Patient #1: Middle-aged lady, with pretty curly hair, but a very deep voice, a shaved face, and generally a masculine body shape (overweight masculine, which is even worse!). She had started to have these symptoms a couple years ago, and went to an endocrinologist, who worked her up appropriately, and determined that she had a high level of testosterone in her blood. There’s only two places that could be coming from: ovarian tumor, or adrenal tumor. Ultrasound failed to show any ovarian abnormalities. So, she had a CT scan, which of course showed a small adrenal mass. Very straightforward so far. It’s the next step that escapes my comprehension.

The endocrinologist then spent two years on attempted (and failed) medical management before referring her to a surgeon. She had an obvious lesion, which grew very slightly over that period, which was almost certainly the cause of her very obvious and, I would imagine, embarassing and handicapping problems. So why on earth would you wait more than a few months before moving to the definitive treatment, adrenalectomy? She said the endocrinologist had wanted to avoid her having to have surgery if at all possible. The laparoscopic removal of the gland was scheduled for 1.5 hours. From the moment she went under anesthesia, it took the experienced surgeon literally only 30 minutes to extract the gland and the small tumor hidden inside. 30 minutes. After she waited more than two years, looking like that. And now we have tissue, and can get a definitive pathological opinion about whether it’s benign or malignant.

The surgeon separates his patient from disease.

Patient #2: This story was told to me by the first “nice” female surgeon I have met, a resident. The other female surgeons, residents and attendings, I would rather not imitate completely. Her, I want to be like. She smiles, and listens to her patients.

A while back, she was on the ICU team, day shift. One night a young man was admitted with a transcranial gunshot wound. By definition, unsurvivable. The night team, knowing him to be doomed, had put him on 50cc of iv fluids and stuck him in a corner of the ICU, obviously expecting him to die within hours, on the next shift. As the resident was hurrying through the ICU to do a procedure on another patient, the young man’s nurse caught her, saying he was hypotensive, and could she do something about it. The resident reflexively ordered a one-liter normal saline bolus. A few minutes later the nurse paged her urgently: the blood pressure was now 40/–. The resident hurried over to the room, without really thinking about which of her many critically ill patients was in it. Finding only one peripheral line, she started a central line, pushed fluids, placed an arterial line, started pressors, and generally spent the rest of the day pulling the young man out of the jaws of death. He survived that day, although when she had time to think she could see gray matter in the dressings on his head. For the next two months of her rotation, she watched over him, in spite of the unenthusiastic attitude of the night time. She closed the defects in his skull, and later got the neurosurgeon to do a ventriculostomy when he developed hydrocephalus.

Every day on her rounds, she would walk into each patient’s room, call their name loudly, and ask them to squeeze her hand. Given the nature of surgical ICU in a trauma center, she hardly ever expected or got a response. But one day, she took the young man’s right hand, and made her usual request. To her utter astonishment, he lifted his left arm across his body and squeezed her hand firmly. Eventually he recovered extensive use of the left side of his body, and was definitely alert and responsive. Currently he’s in a rehabilitaton/nursing home, and she checks on his follow-up CT scans every few months.

So, he’s not in great shape; but he’s not dead, either.

Never give up.

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