Mammographic Misery and the Plight of the Perpetual Patient

Mammograms save lives.  Despite several controversial studies over the last couple of years, there is no question in my mind or that of most other health care professionals that annual screening mammography for women over age forty has completely revolutionized the treatment of breast cancer.  Those studies can’t claim that people regularly receiving mammograms don’t have better rates of survival or cure from their disease–they claim, with mixed success, that providing a large population of women with mammographic screening is not cost effective.  What price a life, you ask?download

When I began performing surgery for patients with breast cancer in 1982, the typical patient presented with a mass she had felt herself.  By the time she came to me for surgery, her cancer was often in a relatively advanced stage.  Surgery involved complete mastectomy, usually with the removal of large numbers of her underarm lymph nodes, too often leading to disability and disfigurement.  This was followed by chemotherapy and radiation therapy. Worst of all, survival rates in this group of patients rarely reached 80% for the five years following surgery.

Fast-forward to my current practice.  Over 90% of women referred to me for surgical treatment of newly discovered breast cancer are now presenting with a lesion found on their annual screening mammogram.  Almost all of these lesions are about the size of a pea or smaller, having been discovered years before they grew to a size that could be felt on examination.  These early cancers have not spread to the patient’s lymph nodes or anywhere else in her body. There is no need for mastectomy to achieve a complete cure from this early stage of cancer.  Indeed, I can reassure patients that equivalent cure rates for such small cancers can be achieved by a small lumpectomy and a sampling of one or two lymph nodes, a procedure that takes less than an hour.  The patient is home later that morning and experiences minimal discomfort.  Newer forms of radiation therapy permitted by such early diagnosis expose only the localized tissue and can be achieved in five days, rather  than the whole breast radiation therapy over 4 to 6 weeks required in the past.  Most significant of all, this minimal therapy now provides cure rates well over 90% in these early stage patients.

All of this revolutionary success in the treatment of breast cancer has been made possible by earlier diagnosis due to routine screening mammography.  So don’t buy the hype–there is no controversy amongst practitioners over mammography:   A mammogram once a year can save your life.

But that’s not what this post is about.

Let’s talk about what happens after:  After that excruciating moment when I tell you that the biopsy showed cancer.  After the discussion of what we need to do, how soon we can do it (“Sorry, not yesterday”), what happens after the surgery.  Surgery for the treatment of breast cancer is safe, straight-forward, and relatively painless.  To be honest, surgery for breast cancer is the easiest operation I do.  Patients usually are surprised by their rapid recovery.  They come back to my office a couple of weeks after surgery feeling great.  Over the next several months, I see the patient as she completes her recovery and any additional therapy that’s recommended, usually a short course of radiation therapy and a daily estrogen-blocking pill.  By six months after her diagnosis, she’s feeling great and has her life back.   And then reality sets in:

The reality being that you are not really convinced you’re cured of cancer until the moment you die of something else.

We’ve moved from a paradigm of the valiant patient bravely battling her cancer to the successful breast cancer survivor–who now must live forever with her diagnosis.  It’s not a battle with cancer.  Battles are fought and won, and then we can move on. You don’t just fight cancer–you survive cancer, and then you live with having had cancer. This is a burden that few who have not experienced the diagnosis, or lived with someone who has survived cancer, can appreciate.  It doesn’t matter how great you feel, or how many times the doctors say that you’re doing great, or how great your spouse or friends say you look–you worry.  You worry every day.  Because you remember feeling pretty darn great just before the doctor told you that you had cancer.

Of course, we all worry about getting some disease or another.  We worry about that dark mole on our arm that might be a little bigger, particularly after we hear of a young friend recently diagnosed with melanoma.  We worry about heart attacks, because we get chest pain every time we eat Taco Bell or palpitations at the gym.  It’s not the same. It’s not the same because you’ve never been told by the doctor that the biopsy is positive, that your worst fear when you walked into the office was true.  You’ve heard of Post-Traumatic Stress Disorder?  This is Post-The Test Was Bad And You’re Totally Screwed But Now You’re Finally Better Stress Disorder.  And it’s every bit as bad. Maybe you didn’t experience faceless bad guys shooting bullets at you in Iraq, but you experienced some pretty heartless machines shooting xrays at you every day for a couple of months, or smiling nurses apologizing as they stabbed the needle in your vein for the third or fourth time, or watched the strange colored fluid dripping into your body knowing that in 24 hours you’d be doubled over the toilet vomiting because that’s just how this stuff works.  Cancer sucks, and it doesn’t stop sucking just because everyone tells you that you’re cured.

Sure, they say you’re cured.  But you don’t really believe it.  You don’t believe it because we keep sending you for more tests and more mammograms and more CAT scans and more PET scans.  If there were a PUPPY scan or a CUTE FUZZY BEAR scan, we’d send you for that, too.  If I’m cured, you keep wondering, why do we keep looking for it?  And every time you have to go for the test, it’s an opportunity to relive that special feeling you had that time when the test came back bad.  You relive that feeling for the week before you take the test, while you’re in the machine trying to breathe during the test, and for every single second until the doctor calls to tell you that it’s okay. This time, you think.  It’s okay this time.  The elephant steps off your chest–but he doesn’t leave the room, he just steps behind you for awhile.  Until the doctor says that it’s time to do another test.  And there is always another test.  If I’m cured, you think, why do we have to keep looking?

So here we are:  Surviving today.  The test was good.  Enjoy it.  You can run faster than any old elephant.

 

 

 

Anesthesia is Hard-3

The Subtle Science of Sedation

As a general sugeon trained in a specific era and at a particular type of academic institution, I was taught that I should be able to do everybody’s job in the hospital just a little better than the folks whose job it was to do just that thing full time and to the exclusion of everything else after spending many years learning to do just that stuff.  It was believed that in this manner, we could protect our vulnerable, recovering patients from all the other doctors and health care professionals who didn’t care as much about the patient as we did.  With the foregoing mindset, I launched upon a two month rotation on the anesthesia service of a very large, very academic medical center.  One can easily foresee that this was not to go very well.  Not well at all.  Anesthesia practice is predicated on a team approach, an “all-for-one,” “we’re all in this together for the good of the patient,” approach. If an anesthesiolgist (or anesthetist) is having difficulty with an intubation or the patient takes a sudden turn, he or she is trained to immediately seek the assistance of a colleague.  Ego is put aside for the good of the patient.   I was trained to take a different approach.Top Gun

For reasons that still elude me to this day, during this anesthesia rotation I was permitted to manage patients with an extraordinary degree of independence.  This may have something to do with the fact that I had no official supervisor.  I fell through the cracks, in a way, and the result was that I managed the anesthetic of quite a number of patients with a degree of independence not even given to anesthesia residents until their last year of training.  The physicians directing me thought that everything would be okay if they just assigned me the simplest, most straight-forward cases.  Interesting point, though, is that there is no such thing as an easy case for the truly incompetent.

Many cases come to mind.  It should be noted that I did this anesthesia rotation during a time period and in an institution that held the technique of regional anesthesia in very high regard.  That is, every case was approached with the attitude of “Why not use a spinal?”  So I did a lot of spinal anesthesia.  I got, I thought, very good at spinal anesthesia.  I could place a spinal in a couple of minutes on patients of every age and body type.  I was instructed in various approaches and was fairly skilled at several of them.  Wherein lies the problem.  The technique of anesthesia is not difficult to master, it is the practice.  As a surgeon in training, learning technique was what I did.  I didn’t have a clue about anesthesia practice, however.

