Monthly Archives: April 2013

You, Too Can Be a Writer!

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~first posted 21 Dec 12

I’m sorry, but I am of the opinion that writing is not all that difficult. I know, that sounds wrong. We are all avid readers, we live in awe of the great books we have read over the years. As individuals and as a society, we pay great respect to our authors. They are constantly on Fresh Air, The Colbert Report, The Daily Show, Sixty Minutes–hell, they’re everywhere. It’s like they’re superstars, even though most are not all that photogenic and many mumble a lot. But we love them, one and all.IMG_0641

We love them, even though what they do isn’t all that difficult. I presume that they are caught up in the whole cult of the mysterious, creative artist thing we have in this country (though not to the degree they have it in France, say, or Sedona). I can assure you, however, that what you do for a living every day is much more difficult, and I say that without being completely certain what it is that you do. It’s easier, believe me. I bet that at your job, you don’t get to show up whenever you like, take a nap whenever you like (writers call this story development), grab a snack whenever you like. You probably can’t perform your job half-drunk or recovering from a bender (admittedly, I’m making some assumptions here; like you’re not a NY State Supreme Court justice). But the writing part, I hear you protesting, the writing is hard. Actually, it isn’t. If the writer can’t think of the right word, they have all kinds of reference books he can consult to help find it. If you write something really awful, they let you go back and rewrite it as many times as you need to–kind of like going to Yale. Hell, you don’t even have to be a really good speller–chances are they’re going to hire somebody to fix all that stuff anyway. I have to tell you, writing really isn’t all that hard. Certainly a lot easier than trying to get a half-trained surgical resident through the removal of a tumor from some patient’s liver without cutting open something that’ll make a big mess. I know, I’ve done both and believe me, the surgery thing is way harder. And you have to stand through the whole thing.

No, the writing thing is pretty easy. Even the hardest part–the part where you come up with the idea–is pretty straightforward. You’ve done it, I’m sure. You’ve had great ideas for a novel. You’re living with a schnook that’s more of a character than you find in most novels. You may have even lived through one or two things that would make a great story. You’ve told people about it, but mostly while you were pretty drunk at a bar that was so loud that she wasn’t really listening but just nodding and smiling to be nice. You could write a book.

But you haven’t. You should you know. It’s not that hard.

Evidently, My ICU Has A Helluva Skylight

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True Stories From The Front Lines Of Medicine

Patients die.  It is a sad fact of life for all physicians, but particularly acute for us surgeons.  When I operate on an individual, they have entrusted me with an incredibly personal, invasive, singular interaction; an interaction that is intense and unique. Like up to my elbows in their innards kind of intense and unique.  As such, whenever one of my patients dies, it is a personal loss for me, a loss that one never really gets over.  As I sit here, I can see the faces and hear the voices of literally scores of individuals, young and old, men and women, with whom I have sat, and held their hands, promised them that I’d do my very best for them, and watched as they died, despite my efforts and promises to the contrary.  And then went to tell their husband, or wife, or father, or mother, or child that their loved one was dead, and I was sorry.  It happens.  For some reason that I’ve never figured out, though, only the nice patients die.  The really irritating, obnoxious ones never die.  Ever.  There’s a lesson in there somewhere, but one you probably shouldn’t share with your children.Minolta DSC

About six years into my practice as a busy academic general surgeon, I saw an elegant, elderly gentleman in my office in consult, Mr. Smith.  He was 81 years old and sharp as a tack, well spoken and funny.   A recent colonoscopy performed to evaluate anemia had discovered a bulky cancer in his colon, just above the rectum.  He was referred to me for surgery.  I sat with him and explained the situation, the nature of the surgery that I recommended, the four or five days he’d probably need to spend in the hospital afterwards, the nature of his anticipated recovery.  He was accompanied by his two adult children, who seemed more concerned and put off than their father; each of which asked appropriate and intelligent questions.  I assured one and all that, despite the diagnosis and the gentleman’s age, I thought he should do well and had an excellent chance of being cured from his disease.  We scheduled the operation.

