Coming this Summer:
They say the Devil’s greatest trick was to make us believe he didn’t exist. God’s greatest trick was to make us believe He did.
Coming this Summer:
They say the Devil’s greatest trick was to make us believe he didn’t exist. God’s greatest trick was to make us believe He did.
Every crisis chooses its heroes. The heroes do not volunteer for the role. Brave souls do not rush to the front line to save us. The heroes, ordinary folk until now, are plucked from their previous lives without warning, whether they are willing or not, whether they are ready or not. In this crisis, there are many heroes (see Heroes in Masks with Mops). Everyone who shows up for their shift—whether they be nurse, houseman, security guard, food service worker, physician, or one of the countless other individuals needed to care for the tsunami of sick COVID-19 patients overwhelming our hospitals–is truly performing an act of courage each and every day. The heroes for the history books, though, the heroes who will be remembered by their colleagues long after this plague passes, are the anesthesiologists, nurse anesthetists, respiratory therapists, and ENT surgeons who find themselves staring down this monster every day–some many, many times on a really bad day. These are the special people whom we will always remember with an admiring nod and a tear of appreciation.
The AIDS epidemic was the last plague that truly threatened US medical workers. While Ebola and H1N1 challenged us, neither of these crises presented a general threat to the health of our practitioners in this country. AIDS, however, during the terrible years of the late Eighties and early Nineties, killed our practitioners as well as our patients. We forget now, because of brilliant scientists like David Ho and countless others, who have given us effective treatments for HIV. But for several years, AIDS actually was the leading cause of death of people under age 40 in this country, the only time any disease displaced trauma from the top of the list. AIDS killed EVERYBODY it infected. And if the medical professional caring for the critically ill AIDS patient suffered a significant exposure, there was a definite possibility that they would die–horribly, because everyone with AIDS in those days died, horribly. Whole wards were filled with young people dying, horribly. Many AIDS patients developed severe intra-abdominal crises that required urgent surgical intervention. Surgery on these patients was fraught with the possibility of killing the surgeon, because these patients generally had extremely high viral loads at the time of their surgical crisis. This was the first time in memory when we had a national discussion about whether a doctor or nurse was morally obligated to care for an ill patient.
Doctors and nurses were dying. General surgeons, resident surgeons in training, orthopedic surgeons, surgical techs, and scrub nurses were at risk from needle sticks, blood splatters, intra-operative incidents of all kinds; significant or seemingly mundane, but now mortal injuries. Some surgeons refused to operate on HIV positive patients, hiding behind the argument that the patients were all dying anyway. This left the rest of us scrubbing on more and more of these dangerous procedures as others subtly deferred consults. Scrub techs and nurses willing to operate in dangerous conditions were increasingly called upon to fill in for those who declined. NY state entertained a law requiring surgeons who seroconverted to notify all patients of their status in the never-proven concern that a patient might contract the disease from the practitioner. So we stopped getting tested after every needle-stick, we even stopped donating blood, because we were not only risking our health, but also our ability to practice. It was a double-edged sword, with both edges pointed toward the practitioner. We stopped telling our spouses and colleagues about every torn glove or needle stick during an AIDS patient operation, because we stopped thinking about it as soon as we left the OR. But we kept operating on HIV patients, trying blunt-tip needles, extra-thick latex gloves, even chain-mail gloves—none of which helped in the least. Be careful, assume every patient is positive, universal precautions, we were told—all of it went right out the window with the next trauma patient in shock.
This plague has picked a different hero. Now, the riskiest moment for the health care practitioner is the intubation of a deteriorating COVID infected patient. In every hospital, anesthesiologists, anesthetists, and respiratory therapists, as well as many emergency medicine physicians and ENT surgeons, are placing their heads in the maw of the dragon as they insert an endotracheal tube needed to save a patient’s life. There is not a more dangerous maneuver in our current practice. Even worse than the surgeon operating on the AIDS patient, our modern knights staring down this dragon are not protected with chain-mail gloves, cannot even see the enemy, because it attacks—not in a spray of blood or with the pain of an errant needle—but in an invisible miasma. The risk of each individual intervention may be less, but the anxiety so much greater, as no one knows as they pull off their mask if, on this occasion, the dragon’s breath got past their shield. There is no choice but to take a deep breath, say a little prayer, and go on to the next patient.