On one Monday morning, I was assigned to provide anesthesia to a patient undergoing an open knee procedure to be performed by the Chairman of Orthopedics.  It should be noted that the Chairman of Orthopedic Surgery was equivalent to Tutenkamen of ancient Egypt.  He was easily the institutional equivalent of The Chaiman of Thoracic Surgery (see “Mommas, Don’t Let Your Babies Grow Up to be Surgeons”), but more powerful.  Therefore, this assignment surprised me.  I had been on the anesthesia service for several weeks and was looking good. (Definition of looking good:  Nobody knew who I was.  That is, I hadn’t been noticed at all since I hadn’t killed anyone yet.  Close, but no permanent loss of life.)  Even so, this was a plum case, usually assigned to a senior anesthesia resident.  But the seniors were all away at conference and the administrative anesthesiologist had no idea who I was, he just knew that I wasn’t a junior anesthesia resident and assumed I, therefore, must be the guy.  I shrugged and trundled off to see the patient.  He turned out to be a twenty year old football player who had blown out his knee in practice.  Nice guy. Very large.  Muscular.   I introduced myself, did my preop assessment, and informed him that I’d be giving him a spinal anesthetic, of course, since I gave everybody a spinal anesthetic.  The patient was fine with this.

Placement of the spinal went great.  It always did, I was pretty good at it.  I got the patient comfortably positioned on the OR table and started in on my hypnotic “You are getting sleepy” dialogue with the young patient as I began to infuse a little hypnotic potion in his IV.  Again, this was the eighties, when about the only IV drug for this sort of thing was Valium, a drug which was notorious for its great variability in effect when given IV, particularly on young, anxious individuals.  Like football players undergoing sugery.  I checked the efficacy of my spinal anesthetic and was pleased to note that I had achieved a unilateral (one sided) block to a level of about the groin.  It was even on the side to be operated on.  Perfect.  I was proud of myself.  I had dosed the spinal for a duration of two hours, as the Chief Orthopedic resident doing the case with the Chairman of Orthopedic Surgery told me the case would take “about an hour, hour and a half, tops.”  I gave the patient a little more Valium in the IV and murmured sweet nothings in his ear.  He was asleep.  All good, I started my charting.

I turned away from my charting when the patient asked what was going on.  I was annoyed, as the patient had been nicely sedated and asleep.  Nothing should be going on.  I looked over the screen to see the Chief Ortho resident putting a pneumatic tourniquet high on the thigh of my patient.  “Hey,” I said.  “You’re operating on his knee.”  The ortho resident smiled at this information.  “Orthopods hate blood,” was his response.  This was a little problem.  A pneumatic tourniquet inflated to twice my patient’s blood pressure did not feel good.  While it was within the region of my block, it was much closer than I had anticipated.  I dialed the OR table to trendelenburg (head down) position, hoping that I could get the local anesthetic bathing the patient’s spinal cord to drift a little more upstream, giving him a higher level of numbness.  This only works for a few minutes after the spinal was placed, however, so I wasn’t feeling terribly confident at this point.  And I couldn’t recheck the level of anesthesia, because now the nurse was starting to prep the patient’s leg with antibacterial solution.  Just to be safe, I elected to give the patient more Valium.  And some intravenous morphine, too.  Just in case.  Back to charting as the patient began to snore.

The case began uneventfully.  The patient snored peacefully through the initial incision and exposure, my spinal having achieved a nice, dense block.  The chief ortho resident, like all chief ortho residents at institutions of great learning such as this one, was brilliant and highly skilled.  I watched over the sterile drapes as the chief resident put down his instruments and started to do nothing.

“I’m pretty sure you’re supposed to fix it, too.  That’s what it said on the consent, you know,” I said to the ortho chief.  Ortho chief smiled at me.  “Gotta wait for The Big Man.  That’s his job,” ortho chief replied.  I looked at my watch.  One hour into the case.  I looked at the upside down face of my linebacker patient.  He was smiling through a nice, drug-induced dream.  I shrugged and went back to charting.  Half an hour later, the Chairman of Orthopedic Surgery had still not arrived.  “Call him,”  I told the ortho chief resident.  “Yeah, right,” was his response.  “How long once he gets here?” I asked, looking at my watch.  ‘Hour and a half, tops, the guy had said. I began thinking that I might have to switch to a general anesthetic if this went on too long.  For that, I would have to call in my attending to let him know what I was doing.  That would be embarrassing.  I existed on the technique of staying inconspicuous.  If I called in my attending, I would have to explain that I had miscalculated the dose on the spinal.  Embarrassing.  “Once he gets here?  Not long,” ortho resident said.  He went back to doing nothing.  My patient chortled.

Chairman of Orthopedic Surgery swept into the room ten minutes later.  Finally, I thought.  I checked the patient.  He seemed comfortable, though his heart rate was up a bit.  More Valium.  A touch more narcotic.  I looked over the drapes.  Chairman of Orthopedic Surgery was still not scrubbed in.  “Where’d he go?” I asked.  Ortho resident shrugged.  Ten minutes later, Chairman of Orthopedic Surgery, gray haired and dashingly handsome, re-entered the OR, hands held up and dripping.  “Let’s get this man back on the field!” he boomed.  “Go Yellow!”  I rolled my eyes.  Finally, I murmured under my breath.

“It hurts,” my patient said.  I looked down.  His eyes were open.  “My leg hurts,” he said.  I looked over the screen.  Chairman of Orthopedic Surgery was finally thinking about maybe doing some surgery.  I looked at my watch.  Ninety minutes of tourniquet time.  Ouch.  “No problem,” I told the patient.  I infused narcotics. More Valium.  His eyes closed.  This was going to be close.  “Not long once he gets here,” the resident had said.  Just in case, I started drawing up drugs for a general anesthetic.  Just in case.

The patient murmured something unintelligible.  His heart rate was up.  His eyes were closed.  “What did you say?” I asked softly, mouth close to his ear.  “Fucking son-of-a-bitch,” he murmured softly.  Oh, that’s what you said. I gave more Valium.  I looked over the drape.  Chairman of Orthopedic Surgery was chatting up the scrub nurse as he slowly repaired linebacker ligaments.  I made a hurry-up gesture to ortho resident.  He smiled and shrugged sheepishly.

That’s it, I thought.  Embarrassing or not, I better call my attending and switch to general anesthesia.  It wasn’t my fault that the Chairman of Orthopedic Surgery was a molasses-slow, late-arriving horse’s ass.  We were over two hours on my spinal.  No way I had any anesthetic left at the level of the tourniquet.  We were on borrowed time.  I started to turn around to use the phone to call in my attending.

Now every anesthesiologist (and anesthetist, okay?) knows that there is a perfect plane of sedation that you don’t ever want your patient to achieve.  It is that level of sedation where the patient is confused and completely disinhibited, but not asleep.  If this were Top Gun, and I was a taller version of Tom Cruise, the Maverick of brash anesthesiologists in training, it is at this exact moment that the soundtrack switches to a very loud rendition of “Danger Zone.”  As I dialed the phone with my back to my patient, I heard the sound of Velcro arm restraints being ripped in two.  Then I heard my patient say, very loudly, “FUCKING SON OF A BITCH.”  I turned back to see my very large, linebacker patient sitting bolt upright on the OR table.  He had ripped down the drapes between us and the operating field.  The patient stared at his open knee.  He repeated “FUCKING SON OF A BITCH.”  The Chairman of Orthopedic Surgery, the ortho chief resident, the scrub nurse, and the medical student hoping to some day become an orthopedic surgeon, all stared back at the patient, incredulous.  In the words which would later be stolen by Goose in that classic movie, I said, “This is not good.”