The operation, like most, went very well.  The tumor was indeed large but without invasion into adjoining organs or obvious metastasis.  I successfully maneuvered the senior resident scrubbed with me away from cutting the ureters during the dissection.  Blood loss was minimal, the tumor removed smoothly, the bowel’s continuity restored.  The anesthesiologist was impressed with the old man’s resilience and heart, having turned not a hair throughout the procedure.  As was common practice, however, I directed the residents to admit the gentleman postoperatively to the Surgical ICU, just to be on the safe side and monitor him closely.  You learn quickly that the frail and elderly patients do very well if treated well, but they don’t take a joke very well.  One complication, the kind that more robust patients will tolerate and overcome, will often lead to this type of patient leaving the hospital by way of the loading dock.  So, the SICU for a day or two, just in case.

That operation had been my first of the day.  I completed my list of surgery and donned a white coat over my scrubs to make evening rounds.  I had already rounded early in the morning with the residents on all the inpatients on my service, so evening rounds were limited to those I had operated on earlier or that I felt would benefit from a second look before I went home for the evening.  My last stop this evening was to the SICU to visit my nice, elderly patient from whom I had resected the colon tumor that morning.  I entered his room to find the gentleman hooked up to all the usual devices, the monitors beeping happily.  The patient was lying in the bed and appeared perfectly comfortable, his eyes open and staring at the ceiling.  I smiled and greeted him by name, but he ignored me.  I didn’t recall him being hard of hearing, but there was a lot of noise and distraction from all the machinery in the room, so I wasn’t surprised by this.  I spoke more loudly, asking him how he was feeling and assuring him that the surgery had gone just as planned, that the tumor had been removed completely and without difficulty.  He ignored me the whole time, continuing to stare at the ceiling.  I grew quite concerned and finally shook him gently by the shoulder and called his name again more insistently until, finally, he took his eyes off the ceiling and looked at me.  He smiled, recognizing me and acted like I had just arrived.  I repeated that the surgery had gone well.  He just nodded and went back to looking at the ceiling.  This was starting to piss me off.  I mean, come on, just a quick “Thanks, doc,” would do.  A little acknowledgement of an effort well done, another life saved–though, of course, it’s just my job, you know, just what I humbly do each and every day.

“Mr. Smith, are you okay?” I finally asked, irritated.  “Yeah, fine, doc,” he says, still not taking his eyes off the ceiling.  “What are you looking at?” I finally ask, looking up and not seeing anything more interesting than faded ceiling tiles.

“Heaven,” he says, smiling.

“I’m sorry?  What was that?”

“Heaven.  See?” he says, pointing up.  “I see heaven.  And angels.”  He’s smiling, goes back to ignoring me.

“Stacy!” I yell out the door.  Mr. Smith’s ICU nurse, Stacy, comes running in.

“Something wrong, Dr. Geller?”  She can see I’m upset.

“What did you give this guy?”

“Nothing, Dr. Geller.  I was just in a few minutes before you, asked if he wanted something for pain.  He said he was good, I didn’t give him anything.”

“You gave him Demerol, didn’t you, Stacy?”  Demerol was notorious for giving elderly patients hallucinations.

“No, I didn’t, Dr. G.  Why, what’s wrong?”

“Mr. Smith is looking at heaven up there,” I say, pointing.  “And angels.”

“Oh.”

“Yeah.  Oh.  Maybe you can check to see what they gave him down in Recovery, before he came up.”

“That was before noon, Dr. G.  Don’t think they gave him Demerol.  I’ll check, though.  Anything else?”

“Yeah.  Everything. Get everything, stat.”

“Huh?”

