memorable patients


Surgery has no room for errors. If they happen, there’s nowhere to hide. You cut the wrong thing in the OR, and everybody knows about it. Even if it’s something as relatively simple as getting into the hernia sac you were trying to get around, everyone knows because you have to call for a suture to repair it with. Anything bigger is even more obvious.

When your patients die, everyone knows that too. What happened to so-and-so? Where’s the patient who was in that room? What’s with the blood and paper all over the floor? Why’s your attending so gloomy today (in fact why is the entire service colored grey)?

You also can’t hide in the sense of withdrawing from the life of the hospital. Just because one person died, there are still a dozen others needing help, even others with the same problem. That’s what’s really getting to me right now. One person died, and there’s another patient with an extremely similar problem, whom we simply have to operate on. It would be irresponsible not to – and yet it feels irresponsible to go ahead. Statistics say there was a 1% mortality rate, and that patient bought it – so really the next hundred ought to do great; but I don’t want us to do that same operation again so soon. It seems like tempting fate. I can tell the attending doesn’t want to, either. For a guy who doesn’t talk much anyway, the main way he shows emotion is by talking even less, and more inaudibly than usual (which is harder to deal with than another attending cursing and swearing). But he has to take the case. There’s no one else who can do it, and the other patient can’t wait.

I guess it would be more accurate to say there’s no room for denial. Errors, and inevitable complications, occur. The big thing is not to hide from them. You can’t be so insistent that there were no technical errors that you refuse to go back to the OR for postop bleeding. You can’t ignore an enterotomy and hope it goes away without you stitching it up, and admitting to yourself and the scrub and the circulator that something slipped. You can’t pretend that the patient didn’t die, and that if you don’t even think about a patient with that disease for a month, it will somehow undo their death.

(Which is why I hate euphemisms, especially at M&M: “The patient CTB (ceased to breathe).” Come on guys, we’re surgeons. The patient died, is what they did. They’re dead. That’s why we’re discussing it.)

I hate it when my patients die. Somehow it feels worse when I wasn’t there at the time, as though in addition to generally having let them die, I also failed to be with them when it mattered. At least I didn’t have to see the family. . . I can’t even think about them. I can say to myself, the person I was talking to yesterday is dead and gone. . . but I can’t bring myself to even imagine the family, how they received the news . . .

I was fuming this evening, and the rest of the residents were tickled. They think it’s a joke, to see how much strong language I’ll use when I get upset. So far I only go in for colorful epithets; they’re waiting to catch some dirty words, which makes it dangerous to get angry around them.

One of the critical care consultants is driving me crazy. He interferes with my patients, and he shouldn’t, and I haven’t quite got up the nerve to tell off an attending from another specialty (and I rather doubt that it would do any good if I did; he strikes me as being very good at looking down his nose at anyone who tried it).

The last time I had to deal with medical consultants trying to manage critical surgical patients was in the burn unit last fall, and then at least I could tell myself that I knew nothing about critical care but what I was picking up from the nurses (if they reported something to me from overnight, I knew they considered that important, and I should pay attention), so I couldn’t possibly presume to criticize the medical folks. Now, admittedly, I am far behind a board-certified critical care specialist, but I do know more than I did then. I also think that spending a month learning to think like the most finicky doctor I have ever met, one of the trauma doctors who will spend an hour making sure that every single thing is perfect for one patient, has taught me something.

So, I (and my chief) object tremendously when this particular consultant (the rest of his group does it too, but he’s an egregious offender) tries to take over the entire management of a surgical patient whom he was consulted on either for vent management, or as a courtesy because the patient is in the ICU.

