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.

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…”