I grabbed the full syringe of Surital that I had just drawn up in anticipation of having to induce general anesthesia.  A “stick” of Surital, a short-acting barbiturate, was our general anesthetic induction of choice in those days.  I rapidly pushed the whole stick into the patient’s IV.  He flopped back with a thud onto his pillow, deeply unconcious.  I readjusted the sterile drapes to once again separate my world from the sterile operating field.  I infused a muscle relaxant into the patient’s IV and proceeded to intubate the patient and connect him to the ventilator.  There was complete silence in the OR.

The Chairman of Orthopedic Surgery broke the silence.  “What the FUCK was that?” he asked.  I returned to charting my new anesthetic technique.  Not a good time to call my attending just yet.  “You there,” the Chairman of Orthopedic Surgery bellowed.  “Behind the drapes!”  I stood up.  “Yes, sir?”  “What the FUCK was that?” he repeated.  “What?”  I asked.  He looked at me, astonished.  “What?  What, what?  That!”  he said, pointing at me, then down at the patient.  “Not sure what you mean,” I said.  The Chairman of Orthopedic Surgery looked around at the others scrubbed at the OR table.  “Didn’t you guys see that?” he asked.  Ortho resident shrugged.  Med student nodded.  Scrub nurse chose to straighten the instruments on her back table.  This just made the Chairman of Orthopedic Surgery a bit more pissed off.  He strode over to the wall and mashed the bright red code blue button on the wall with his bloody, gloved hand.  No less than five attending anesthesiologists came crashing through the door.

“WHAT?”  “What’s going on?”  “What’s wrong?”  “Is it a code?”  “Aarhgh?”  They each said, surrounding me.  I shrugged and pointed to the Chairman of Orthopedic Surgery.  Two nurses rolled the code cart into the room.  More anesthesia attendings and residents entered.  Everyone looked around.  Everything looked okay.  The patient was asleep, under anesthesia.  The ventilator sighed assuringly.  The monitors beeped happily.  I reapplied the Velcro arm restraints and said nothing.  The anesthesia attendings turned to the Chairman of Orthopedic Surgery.  “What’s wrong?” the senior anesthesia attending, my attending, asked him.  The Chairman of Orthopedic Surgery stammered, “The patient, he was awake, he screamed at me, he called me a fucking son-of-a-bitch!”  The anesthesia attendings all turned to me.  “I had to switch to a general.  The tourniquet time is over two hours.”  I raised my eyebrows significantly and rolled my eyes toward the Chairman of Orthopedic Surgery.  “We had to wait over a half hour for What’s His Name, here.”  The Chairman of Orthopedic Surgery began to turn bright red.  “Do you know who I am?” he seethed at me.  I shrugged.  Went back to charting.  My attending stepped over and began to assess the patient.  Everyone else drifted out, shaking their heads.  The code cart was withdrawn.  My attending went over my anesthesia record, which was perfect, by he way.  I loved charting.  It made everything look so neat.

The Chairman of Orthopedic Surgery was still seething, arms crossed.  “Well?” he demanded of my attending.  My attending straightened up from the chart and looked at the Chairman of Orthopedic Surgery.  “You’re pretty long on the tourniquet, Bill.  Maybe you should try to finish up?” my attending said.

“That’s it?” the Chairman of Orthopedic Surgery asked.  “That’s all you’re going to say?”

“Yeah,” my attending said.  “And now I’m leaving.”  He turned to me before he left.  “Give me a call if you need a break, Geller.”  He winked at me.

 

 

(CRNA)nesthesia isn’t Easy-2

Sunday at the VA edition

[N.B.:  As our troubled VA system is currently in the news, I should say that this post makes reference to a very bygone era, by which I mean the Eighties.  The conditions described herein in no way reflect the status of our modern VA system.  I’m sure.  I hope.]

Not surprisingly, it took less than 48 hours after posting “Anesthesia isn’t Easy-1” before I heard from my nurse anesthetist friends.  And a few other anesthetists.  Quite a few, actually.  Unfortunately, the awkwardness of our medical lexicon precluded the appropriate repeated reference to our anesthetist colleagues (how many times can I write “anesthesiologist/anesthetist” in a 500 word blog post before even I stop reading the thing?).  It goes without saying (since it seems I didn’t say it) that pretty much everything I wrote in AIE-1 applies to our CRNA brethren.  There, I said it.Tinc of Cocaine

As I mentioned in that last post, a doctor’s early training is formative in many, many ways.  In my own experience, I came to love CRNA’s in general (and one in particular) during the second year of my general surgical residency. No, not the CRNA my future wife kept trying to fix me up with so that I’d quit asking her out. Different CRNA.

I was doing a rotation at the enormous VA Medical Center associated with my residency.  This was an institution that could easily serve as a setting for Game of Thrones or, maybe more appropriately, The Desolation of Smaug.  Built in medieval times, this fortress hospital was over a thousand beds and could be seen from space. It was somewhat past its prime.  By about a half century.  Many dusty corners, so to speak.  Actually, entire haunted wards.  Scary.  Dark.  Huge.  On one occasion I remember, when we sent a medical student to go find the patient who was using the central venous catheter so that we could clean it off and use it on another, really sick patient, the student got so lost we didn’t see him for almost a week.  We had to send a posse to a neighboring VA hospital for the catheter, I think.

Despite the incredible hugeness of the facility, it possessed an Emergency Room about the size of a broom closet.  This was specifically designed, I believe, to discourage our veteran  patients from considering the VA hospital as a potential site for emergency care. Which was an especially good thing, since despite the overwhelming hugeness of the facility, there was only one junior surgical resident on call in house on weekends. For all surgical specialties.  All of them.

Surgery call was especially exhausting due to the ridiculous policy that the surgery resident was required to respond to all Code Blue calls throughout the hospital, specifically because there were no respiratory therapists or anesthesia personnel in house.   So the surgery resident was required to do all intubations (establishing emergency airways in patients).  This was particularly problematic since many (most) junior surgery residents pretty much suck at intubations.  And since nobody else on the code team could do anything until the patient was intubated, some codes were very, very brief.  And even though over half of the wards had been closed down, there was no consolidation of the active wards.  Patients were scattered through two towers of a dozen stories each, with an elevator system dating back to the Civil War.  Any attempt to wait for the one functioning elevator car and you’d invariably arrive in time to pronounce the patient dead.  And since this was the VA hospital, it wasn’t unusual for there to be two or three codes in an hour, at any time of day or night. We were all in great shape as a result.  The original stairmasters.

One time as a second year resident,I found myself on call, alone, on a sunny Sunday afternoon.  I was running around doing all the scut work that we had to do in those days, drawing arterial gases on the ICU patients, admitting the preop patients who would have surgery during the coming week, that sort of thing.  The sort of thing that could easily keep four or five junior residents too busy to eat or sit down.  I was doing pretty well, thanking my lucky stars that there miraculously hadn’t been any codes to interrupt my work, when I simultaneously heard myself stat paged overhead and my beeper went berserk.  I didn’t recognize the number.  Which turned out to be the ER.  “We have an ER?” I asked the frantic nurse on the other end of the phone.  “Get down here STAT!”  was her reply.

