memorable patients


I can’t decide whether it was a good or bad day.

A lady who was supposed to have a major vascular procedure developed a very serious complication early in to the operation. Through a complicated series of events, the attending got the impression that she was better, and went to his office. I came back to check a little later, and found her much worse. (And I didn’t get up the nerve all day to go and chew out the people who were responsible for letting her deteriorate unnoticed; not that noticing would have changed the course of events. I need to grow a spine and some teeth, and they’ll hear about it tomorrow.) By this time the attending was gone, and every single other surgery resident in the hospital was scrubbed in the OR. So I had her to myself all day.

It was good, because I got to handle an ICU admission, with lines and diagnostic tests and everything, on my own. It was bad, because it took me four hours, and I didn’t get to pay attention to any of my other patients till late in the day. It was good, because I finally put in my first radial arterial line completely unsupervised (as usual, when you are the only person who can help at all, the impossible becomes possible; the attending said categorically – one of the few instructions he gave me – “put in an a-line;” and I wasn’t about to call him and say I couldn’t do it, until I’d tried all four options; fortunately the second radial artery worked); it was bad, because it took me nearly an hour, between trying, and thinking about it, and trying again, to get it done. Starting in July, I’m going to need to be able to do this whole thing in one hour or less.

The really bad part was talking to the poor lady’s husband. We needed his consent for something part way through, so I had to go track him down in another part of the hospital, and then explain quickly that things had deteriorated, we needed him back over there, and we needed consent. . . I am not good at giving bad news. I think if I hadn’t been choking up, and probably visibly disturbed, myself, he might not have taken it so hard. Probably he would have been just as upset; but it’s not reassuring when the doctor is on the verge of tears. I felt like someone could be videotaping me as an example for medical students of how not to give bad news.

One reason I decided to avoid OB was because I couldn’t stop crying for joy every time a baby was born (yes, ok, irrational; I couldn’t help it). Now come to find out, although I’m getting better at not crying while taking care of my patients, I have trouble keeping my voice level and my eyes dry while giving bad news, or discussing a poor prognosis or imminent death. The prospect of the family’s grief almost bothers me more than the patient’s condition, maybe because the patient isn’t aware of what’s happening.

I wasn’t comfortable with that whole part, either, being basically the only person to discuss symptoms, diagnosis, treatment plans, and prognosis with the family. We did consult a couple people, but of course they didn’t talk to the family. The attending was unavoidably detained (he’s a good guy, he talks to families reasonably often, unlike some surgery attendings, who always leave the whole social interaction bit to the residents), and the rest of the team was also in the OR. So it was the intern doing all the talking; at least I’ve learned to be vague about the prognosis. That way if it’s better than I realize, someone else can always give the good news later; and if it’s worse, I’ve just introduced the subject gradually.

Then once that was somewhat settled, I discovered that various others of my patients had had significant things happening to them, and no one had thought it worth calling me, so at 5pm I was trying to fix a day’s worth of trouble. Splendid. I’m learning why the senior residents are so paranoid. There isn’t time to say, I’ll come back and think about this later. You have to act on everything as soon as it comes in front of you. I thought I had a busy day, with one ICU patient and three troublesome floor patients (many others were behaving nicely). What am I going to do in July, with thirty or forty ICU patients, and fifty or sixty floor patients on my hands at once?

It’s a bad day. I discharged my poor fellow with terminal cancer – again. We ended up crying and holding each other’s hands, and it was all I could do not to hug him, because if I had he would never have let go, and I would have dissolved, and it would have been too hard to go on to the next patient. The fact that he’s a little demented and doesn’t remember the details of our conversations doesn’t make it any easier to say goodbye to him.

Another patient, a good ways out from a big surgery, had a major setback today. We were all crushed. We thought he was good, he was flying, he was going to be a success, almost ready for discharge – and now this. So utterly disappointing.

I keep doing stupid little things; nothing major, I just can’t seem to get the details right. I feel like an idiot, and like everyone else thinks I’m an idiot. It helps a little when the OR nurses say things like, “Oh, here’s Dr. Alice! So nice to have you today!” But really, it doesn’t matter if people like me, if I can’t do my job as well as I ought to. Being friendly isn’t a substitute for getting things right, because people’s lives depend on me – and will do so even more next year.

And tomorrow, I’m assigned to a case which has an 85% chance of turning into a real mess. The other interns and I have been playing hot-potato with this scenario, and I lost. Hopefully we’re overestimating the potential for all-around trouble; but with our luck so far, we’re only underestimating.

And I have a beautiful controversy on my blog, and I don’t have time to write as much as I want to.  :S

But I am still thrilled to be doing surgery. I’m just getting to realize what fun it is to have spent an entire year (mostly) on surgery, not rotating through other things like medicine and peds and neuro. So nice to be out of medical school and able to throw all my energy into one area. (And seeing how little all that has accomplished, it’s a good thing I haven’t had any more to work on!)