Today, without talking to anyone from the surgical service, he sat down with the family of a patient he’d met yesterday, and told them the patient was essentially brain-dead, and they ought to withdraw care, basically now. Then he ran into me inside the unit (I had just come up to have a similar, but perhaps more gradual and gentle, conversation), told me flatly that he’d told the family care was futile, and he expected “we will end up withdrawing before too long.” I was furious; I think there was smoke coming out of my ears. That’s my patient. I spent a month taking care of him, nursing him along, watching him slide out of my reach; I was heartbroken when I came back one morning and found him on death’s door in the ICU. I have talked to his daughter every day for a month. I know him; I know his family. He’s mine; or at least he’s my attending’s. This jerk met the whole group yesterday in the middle of a disaster; who does he think he is, to go telling them things like that, without talking to us? My attending or I should be the ones to say, We’re sorry, we failed, we couldn’t save him, he’s going to die, it’s best if you let him go. (And he’s not brain-dead; he’s not good, he’s not conscious, but he’s not brain-dead. I really hate it when consultants, usually critical care or neurology, try to call my patients brain-dead when they’re not.)

Grrr. I think next time I meet the guy doing things with my patients, I might say something; hopefully (in that grand British phrase) more in sorrow than in anger: “I’ve known this guy for a month, I’m really upset by his condition, and I feel like it would be more appropriate for someone like me or my attending, who have a rather longterm relationship with the family, to be the ones to break this news and discuss this situation with them. Now git!”

One of my patients this month has been an amazing teacher. He hasn’t said a word yet, and I might be off the service before we get him off the vent and onto a trach that he can talk with, but I’ve already learned a lot from him.

He was in a car accident, and came in with some broken ribs. Not bad, right? So no one could understand why his vital signs steadily dropped in the trauma bay. He looked good initially, but right when the team thought they had him figured out and ready for admission upstairs, he took a turn for the worse. The on-call attending stayed four hours late, intubating him, scanning him again, starting him on pressors, fighting with the vent settings, trying to save his life, and completely lost as to what the problem was.

He got to the trauma unit eventually, and I picked him up. We spent the next three days desperately trying to figure out what on earth could be wrong with him. He seemed to be septic – but how can you be septic from the moment you hit the door? That should be something that starts three or four days in, not that gets to its worst three days after admission.

Finally, the attending who had first admitted him came back on call. He came to get signout from another attending, and found us all kind of hanging around this patient’s room. He was by that point on three or four pressors, and extreme vent settings were barely keeping his oxygen level in the acceptable range. The attending looked at the situation quietly for a couple of minutes and then announced, “He’s clearly septic, and we have no idea why. It’s time to do surgery. I’m calling the OR.” The rest of us mostly shrugged our shoulders, considered that this attending was being the worst kind of cowboy, and left to get some sleep.

The next morning, we discovered that the patient had suffered massive intra-abdominal injuries, severe enough to make him septic within hours of his reaching the hospital. Due to various considerations, our best efforts had failed to diagnose the problem. That attending operating on him – jumping blindly over the cliff, just to see what he would find – saved the patient’s life.

Lately, he’s doing better. He’s alert, which is more than he was for many days after admission. His abdomen looks like it might eventually – weeks or months from now – recover. He’s not septic anymore.

We were ready to give up on this guy. I still can’t believe that he’s actually likely to leave the hospital now. Along with the whole idea of not giving up on people till you’ve given them every possible chance, I learned from the attending: a surgeon’s job is to operate. That’s the reason our patients belong to us, because a lot of them really do need surgery. There’s a place for not operating without investigating first and having some idea what you’re going in after; but sometimes, cowboy is the only way to be, the only behavior that will give your patient a chance. Trauma is a surgical field because trauma victims often need to be operated on. When in doubt, cut (or think seriously about doing so). I’m still trying to figure out how much weight to give this lesson, but it will stick with me for a long time.

There was another patient like this last month, too, on the vascular service. He’d had a simple operation, and three days later crashed into the ICU overnight. We had no idea why. We couldn’t figure out what about the surgery he’d had could possibly be making him so sick. In desperation, the vascular surgeon consulted one of the general surgeons, who looked at the patient and the labs and scans for about half an hour, and then shook his head. “I don’t think it will do any good, but let’s call the OR for an emergency case. We have to at least look.” And sure enough, he had a perforated ulcer that had somehow randomly developed at exactly the same time that he came in to get a vascular problem taken care of. That patient also would have died within hours if the general surgeon hadn’t decided to take a chance and just look, to make sure nothing was missed. CT scans are so fancy nowadays, we think if we can’t see it on the scan, it isn’t there. The younger surgeons and residents especially tend to forget that some things can only be found by putting your hands inside and touching the problem.