I had to ask a janitor where the ER was, but I got there.  When I arrived, I saw an elderly internist/ED doctor and several nurses crammed into the tiny space around the one stretcher.  Sitting up on the stretcher was the largest vet I had ever seen.  Easily over 400 pounds and like six six, he was hunched over and breathing really, really fast.  He was also making a sound that no person should be making–a high-pitched crowing sound called stridor.  This, I remember thinking, is not good.  “Thank god you’re here,” the ancient internist said, turning to me.  Nobody had ever said anything like that to me before.  “Not really,” I remember thinking.  “His dentist sent him over,” the internist continued over the loud crowing sound of the man struggling to breathe.  “Really?” I said, trying to sound calm.  “His dentist?”  “Yes, yes,” the internist continued, pulling me up to the stretcher in an effort to get me to take charge.  “He thinks he might have Ludwig’s angina.”  I nodded sagely.  “Could be.  He might.”  No idea what Ludwig’s angina might be.  Looked bad, though. “What would you like me to do?  He need a line?” I asked.  I was really good at starting IV’s.  “No, no,” the internist said, gobsmacked.  “He’s got an IV.  You need to take care of his airway.  Right now!  Or he’s gonna die!”  Oh.  I remember the patient following this conversation with great concern.  I think he felt pretty much as the internist did.  “Of course,” I said, reassuringly.  “I’ll be right back.”   Then I ran away as the internist asked where I was going.

I ran to the OR.  There was no chance that I was going to be able to intubate this guy, of this I was sure.  Besides the fact that the man was huge, panic-stricken, and had an airway that was swollen almost completely shut–I sucked at intubation.  Just ask my last three code patients.  Except you can’t, because they’re dead.  The only hope was to grab an emergency tracheostomy tray so that when the guy was unconscious from hypoxia and not quite dead, I might be able to do an emergency trach.  About one chance in a million, give or take.  Still better odds than me successfully intubating the guy awake in that ER.

I slid around the corner into the OR and stopped dead in my tracks.  Usually, the OR would be dark and empty on a Sunday afternoon.  But the lights were on.  I ran into the anesthesia office and saw two huge shoes on the desk.  Tiny Ted was asleep in the chair.  Ted was the Chief and only CRNA at the hospital.  Actually, he was the entire anesthesia department, functionally speaking.  A grizzled bear of a man in his late forties, Tiny Ted was pretty much the only person interested in actually administering anesthesia to our patients.  The anesthesiologists in the department specialized in explaining why our patients couldn’t have surgery.  If you really wanted to operate on someone, you got Ted.  He was good natured, always wanted to work, and was supremely capable.   “Ted!” I yelled at him, shaking him awake.  “What are you doing here?”  “Stocking the drawers, getting ready for tomorrow,” Ted said, coming awake.  “And staying away from my wife.  Why?  You look like you’re about to piss in your pants, Geller.  What’s up?”  I explained about the patient with Ludwig’s angina.  “Nasty,” he commented, rubbing his stubbled chins.  “Let me guess, Geller–you came here to grab a tray so you can do a slash trach down in the ER?”  I nodded sheepishly.  “Why don’t you just shoot him in the head?  Be more humane, less messy.  Less likely to kill him, too.  I heard about your last trach, Geller.”  {see “Equinimity“} He let me squirm for a minute before slapping me hard on the back.  “Get your patient up here and set up a room for a trach.  I’ll give you a hand.”  “Thanks, Ted,” I said, relieved.  “Where are you going?” I asked.  “Get some coke,” he said, leaving.  “You’re thirsty?” I asked.  “Not that kind of coke, Geller.”  Oh, I thought.  Maybe I caught Ted at a bad time.

With the help of two orderlies, I got the patient lying semi-reclined on an operating room table.    I had set up my instruments and a scalpel, which the patient was staring at fixedly.  He was also breathing about forty times a minute and his stridor was even higher pitched than before.  He looked about twice the size of Ted, and Tiny Ted was a rather big man.  That’s why we called him Tiny Ted.  Also, I noticed at this point, the patient had the interesting anatomic feature of having no visible neck.  His head apparently sat directly upon his chest.  Great.  “This here,” Ted said, interrupting my rising sense of panic, “is the entire stock of cocaine in this institution.”  He held up an impressively large vial labelled 4% Tincture of Cocaine.  “Can we talk about that later, after this?” I asked him.  I really needed Ted’s help.  “This is what’s going to happen,” Ted continued, ignoring my comment.  “I am going to take one shot at intubating our friend here.  Exactly one shot, period, amigo.  If I can’t tube him, it’s your turn.”  He stared at me.  The patient stared at me.

I nodded solemnly.  “And then he’ll die a horrible, bloody death,” I thought to myself.

“And then he’ll die a horrible, bloody death,” I heard out loud.  I thought somehow my thoughts had become audible.  But no, it was just Tiny Ted saying what we were both thinking at that point.  The patient appeared somewhat more distressed at this.  “Don’t worry,” Ted said brightly to him, “you’re going to do fine.”

“Probably not,” I thought.  “Just kidding,” Ted said.  “But I’ve got cocaine.  You ever do coke?” he asked the patient.  The patient barely managed to shake his head, being pretty much fully occupied with struggling to draw his last breaths through an airway about the width of a swizzle stick.  “You’re going to be fine,” Ted said again.  Tiny Ted, the master of mixed messages.

At this point, I took up my position over the patient with a #10 scapel in (trembling) hand.  Ted lowered the head of the OR table as the patient’s eyes, now big as saucers, never left mine.  Ted began a complex ritual of spraying cocaine into the patient.  This was accompanied by a soothing Hindu prayer chant, intermixed with an off-key rendition of Tupac’s “God Bless the Dead.”  (Actually, I made that last part up as a shameless, subliminal pitch for my first novel.  He actually was tunelessly singing “White Lines (Don’t Do It)” by Grandmaster Melle Mel.)  After something intravenous, Ted began a process of inserting a series of cocaine soaked cotton tipped applicators deeper and deeper into the patient’s nose.  Eventually he had about four sticking out of each nostril.  The patient seemed happier.

“Here goes nothin’,” Tiny Ted announced as he dramatically took endotracheal tube in hand and waved it over the patient’s face.  The patient had his eyes closed.  Seemed like a good idea, so I closed mine and silently promised God all sorts of stuff if He didn’t make me cut open this man’s throat.  A chocolate ice cream sundae, if the occasion arose.  And other stuff, too. Like learning to intubate better.

“Done,” Ted announced.  I opened my eyes.  There was a tube sticking out of the patient’s nose.  The stridor had stopped, replaced by the sound of easy, ventilator-assisted breathing. Ted was busy pushing enough muscle relaxant through the IV to put down an elephant for a month.  “This should keep him from pulling the tube out until I get of here.  After that, he’s your problem, Geller.”  I nodded and put away my scapel.  I could have hugged him, but it would’ve been awkward.

“Thanks, Ted.”

“No problem, Geller.”

