second chance

I admitted a patient from the ER one night over the holidays. The ER called with a CT scan showing diffuse pneumatosis, and the most obvious portal venous air I’ve seen so far. The patient himself looked far better than the scan, and was amazingly comfortable, considering that he had a heart rate of 140 and was already in acute renal failure. He was so comfortable that it was very difficult to persuade either my attending, or the patient, that he needed emergency surgery. (“Pain out of proportion to exam, Alice. You can’t tell me he has ischemic bowel and no pain.” I insisted, so we didn’t really lose any time, but it was a little disconcerting.)

As for the patient, that was the worst conversation I have ever had to have. Telling a family that someone died is easier. Telling a man who’s chatting happily that he’s almost certainly going to be dead within 24 hours is nearly impossible, either to find the words, or to convince the patient. I had to not only convince him that matters were this serious, but also discuss the option of surgery – his only chance of survival, but a very slim one, with a significant chance of a long ICU stay and major morbidities, if he did survive. (Some might say that with that CT scan, we shouldn’t operate. 1) You can see pneumatosis and portal venous air from a bad bowel obstruction, which can be salvageable. 2) He was relatively young, and with few comorbidities. We never did figure out what caused his ischemia.)

In between talking to him, I was calling the chief and the attending and the OR and the ICU, getting iv fluids and antibiotics running, and moving him to preop holding. Not much time. No sooner had I settled him in preop, with a nurse to watch, and the attending about to walk in, than the trauma pager started going off with multiple gunshot wounds, so I had to leave him. Three hours and several traumas later, I found him and the chief resident in the ICU. The operation had been completely unsuccessful; there was absolutely nothing to be done. His body was shutting down, and there was barely time to have the family at the bedside before he died.

I felt awful afterwards. Not just because it was the holidays, and we had lost a previously healthy man suddenly, but because I had spent half an hour talking to him about his death, and had never talked about what would happen to him after death. I had watched somebody dying, and had never even mentioned God or heaven or hell. Which meant that I did him exactly no good at all. He died, as I knew he would, and had to face eternity, and I hadn’t even mentioned it.

Yesterday one of the PACU nurses came up to me. (At night PACU and preop are staffed by the same nurses.) “Remember that man with the ischemic bowel who died? I went to the funeral home. I had to tell his family something he told me that night. He said, ‘I’m not worried about this, because I’m putting it in God’s hands. He took care of me when I had surgery 30 years ago, and he’s taking care of me now. If he wants me to live, I will; and if not, it’s all right. If I don’t make it through surgery, tell my family I’ll see them in heaven.’ ” I started crying in the middle of PACU. He’s safe, after all. I didn’t do anything I should have, but he knew better than me. Next time, I won’t make the same mistake.

(As for the nurse, I have a whole new respect for her, going out of her way to comfort not only the family, but also the other caregivers.)

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not just in the books

I had a very puzzling experience last night. The arrest pager went off, and I happened to be just one floor above, so I got there a good deal faster than most of the rest of the response team, several floors below. So when I arrived, it was just a few of the floor nurses and an aide. One was making a respectable (although to my mind not very successful) attempt at bagging. Another was doing compressions, and stopping every few seconds to look at the monitor. To me, the monitor looked like torsades immediately, the only time I’ve ever seen that rhythm in real life.

Finding myself the only doctor on the scene willing to talk (the interns had a deer-in-the-headlights look), I announced, “That looks like torsades. It’s a shockable rhythm. Where’s the defibrillator?” One nurse pointed out that she was attaching the pads to the machine, while the other two immediately contradicted me, saying that the rhythm was not torsades, or that it was not shockable. They kept doing compressions.

Clearly I need to learn how to talk louder in emergencies – that particular crowd-control voice which rides right over all the other noise, without being quite as energetic as shouting. (The first time I was alone in the ER with a bad trauma, I found myself squeaking quite shockingly. At least now I lower my voice, instead of raising it, to get control.) It took a little bit of effort to get them to stop compressions long enough to get a real read on the monitor, and strangely enough it was torsades (torsades de pointes, a particular type of ventricular fibrillation, where the waves alternate in height); in this case, it was a beautiful spindly pattern, completely classic (says me, the first time I’ve seen it). Then of course there was the matter of figuring out how the defibrillator worked (an area where I will freely admit that once I got them to go along with me, the nurses were better at the mechanics than I was). We shocked him once, and it worked almost immediately.