When our anesthesiologists, anesthetists, ER docs, and respiratory therapists applied for training, none of them took a moment to ask themselves if they were brave enough to do this work. The job interview didn’t include a question about courage. No one signed up for this. They just do the work we need them to do to save our lives. When this is finally over, we will not forget that.
The physicians and nurses facing the onslaught of this pandemic are undoubtedly heroes. We salute them for leaving their homes and families every day to face the risk of personal illness and death. Their bravery is an inspiration. That bravery is a product of the oath that each swears upon entering this profession. There are others in this struggle, however. Others who never swore an oath to use their skills to care for the sick and injured. Others who are every bit as critical to these efforts, but who are not receiving accolades and applause as they make their way to hospitals every day, to work another shift at great personal risk. I am speaking of the janitors and housemen and women who work in our hospitals all day, every day.
These brave individuals serve an indispensable role in caring for patients and keeping the medical system working. They transport the patients to the ICU’s, and in so doing, are exposed to the same risks as the treating physicians and nurses. During the painful learning process of caring for the sickest of the COVID-19 patients, it was discovered that the technique of prone ventilation, in which the patient is positioned on their belly while on a ventilator periodically every day, is the only consistently effective therapeutic intervention so far. But this treatment requires the careful repositioning of a sedated patient in critical condition, a process that requires a team of nurses, physicians, and other health care workers to effect safely. Those other health care workers are often Physician Assistants, or Surgical Techs displaced from the now-idle operating suite, and Housemen and women. This oft-repeated therapeutic maneuver puts all members at an equal risk of infection. And while nurses and physicians, PA’s and NP’s are carefully trained and experienced in how to minimize their risks, these other critical team members have–until this moment–not prepared professionally for this effort. Nonetheless, we expect this, and much more, of them. They have stepped into the battle without hesitation.
Janitors also are unsung heroes in this crisis. They are required, just as the physicians and nurses, to don PPE and masks to perform the critical duties of cleaning the rooms and care spaces of the contagion which is pervasive in their work. Our janitors are no less courageous in their efforts. Indeed, maybe more so, as the physicians and nurses are almost always working as a team, with particular monitoring for the proper removal of protective garb and other concerns to minimize risk. Janitors, however, are often working on their own, with no such assistance. Every ICU room, every ventilator, every ER bay, must be cleansed and prepared, else risk injury of the next patient. Without the critical services of the janitors, the system cannot provide care.
These brave health care professionals, the janitors and housemen and women in every hospital, are working just as hard and at just as great a risk, as our physicians and nurses. They never swore an oath. They don’t get the same benefits, or the same pay, or the same accolades. But they deserve at least as much of our gratitude.
Ten minutes into a redeye on JetBlue to JFK, I pull out my earphones in the middle of Nathaniel Rateliff and the Nightsweats’ “Son of a Bitch” to ask my wife why she’s reaching over to ring my call bell. “They just asked for any doctor on board,” she explains. “You’re a doctor,” I point out. “Yeah, I don’t think any of these passengers is looking for an emergency mammogram,” she explains.
The senior flight attendant appears at my elbow. “You’re a doctor?” I nod. “What’s up?” I ask. “Do you have some proof? An ID of some kind?” Geez, this guy is pretty demanding. He scans my surgeon’s club card like a Manhattan bouncer. “Great,” he pronounces. “Follow me.” No problem, I think. I’ve done this drill a few times before. Almost every time, it’s a hyperventilating passenger with more anxiety than pathology.
Senior flight attendant introduces me to my fellow passenger, who is standing and clutching the seats on either side of the aisle in obvious distress. Oops, I’m thinking, this lady looks like a real sick person. She’s trying to breathe at about thirty times a minute, shrugging her shoulders with every breath. She looks scared; like a person who can’t breathe, scared.
“Hi,” I say. “I’m a doctor. What’s the problem, ma’am?”
“Let’s get you sitting down,” I suggest. Before you fall down, I don’t add. Because if this lady passes out in the aisle, it’s going to take me and about twelve of my fellow passengers to pick her up. Not gonna be a pretty picture.