 

 

Anesthesia isn’t Easy-1

The Michael Jackson Edition

A doctor’s formative years are often telling.  If during the first year of medical school you fall in love with gross anatomy, you really have no choice but to pursue a career in surgery. After spending a year exploring the new and fascinating territory that is your personal cadaver, dissecting along tissue planes formed or nerves stretched as an embryo, some of us just can’t see putting it all aside.  Very soon, one realizes that the only physicians that need to know much about anatomy are surgeons and gynecologists.  Everyone else is pretty much practicing applied pharmacology.  Doesn’t matter where the iliopsoas muscle lives or if it’s your hypogastric plexus that’s pathetically paretic–write the script and see if the patient is better in a couple of weeks. If you love anatomy, if you pine for those early mornings smelling the formaldehyde perfume of your best dead friend, you’re going to be a surgeon.images

Similarly, anesthesiologists are practicing practical physiologists.  In the physiology lab, the subject (woof!) is attached to an array of monitors as the recently pubescent physician infuses various pharmacologic agents or inhaled mixtures of oxygen plus whatever.  Agent X goes in the vein, the heart rate goes up and the blood pressure goes down.  Reverse the effect with agent Y.  See what happens when you add a dash of inhaled agent Z.  At the end of the lab, give the happy subject a treat.  Seven years later, anesthesiologists are expertly doing the same thing to people.  Except for the treats.

During the formative years of every physician, but anesthesiologists in particular, one learns a great deal of respect for people physiology.  People are predictable, but not perfectly so.  We are men, or women, or children–not machines.  Herein lies the challenge.  Almost every time you give the patient your dependable drug, he responds as expected.  Almost every time.  It’s that “almost” that challenges every anesthesiologist.  The occasional patient that responds not quite as expected, a little too emphatically or a bit reluctantly.  Adjustments are titrated on the fly.  The rare, but really exciting, individual that displays a completely inappropriate response, such as anaphylaxis.  It is for this reason, this subtlety, that anesthesiologists are carefully trained, not born.  Like the practice of surgery, it is not a skill that can be mastered by reading the textbook, even if you’re really smart.  The really smart/experienced anesthesiologists know this especially well.  Then throw in the fact that the patient is having the trauma of surgery that the anesthesiologist must compensate for.  Some surgical procedures are more easily compensated for than others.  Some surgeons are more easily compensated for (see earlier blog post Never Say Oops in the OR“).

The practice of anesthesiology, however, suffers from one towering challenge above all; a challenge unique among all physicians.  Anesthesiologists must be perfect.  It’s a problem.  No other physician is held to such a high standard.  If you come to your surgeon with a tumor blocking your bowel, rest assured that he or she is going to do everything in his/her power to extirpate the neoplasm and restore your comfortable continuing existence.  But there will be pain.  And a scar or two.  Perhaps you’ll have some hiccup in your ability to digest really deep dish pizza from now on, but you’re happy to be alive.  Same with every other field of medicine–except anesthesia.  The practice of an anesthesiologist is to take a perfectly mentating person and put him into a profound coma.  But just for a while, then magically reverse that comatose state and restore the patient immediately to complete normalcy, preferably without any trace of the experience, not even nausea or a missing molar.  No fair if the patient is just about the same as before he had the life-saving procedure; say, he can remember almost everybody from his high school graduating class but has a slight problem coming up with the name of that girl he married.  Not good enough.  The patient must awaken happy, comfortable–normal.  Best case scenario, the patient emerges from anesthesia by completing the punch line to the joke he was reciting at the time of anesthetic induction three hours ago.  Extra points for an exceptionally satisfying dream during the procedure.  Nothing less than a perfect return to the pre-anesthetized state is acceptable.

As one can imagine, this can, at times, be a bit of a challenge.  Consider the inconvenient fact that nobody who’s normal lays down on an operating table.  Patients are sick, many very ill, some with years of undiagnosed/uncared-for illnesses now being subjected to the significant stress of an operation.  The most stressful thing this patient experienced in the previous ten years may have been lifting the television remote control.  Occasionally, the patient is horribly, critically ill.  Doesn’t matter–the anesthetic must be perfect, and certainly not the cause of even the sickest patient’s demise.  The surgery is allowed to kill him, but not the anesthetic.

So if you’ve ever had an operation, and you didn’t spend the entire time screaming, and you woke up pretty much thinking like your self thought before that whole operation thing: Thank your anesthesiologist.  Send him a card.  Or actually pay the bill.  Whatever.  Just don’t try it at home.

Killer

Quote

The young resident was flabbergasted to learn, in casual conversation, that the attending radiologist sitting next to him all morning had been in the Marines prior to going to medical school.

“Wow,” the student exclaimed in open admiration.  “Did you kill anyone?”

The radiologist shook his head.

“Not until I became a doctor.”

 

~CB, 2013

Automated Malpractice and Digital Dishonesty

Quite a few years ago, I was conducting morning teaching rounds on the surgical service of a university teaching hospital.  Teaching rounds are a combination of patient care and education, the educational aspects directed at the bevy of residents and medical students in attendance.  We stood outside the room of a postoperative patient who wasn’t doing well.  Either was the senior medical student struggling to explain just what was the reason that the patient’s health was failing.Minolta DSC

“What’s the white count this morning?” I asked the man.  He was an over-achieving rotator from another school, doing a senior elective on our service.  He suddenly blanched.

“I’m sorry?” he said.

“Don’t be.  Just tell us the white blood cell count of the patient this morning.”  I waited.  He looked at his junior resident.  The junior resident looked at the senior resident.  The senior resident looked at the chief resident.  The chief resident looked at me.  He shrugged sheepishly.  “No one knows the patient’s white count this morning?”  I asked.  Everyone looked at their shoes.  “Did you operate on this patient?” I asked the student.  He nodded.  “And though the patient trusted you enough to let you operate on him, you just don’t care if he lives or dies at this point?”

“I care,” the student replied, indignant.

“Just not enough to check his white blood cell count, is that it?” I asked.  The student wisely said nothing.  “It would be reasonable to suspect that your patient is suffering from an infectious complication from your operation.  If you do not make the diagnosis soon, he will die from your operation.  I suggest that you check his white blood count.”  Everyone nodded assent.  We moved on to the next patient.

Twenty-four hours later, we all stood once again in front of the same patient’s room.  The patient had spiked a high fever overnight.  “White count?” I asked the same student.

There was the briefest pause before the medical student said, “Twelve point two.”  Which was a lie.  He was a pretty good liar, looking me straight in the eyes as he said it.  I had checked the patient’s white blood cell count before rounds.

“Take this dime,” I said, handing a coin to the student, “and call your mother.  Tell her there is serious doubt about your ever becoming a doctor.”  All twenty members attending rounds looked at me with a blank, uncomprehending stare.  “Really?” I asked.  “Nobody’s ever seen The Paper Chase?”  They all shook their heads.  The student had gone beet red with embarrassment.  “Look,” I said.  “You screwed up.  I told you to check this patient’s white count.  You didn’t.  You have a responsibility to this patient.”  The student, his resident, and the chief resident started to explain about all the traumas cared for overnight, about how busy the service had been saving lives.  I held up my hand.  “I don’t care.  You screwed up. You all screwed up, by letting him screw up.  You are failing this patient.  But that’s not why I’m pissed.  We all make mistakes, every one of us.  Every day.  Can’t be helped. But you can’t lie about it.  You can’t stand here and pretend that you did something that you didn’t.  You can’t give me false information, information that may lead to my decision regarding the care of this patient, just because you’re too weak to admit that you didn’t do what you should’ve.  What this patient needed.  That’s not acceptable.  You can’t lie.  Not to me, not to this patient, not to your fellow residents or students.  Because if I can’t trust you, I can’t let you take care of my patients.  Worse, you are lying to yourself.  If you can’t trust that what you wrote in a chart last month was actually something you did–and not just something you made up because you didn’t have the time to actually check–you will hurt your patient.  Lawyers can lie.  Accountants can lie.  Stockbrokers can lie.  Surgeons can’t lie.  Surgeons who lie kill patients.  Go check the patient’s white count.  And while you’re at it,” I said, turning to the senior resident, “book the patient for reoperation this afternoon.  Because his white count this morning is 22,000 and I think your patient has an anastomotic leak.”