The entire event felt surreal. For one thing, torsades. I was starting to think they were purely a textbook phenomenon, like Janeway lesions and Osler’s nodes, antique entities that no longer visit us in real life. Then, the nurses. They were specialty cardiac nurses, twice my age, but seriously? They’ve worked with me off and on for two years. Why didn’t they recognize that it was at least some variety of vfib, and why were they arguing with me? And lastly, the defibrillator worked immediately. That made the whole thing feel like a badly scripted episode from ER: conflict between resident and nurses, and then the defibrillator working like magic. I was so surprised by that, it took me a second to think of what we ought to do next (intubate the poor fellow, who was still blue, despite a strong pressure). (And for icing, the interns standing by gaping at me and the nurses. Yes, it’s June. Yes, these were the old interns. Don’t ask any more questions.)

In any case, for all the chaos, it was the most perfect code I’ve ever been to, and the most perfect code I’ve ever run. So much nicer than the usual asystole arrests, where you can’t shock, just do compressions and push drugs and it never really works that well. Next time I’m going to see if I can not blank out when looking at the defibrillator.

(And yes, as various people pointed out to me later, the textbooks also say that magnesium is the appropriate treatment for torsades. To which I say, 1, I’m not going to discuss whether I remembered that detail or not; 2, in any case, in a code on a regular nursing floor, one has a much better chance of getting the defibrillator to work than of finding magnesium and pushing it fast enough to make a difference. Next time, we’ll schedule the torsades, and arrive with magnesium in hand. The discussion with the nurses was about the diagnosis, not the treatment.)

 

motivation

It was an extremely busy day. I did not stop running the whole time, and really the only reason I can think of why nothing bad happened was that the ICU patients had the good sense to keep in order. If one of them had gotten in trouble, the whole juggling act would have fallen apart.

There was an elderly lady with a huge abscess. I mean huge; I could fit my hand in it. I spent fifteen minutes draining it, feeling bad about hurting her, because it was so big I couldn’t possibly numb the whole thing up, so I had to do it with only lidocaine in the area of the incision, and the rest of it was relying on elderly ladies’ well-known capacity for stoicism. It was a really ugly abscess, too. It made me nauseated, and that’s hard to do these days. It smelled so bad I had a headache for the rest of the day, and I could still smell it – it had to have been imagination – after changing my clothes and showering.

Finally, when I’d used up several packs of gauze, plus towels and washcloths, emptying it, packing it, and then cleaning her up afterwards, she reached for my hand. “Thank you so much, honey. People have been telling me for weeks that they can’t do anything to make me feel better; that I’m too old to do anything, or that my heart history is too bad, or my lungs are too bad. You’re the only person who’s actually done something about the problem. God bless you.”

Well, by the time I saw her, it was impossible not to do something, so I can’t take too much credit for the action. But her smile was worth the whole ugly mess.

 

taking off the training wheels

Call last weekend was one of the wildest days of my career to date, including some events that I’m literally not thinking about because, despite my predilection for seeing how close to the edge of a cliff I can get without falling over, I don’t dare to examine those events in detail. And that was only the beginning.

The last consult of the day was for an elderly patient with peritonitis. She had multiple other comorbidities, making the idea of operating on her quite daunting. Nevertheless, as I’ve told the medical students many times, if somebody honestly has peritonitis, then they need surgery. So I had to explain to the family, who thought they’d come in to the hospital for just another bout of the stomach flu. The altered mental status, clammy skin, absent urine output and glazed eyes didn’t have the same instant significance for them that they had for me.

Once they agreed that, despite the risks, they would rather take the risk of death with surgery than the certainty of death without surgery, I had some more calls to make: the senior resident, to come in from home. The OR, who suggested that they had other cases running and perhaps we could wait a couple hours; which returns to the principle that real peritonitis means surgery right now if physically possible, even if that means calling staff in from home. (Perhaps it comes from so many years listening to my father the anesthesiologist making call after call trying to arrange anesthesia and nursing coverage for night and weekend ORs; I haven’t quite adjusted to being the surgeon, the one who declares that it needs to be done, and then leaves it to the OR team to figure out how to make it happen. Not to be authoritarian, but someone has to be the one to say that an emergency is an emergency.) And the attending, one of the older ones, who believes in rattling the juniors at all opportunities. He drilled me with questions (all the labs; the medical history for the last two weeks; recent imaging; why didn’t we do this or that test); and above all, are you really sure that this sick old lady has peritonitis – so sure that you’re going to put her through the risk of an operation. I stood up to him, but by the time he hung up, I was very glad to see the senior resident arriving, and equally impressed by the patient’s physical exam.