“Can’t–sit. Can’t—-breathe.” She shakes her head. Okay then–let’s talk here. “What’s your name, hon? Marie? Great, Marie. Are you having any pain?” She nods vigorously in time with her rapid breathing. “Where is your pain?” She lets go of a seat to tap her chest, then grabs on again to keep from toppling over. “Okay, pain in the chest. Got it. Do you have heart problems?” She nods enthusiastically. “Diabetes?” She nods. “Emphysema?” She nods. Well, maybe she’s just agreeable. “Anything else?”
“Do you take insulin?” She nods. “Did you take your insulin today?” She nods. “Did you eat anything before you got on the plane?” She shakes her head. Great. Not just being agreeable, then. “Any other health problems, Marie?”
“Kidneys? Kidney failure? Are you on dialysis?” She nods vigorously. “When was your last dialysis?”
Great. She’s probably on a Monday-Wednesday-Friday schedule. Today is Sunday. Which means her last dialysis was over 3 days ago. Which is a long time to go without dialysis.
So far I’ve diagnosed this lady as probably being in respiratory distress due to florid congestive heart failure, probably having an MI (heart attack), and likely to lapse into hypoglycemia at any moment. I’m thinking anxiety is not the main problem this time around. I’m going to need to do some kind of real doctor-stuff, not just my usual professionally reassuring murmuring. Which is sort of a problem, because I’m a surgeon, not an internist. But I’m a general surgeon, and we all think we know everything about everything, anyway. So there is that going for me.
With flight attendants’ help we clear the back row and get my patient semi reclined and out of the aisle. Oxygen mask applied and helping–as in her lips are no longer purple. Reassurrance. But patient still expressing distress, feeling of impending death, invoking need for Jesus to save her; none of which are considered ‘good signs’ in this setting. Most important, she is still having chest pain. I break open the completely inadequate first aid kit. The kit is composed of many, many sealed plastic bags with various drugs and things, poorly labelled and completely unorganized. A bag of saline with no catheter to connect it to the patient. Helpful.
I find the blood pressure cuff and get some vitals. It takes me three tries to convince myself that her pressure really is sky-high, as in ‘impending-stroke’ high. Her breath sounds are even noisier than the aircraft engines and her heart is going so fast I can’t tell if she has a murmur which is just as well because I was never any good at hearing murmurs anyway. My exam does reveal that she has a dialysis access fistula in her left upper arm which has a bounding pulse–which is good, I think.
So at this point I tear open all the little plastic bags and start giving drugs to my patient. Glucose gel under her tongue for hypoglycemia, nitroglycerin for angina, aspirin for the acute MI. I’d love to start an IV but, again, no angiocath in the kit. Great.
The patient looks better but not great–as in, she now looks like somebody who may die soon rather than at any moment. I call over the flight attendant and mention to him that this lady may die at any moment. She is almost certainly not going to hang on like this for the five-plus hours it’ll take us to get to JFK, not to mention the additional half-hour taxiing to the gate. Time to land, buddy. He gives me his shocked face and mentions that maybe I should talk to the pilot. Good idea. He gets me on the little intercom thing and I introduce myself to Captain Pilot. He asks me about my patient. I explain the situation and tell him in no uncertain terms that she needs to get to a hospital as soon as possible. To my chagrin, the pilot is not enthusiastic about my recommendation. He’ll check in with “MedCon” and get back to me. Really?
More drugs, more oxygen and Marie is alive but still having chest pain. Not good. Blood pressure is better, though. And her breathing is much better. At this point, helpful flight attendant informs me that I’m only allowed to use one more oxygen cylinder. “I’m sorry, why’s that?” Turns out that the plane only carries three cylinders and if I crack open the third one, I’ll violate safety protocol since the attendants need oxygen in case there is a decompression emergency. I inform him that if we are that fucked to have a decompression on top of what’s going on here, he’ll have to hold his breath. He doesn’t find this funny. So maybe, I suggest, he should get the pilot to land this plane like I said twenty minutes ago.
The pilot calls back to inform me that MedCon doesn’t feel the patient’s condition merits diversion. They recommend I continue current therapy, monitor vitals, and report back in thirty minutes with an update. I am pissed. I don’t know who “MedCon” is but I’m no fan. I inform Captain Pilot that if he doesn’t land this plane soon he’ll have a corpse in the last row of his plane. He promises to get back to me. I crack open the third–and last–oxygen cylinder. Flight attendant gives me a very concerned look.