The embarrassed, hotshot medical student went on to be a very good orthopedic surgeon.  I like to think that he learned something that day about patient care and responsibility.  I don’t know for sure.  I am sure, however, that it no longer matters.  Every physician is now systematically dishonest on a daily basis.  Every one of us.

During the past two years, hospitals and medical practices across the country have been required to implement an electronic medical record system.  Every single health care practitioner has been falsifying patient records on a daily basis as a result.  Not by a desire to be dishonest, or any lack of effort on behalf of our patients.  It is now a systematic requirement.  Which is particularly ironic, because the intention of the electronic medical record mandate was to increase the quality and accuracy of medical record keeping.  The result has been the exact opposite.

“You can’t be a doctor without a pen,” the adage goes, because the foundation of all medical care is the medical record.  This was actually a major plot point in a book by Tom Clancy (may he rest in peace), where the ophthalmologist wife of our hero, Jack Ryan, points out that “if it wasn’t written down, it didn’t happen.” Patriot Games, I think.  I could be wrong.  Anyways, it’s true.  If it happened, you document it.  That way, everyone knows what was done, how, and why.  Want to know if I removed the appendix while I was inside that patient during surgery?  Read my operative report.  If I didn’t say I removed it, the appendix is still there. The corollary was also true: If it was written down, it must have happened.  If I wrote the lab test down, I checked it.  Simple.  Patient care depends on it.

Nothing’s so simple anymore.  In the era of the electronic medical record, everything is already written down, whether it’s true or not, whether I saw it or not.  Prepopulated rubrics, standardized physicals with normal findings documented by default, cut-and-paste patient histories with negative answers already filled in for all those questions the doctor may or may not have actually asked.  We can’t trust any of it any more, because we didn’t write it.  The computer did.  And nobody, no matter how professional or conscientious, can possibly undo all the stuff automatically done by the computer in the name of quality patient care.  Except most of it is bullshit.  Almost all of it.  Even the stuff I did myself, last month or last year.  When I look at a physical exam form, I can’t be sure that I really felt the patient’s pulse as it says on the record, or did the computer fill that in and I didn’t take the time to delete it?  Patient care decisions are now made on the basis of this flawed type of documentation every day.

It wasn’t supposed to be this way.  I was in Washington when the first discussions were being held about implementing an electronic medical record.  The advantages are obvious.  No more unintelligible doctor writing leading to patients getting the wrong drug.  Universal access to critical information on a real-time basis, eliminating repeated tests and procedures.  Less waste, greater safety.  It was all completely laudable.  Government and private industry allied to make health care better, cheaper, safer.  First step was to develop ground rules, a basis for all records to be standardized, to be developed by the US Bureau of Weights and Measures.  Never happened.  Too much money was at stake.  The government mandate, well intentioned but flawed in its implementation, was usurped by the greed of private industry.  Billions of dollars were at stake.  Lives were too, but nobody really stopped to notice.

Last year, I was called upon to be an expert witness in the defense of two emergency medicine physicians in New York.  The ER doc’s had heroically resuscitated a motorcycle rider who had suffered a traumatic amputation of his leg.  Sadly, the man had died from his injuries.  The family sued, alleging incompetence on the part of the treating doctors.  As far as I could tell from my review, the doctors had done everything they could possibly have done to save the man’s life.  I testified to this opinion in court.  With a dramatic flourish, the plaintiff’s attorney projected a ten foot high image of a page from the hospital record.  “Explain this, Dr. Geller!” the attorney demands, using his laser pointer to demonstrate where the medical record states that pulses were present and normal in both feet.  “These doctors didn’t even examine the patient, didn’t even realize that the patient’s leg was missing!” the attorney declaimed.

“No, not at all,” I had to explain to the jury.  “These doctors were so busy trying to save this man’s life, they didn’t have the time to uncheck the boxes on the computer form where it automatically fills in normal pulses for the feet of every single patient.”  It took me almost a half hour of explanation to the jury.  I thought I sounded like an idiot trying to explain this ridiculousness.  In the end the jury understood, and the physicians were acquitted.  It’s like something out of Joseph Heller’s novel, Catch 22.  Or MASH.  But with real dead people.

 

Blind Man Blogging

I’m sure that you’ve noticed the lack of meaningful posts to this blog in the recent past, and I’m sorry that your lives have been sadly devoid of the warm glow that makes life worth living as a result.  (My wife assures me that you haven’t noticed.)  “We understand completely,” I hear the throngs acclaim, “how could we miss the recent evidence of the overwhelming effort that was obviously required to bring The Problem With God to fruition, now available at Amazon and for the Nook?” (They have no idea what I’m referring to, my wife informs me, trying to set my mind at ease.)  Or perhaps it was the press of getting ready for the craziness that is the holiday season, you conjecture.  (They don’t conjecture, my wife interjects, because they haven’t noticed.  If they noticed, they wouldn’t care, she reassures me.  And by the way, she adds, there is no ‘they’ anyway.  There is only the empty, black nothingness that lives behind my computer screen, she smiles.  She’s my rock.)eyeball5

While I certainly appreciate your willingness to excuse my lack of creative fecundity (or should that be, fecund creativity?), I feel compelled to explain the real reason for my paucity of posts.  I can’t see worth shit.

It’s true.  I’m writing this by sensing the individual letters by pressing my nose against the screen.  (Consonants smell like toast, vowels like fruit.  The letter ‘y’ smells like wet dog.)  Obviously, this is a slow and inexact practice.  Actually, this post would’ve gone up three days ago except the ‘save’ button smells exactly like ‘delete.’

Here follows a tale of yearning, fear, and cosmic payback; certain to stimulate your need for schadenfreude and ‘thank-God-it’s-Geller-and-not-me-or-someone-I-really-care-about’ relief that is so especially appropriate for this holiday season:

Yearning:  I have worn glasses since I was seven years old.  My mother actually claims that I was born wearing glasses, which made for a particularly painful delivery for which I was never properly appreciative.  I don’t believe this, however, as one of my most profound childhood memories is of that exact day in the third grade at Einstein Elementary School when I joined the rest of my fresh-faced classmates in lining up for eye exams in the cafeteria during recess.  How clearly I recall the looks of sad compassion on the faces of the grownups as they shook their heads and announced that I had failed my exam.  Failed!  That was the exact term they used, the word they checked off on the mimeographed form they made me hold all day, staring at it (cruelly blurry, all those mimeos were blurry), finally carrying it home to present to my disappointed parents.  They shook their heads in consternation and I burst into tears at the kitchen table.  It was the first test that I had ever failed.  Not to worry, my parents reassured me, you can just wear your bother’s hand me down glasses.