She did well – much better than I expected. She’s already extubated, ready to start eating, and looking ten times better than that night (when she was nearly ready to be intubated simply for respiratory distress, by the time we got to the OR).

That was the first time I’ve made a hard call on a patient needing surgery. Deciding that a patient with a moderate small bowel obstruction can have an NG tube and be observed for twelve hours, or that a child with a good story and a good exam has appendicitis, that a patient with a cold, ischemic leg needs intervention, or that someone with a perforated ulcer needs surgery – those aren’t hard; they’re cut and dried. This patient wasn’t straightforward at all. I was the senior surgery person in the hospital, and I dragged everyone in from home, and forced the family to make a difficult decision, based on my clinical assessment. I’m sure this story is not that impressive to any experienced doctors who may be reading, but it was new for me.

And next month I get to do that every single night. . .

 

a good reminder

There’s a certain patient population that surgeons see too much of: a particular personality type among lonely middle-aged females, who tend to develop excruciating (to them, at least) abdominal pain, and turn up in clinics and ER rooms with distressing frequency. All too often, what they’re really looking for is a percocet script to last them through a difficult week. Unfortunately, it takes some expensive scans/consults/scopes to rule out other problems. (There’s more to this scenario, but I don’t want to give too many details; there’s a reason for my cynicism.)

I spent the last year figuring out that these patients do exist, and that some people with abdominal pain are never going to get better until someone (either a determined intern, an attending tired of hearing about them, or an efficient case manager) puts their foot down and shows them the door.

Now I have to relearn the fact that just because a patient fits a certain profile, she is not necessarily without real problems.

Two patients, actually. The first seemed a classic instance of nothing to treat. She’d been calling the office for a few weeks, complaining of vague abdominal pain, with alternating diarrhea and constipation (this kind of alternating symptomatology often turns out to be simply “irritable bowel syndrome,” which to my mind is GI-speak for “I have no idea”). Finally she came in to the ER; the pain was worse, she simply couldn’t stay at home. A CT scan showed nothing at all, not even anything to theorize about. She spent a few days in the hospital; we shook our heads every time we discussed her on rounds, and couldn’t think of anything particular to do. Eventually she felt better and went home.

But the calls to the office continued, and a week later she came back in. The pain had started at 3pm – precisely – and had never let up since. The CT scan was still impressively benign. But this time she looked so miserable that we had to rethink our conclusions. Plus, being able to pinpoint the exact moment the pain started is usually a bad sign. She was taken to the OR, and found to have a small fascial defect, with a loop of ischemic bowel inside it. Apparently the defect was so small that it was invisible on CT. The loop had probably been intermittently trapped in there for the last month, and this time it was squeezed tight enough to be ischemic, and swollen enough not to slide out on its own. The next day she was a different woman: walking laps in the hallway, smiling, anxious to get back home – and refusing any narcotics at all.

A week later, we got one of our favorite consults. The only time worse than five minutes before evening signout is ten minutes before morning sign-in. Do we have time to see the patient before the chief arrives? Is it better to do a quick job on the consult, maybe miss something in haste, or appear uninformed at sign-in, and then go take more time afterwards?

The patient was a retired gentleman who had been admitted by medicine with complaints nonspecific enough that the ER didn’t even consider a surgery consult. Overnight, he’d complained of increasing abdominal pain. A CT was at length obtained. The radiologist discussed various “unusual findings,” but couldn’t pin down anything specific. Most people who saw him were unimpressed, since he’d been admitted with a smorgasbord of nonsurgical issues (headache, leg swelling, palpitations, etc). But when we finally got to go through the CT carefully, we recognized the most classic case of an internal hernia I’ve ever seen. (These are usually difficult to visualize on CT, and radiologists often don’t call them; it takes a surgeon who’s been dealing with the population prone to developing them for years to have any reliable interpretation of them.) He rapidly earned a trip to the OR as well.

Take-home lesson: just because the last ten patients I’ve seen with this medical history and these complaints had absolutely nothing wrong with them, does not mean that this patient has nothing wrong with him. Each patient deserves a completely fresh slate, and a ground-up approach.