Captain Pilot calls back twenty minutes later to inform me we’re diverting to Denver. Hallellujah! We’ll be down in 40 minutes. Hold it–what? Forty minutes? Captain Pilot lectures me that this is “not easy”, that Denver has “weather”, that it’s going to be “pretty damn bumpy” and he needs to get off the intercom so he can do pilot stuff so I should take care of the patient now, Bye. I’m hoping he’s smart enough to call ahead for an ambulance. Attendant assures me he is.
Half an hour later, I look past my patient and see lights out the window which is the first good time on this whole damn flight. “You’re going to be fine, Marie.” Woo-hoo! Celebration is short lived as pilot instructs everyone to buckle up for an unscheduled landing because the doctor in the back row is making us do this and by the way it’s going to be pretty damn bumpy because there’s a thunderstorm over Denver airport where we’re about to make an unscheduled landing so good luck with that. I’d be pretty pissed at the tone of the overly detailed announcement except I’m busy trying to keep my patient breathing and the last O2 cylinder has been on fumes for the last 3 minutes. I strap in and strap in Marie next to me across two seats and position myself to keep my hand on her pulse as the gear and the flaps come down and we’re bouncing all over the dark stormy skies of Denver, a flash of lightning illuminates the plane and I see a few folks from the back rows looking at me like, “If we crash and die, it’s all your fault, asshole.” So I smile except at that moment I realize that I can no longer feel a pulse on my patient. I attempt to discuss this problem with Marie but her eyes roll up in the back of her head and she slumps over as she stops breathing and proceeds to die.
“Oh, fuck! Really, Marie? Now you pull this?”
I unbuckle and stand up so I can lay my patient across all three seats. Helpful flight attendant yells at me that I must remain seated, we’re landing. Yeah, right. I start doing CPR which of course causes everyone in the last four rows of the plane to start screaming, which makes it tough to hear the automatic external defibrillator announce that “No, your patient does not have a shockable rhythm so, sorry, I’m not going to be much help. Just keep doing the chest compressions. Click.” Which I do while alternating breaths with the Ambu bag hooked up to the empty oxygen cylinder when a very pleasant young lady appears next to me as the plane jounces onto the runway and she asks, “What the hell are you doing?” I explain that I’m doing CPR, are you a doctor?” “I’m a family practitioner, can I help?” “Well, yeah, lady, where you been the last few hours or are you an Leprechaun Family Practitioner that just magically arrived on this airplane?” “Sorry, I was asleep, I didn’t know.” So she starts doing compressions so I can give drugs. Of course, I don’t have a working IV so I shoot an amp of epinephrine transtracheally into her windpipe and shoot another one into her fistula followed by an amp of bicarb because, well, what the hell, it can’t hurt and just might help. Mr AED still isn’t going to shock anybody but there is a pulse which is a definite improvement. Late Arriving Family Practitioner and I alternate doing chest compressions as several of our fellow passengers helpfully record our efforts on their cellphones. A kid leaning on the back of his seat keeps asking if that lady is dead and I’m impressed by my colleague telling him to shut up and go back to playing video games. At this point, the plane arrives at the gate and quite suddenly a squad of EMT’s arrive and somehow get not-entirely-dead-Marie on a gurney and up the aisle to the concourse. Well-Rested Family Practitioner and I follow and see that Marie really does have some type of rhythm on the monitor just before they package her up and speed away towards Denver General. Vaya con dios, Marie!
Well, that was fun–not! I walk back to my original seat next to my wife and realize that my hands are shaking. I’ve done surgery for over thirty years, including a lot of pretty crazy trauma stuff, and I’m sure that this is the most shaken I’ve ever been after taking care of a patient. I was planning on discussing these feelings with my empathetic and supportive spouse, but I’m shushed by her so we can listen to the pilot announcing that, no, we won’t be taking off shortly to continue our voyage to JFK. Rather, he explains, this emergency diversion required by the doctor sitting in seat 6B has eliminated any chance of making it to JFK to be home with your loved ones or to make all those connections to lots of fun places because the doctor used up all the oxygen and the crew is traumatized and not allowed to continue so we’ll all be spending the rest of the night here in Denver International and we’ll try to get you seats on a plane in the morning to New York or somewhere, probably. Thanks for choosing Jet Blue!