The other day I saw my first ED thoracotomy. For those of you who aren’t medically fluent, that means splitting someone’s chest open in the trauma bay of the ER in a usually doomed attempt to save their life by cross-clamping the aorta to prevent bleeding, and dealing with fatal holes in lungs and heart. The success rate if this is performed for penetrating trauma (gunshot, stab wound) is commonly reported as somewhere near 5%. Perhaps not that much, although we did recently have a guy be discharged less than a week later. The indications are few and far between: for blunt trauma (which means that the attempt will probably be worthless, since if the person is dying of a blunt chest trauma it implies a massive disruption of the aorta, or something else impossible to fix) it’s only strictly indicated the patient codes while being wheeled into the trauma bay, or shortly thereafter. For penetrating trauma, the rules are a little broader, involving loss of pulses anytime after the medics get there.

The trauma team was short-staffed. It was the kind of day where all the junior residents know they’re supposed to come and help if things get hairy and they can manage it. When the page went out, “trauma code, gunshot wound to chest, unknown male, intubating, eta 5 min,” we knew it was finally real. Our trauma center tends to do a lot of fake penetrating trauma: gsw to chest, really through the flesh of the shoulder; gsw to abdomen, a glancing blow across the flank; stab wound to chest, a 1cm flesh laceration; and so on; which are all billed as trauma codes, because they’re quote penetrating. But if this guy was getting intubated – that’s real. I was in the ER anyway seeing a flow of consults, and now I was just waiting for CTs to get done. I knew they wouldn’t happen while there was a trauma in the vicinity, so I had time to go see.

The trauma chief and intern always put on gowns, face shields, and shoe covers for these things, because you never know how much blood there will be. This time we all, including the attending, who rarely has to get his hands dirty, covered ourselves from head to toe in paper and plastic. The trauma bay looked more like an operating room than a space in the ER by the time the ambulance rolled up. The trama chief, who’s done this a couple times before and doesn’t really need instructions from the attending any more, was very organized, determined to avoid the kind of chaos that sometimes ensues when a trauma is halfway between nonsensical and deadly serious. He handed out orders: I’ve got the thoracotomy tray, you put in the left-sided chest tube, you do a cut-down and get access, you look for an ABG, you’ve got the airway, you help with the airway, keep xray out of here there’s no time for them.

One of the techs looked out the door as the ambulance rolled to a stop. “They’re doing chest compressions, guys,” he reported; and the chief broke the final seals on the sterile thoracotomy tray.

The medics wheeled in, transferring the patient onto our gurney, giving their meager report: gunshot wound, down for maybe twenty or thirty minutes by now, maybe more, pulses in the field, lost in transport, finally intubated a few minutes ago. Then there was a perfect storm of activity, but all in dead silence, because no one needed instructions, and we could all tell by the skin’s gradual transition from pink to grey that this story was not likely to have a good ending.

I think my mind did something funny, because I somehow didn’t even look until the chest was wide open and the chief had his hands deep inside, probing for the aorta to cross-clamp. Ok, so I had been assigned something else to do, but you would think I would look at the first time I’ve ever been present for this legendary maneuver.

It didn’t matter, in the end. The bullet had torn straight through the apex of the heart, shredding the muscle. A liter of blood and clots poured out when the chief had the chest open, and then the heart was loose and floppy in his hands. The hole was too big and ragged to do anything about, and there was no blood left inside to try to keep in, anyway. (Which makes me question the theory of his having had pulses until just before he arrived; I don’t see how he could have lived twenty minutes with that big a hole in his heart. Tamponade, maybe.) Somebody had good aim; unusually good aim; fatally good aim.

(The cops are kind of funny at these scenes. They hang around at the edge of the trauma bay, fascinating to us because maybe they know what happened, and we don’t, and most likely they’re going to arrest someone based on what our attending tells them. Then one of them steps forward as the assembled techs, nurses, and ER residents fade away, and asks, “Is he deceased, then?” And we all shrug, and I’m left to answer. “Yes sir, he’s dead.” His chest is gaping open and most of his blood is on the floor, there’s a tube in his throat that’s not connected to anything. Yes, he’s dead.)

Everyone else is gone now, and it’s just handful of surgery residents left standing in the blood and litter of papers on the floor. The man’s face is completely grey, a strange contrast to the blood scattered so liberally over the rest of his body, and indeed over us as well. Without a whole lot of conversation, the attending grimly motions us all over to the right side of the chest, determined to make sure that we all know what the aorta feels like when you’re hunting for it blind, arm reaching in past the elbow, the view obscured by the lungs being inflated by the ventilator, and no time to think. Based purely on feel, the chief had somehow separated the aorta from the heart above it, the esophagus beside it, and the spinal muscles behind it, and clamped it just above the diaphraghm. It felt strangely limp, unnaturally empty. For this guy it’s too late; but we’re not going to waste the opportunity, since nothing can hurt him any more, to learn things that could save someone else’s life in the future.