Since that day, I have worn glasses.  I never complained, despite seeing the world through someone else’s corrective lenses.  Since I didn’t know any better, I accepted the distortion of the world about me, the crazed funhouse mirror appearance of the adults looming over me, the facial expressions of those I loved always looking like something out of that Twilight Zone episode that gave everyone nightmares.  (In the Eyes of the Beholder, I think it was called.  This will prove ironic.)  A lifetime of watching my glasses fly across the room whenever some perceived insult led to a slap in the face, of watching my glasses fly onto the infield grass of the Matterhorn ride at Disneyland (a story for some other time), of a hard packed snowball with my glasses in the middle thrown into the windshield of the principal’s car as it sped from the parking lot.  The principal returned my glasses but he was not happy about it, not one bit.  And they never quite fit right after that.

For just shy of a half-century I happily accepted my facial appendage. I must admit, however, that I yearned to see the time on the bedside clock every morning.  I yearned to actually see through a telescope, a microscope, an otoscope, an opthalmoscope, and not just to pretend I could see what everyone else could see.  I yearned for clarity.  But I always kept this yearning to myself.  And I never let this yearning get so out of control that I ever, ever considered getting contacts.  Never.

Fear:   The entire concept of contact lenses horrifies me.  The name horrifies me. I mean, the “contact” the name refers to is your eyeball.  I don’t do eyedrops, no way in Hell I’m sticking a piece of jellied plastic in my eye unless it’s kicked up by the rear wheel of a passing cement truck.  I’ve cleared out my eye doctor’s waiting room on several occasions because of the screaming elicited every time he tries to measure my intraocular pressure.  “Just a puff of air,” my ass.  That thing is a medieval torture apparatus.

There came a day, however, when the yearning for clarity was joined by a dangerous disability to see certain items at night; things like moving cars, traffic lights, and pedestrians.  A certain small dog, I think.  Enough is enough, I believed.  I deserve, I need, to see!  This feeling was only strengthened by an unfortunate episode in the operating room recently.  I had the privilege to operate upon an optholomologist.  Nothing major.  As he was lying on the OR table before surgery, I engaged him in lighthearted banter, in the fashion of reassuring him and setting him at ease.  (Doctors are the worst patients.)  I’m thinking of having surgery soon myself, I said to him conversationally.  Really, he asked, what kind of surgery?  Well, I admitted, these cataracts are really starting to bother me and I was thinking–the guy sat bolt upright on the table.  “You can’t see?” he asked me.  “I think we should cancel this surgery.  You should not be telling me such things.  I think we should reschedule.”  I’m pretty sure he was kidding.  It didn’t really matter anyway, since at that moment the anesthesia hit him and he fell back, unconscious. I don’t think he remembered the conversation afterwards.

It bothered me though.  He might be right.  I should be able to see.  I want to see.  So I went ahead with the cataract operation.  The world went dark.

Cosmic Payback:  The surgery went fine.  Before the operation I told the anesthesiologist, a friend of mine, that if I’m awake, I’m screaming. (Doctors are the worst patients.)  When I eventually awoke face down in the parking lot, my old milky, calcified lens had been plucked from its dusty lair and replaced with a shiny new piece of plastic.  Never felt a thing.  The next day, my blurry ophthalolomomolologist was pleased with the result.  [Brief Aside:  It is my theory that while constantly smiling and chipper, all opohthlolkmologistolists are secretly angst ridden and angry because even they really have no idea how to spell the name of their profession.]  I was also fairly pleased, except for the little inconvenience that I couldn’t see a thing.  “Yeah,” he explained, “that’s to be expected.  You’ll need to wear a contact lens in the other eye for a month until we operate on that one.”  “I’m sorry,” I said, “I thought you said something just now about contact lenses.  So much for my other senses taking up the slack, huh, doc?”  “No, really,” Blurry Bob confirmed (I don’t think I actually called my opthalcomologist that to his face, I was just upset and it seemed an appropriate moniker at the time.  I may have called him “The Butcher of my Eyes” once or twice, though.  Like I said, I was blind, and upset.)  He explained the dark, arcane science of quantum optical physics that made no sense to me but ended with the cosmic certainty that my glasses were now useless.  My mind could not reconcile the new view from my left eye, soon to be perfect in viewing things on the horizon but only magnified fuzziness anywhere within shouting distance, with the lifelong image from the right eye, nice and sharp up close but gelatinous and unformed beyond the end of my arm’s reach.  An insurmountable dichotomy that will destroy my mind, he explained.  “We’ll just set you up for contact lens instruction.”  Yeah, right.

I stumbled into the optician’s subterranean lair and began screaming at “Hello.”  The instruction did not go well.  While the instructor was nice and patient (at first, though with a disturbingly evil, maniacal laugh), I knew she was starting to get a bit testy with my lack of ability to shove my hand in my eye when she suggested that my wife, a veteran contact lens user of decades, could do it for me.  Sure, that sounds like fun.  Then they started to talk about “plungers” and showed me a rusty ice pick she uses to remove “a displaced lens,” whatever that means.  Something about the lens ending up behind my eye and stuck to the frontal lobe of my brain.  Hers was a unique and effective teaching technique.  I left sightless, wounded, and with a jelly blob folded into my one good eye.  But I’m still reluctant to let my wife of thirty years scrape this thing off my eyeball.  She is enthusiastic to help, however.

I can’t wait to get the other eye operated on.  In the meantime, I’m coming up with reassuring new explanations when my patients ask why I was just led into the OR by a seeing eye dog.

GSW Head: 22Nov1963

During my training, I spent a couple of months at Parkland Memorial Hospital in Dallas. Parkland has always been a leading institution in trauma care and I was there to learn from the best. It was, of course, the hospital that cared for President Kennedy when he was assassinated fifty years ago today. I still clearly recall that day decades earlier, and the pervasive sadness that followed for weeks thereafter. It was a sudden and tragic wrenching of the world for all of us, even those too young like myself to fully comprehend what had happened or why. Actually, the most harrowing part of the whole ordeal is that none of the grown-ups seemed to know why, either. I recall still the sense of confusion and of becoming unmoored from our previously happy lives.  Whenever I confront this event, I still feel a deep sense of loss and unease.  We still don’t know why.IMG_1278

Parkland does not shy away from its history in this event. I worked for two months in the large Emergency Department, lovingly referred to as “The Pit.”  It was still run by the surgical residents.  When I was there, I worked in the same resuscitation rooms where the victims that day were treated.  A plaque recognizes the event.  During my rotation, I had the privilege of listening to one of the participants relate the events of the tragic day.  His story, as I recall it, follows.

The work in the Pit was steady, as was usual for a Friday.  We were all aware, of course, that the President was in town, but nobody gave the fact a moment’s thought.  We were just doing our usual work when a clerk came over to tell me that she had just gotten a call saying that the President was being brought over by ambulance.  It was 1963–there was no radio communication between the hospital and the ambulance services.  She didn’t know who had called or if it might be a prank of some kind.  I called over my Chief Resident to tell him about the phone call.  “What do you want to do?” I asked him. “Should I call the attending?”

“We better wait and see,” he said.  “Probably somebody’s idea of a joke.”