At this point there is a general groan and many pointed stares pointed pointedly in my direction.
As we all gather up our carry-ons and make for the exit, I see Captain Pilot leaning against the doorway to the cockpit. I stop to chat. I introduce myself as the doctor who was on the other end of the intercom. “Oh,” he says without a smile. “That was you.” I agree that was indeed me. Just because I’m curious and still a bit pissed off, I reveal to Captain Pilot that I was surprised that there was such reluctance to land the plane even though it was my professional opinion that his patient was going to die otherwise.
Captain Pilot looks at me with a steely gaze and, in that Southern pilot drawl that they all have, says, “Doc, you got one life to worry about back there. I gotta worry about 186 lives. You do your job, I’ll do mine.”
I guess that’s pilot talk for “thanks for your help.”
Society punishes those who improve it. Emerson observed this fact when he gave up a promising Christian ministry career to instead minister to all of mankind. Don’t expect awards and accolades from the psychiatric profession for bettering it. The awards go to those who maintain the status quo, not to those who change it. Freud never won a Nobel prize; they gave it to the fellow who introduced frontal lobotomy.
Difficult doctor (def): a physician that disagrees with, or fails to immediately and graciously comply with, the expressed directive of any nurse manager or hospital administrator. [cf., Policy relating to the Reporting and Disciplinary Procedures for Difficult Doctors]
Many of you are painfully aware that our work environment has recently become–how best to phrase it? Silly? Unpleasant? Challenging? Flat out, batshit crazy? Yes, let’s go with that last one. (See Doctors Without Barbers). And I’m not even going to grace these new policies with any discussion, because they are so imbecilic as to not merit even this amount of attention.
(Doctor, you can’t leave the OR without a jacket. The short, paper one. No, no, no, doctor, not the full length disposable one. Oh my god no, not the full length disposable yellow one, that’s only for isolation and an alarm will go off if you walk out of here with that on. Wear this one, it’s required, but make sure to take it off and replace it with the full length disposable one you had in your hand a minute ago if you step into the hallway with the brown guardrail to tell the family that your patient survived their operation, then take the full-length but not yellow one off and put the short coat back on when walking between the brown railed hallway and back to the OR, then remove the short coat before scrubbing for your next surgery but you can’t don a surgical mask after donning your coat because that would lead to shedding of dangerous skin cells onto the coat, rendering the entire environment a potential health hazard but you can’t go into the OR without a mask and you can’t walk down the hall with a mask dangling on your chest and you can’t walk down that hall to get a mask without the coat on so I guess you’ll just have to not operate any more today, okay? Sorry, doctor, it’s the policy. Have a nice day.)
Those in the business know that I’m not making any of that up. Really.
So, I received the following email recently from our hospital administrator:
Dear Surgical Physicians, Nurses, Techs, and all Operative Colleagues:
As you are aware, our policy for Surgical Attire is based on National Standards, and was developed to ensure our commitment to Patient Safety , which remains our core value. In addition, proper surgical attire continues to be a major focus for both CMS and the State Department of Health. Unfortunately, many of our sister hospitals (as well as hospitals in other systems) have found themselves in a position where physicians and staff members were not following policy to the specified level, and were subsequently placed on periods of Immediate Jeopardy, in which they were at risk of losing their Medicare and Medicaid funding.
We are doing everything we can as a hospital to follow our policy and avoid situations such as that. I am attaching our Surgical Attire policy as a refresher of the expectations at [our hospital]. At the current time, I will remind you that ALL hair is to be covered, including sideburns and hair at the nape of the neck, as well as any facial hair (i.e. mustache). Our strongest recommendation is that to make it most easy for you to comply, surgical hoods should be worn, often in conjunction with a surgical cap, to allow maximum of hair coverage with minimal effort. Mirrors have been added around the operating theater to allow each physician and staff member to best police themselves.
