.

Back at the beginning of the year I heard some conversation among the seniors to the effect that “it’s your worst nightmare, to be told that your patient is coding and so-and-so is running it.” I couldn’t imagine how they could say that. Now I know. There are a couple of people who already make me uncomfortable when I have to sign patients out to them. Maybe I’m just being arrogant; who knows how the other interns feel about leaving patients with me? I think I’m at least diligent, but I make lots of mistakes.

Plus, my pager broke. All the floors except for the one that pages me most often were still getting through, but the nurses on that floor became convinced that I was deliberately ignoring them, and started telling all the other night staff so, before I heard about it. Bother. I was surprised to find out how much of my identity is tied up in that little pager. I had to trade it for a different one, and I felt disoriented all night. I have my buzz, and my alarms, and my screen style; and without them, I forget how to process calls. Fortunately it’s fixed now.

They sent me on a donor run today. A donor run is when a transplant surgeon travels to an outlying hospital to harvest organs. As far as I can tell, there’s a call schedule shared between the transplant surgeons in a large area, but going out usually implies that you plan on using at least one of the organs at your own institution. Usually this is the liver, since this is the trickiest to harvest correctly, and the surgeon likes to know that no useful pieces were accidentally left behind, and no unrecognized variant arteries were damaged.

“They” sent me, as in the senior residents universally declined to go (bad time of day, weekend, weather, etc), and were secure in the knowledge that I would jump all over the opportunity if they let me. When I told the attending I was being sent, his response was: “You? !! Oh, really. I guess so.” Later on: “Why on earth did they send you? Where are the other guys? They’re a bunch of lazy slackers . . . I’m going to be grouchy about this for an hour. Go to sleep.” Five minutes later: “Do you tie well?” Me (afraid to claim something I won’t be able to live up to): “I wouldn’t want to say that.” Surgeon: “You should be able to tie well. If not, you should be practicing. If you can’t tie well, no attending will let you do anything. . . So, Alice, can you tie?” Me: “Oh yes, very well!”

This surgeon is young, dedicated, ambitious – aggressive, even. He makes himself available at all hours, ready to go on donor runs at any time, and then come back and spend the next eight to twelve hours transplanting what he harvested. I called him once at night to say I felt uncertain about a patient. He reassured me over the phone, and then fifteen minutes later turned up in the patient’s room, sitting down to chat with him, and then to explain the lab results to me in detail.

He holds himself to very high standards, and he demands the same from the residents. When he called to tell me to go on this run, one of the senior residents remarked, “He’s an old school surgeon. If things aren’t exactly right, he’ll get upset. Don’t take it personally.” I’m still not sure what he was talking about. I take this attending’s remarks personally to the extent that I’m pleased he recognizes me now, even if he’s not exactly thrilled to have me with him. I’ve made mistakes around him, and he knows that. On the other hand, after a few hours of sleep, he was much more cheerful, and by the end of the trip kept repeating how much I’d learned today, and how I would learn even more, and get to do more of the procedure, on future runs. I know that I don’t know enough – anatomy, surgical technique, transplant lore – and the best way for me to learn more is to have him firmly unhappy when I don’t work hard enough.

As for the procedure itself, what can I say? Regard for current news prevents me from going into much detail, except to say that the patient had sustained clearly unsurvivable injuries, and was pronounced brain dead before we were even called. The entire proceeding was marked by respect for the family’s wishes (allowed to take this, not allowed to take that, make things look good for the family), and some (limited) sorrow over a young person’s tragic death. Not too much of that, however, because frankly this is a brutal procedure, and the only way to do it is to completely block consideration of the donor as once-living (he’s dead now, completely dead now) and to concentrate on the patients whose lives will be saved by what we did. I did my best to do exactly what the attending wanted, and although my skills still leave a great deal to be desired, I did tie well enough not to tear blood vessels or leave them leaking, and at least I answered all the anatomy questions correctly.

Some people question the ethics of transplantation, denying the existence of “brain death.” I’ve thought about this a fair amount, since this would be absolutely impossible to do if there were any question of the donor being in any sense alive. (Remember that one of my reasons for staying out of ob/gyn, in the end, was concern about the abortifacient nature of contraceptives, since almost every single one acts in some aspect by preventing implantation of a conceived child.) I concluded in the end that brain death, when rigidly defined (absence of every single brainstem reflex, no confounding circumstances, after extensive testing) and properly diagnosed (by two doctors from separate services, apart from the transplant surgeons) is a real entity. This patient, for example, still had oxygenated blood flowing to his organs, but only because of aggressive ventilatory support and several iv pressors. In fact, our work was made more difficult by the fact that he was becoming very difficult to oxygenate, or to maintain a pressure on. He was indeed dead, and his body was on the edge of shutting down despite all our technology. We hastened nothing. I think some of the lay objections stem from a confusion between brain death (the concept that the brain is as vital an organ as the heart or lungs, and once it stops working, the rest of the body will follow shortly) and “permanent vegetative state” (which is a vague and difficult to diagnose condition in which the person breathes on their own, but doesn’t seem to respond to stimuli; this is what people recover from on very rare occasions). People cannot recover from brain death.

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