Cut On The Dotted Line

I’ve been trying to avoid talking about health-care reform (or deform, if you want to be accurate) on here, because it makes me so angry that I’m virtually speechless. I’ve also stopped talking about politics with my liberal friends at work. I used to enjoy a friendly debate, but there’s nothing fun about the looming disaster.

I can’t not talk about this any more. I just opened a mass email to all the physicians at my hospital, informing us that, in addition to compazine (a very basic anti-nausea medicine; cheaper and more effective than zofran, and less sedating than phenergan; my go-to drug for post-op nausea) and some iv narcotics, and antibiotics, there is now a national shortage of propofol (the fast-acting sedative used to induce anesthesia for a general case, used as almost the sole agent for a conscious-sedation outpatient procedure, and relied on heavily to sedate ICU patients, because its very short duration of action means you can turn it off quickly to check for neuro status, and trials of vent weaning, and get it back on quickly if needed), and we are going to be using the European variant, whose key features are that people who are allergic to peanuts can’t have it, and it doesn’t have the same anti-microbial agents built in, meaning it’s more liable to acting as a culture tube for bacteria.

I can’t see any explanation for this sudden, simultaneous shortage of all kinds of basic drugs (which I have never seen before in my career; one at a time, maybe, and usually more rarely used drugs) than that pharmaceutical manufacturers are scared stiff of the antics in Congress, and are trying to cut their losses by not manufacturing surpluses when they can’t tell if they’ll get paid properly in the near future.

In other words, it’s starting to feel like a third-world country (or maybe just Europe) and they haven’t even settled on which gigantic, mysterious, debt-riddled, unworkable socialist plan they’re actually going to force down our throats. (Anyone else seeing this phenomenon too? Any less depressing explanations?)

60% disapproval rating across all polls, and it’s still full-steam ahead? Who still thinks Obama gives a rat’s — what the people really want?

Although I have to say, since a majority of the American people were idiots enough to vote for this traitor, after having heard him advertise his socialist agenda loud and clear for a year’s worth of campaigning, it’s their own fault that he’s now giving them exactly what he promised. (And I say traitor because I mean it, in the sense of someone who’s committed to the destruction of Constitutional government and the traditional American way of life, and perhaps even national security. Think KSM trial in New York.)

If any non-medical people are reading this, and if you’ve been wondering what the medical profession thinks of Obamacare, I have two remarks for you: the AMA does not represent us, and we haven’t been screaming simply because we’re too busy taking care of patients, and too despairing of being able to stop this railroad crash, to try to express our fear and disapproval. (And a minority of us are socialists, don’t ask me why.)

Guys, this is how freedom is lost: we’re celebrating Christmas, we’re not watching, and Obama and his socialist cronies in Congress are about to transfer 15% of the national economy to government control, after having already taken banking and finance. . . this is going down fast. I’m glad I got to at least see America as a free nation, although I guess I won’t get to spend much of my grown-up life in that country. . . If I wanted socialism and multiculturalism gone crazy, I would move to Europe. . .

Merry Christmas.

It’s starting to dawn upon me that all the chiefs and attendings I’ve found very annoying or stressful have actually been teaching me a great deal. Most of them, because it was their personal demand for excellence and thoroughness which was irritating me; a very few, because their laziness was forcing me to take more responsibility for being the thorough member of the team.

Too bad that it usually takes me six months after a rotation to realize what any particular chief or attending taught me.

But I recognize now that my regard for getting some degree of social history; my attention to looking at all the available imaging; my goal of knowing absolutely all the details of the medical history before calling the chief or attending; my thinking about electrolytes in the ICU; my thinking about DVT prevention – they all came from chiefs and attendings whom I found nearly intolerable at the time – because I wasn’t yet prepared to think that hard or that thoroughly about “only” a surgical patient.

Now if I can just think of that when I’m getting annoyed at someone. . . what is it that they’re teaching me?

I remark on the above, in order to avoid relating in detail how extremely annoyed I am at an ER resident and attending, who called us ten minutes before signout with a claim of appendicitis, on a college-aged female, without obtaining a white count, a pelvic exam, or a CT scan. I’ll grant that the CT scan is probably unnecessary. But they seriously seemed to expect us to book the patient for the OR without knowing any lab values, and without anyone having done a pelvic exam. (She had pain, but no peritonitis.) Please tell me if I’m mistaken, so I can stop being annoyed at them; but in the real world do ER physicians call surgical consultants without either a CT or a pelvic, on a young, sexually active female patient?