You are all professionals, and your professional obligation is that you will comply with hospital policy. We will be conducting periodic observations to make sure we are compliant. I would ask that all staff please look to help any other physician or staff member who has not noticed that there is errant hair, or other non-compliance with the policy.
I am confident that we, as a hospital, and YOU as the Operative team, will be compliant and successful.
Vice President Medical Affairs & Chief Medical Office
So much of what is wrong with our current OR work environment is summarized in this completely nonsensical email. Let’s discuss:
“As you are aware, our policy for Surgical Attire is based on National Standards”–actually, no, it isn’t. It is an ungrammatical, unscientific, ad hoc mash-up of AORN policy recommendations, in-house silliness, and a good bit of complete nonsense. It has no basis in JCAHO or Department of Health standards. It directly contradicts recommendations by many national and international scientific organizations, including the American College of Surgery Manual of Perioperative Care and a recent policy statement by the ACS. There is nothing about it that even approaches a rational scientific basis or accepted standards, national or otherwise. It in no way represents any form of consensus of surgeons, nurses, or surgical technicians, either within the institution or at the level of representative organizations. It was authored by a couple of nurse administrators who haven’t seen the inside of an operating room in decades while sitting in a hospital conference room with a few administrators lacking any clinical insight whatsoever and absent any physician, anesthesiologist, or surgeon who might contribute rational insight into the process; i.e., dissent. The resulting policy was then filed in the Manual of Procedures and Policy without benefit of review by the Chief of Surgery, his designate, the OR committee, or as an agenda item at the surgical departmental meeting. Or by the Chief of Anesthesia, or at the anesthesia departmental meeting. Or by the Chief of OB/Gyn, or at their departmental meeting. Or by the Chief of Orthopedics, or at the ortho departmental meeting. Of course it wasn’t, because the physicians affected would’ve pointed out that the document was nonsense. They would be “difficult.”
“developed to ensure our commitment to Patient Safety , which remains our core value”–unfortunately, your core value has been repeatedly demonstrated to be maximizing revenue. Capitalizing the phrase “Patient Safety” in all official emails does not make it your priority. You have an amazing capacity to re-interpret your institutional commitment to Patient Safety if this proves too expensive. It just so happens that arbitrary rules regarding surgical attire costs the hospital nothing. And by the way, if you truly believe that the type of hat worn by a surgeon or OR nurse is an issue of patient safety, you really shouldn’t be allowed to come to work as a hospital administrator.
“Our strongest recommendation is that to make it most easy for you to comply, surgical hoods should be worn, often in conjunction with a surgical cap, to allow maximum of hair coverage with minimal effort.”–of course, this recommendation makes no sense, which is obvious to anyone who has actually set foot in an OR, and creates a situation in which you will be unable to operate, or keep from sweating into your patient’s wound (recent policy change takes away the ability to control OR room temperature without contacting an administrator), or breathe. We’re just interested in making it “most easy for you to comply.” Comply or die, whatever. Minimal effort.
“Mirrors have been added around the operating theater to allow each physician and staff member to best police themselves.”–I have no words.
“I would ask that all staff please look to help any other physician or staff member who has not noticed that there is errant hair, or other non-compliance with the policy.”–Please report your fellow workers to the authorities. You may be awarded the coveted “Employee of the Month.”
And more recently, yet another hospital email regarding this same subject ended with the following threat:
Please review the attached Guidelines for Operating Room Environment and Surgical Attire Policy.
Non-compliance with our policy will compromise the Hospital’s position with the DOH and may lead to financial penalty for the Hospital. For physicians who are found to be in violation of our policy, a ‘non-adherence to policy that compromises patient safety’ note will be placed in the credentials file as part of their OPPE.
So, it’s okay that the OR nursing supervisor is “surprised” to realize that my hospital has no CO2 cylinders available when the tank goes empty halfway through my laparoscopic procedure, which results in no incident report, meeting, or repercussion of any sort, but if I fail to wear a disposable short coat while walking between the OR and the recovery room I will be cited as “compromising patient safety.” A note will be placed in my permanent record.
“Finish each day and be done with it. You have done what you could. Some blunders and absurdities no doubt crept in; forget them as soon as you can. Tomorrow is a new day. You shall begin it serenely and with too high a spirit to be encumbered with your old nonsense.”
― Ralph Waldo Emerson