“Stat, Stacy.  EKG, blood gas, complete metabolic panel, CBC, chest x-ray.  Now.  And get the ICU resident, tell him I need him in here, please.”  I start to examine Mr. Smith while he continues to smile beatifically at the ceiling.  ICU resident arrives, asks what’s up.  I explain that Mr. Smith here is seeing angels, which I believe is not a good sign.  I would like him to pay particular attention to my patient tonight.  Please.  No problem, he says, in that special resident’s tone of voice that implies that I’m an idiot.  Which I don’t mind, as long as he watches my patient.

Of course, Mr. Smith’s exam is completely normal.  His vitals are perfect.  His abdomen is soft, his incision clean and intact.  Every test comes back perfectly normal.  Mr. Smith is still smiling at the ceiling as I throw up my hands and head home.  He doesn’t say good night.

I’m awakened by my beeper at 3 AM flashing the STAT PAGE signal.  I don’t even look at the number, I know it’s going to be the ICU.  I pull on my clothes and drive like a crazy person to the hospital.  Judgmental ICU resident and Stacy are busy coding Mr. Smith.  Billy, the former college football star turned ICU nurse, is doing the chest compressions.  Who’s the idiot now, huh?  “What happened?” I ask, examining Mr. Smith’s belly.  Which is still perfectly soft.  His incision still looks great.  Only problem is the guy has no heartbeat.

“No idea,” overconfident resident and Stacy say in unison.  “He was fine ten minutes ago.  No problem.”

“Hold compressions,” I say to Billy, watching the monitor. Nothing.  “Call it.  What time?”  I hadn’t put on my watch.  [Brief Aside:  If you have been following this blog, you have probably already figured out that you really do not want me running your code.  Really.]   I leave to wash my hands and call Mr. Smith’s children.  The daughter thanks me (next of kin always thank you when you tell them their loved one just died) and says she and her brother will see me in the morning.  I feel like crap and go home to go through my usual postmortem ritual at 4 am of sitting at the the kitchen table, eating lots of cookies and milk as I try to figure out just how I screwed up this time.

The next morning I sit down in the conference room with Mr. Smith’s children.  I feel awful.  “I’m so sorry about your Dad,” I begin, but they cut me off.

“Please, Dr. Geller, don’t be upset.  Dad was fine with it.”

“I’m sorry?  Fine with what?”

“Dad told us he wouldn’t be coming home.  He made all the arrangements.”  I’m just staring at them, trying to get my mouth closed again.  “Really, Dr. Geller.  Please don’t be upset.  We really appreciate everything you did–”

“Killing off your Dad, you mean?”

“No, not at all.  Dad really liked you and I know he’d tell you that he really appreciates everything–”

“If he were still alive, you mean?”

They nod.  “Exactly.  We’re good here, Dr. Geller.  Really.”

Just wish I was.

Mommas, Don’t Let Your Babies Grow Up To Be Surgeons

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There is a reason surgeons are generally disliked by other physicians.  And a lot of other people, too.  A fair percentage of us are assholes.  While disagreeable surgeons may be easily found in every field of surgery, it is universally agreed that the biggest assholes are thoracic surgeons.  There are many reasons for this, generally relating to the type of person attracted to a program that requires every-other night call for upwards of seven years.  There are other reasons, too.IMG_0122

As a senior medical student, I considered myself hot shit.  I was smart and extremely hard working–in other words, I had no girlfriend.  As a hotshit senior medical student at an institution that considered itself to be the world’s best medical school, and destined in my mind to be a famous surgeon, I felt compelled to do an elective rotation on the thoracic surgery service at the University Medical Center.  The audacity of such a move cannot be overstated.  This was undoubtedly the most demanding rotation a student could elect.  Actually, the term most often used by my predecessors was “abusive.”  My two housemates, at the time, were both performing elective radiology rotations in Hawaii.  They came back tan and able to surf.  Also, with a condition that required antibiotics and, for one of them, eventually required clandestine child support.  I never left the hospital.