It was somehow not as dramatic as I’d expected, the actual event. Perhaps because the conclusion was so clear from the moment the medics walked in. Perhaps it would have been different if we’d really though there was a chance.

But it raised the same old questions for me: the chief tore this man’s chest open and plunged both arms in, recklessly dissecting down to the aorta. Will I ever be able to do this? Do I want to be the kind of person who can do this?

The chief said almost nothing, before, during, or after the incident. He’s grown a silent, protective face over the last year. I remember in July, his face used to give things away, and he would get hurt by it, when confronted by an attending in the OR or in M&M conference. Now his face is almost always the same, no matter what’s happening – years older and locked like a bank. He’s got two months to go on trauma; and that’s the only thing pulling him through; that, and his wife. So I think inside, things like this disturb him, too; but he doesn’t talk to us much about it anymore. Maybe his wife hears, but no one else.

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.

The other day I got to watch the chief doing a laparoscopic cholecystectomy (gallbladder removal). For him it was easy. He only took the case because going in we were concerned about a lof of inflammation and scarring, which turned out not to be there.

As a student, when I watched laparoscopic cases, there was a fair amount of boredom involved. On one hand, I could see everything much more clearly than during an open case, when only the two people directly operating can actually see what’s happening, and not always easily even then. On the other hand, I have a strong propensity for falling asleep whenever the ambient lighting falls below a certain level; even holding the camera didn’t always keep me from drifting off.

Now that I’ve done a [very] few lap choles myself, it’s another story. I was very interested to watch the chief’s every step: how smoothly he peeled the gallbladder off the liver, and swept away the adhesions, how precisely he dissected down to the cystic duct and artery. No wasted steps, no fumbling – every move went exactly where he intended and moved the procedure forwards.

————

One of my patients last week was just about perfect: young enough to recover very quickly, with a disease that absolutely warranted surgery, but shouldn’t affect her much once she’s gotten over the surgery. Her family was supportive, practically living in the hospital, attentive, but not smothering. She herself asked intelligent questions, exactly the things she needs to know and ought to be concerned about, but not too many silly questions or impossible ones – and she seemed to understand the answers. We don’t often meet such ideal patients. Everything went smoothly in the hospital for her, and with as wonderful a family and an attitude as she has, I expect she’ll do very well at home, too.

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.

Just spent nearly the entire night working on the most horrible hand injury I’ve ever seen. I brought some textbooks, planned to study conscientiously all night, got bored, said it too loudly, too many times, and of course got called by the ER. (Note: even more certainly than the taboo against saying “quiet night” is the rule against walking into the ER without having been called; it’s just asking for trouble, and you’ll always get what you ask for. I was going to look for some ivs to start, but instead I got this.)

It was messy, nasty, bloody, bits and pieces hanging out all over the place. I didn’t particularly enjoy that part of it, but with the patient and family looking so horrified, it’s not too hard to keep calm, act like you’ve seen it all before, and try to normalize it for them by showing that you, at least, are not disturbed. The really bad part was that the poor guy had just essentially lost his hand; not all of it, but it won’t be much good to him after this, and he knew it. He won’t be able to work, not as he’s used to, and he knew that, too. And what could I say to help with that?

To my surprise (after I’d gotten started, I remembered that back when I was doing plastics, I never managed to get a digital block to work), my digital block worked very well, right off the bat. (injecting local anesthetic in a few exact spots at the base of the finger to specifically numb the digital nerves that run on either side of the finger, rather than having to put anesthetic all around a large injury) I guess I’ve learned something about needles and anatomy since July. I think I did a good job for him, but it’s hard to feel satisfied, considering how un-useful any kind of a good suturing job is to him.

Right when I finished, and was starting to work an another hand consult in the ER, a nurse stat paged me from the floor: “There’s bright red blood pouring out of the patient!” She sounded so panicked I didn’t try to figure anything out over the phone, just asked her to hold pressure, and ran up there. There was no bright red blood, just a small pool of brownish fluid, and the patient sitting there shaking his head. “I feel just fine, it’s nothing, I told her that, I don’t know what y’all are so excited about.” After investigating a little, I agreed with him, and went back to the ER. I mean, the difference between bright red and dark brown is fairly clear, don’t you think? But at least I got good practice, running through in my head what I would need to do if it was real. And one should never complain about a patient not bleeding.

I was being cocky, daring the ER fates, by talking about being bored. I learned my lesson for the month: bored is good.

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