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.