The thoracic surgery service was run by a young, brilliant, academically-trained surgeon.  For many, many reasons, too many to go into here, I regard him, to this day, to be the greatest asshole the surgical world has ever known.  I spent two months on his service, rarely leaving the hospital except to change clothes.  He never learned my name.  The tone of the service was evident almost immediately.  On my first day, I was told to scrub in on a complex operation being performed by Dr. Asshole.  This didn’t faze me, as I had already completed two lengthy surgical rotations and felt at home in the OR.  In addition, I had spent the vacation time prior to this rotation reading everything I could about thoracic surgery and Dr. Ahole’s publications–all of them.  I told you, I was hot shit–and had no girlfriend.  Anyway, I scrubbed in and introduced myself to silent nods all around.  Dr. Ahole seemed at ease, bantering with the Chief Thoracic Surgical Fellow as the operation proceeded smoothly.  I was familiar with the procedure from my readings and quite knowledgeable regarding the controversies surrounding it, as well as Dr. Ahole’s writings on the subject.  As the majority of the operation was accomplished and the chest was being closed, I gently but professionally asked Dr. Ahole a question; an insightful, sincere, and well-meaning question.  The question was greeted by complete, cold silence.  During this silence, Dr. Ahole stopped working, carefully put down his instruments, and looked me straight in the eyes.  “Who are you?” he finally asked.  I reintroduced myself, it having been a full forty minutes since I last told him who I was.  At this, he gently shook his head, picked up his instruments, and went back to helping close the chest.  During the subsequent eight weeks of working with him, he never said another word to me.  Great guy.

During this rotation I became good friends with the Chief Thoracic Surgical Fellow (CTSF), a very decent individual, married with two kids, who spent every single moment for two years in the hospital.  Every few days his wife brought his kids over so that they could all have dinner together and the children reminded that their mom really wasn’t a single parent, meeting lovingly in the hospital cafeteria.  She also brought him clean clothes for office hours and conferences–every other moment he was dressed in scrubs.  He was a great teacher and mentor.  About three or four weeks into the rotation, I was scrubbing with the CTSF, getting ready for a very interesting procedure.  It was one of Dr. Ahole’s specialties and he did a lot of them, patients coming from literally all over the world to have him perform the operation.  Usually, Dr. Ahole would appear about thirty or forty minutes into the operation, allowing time for the CTSF to get the patient positioned and the chest opened with the Senior Surgical Resident currently rotating on the service.  On this day, however, Dr. Ahole suddenly appeared and started scrubbing with us.  He was in an exceptionally good mood, joking with the residents (and, of course, completely ignoring me).  Just before we’re all ready to quit the sink and head for the OR, Dr. Ahole turns to the CTSF and asks, “So, Paul, how long?”

“I’m not betting,” Paul, the CTSF, replies.

“You have to bet, Paul,” Dr. Ahole responds.

“I don’t think it’s right, Dr. Asshole.  I can’t bet you.”

“If you don’t bet, Paul, you might as well scrub out because I’m gonna do the whole goddammed case with whoever this asshole is (nodding at me), then.  You won’t touch the knife.  So, how long?”

The CTSF shrugs, “Fine.  Thirty minutes.”

“Great, thirty minutes, twenty bucks.”  And Dr. Ahole sweeps into the Operating Room.

“What was that?” I ask the CTSF

“Shut up.”  He followed Dr. Ahole into the OR, and I followed him.

Dr. Ahole, as Chief of the Division of Thoracic Surgery and a very busy surgeon, had his own operating room with a dedicated team of nurses and technicians.  He had been at The World’s Best Medical Center for quite a while and his team was exceptional.  As a testament to their experience and competence, whole procedures would often be accomplished without the surgeon ever asking for an instrument.  He would put out his hand and Stella, the scrub nurse, invariably slapped the exact right instrument into his palm without the great man’s eyes ever leaving the operating field.  In two months, I never saw her give him anything except the exact right instrument without so much as a fraction of a second’s hesitation.  Stella was a middle aged African-American woman, tall and soft spoken, who scrubbed on all of Dr. Asshole’s procedures.  The two circulating nurses on the team were just as dedicated and competent.  Every operation was like a beautifully choreographed ballet.  And there was never any doubt in the room about who was the principal dancer, maestro, and sovereign authority.