The weekend wasn’t quite as bad as expected. Enough sick patients and enough traumas can get even the slowest of attendings to start moving, and I like this attending better at midnight, arguing with helicopter command about the tenth ridiculous trauma alert of the evening and struggling to keep the seven car accidents and six motorcycle accidents straight, than during morning rounds.

On the other hand, I had trouble with lines again. I got some good a-lines in, hurrying before rounds started. (I’m afraid I drive the ICU nurses crazy. I show up right after shift change and insist on putting in lines or changing wound dressings, right then. My only excuse is if I don’t do it then, it won’t happen. I didn’t stop moving for 30 hours this weekend, and lots of small things didn’t happen, because there wasn’t time.) But for the rest of the day, all the central lines I tried didn’t work. There were good reasons, but I expect I’m making the seniors who were forced to come help rather nervous about my performance next month. Ah well, let them be; I’m nervous too.

We saved a guy’s life (intubated, lines, the works), and he woke up the next morning to yell at us about some chronic pain issue that had nothing to do with his arrest. When someone’s arresting, you have no idea what kind of person they are; but I’ve found so far that the more dramatically you save someone’s life, the more likely they are to be a nasty personality who won’t ever realize what happened, or even say thank you for taking care of me, let alone, for saving my life.

It’s long been an ambition of mine to calculate some real live TPN. Sadly, although this is a traditional and important part of the surgeon’s trade (being able to provide total parenteral nutrition for someone you’ve operated on), at my hospital it tends to be taken over by the pharmacists or by a physician who specializes in nutrition, because the surgery attendings have no interest in managing outpatient TPN. But in the trauma ICU, we take care of all critical care issues for our patients, including doing the TPN at least through the pharmacists on our team. Sunday, no special pharmacists, and the attending said to start TPN now. So, after 30 hours of being up, I tried my hand at TPN calculations. They’re not that complicated, if you can just keep your eyes open. The weekend pharmacist seemed to think they were reasonable, so we’ll see tomorrow how it worked.

I’m not going to say how many hours I worked in the last four days, in case the ACGME ever finds this blog. Let’s just say neither I, nor the other residents involved in the holiday weekend, plan to let anyone know officially how much time we spent in the hospital. Our program is good to us as a matter of course, and we have no intention of letting the cracks show.

I saw half a dozen unique cases; not just zebras, but orynxes and wildebeests – legendary diagnoses that even the attendings who diagnosed them had never seen before. My patients got such continuity of care, it was unbelievable; they started asking if I actually have a house, or just live in the hospital. I got to see cases, the postop course, the complications, the treatment of the complications, the result of that treatment. I wouldn’t have wanted to miss that, just for a few more hours of sleep.

I’m also wildly excited because I got to do three central lines in the last two days. The last one I did without anyone watching, because we were too busy, on an immensely obese man, heavily anticoagulated, with such bad access that no one could actually tell me what his coags were, except high. He needed dialysis, and was short of breath sitting up, let alone when I tried to get him to lie flat so I could do the line. He was on a dismal medicine floor, with a nurse who looked nearly as scared about trying to do the procedure as the patient was. I questioned my judgment in trying to pursue the line, but went ahead for two reasons: he really desperately needed dialysis access (which meant it would have to be a gigantic catheter; which meant if I messed up, there would be massive bleeding) and there were no other options at that time of day, and medicine had asked us for help. Two very good reasons to play cowboy. I dived in, and between sweet-talking the patient into lying still a little longer while I poked needles into him (he was too huge for the lidocaine to cover anywhere near the territory involved) and walking the nurse through opening various kits for me, I managed to get the line in. Just as I was catching my breath, not quite believing it was in, the chief walked in to check on me. His eyes went a little wide when he saw what I’d tackled, and accomplished, but he just said, “Good job.”

So I’m psyched. I took a risk, and it paid off; I made a judgment call, and it worked. I can actually do tough procedures on my own. The nurse thought I was being calm. Maybe I’ll be a surgeon some day.