 

prejudice

A few hours into a busy morning – the kind that always develops when, building on a string of slow days, I have a stack of journal articles to read and paperwork to do – I got a nonsense consult. Nonsense as in, all the surgery attendings in the hospital already knew about the patient, and had discussed her condition at length and leisurely among themselves. As a result of this consultation, spread over three days, they had decided that the one attending should officially consult the other attending. Which means his resident, that is, me, needed to go put an official note in the chart to let the poor medicine team which was babysitting this patient know that the surgical attendings have changed.

So my seeing the patient and writing a formal consult was going to contribute absolutely nothing to the patient’s care or to my team’s knowledge of her; but it had to be written.

It didn’t make me any more enthusiastic that the picture I got from the chart before going into the room was of a patient seeking pain medication. Sure, she had a couple genuine chronic conditions with biopsy documentation of their existence; but she was on a lot of narcotics, plus some valium thrown in. She had been on disability for years, even before this most recent, serious problem cropped up.

I was in for a surprise.

She was polite, pleasant, and a very coherent historian (first clue; real seekers try to muddy the waters). She was able to tell me all the studies that had been done, and gave me a timeline of her symptoms and the path to the final diagnosis.

I asked how long she’d been on disability, and all of a sudden she started talking. She’d been injured a few years before, but had kept busy up till last month taking care of her father, whose health had declined precipitously. Last month he died at home.

I didn’t have to say anything at all; she just wanted someone to listen. She told me about her mother’s poor health and inability to care for her husband, about how painful it was to watch her father getting continually worse. She told me about how he joined the army right after Pearl Harbor, flew several bombing missions, and was eventually interned in Switzerland, then came back to get married and start a family.

There was a lot more – his death had hit the family hard, and it sounded like the siblings weren’t relating to each other well now – but I wasn’t looking for holes in the story any more. No slacker takes disability, then works 24/7 caring for a dying parent. Most healthy people don’t do that much.

At the end of that talk, I understand why psychiatrists don’t believe in physical exam. After that much sharing, it’s rather anticlimactic to ask if you can listen to the patient’s lungs.

 

luck of the draw

This is getting better. I got to do another bronchoscopy today, and actually saw something useful (instead of just getting the scope jammed inside the tube and not being able to move; while the attending kept saying, “You see the carina? Go down the right side, ok, now go down the left side. . .” while I wasn’t actually moving at all, and then wanted to know why I wasn’t done already).

The rest of the residents want to know why it’s always my patients who need all the procedures. Somehow, I’ve managed to do almost all the procedures so far this month, without actually stealing anything from them. I wouldn’t mind if my patients would stop crashing, but I’m not controlling that. I need to make an effort not to pick up the sickest of the new patients every morning, so we can share the excitement.

At one point there were enough traumas coming in (as a general principle, men over 70 should not be allowed to climb ladders, and people over 90 should not be allowed to walk on stairs) that I was admitting by myself again. I got the sweetest little old lady, who very calmly coped with us running all around her in the trauma bay, and told me, “There’s nothing wrong with me, sweetheart. I know you need to check, but I’m really just fine. No, I never had any surgeries. I usually don’t come to the hospital, you see, until lately. No, nothing’s hurting me. I told you there’s really nothing wrong, you don’t have to worry.” There was something wrong (little old ladies over 70 always break something when they fall), but hopefully it won’t be too serious, especially since her first words, when I told her the bone was broken, were, “I’m not going to have surgery, ever, no matter what, so that settles it.”

The fun part was when her daughter came in to see her, and it turned out that I’d spent several nights, one night float month, dealing with this daughter’s post-operative complications. One night she’d have low urine output, another night an arrhythmia; then she got an ileus and was throwing up and I had to put in an NG tube; and so on and on, till I finally got off night float before she left the hospital. She was quite well now, and told her mother everything would be fine, she knew the doctor. It was sweet, but also a little daunting, that I’ve been in one hospital so long that I’m starting to treat families. I wasn’t expecting quite this much continuity in surgery residency.

 

denial

Surgery has no room for errors. If they happen, there’s nowhere to hide. You cut the wrong thing in the OR, and everybody knows about it. Even if it’s something as relatively simple as getting into the hernia sac you were trying to get around, everyone knows because you have to call for a suture to repair it with. Anything bigger is even more obvious.

When your patients die, everyone knows that too. What happened to so-and-so? Where’s the patient who was in that room? What’s with the blood and paper all over the floor? Why’s your attending so gloomy today (in fact why is the entire service colored grey)?