(I’m sure they’re teaching me how to be polite to frustrating referring physicians. . . like the PCPs whose first test for gallbladder disease is the HIDA scan. . . I haven’t quite learned it yet.)

It’s been a while since I’ve had to realize that just because something looks easy doesn’t mean it really is. How many times I’ve watched from the sidelines as an attending and senior resident waded deep into the abdomen, hunting out a cancer or perforation and resecting it. For some reason, that particular endeavor, more than peripheral vascular surgery, or breast surgery, or bariatric surgery, has captured my interest. (The closer I get, I’m starting to question that interest, but that will take a while to sort out.) First I was impressed, then I started to think that it didn’t look that difficult, and surely I could do it, too.

So it has been my picture of the glory of being a senior resident to participate in a major abdominal case. I got one, once, as a second-year, but I was pretty lost, and mostly just assisting the attending. She did let me do a few key parts, and that has pulled me back for more; but I had never really done such a big case.

Until last week. The chief was scrubbed in a Whipple, so I got the colectomy. Which was fair, as I had been rounding on the patient for the last week, as the attendings discussed back and forth whether or not to proceed with surgery. The indication was a little uncertain, and the patient was far from being a good operative candidate. Textbook, in fact, for who you should go to all lengths to avoid operating on. Finally, though, circumstances forced our hand, and we decided to go ahead.

It was a little bit of a rocky start when, while anesthesia was intubating the patient, and the attending and I were reviewing the CT scan, he asked me, “So how many of these have you done?” I’m a bad liar. I hesitated for a second. “A few.” He raised an eyebrow. “Well, one actually – and a couple more, laparoscopically, on pigs.” He started laughing. “Next you’re going to tell me, none, but you dissected it in anatomy class first year of med school!”

I was kicking myself for once again being too truthful for my own good, (such a fine line between endangering the patient by claiming to know how to do something you don’t, and destroying your chance of getting to practice by admitting to too much ignorance), but when we had all the drapes up, and the suction and bovie cords thrown off, the attending, hardly glancing in my direction, said, “Let’s start” – and the scrub tech handed me the knife. First time any attending ever let me set out on my own private expedition, as it were, to get into the abdomen. No directions, no comments, as I started cutting down to the fascia; just a minimum amount of counter-traction.

It only got better from there. He discussed the next steps with me as though I had any idea or say in the matter, and then let me do virtually every bit of the work, for the next several hours. And it was work. I had thought holding a retractor for hours at a time was hard work. Not much, compared to trying to hold back six feet of intestines with three fingers, spread the mesentery with the other two, and cut with an accuracy of millimeters with the other hand. And at every step, the thought that if my hand shook, or I misinterpreted the nature of what I was looking at (harmless fat, vs. a significant vessel), I could kill the man who had put his life in my hands.

I was tired, and ready to be done a good while before the end; but of course the most significant parts – the anastomosis, and the fascial closure come at the end. The idea of doing a couple of these a day – and maybe more at night – as early as next month, and certainly for years afterwards, is a just a little bit staggering. (And I now have a lot better understanding of what the attendings and chiefs have been complaining about when they discuss the difficulty of operating on obese patients. Even in a person who’s only moderately obese, the weight and depth involved in abdominal surgery, and the strength needed to work against it, is significant and exhausting, and the visualization is frustratingly poor.)

But everything comes with practice, right? And what triumph when I found the right plane, when the anastomosis went together, when the skin was closed, when the patient woke up (and was still alive a week later, proving that the textbooks don’t have the final say).

A call-night story:

Sometime after the third unsuccessful code, and after walking the intern through a line in the ICU while we were both being paged by four or five separate nurses for patients with increasing abdominal pain/no urine output/difficult to arouse/heart rate of 150, we were admitting another patient in the ER, when the ER radios started chattering, and then people started walking up to me (the charge nurse, some ER residents, the tech who’s best at getting ivs on hypotensive patients): “Alice, did you hear yet? We’re getting a ruptured AAA. It was exciting the last time we did this together, huh? We’ll make sure to give you a heads up when the helicopter gets closer.”

The intern was also excited at the prospect. I used to be excited. By now, though, ruptured AAAs are no longer new and thrilling, they’re old and stressful. I would be just as happy not to be the point person for coordinating the response, and finding out if I can move things fast enough to save a person’s life. (I am still looking forward to actually being the lead resident on my first open AAA; probably that won’t be as great as I expect, either.) Called the OR, called the ICU, made sure that the ER had already told my attending what was happening. Then I ran upstairs to swing through the ICUs quickly, check on my hypoxic vent patients (solved by turning everyone’s PEEP up), and warn the nurses to ask quickly if they needed anything, because we would be unavailable for a while.