I went by my mailbox the other day to clean out the usual accumulation of useless fliers and advices from the administration (a new administrator; a new policy; a hospital picnic), and was astonished to find a card in the box.

It was from a woman whose husband’s hand I had sewn up back in March. It wasn’t the most horrible injury I saw that month, but it was certainly sickening to people, like the man and his wife, who hadn’t seen anything like it before. It had taken me some effort to talk him into letting me take my time and do things carefully. Once I got the anesthetic in it hadn’t been that bad. I think the previous ER where he’d been had tried to do a digital nerve block and failed. I got it right (for the first time ever, to my own surprise; but I didn’t tell them that), and then he let me cut and sew as I saw fit.

Anyway, the card was to say that his hand was working well, and the doctors thought the nerve would grow back in time, and it was nearly as good as new. This was not a short card; it was a big hallmark card, filled up with writing. I think I started crying in the hallway. I’ve had people say thanks before, but to take the time and effort to write a whole card and mail it to the hospital – unbelievable.

A few days later I ran into the wife of the man with really the worst injury I saw that month, the one that I could barely stand to look at. (Broken bones turned all wrong-side-out really turn my stomach.) I didn’t recognize her, but she stopped me and started exclaiming about how well it turned out, and how the plastic surgeons in the office had said I’d done the right thing, recognizing how much tissue was viable and should be repaired, and removing what wasn’t salvageable.

I don’t know what to say about any of this. I’m disturbingly surprised to hear that my hand surgeries turned out well, and touched by the patients’ gratitude. Getting this feedback is even more satisfying than simply looking at the hand when I was done and thinking I had done well. This is what it must feel like for the attendings in their offices, to have people come back and say that they’re better and the surgery helped them. This could be fun to keep doing.

Since I’m handing out advice right and left (I think I’ve run out of intern advice, though; maybe next year I’ll have some things to say about annoying interns, of whom I’m sure I’ve been one), maybe I’ll throw out some for patients.

Although really these are more anecdotes about my favorite patients. Out of the whole year, I think my favorite, and best memory, is this one old gentleman who learned my name pat the first time I introduced myself. After that, every time I walked into the room (usually at 5am), his eyes would literally light up. “Dr. Alice! Thank you for coming! It’s so good to see you!” I was almost embarassed to be there, because here I was waking him up, and I hadn’t done a blessed thing for him yet, and he was so happy about it. Actually, I think it started because one of the first days I came to see him, his wound dressing had gotten all disarranged, and he was worrying that when the nurse finally came to change it, it would hurt a lot. I needed to see the wound for myself, so I just changed it quickly and fairly painlessly. Since then, although he kept coming back in with complications, he was always so cheerful and grateful that everyone loved talking to him.

Then there was another lady, who had what you might call a chronic hospital course. She’d stay for a few weeks, go home, come back in less time than it took her to leave, and stay a while longer. When I got signout about her, changing services, I got the phrase “pain issues,” which usually indicates a drug seeker that people have gotten tired of dealing with. For the first couple of days, that seemed to be all there was to it. She had had a lot of surgeries, which resulted in a lot of pain. She’d spent enough time in the hospital to be fairly tolerant to narcotics. But then I started to realize that if I came to talk to her at the times when she wasn’t in as much pain, she was a very nice lady. She wasn’t defeated by all that had happened to her. She worked hard with the physical therapists, and could be often found up moving around by herself. Finally, I realized that she had the same goals we did: despite her complaints of pain, more than anything else she wanted to move away from iv narcotics, and get out of the hospital and back to being independent. At that point it became easy, and she and I worked together as a team to wean down the doses.

Basically, don’t make the doctors and nurses afraid to come in your room. The people who smile when they can, say thank you every now and then, and speak politely, will have nurses come quickly when they call for help, and doctors who come to check on them frequently, and are willing to spend a while discussing plans and alternatives; whereas the patients who make it unpleasant to come into their room will get much more grudging service all around. Unfortunate, and despicably human on our part, but there it is. A little politeness will go a long way towards making your hospital stay smoother and a little more pleasant.

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