On this day, however, it was immediately apparent that something was up.  As Dr. Ahole dried his hands, he asked Stella how she was doing, and made small talk about her family.  “Just fine, Dr. Asshole, thanks for asking,” Stella replied, smiling.  I’d never seen him so personable.  Maybe my impression of him as the world’s biggest prick wasn’t completely accurate, I remember thinking.  “Everybody all set?” Dr. Asshole asked jauntily.  Everybody enthused their affirmatives, and the CTSF made the incision.

The operation was going great,  Dr. Asshole was letting the CTSF do most of the work and Paul was an extraordinarily skilled operator. Dr. Asshole was actually complimenting him on his technique.  About twenty minutes into the operation, Dr. Asshole, in a completely nonchalant tone and without looking up, asks Stella for a curved Satinsky clamp.  Immediately, Stella shot a glance at the circulating nurse.  The circulating nurse bolted for the door.  Dr. Asshole still had his hand out.

“Dr. Asshole, that clamp is not on my field.  I’ll have it for you in sixty seconds,” Stella stated calmly, though I could tell she had blanched above her mask.  “Is there another clamp that will suffice?”

Dr. Asshole stood up straight and looked aghast.  “You don’t have the Satinsky?” he asked, incredulous.

“Dr. Asshole, we’ve done this operation together over one hundred times.  You have never asked for the Satinsky before.  That clamp is not on the tray.  I’ll have it for you in  thirty seconds,” she responded smoothly.  She was right, of course.  I had, myself, scrubbed with him twice earlier in the week on the exact same procedure and he hadn’t asked for the clamp in question. I had no idea what was going on.

“My God, woman!” Dr. Asshole suddenly shouted.  “How the Hell am I supposed to do this operation without a goddammed clamp? Huh?”

“Is there another clamp I can give you, Dr. Asshole?”

Dr. Asshole reached over onto her tray of instruments, something that I’d never seen any surgeon do before.  The scrub nurse’s Mayo stand was her territory and sacrosanct.  It was almost as if Stella had reached over into the wound to pinch the heart.

“Just give me a fucking clamp,” he growled.  As he grabbed a clamp off of the tray in front of Stella, he knocked about twenty carefully arranged instruments crashing to the floor.  Stella’s eyes were wide above her mask, but she said nothing.  Dr. Asshole began to roughly dissect in the patient’s chest cavity with a long right angle clamp he had grabbed from her tray.  At  this moment, the OR door burst open and the circulating nurse skittered in, breathless.  She smoothly delivered the Satinsky clamp onto Stella’s back table with the practiced motion of a professional baseball pitcher.  Stella smoothly proffered the clamp.  “I have the Satinsky, Dr. Asshole,” she said flatly.

But at this point Dr. Asshole was loudly cursing into the wound as he roughly dissected in the chest.  Dark blood began to well out of the chest cavity.  Paul had become a statue.  He looked like he was in pain.

“Look at this, Stella,” Dr. Asshole nearly screamed.  “Now he’s bleeding, he’s goddammed bleeding because you don’t have the tools I need to do this operation.  This guy’s gonna bleed out because you didn’t think to have the tools I need.”

“I have the clamp now, Dr. Asshole,” Stella repeated.

“Too late, goddammit,” Dr. A snarled.  He grabbed the clamp from her and hurled it across the room, just missing the circulating nurse.  It clanged off the wall behind her.

Stella looked stricken.  There was a brief moment of silence as we all looked at the merlot colored blood welling up from the chest cavity.  Suddenly, Stella burst into tears.  She muttered something apologetic about having to step out for a moment.  She ran from the room, pulling off her gown and gloves.