Back in the ER, five minutes ahead of the helicopter; the charge nurse came up to me again. She’s not usually very cheerful, but I think there was a lot of adrenaline going around, and she was almost smiling. “Alice, I just want to let you know, we brought a patient back with a cold leg. The ER staff haven’t seen her yet, but I thought you would like to know. She’s in room 10.” I had time for one quick look at the cold leg, which wasn’t too impressive. The patient was a frequent flier on the medical services, and vascular surgery had often been consulted for her legs, but never felt moved to intervene. I decided it wasn’t worth spending time on right then.

The AAA patient arrived: intubated, unresponsive, pale, unable to get a pressure, everyone in the room frantically feeling for pulses, unable to decide if we actually felt them or not. No time to waste. “Don’t worry about monitors or blood draws or better access – let’s get up to the OR and sort it out there.” We ran (as fast as you can when you have to wait for an elevator), and soon arrived in the OR. Anesthesia was not completely thrilled with our plan, which was to move the patient on to the table, scrub while they started inhalational agents, and then let them figure out iv access (only one or two peripheral ivs so far) and blood pressure monitoring (none so far) while the attending and chief resident started cutting. The anesthesia staff were good, though; by the time the surgeons were down to fascia, the patient had a central line and an a-line started.

I left an intern to scrub in and help retract (remembering how thrilled I’d been to have that job once), added his pager to my collection, and went back to look at the cold leg. Now 45 minutes later, it was clearly cold and pale. But given the patient’s complicated medical history, and the number of times I’d been consulted for a cold leg (on this particular patient) which turned out to be a non-issue, and given what was happening in the OR, I couldn’t recommend immediate surgery. So I called the radiology resident: “This patient has a cold leg. You could probably do thrombolytics, and in any case you could give us a definite diagnosis of where the obstruction is. Get your attending to come in, right now. My attending wants this done. He’s scrubbed in a ruptured AAA, don’t make me interrupt him to tell your attending to come in.” (Radiology and vascular surgery have a semi-complimentary, semi-adversarial relationship at my hospital. Friendly during daylight, but if you want a procedure at night, you have to dig in your heels and scream bloody murder. Sometimes it does come down to the vascular attending calling radiology and throwing his weight around.)

They came in, and it was a good thing they did, as the angiogram showed a lesion I hadn’t entirely expected. It still required surgery, but by then the AAA was stabilized, and the attending could pay attention, and started a second room.

Not a big deal, really, but I took great pleasure in treating that cold leg all on my own, without talking to the chief or attending till it was all settled; and a little perverse pleasure in taking my attending’s name in vain to get the necessary procedures done.

At the end of the day, all the patients and all their legs were still alive, which was a little astonishing. The only people who seemed to be in danger of collapsing were the vascular attending and chief resident, who had been operating for nearly 24 hours straight, and still had no end of their duties in sight. I don’t know whether to be excited or scared that I’m little more than a year away from that role.

One of the more unsettling experiences of my surgical career to date; and I didn’t think it could get any worse than stumbling through an erroneous CT scan reading during M&M:

I was doing a laparoscopic case (which is enough of an oddity in itself: the number of cases I’m getting this week would be going to my head, if I weren’t so overwhelmed with work outside of the OR that even these longed-for operations seem like a burden). First, one of the most senior attendings in the program wandered in, before we were even prepping, and started quizzing me about what was wrong with the patient, and why I thought so.

Then, after we got started, yet another attending came in; so I had three attendings watching me struggle through a laparoscopic case I had never done before. Of course they had a few helpful pieces of advice each, as well as the attending who was actually scrubbed on the case. Helpful comments like, Why don’t you just flip that piece of bowel over there, you would see so much better; go on, flip it over. (Yes, sir, I would be perfectly happy to, but I can’t seem to make the grasper go there. . . ) Almost more disturbing than them commenting, however, was them just watching. I couldn’t figure out what they found so fascinating. The case itself I didn’t think was that remarkable. It was new to me, but by no means new to the annals of surgery. And they certainly weren’t watching for the pleasure of admiring smooth technique. I thought it was painfully slow going, and I was the one doing it, which means it must have seemed glacially slow and awkward to everyone else. I got the impression they were waiting to see when I was going to tear the bowel. . . I almost respect their restraint in not saying so out loud. . .

On the other hand, that gave it a particularly triumphant feeling when I finally had all the pieces straightened out, and the problem was fixed, and I had done it nearly all myself.