Before we started the third year of medical school, the clinical years, they had us do a workshop on breaking bad news. We had to (individually) tell an actor portraying a young woman that she had melanoma, and then help her deal with the shock of the diagnosis, and get her to understand a bit of the prognosis and the treatment plan. I did pretty badly, as I recall. I blurted out the news baldly, and then sat there, unsure whether to hold her hand, and unable to control the conversation enough to communicate anything else meaningful through her (very fake) tears.

I don’t know if I’m any better at it now, but it’s not for lack of practice. In surgery, there’s a lot of times when people come to see you, somehow not realizing that if they’ve been sent to a surgeon, they’re going to have surgery. Whether it’s in the office, or the ER, or a consult in the hospital, I’ve had a lot of conversations along the lines of: “We now know what the problem is, and you need to have surgery in half an hour/in two hours/tomorrow/next week. The risks of surgery include, but are not limited to, death, serious injury, abscess, wound infection, respiratory failure. Please sign the paper.”

That is of course merely an outline. Depending on how much time we have, I try to spend a little while explaining the diagnosis, and how it leads to surgery, so that it doesn’t seem like we’re recommending this out of the blue – that there is in fact a reason for the commotion. Then I explain what we’ll do during the surgery; depending on how much blood and guts is involved, I may edit this extensively. Then the consent, which always sounds bad inside my head; if somebody asked me to sign a paper accepting all those risks, I don’t think I’d cooperate.

The more of an emergency it is, the sicker the patient usually is, the less likely family members are to be handy, and the more of a rush I’m in. Usually, after calling the attending and the OR, I have half an hour to get the consent signed, have my note written on the chart, get blood drawn for type and cross, a last minute EKG if needed, antibiotics ordered (and call the pharmacy and explain that I mean now, not tomorrow), get the patient transported to pre-op holding, and a quick talk with the anesthesiologists about what we’re planning and what kind of lines might be needed. Plus answering all the other pages I’m going to get in the meantime.

So sometimes, like last weekend, it really does boil down to this (at the top of my lungs, because of course the elderly patients are all hard of hearing, more so under stress): “You have a very serious problem, and if you don’t have surgery you will almost certainly die very soon. You need to have this surgery, right now. But even if we do our best, there’s a very high risk that you will still die, or end up in the ICU, even on a ventilator, for a couple of weeks. Do you understand that? Ok, please sign.” (That was for mesenteric ischemia – dead gut, which had already been sitting around for a while. And then the nurses found the DNR papers, and I had to persuade everybody that since the patient had just insisted that they wanted to have surgery, and wanted everything done, the DNR orders were implicitly revoked, and it was ok to intubate for surgery. Why are DNRs always there when you don’t want them, and never when you need them? Fortunately for all concerned, our preop assessment turned out to be an overestimation of the seriousness of the situation, and the patient spent only one day in the ICU.)

Which is all to say that, as in my medical school days, I’m still trying to figure out how much time to spend commiserating and comforting, and when to move the conversation on to what our plans are. Sometimes it’s easier to have the pressure of the impending OR to set the timetable.

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