The operating room was stone silent.  Dr. Asshole looked at the clock, then at Paul standing on the other side of the OR table.

“Twenty-four minutes.  You owe me twenty bucks, buddy.”

Eventual Rejection

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I’ll be the first to admit that I take rejection badly.  This trait is fine for a surgeon (general anesthesia is a great way to avoid rejection), but is a problem for any new, aspiring, delusional writer, such as myself.  So, today I received the following terse, fairly standard email of rejection:

Thank you for your interest; unfortunately this falls outside of my area of expertise. I wish you all the best finding the right agent and publisher for your work

.-Chris P*__________

I should note that this reply arrived exactly one year after my query submission.Minolta DSC

So, I replied thusly:

Dear Chris:

Thank you for the courtesy of your reply to my query from one year ago.  Congratulations on your recovery from the deep coma that prevented you from replying in a more timely, professional manner. During your  absence, and due to a lack of any evidence during the past year that you or your company actually functions as a literary agency, I and my friends at the DEA have been forced to conclude that the financial transactions masquerading as the activities of a valid agent actually represent a probable money laundering enterprise for a Colombian drug cartel.  You may anticipate further inquiries in this matter.

Again, thank you for taking such a lengthy and appreciative interest in my work.  I’m sorry that I have been forced, in your absence, to pursue another path.  I wish you luck in your future endeavors as a “literary agent.”

Sincerely,

Evan Geller

Which, of course, is yet another reason that I’m not “traditionally published.”

“Discoverability”: An Indie Author’s Publishing Parable

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~first posted 23 Feb 13

[In the manner of those times when you showed up to the lecture that everyone else had cut, and the prof spent the whole class complaining to you about the poor attendance and then was so ticked off he refused to give the lecture…]

You’re not reading this, because you don’t know who I am. You’ve never heard of me, or this blog. Yet here I stand, knee-deep in snow in the Amazonian wildlands, the wind howling about me, as I toil at chopping down this huge tree, a mighty oak of a tree; a damn fine tree, if I do say so myself. And then, finally, suddenly, the tree falls…

…without a sound.IMG_1110

The tree lies there, silent and still, as I stand above it, victorious and proud, sweating, with heavy axe shouldered, my boot atop its fallen trunk. Breathing heavily–falling trees alone in the woods is hard, under appreciated work–I take stock of the magnificence of the work I’ve just accomplished, somewhat chagrined that there isn’t a crowd of appreciative well-wishers gathering about to clap and congratulate me on having accomplished the dropping of such a big and important tree. Why is that, I wonder.

So I wait for a bit; but no, it seems that no one is coming. Or noticed. In the distance, I can see quite a few people milling about other, lesser fallen trees. I really don’t get it, those are like saplings compared to this sucker here. Those folks don’t even seem to know what they’re missing, as if they really don’t know much about trees at all…

“Excuse me,” I hear a small, plaintive voice say. I reluctantly tear my gaze from the other, more appreciated trees, and look down to see a very cute little bunny caught by a branch of my fallen tree. “Excuse me,” he repeats politely, “but I seem to be caught here by your fallen tree. I’m sorry to be a bother, but I never even heard the thing falling, otherwise I certainly would have avoided your tree altogether. Might I trouble you for a little help?’

He is so cute and well spoken! “What is your name, little bunny?” I ask, kneeling next to him. I scratch his head between his pink bunny ears, but he doesn’t seem to appreciate this much.

“Is that important?” he asks, a bit annoyed after the head scratching episode. “I mean, just to move the tree a couple of inches and let me on my way? Are we to exchange insurance information as well? Can I expect a card on Easter?”

“Well, I was just trying to be nice, is all.” He is so fluffy, I’m sorry my tree has trapped his paw. I feel bad.