You also can’t hide in the sense of withdrawing from the life of the hospital. Just because one person died, there are still a dozen others needing help, even others with the same problem. That’s what’s really getting to me right now. One person died, and there’s another patient with an extremely similar problem, whom we simply have to operate on. It would be irresponsible not to – and yet it feels irresponsible to go ahead. Statistics say there was a 1% mortality rate, and that patient bought it – so really the next hundred ought to do great; but I don’t want us to do that same operation again so soon. It seems like tempting fate. I can tell the attending doesn’t want to, either. For a guy who doesn’t talk much anyway, the main way he shows emotion is by talking even less, and more inaudibly than usual (which is harder to deal with than another attending cursing and swearing). But he has to take the case. There’s no one else who can do it, and the other patient can’t wait.

I guess it would be more accurate to say there’s no room for denial. Errors, and inevitable complications, occur. The big thing is not to hide from them. You can’t be so insistent that there were no technical errors that you refuse to go back to the OR for postop bleeding. You can’t ignore an enterotomy and hope it goes away without you stitching it up, and admitting to yourself and the scrub and the circulator that something slipped. You can’t pretend that the patient didn’t die, and that if you don’t even think about a patient with that disease for a month, it will somehow undo their death.

(Which is why I hate euphemisms, especially at M&M: “The patient CTB (ceased to breathe).” Come on guys, we’re surgeons. The patient died, is what they did. They’re dead. That’s why we’re discussing it.)

I hate it when my patients die. Somehow it feels worse when I wasn’t there at the time, as though in addition to generally having let them die, I also failed to be with them when it mattered. At least I didn’t have to see the family. . . I can’t even think about them. I can say to myself, the person I was talking to yesterday is dead and gone. . . but I can’t bring myself to even imagine the family, how they received the news . . .

 

professional courtesy

I was fuming this evening, and the rest of the residents were tickled. They think it’s a joke, to see how much strong language I’ll use when I get upset. So far I only go in for colorful epithets; they’re waiting to catch some dirty words, which makes it dangerous to get angry around them.

One of the critical care consultants is driving me crazy. He interferes with my patients, and he shouldn’t, and I haven’t quite got up the nerve to tell off an attending from another specialty (and I rather doubt that it would do any good if I did; he strikes me as being very good at looking down his nose at anyone who tried it).

The last time I had to deal with medical consultants trying to manage critical surgical patients was in the burn unit last fall, and then at least I could tell myself that I knew nothing about critical care but what I was picking up from the nurses (if they reported something to me from overnight, I knew they considered that important, and I should pay attention), so I couldn’t possibly presume to criticize the medical folks. Now, admittedly, I am far behind a board-certified critical care specialist, but I do know more than I did then. I also think that spending a month learning to think like the most finicky doctor I have ever met, one of the trauma doctors who will spend an hour making sure that every single thing is perfect for one patient, has taught me something.

So, I (and my chief) object tremendously when this particular consultant (the rest of his group does it too, but he’s an egregious offender) tries to take over the entire management of a surgical patient whom he was consulted on either for vent management, or as a courtesy because the patient is in the ICU.

Today, without talking to anyone from the surgical service, he sat down with the family of a patient he’d met yesterday, and told them the patient was essentially brain-dead, and they ought to withdraw care, basically now. Then he ran into me inside the unit (I had just come up to have a similar, but perhaps more gradual and gentle, conversation), told me flatly that he’d told the family care was futile, and he expected “we will end up withdrawing before too long.” I was furious; I think there was smoke coming out of my ears. That’s my patient. I spent a month taking care of him, nursing him along, watching him slide out of my reach; I was heartbroken when I came back one morning and found him on death’s door in the ICU. I have talked to his daughter every day for a month. I know him; I know his family. He’s mine; or at least he’s my attending’s. This jerk met the whole group yesterday in the middle of a disaster; who does he think he is, to go telling them things like that, without talking to us? My attending or I should be the ones to say, We’re sorry, we failed, we couldn’t save him, he’s going to die, it’s best if you let him go. (And he’s not brain-dead; he’s not good, he’s not conscious, but he’s not brain-dead. I really hate it when consultants, usually critical care or neurology, try to call my patients brain-dead when they’re not.)

Grrr. I think next time I meet the guy doing things with my patients, I might say something; hopefully (in that grand British phrase) more in sorrow than in anger: “I’ve known this guy for a month, I’m really upset by his condition, and I feel like it would be more appropriate for someone like me or my attending, who have a rather longterm relationship with the family, to be the ones to break this news and discuss this situation with them. Now git!”

 

scalpels are sharp for a reason

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.