“Nice? Nice would be watching out not to drop a tree on any innocent soul that happens to be passing by. Or at least calling out something before doing so; saying, oh, I don’t know, something like ‘Tim-ber’ or ‘yet another self-important freelancer tediously dropping a tree randomly in your vicinity.’ Something like that would be nice.” I look wounded. “Reed. The name’s Reed.”

“Reed? Reed Rabbit? Is your middle initial ‘R’?”

“No. And my last name isn’t Rabbit, either, it will shock you to learn, I’m sure. As I myself would be, if your last name isn’t ‘Pathetic Dumbshit.’ ”

“Oh. Sorry. Listen, since you’re here anyway, would you like to discuss the critical importance of my tree? Or why this is the most significant tree felled in our lifetime?”

“No.” I see the fluffy bunny struggling to free himself.

“Well, if I free you, can I at least ask you to nibble a bit of the bark here? You know, just take a little bit to get the taste of how marvelous this tree is? Since you’re here already? Just a taste?”

“I think not.” Reed struggles mightily at the entrapped paw, somewhat panicked now. He looks up at me, obviously concerned that I’ve made no move to release him. “Listen,” he says with a slight twang of desperation, “how about you release me and I’ll mention to everyone I meet here in Amazonia just how decent a chap you are? How about that?”

“Oh, so you will try my tree then?”

“No.”

“But then how–”

“Does that really matter? I’ll be on my way, you’ll be happy here with your twisted little bramble bush. I mean, look at this. It looks like a prop from ‘The Charlie Brown Christmas Special.’ Just lift the thing for a second. It’s the decent thing to do.”

I realize that the fluffy little fellow is right, though he seems a rather heartless little bunny. I stoop to lift the tree. “Maybe you could stop by my house here in the woods sometime, try my blog soup.”

“To be honest, I’d rather gnaw off my own paw.”

Lub Dub

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During my Chief Residency (fifth and last) year of surgical training, I was working at the large academic hospital for a three month rotation.  During this rotation, I was in charge of a general surgery service with an emphasis on oncology surgery.  This was a plum rotation for the chief, for we got to perform large operations just about all day, every day.Minolta DSC

While finishing a particularly satisfying distal pancreatectomy with my attending, my junior resident came into the OR, excused himself for interrupting, and told me that he had received a request for a consultation in the Medical ICU to “rule out acute abdomen.”  This phrase, when voiced by any member of the Medical ICU resident staff, uniformly portended disaster.  I instructed him to find the third year resident on our team and for them to go check things out.  I went back to closing with the help of the intern while my attending broke scrub to do whatever attendings did between cases.  Once closed, I left instructions for the intern to write postop orders and, donning white lab coat, took the elevator up to the MICU to check out the consult.

My residents were at the bedside of the patient in question and explained that, as expected, the gentleman was an elderly, sick-as-shit individual,  currently hanging onto the merest shade of life with the help of infusions of every medication the medical intensivists had available.  It was also obvious, from a cursory review of the patient’s medical record, that he had begun the process of dying almost ten days earlier due to impaired blood flow to his bowel.  Though that diagnostic possibility had eluded the medical intensivists, today the rather clear-cut evidence of full blown gangrene of the bowel had pushed them to think fondly of their surgical colleagues for assistance.  Almost any internist will call a surgical consult when the patient is screaming at the top of his lungs about how much his belly hurts.  Of course, the initial reaction to this event had been for the internists to promptly sedate, paralyze, and intubate the individual, six days ago.  Connecting the patient to a ventilator always makes the screaming stop.  Now that the patient had deteriorated to the point of imminent demise, and it was impossible to examine the patient or take a medical history, they had called the consult.

Though unable to perform at this point a meaningful bedside exam, my residents had reviewed the laboratory tests of the past several days, about eighty of which clearly indicated progressive gangrene of the bowel.  They had also reviewed the three CT scans which had been obtained during the past eight days, each documenting the clear progression of gangrenous changes of the bowel.  They also reviewed the medical student’s ICU admission note, cosigned but undoubtedly unread, that listed as number 14 on the differential diagnosis list “Ischemic gangrene of the bowel.”   My third year resident had circled that, written “You think?” next to it with a smiley face.  I instructed my team to get a consent for surgery from some family member and have him down in the OR after my next case.  I told them that if they didn’t screw this up, I’d staff the two of them on it and let my fellow Chief do the last case in my room  He’d be thrilled and they were thrilled at the prospect of doing a real operation.

Two hours later, I was finishing my next case when the intern came in to tell me the consult patient was in OR 7, being prepped by anesthesia.  I said great, good work, I’ll be right over.

I came into the OR just behind an EKG machine being wheeled in by the circulating nurse.  Mr. Really Sick MICU guy is on the OR table with an anesthesia attending and two anesthesia residents buzzing around him.  There’s a nurse anesthetist who looks about sixteen years old sitting at the head, working the controls.  I stand in the door as I watch one of the residents start to hook up the new EKG machine, a most unusual thing to do.

“What’s up?” I ask innocently, to no one in particular.

“EKG’s screwed up,” Anesthesia Resident Number One replies.

“Unusual,” I comment sagely.

“Happens,” he replies, supersagely.

“Is his pressure okay?” I ask.

“Can’t get a pressure off the cuff, too edematous,” Anesthesia Resident Number Two informs me.

“Hmmm,” I reply.  ‘How about the a-line?” I inquire, pointing at the monitor.

“Waveform’s damped, haven’t been able to flush it.  Probably kinked,” Number One again.

“Hmmmmm,” I reply.  I approach the patient and can’t help but notice that the second EKG tracing is not very impressive either.  I gently palpate the patient’s groin for a pulse.  Nothing.

“Excuse me,” I say to the nurse anesthetist, who is listening to the patient through an esophageal stethoscope.  She looks up and pulls the earpiece out to listen to me.  “Excuse me, but do you hear lub, dub?”

“What?” she asks smiling, pleasantly confused by my question.

“Do you hear lub dub, lub dub?  You know, like a heartbeat?”

“Actually, no,” she responds rather sheepishly, “Good breath sounds, though”–more brightly.

“Okay,” I announce loudly, making a show of looking at my watch, “I’m pronouncing at 3:42.  He’s dead.”  All motion stops.  Awkward silence.  Anesthesia attending sputters to life–“What are you talking about?”

“He’s dead,” I deadpan.

“What do you mean?”

“I mean that you have been giving anesthesia to a dead person for–how long have you been in the room?” to the circulating nurse.

“Twenty minutes or so,” she answers.

“Twenty minutes or so,” I conclude.  I smile.  I really shouldn’t have smiled.

Anesthesia attending goes ballistic.  “Call a code!” he yells as he starts to pull all the covers off the patient.  “Start CPR!” to Residents One and Two.  All hell starts to break loose.  “Get a code cart in here!”  Multiple anesthesia attendings and residents begin to flood in through various doors.

“Hey, come on,” I beseech, fairly loudly over the din.  “He’s been dead for almost half an hour–you’re going to start coding him now?”  Awkward silence re-ensues.  “3:42.  Dead.  Elliot–” to my third year, “call the next of kin.  See if you can get an autopsy.”  And I’m outta there, stealing back my case from my fellow chief resident.

Surprisingly, it takes a full two days before I’m told the Chairman wants to see me.  “You wanted to see me, Dr. W*?”

“Yes, Evan.  How are you?  How’s your lovely wife, Sheri?

“Great, thanks.  How’s yours?

“Great, thank you for asking.”  I’m looking at a report on his desk.  Upside down I can make out (all capitals) LUB DUB. Underlined twice, with quotes.   “Say, Evan, just wanted to speak with you about a note I received from the Chairman of Anesthesia.  You might remember a case from a couple of days ago…”