So we waited.  When we didn’t hear anything more, I went back to taking care of the minor injuries that was the usual fare in downtown Dallas.  Suddenly, the PA announced that a trauma was at the dock.  I looked at my chief, who had suddenly become very pale.  We positioned ourselves to receive the patient and the big double doors burst open.  A patient on a stretcher was pushed in rapidly by an army of ambulance technicians.  My chief stopped them to assess the patient, a middle aged white male with an obvious severe gunshot wound.  With relief, he announced, “It’s not Kennedy.  Take him to Trauma Bay One.”  The nurses wheeled the man into the resuscitation bay and we began our assessment.  None of us recognized the victim to be Governor Connolly.  As we were working, somebody announced through the doorway that a second victim was arriving.

“You take it,” the Chief said to me.  I ran out just as another victim was wheeled into Trauma Bay Two.  I bent over the man to see President Kennedy, the back of his head nearly shot off from a severe gunshot wound.  I started the resuscitation protocol.

Within minutes, attending surgeons of every specialty flooded into the emergency department.  We were quickly pushed aside.  Amidst a flurry of activity, Kennedy and Connolly disappeared up the elevators to the operating rooms.  The chief and I sat at the desk in the Pit.  The ER was quiet and empty of patients, as they had all been removed during the crisis.  With no patients to care for, we all just sat, many of the staff crying.  I just stared at the trail of blood that was still on the floor leading out to the elevators.  “Somebody should clean that up,” I thought.

Never Say Oops in the OR

 

As a first year surgery resident, you don’t get to do much operating.  Mostly minor procedures and the simplest OR cases, especially the ones the more senior residents have no interest in, like removing skin lesions or biopsies, that sort of thing.  One of the most common surgical procedures left for the first year residents was the insertion of the chronic indwelling venous access catheter, an implanted device to facilitate infusion of medications, long term antibiotic therapy, or long term IV nutrition.Minolta DSC

This was not only a straightforward procedure, it was a very common procedure at the main University hospital we trained at.  Our service performed this operation over a dozen times a week.  As such, it wasn’t long before even the first year residents felt comfortable in the procedure.  And as first year surgical residents, it wasn’t much longer before we were feeling pretty cocky about our skill in performing this seemingly straightforward procedure.  Of course, as first year residents we had not yet internalized one of the most important tenets of all surgery:  There are no small operations.  Even the most routine procedure, the most mundane biopsy, can go horribly wrong if not approached with the respect deserved by every patient.

Towards the latter part of our first year, the residents spontaneously devised a kind of competition.  As we got really experienced in the procedure, it got to the point where we could  comfortably complete the operation in less than fifteen minutes.  When it went well, that is, which was about 95% of the time.  A couple of us were so “good” that we could occasionally complete the entire operation in about seven minutes.  So an informal competition started up amongst the first years, a hypercompetitive lot by nature, to see who could complete the operation the fastest.  It got to the point where the real objective of the resident was to have the catheter in and be suturing the closure before the attending finished scrubbing, so you could tell him when he walked in not to bother gowning up.  Attendings loved not bothering to gown up.  More time for coffee and chatting up the nurses.

It’s not hard to see where this is going.  The operation of inserting a chronic venous access catheter has nine distinct steps for its successful completion.  I know this, because as we first year residents began operating faster and faster, we managed to screw up each and every one of them.  As was the tradition in our residency program, every time a new screw-up was committed, it was named for its original perpetrator.  My class was instrumental in naming every possible screw-up related to chronic venous catheter insertion.  For the decades that followed our completion of the program, an errant first year resident could be heard being admonished by his attending not to “pull a Geller” or any one of the numerous other maneuvers we invented.  (A complete list of all the named maneuvers is available upon request, but I must pause here just to mention the Schwarma maneuver, in which the very last stitch at the conclusion of the operation is deftly passed right through the catheter, necessitating starting the procedure all over from the beginning.  Schwarma was asked to leave our program after his first year and went on to father many children during his career as a cruise ship physician.)

Step one of the procedure involved introducing a long, large-bore needle into the subclavian vein, a very large vein (about as thick as your little finger) that lies just under the clavicle (collarbone) in the upper chest as it carries blood back from the arm to the heart.  Unfortunately, this was a blind procedure in those days, made a bit more challenging by the fact that the subclavian artery, a large pulsatile structure carrying the entire blood supply to the arm, lies immediately adjacent to the target vein.  And the lung, an organ that really doesn’t like being stabbed by needles as it tends to collapse like a punctured balloon, is located immediately behind the target vein.  Inadvertent puncture of each of these anatomic structures had been accomplished thousands of times by countless surgical residents for decades.  We, therefore, were already trained in the precautions necessary to avoid these structures.  We were much more creative.

As I said, back in those dark old days of my training, this was a “blind stick.” (Currently, technology has progressed to allow real time ultrasound guidance of the procedure.) As a blind procedure, the surgeon is reassured that he had struck the correct anatomic structure with his needle by seeing the gentle return of dark red, venous-type blood from the hub of the needle when the syringe was disconnected.  It was appropriate, however, to quickly cover the hub of the needle with your finger so as to prevent air from being  sucked into the low pressure venous system.  This is called an air embolism and can immediately lead to a cardiac arrest or stroke.  This was to be avoided, having already been done many times as well.  One afternoon, towards the end of our first year, one of my first year colleagues named Dr. Sweetness was performing this procedure, smoothly and confidently proceeding before his attending came in the room.  Actually, he had begun before his attending was even in the operating suite, not that unusual at the time but a sign of cockiness for a first year resident.  Sweetness was pretty cocky at this point, as were we all.  Dr. Sweetness inserted the needle and was immediately rewarded with a flash of blood.  Rather than carefully consider the nature of the blood return, however, he immediately assumed it to be venous and clamped his finger over the hub of the needle.   Like I said, he was moving pretty fast.

Step two of the procedure is to insert a flexible  guide wire through the needle into the patient’s venous circulation, actually passing the wire near the chambers of the heart.  I should digress at this point to mention that it is important not to insert the entire wire into the vein, but rather to hold onto its end.  My fellow resident, Dr. Napoleon, failed on one occasion to follow this simple rule.  He neglected to maintain control of the end of the guide wire, which he smoothly and accidentally introduced completely into the patient’s vein, where it proceeded to pass downstream into the heart and lodge there.  This trick, thereafter known as the Napoleon maneuver, necessitates immediate abandonment of the planned operation and stat consultation with a cardiologist for percutaneous fluoroscopically guided extraction of the rogue guide wire.  This also required a very embarrassing conversation with the patient and his family, a conversation that never failed to upset the attending surgeon.

But I digress.  Sweetness smoothly introduced the guide wire and maintained control of its end throughout.  He did not, however, appreciate the fact that he had introduced the guide wire into the subclavian artery, not the vein.  In and of itself, this would not be remarkable, for as I mentioned, this particular maneuver had been done literally thousands of times.  Usually, however, the operator was immediately aware of the error when, upon removing the syringe from the end of the needle, bright red blood (not deep purple as it should be) sprayed like a fire hose into your face.  At that point, the surgeon need only fight the urge to curse or say “Oops”  (“Never say ‘Oops’ in the OR”) and remove the needle from the wrong vessel, then to hold pressure until the body’s natural tendency to recover from our screwups takes effect.  No permanent harm, no foul, as they say.  Unless, of course, you don’t realize what you’ve done.

This particular patient also had the unfortunate combination of low oxygen saturation in his blood stream and low blood pressure introduced by the inexpertly administered anesthetic provided by the first year anesthesia resident.  Therefore,  Sweetness didn’t realize he was in the artery.  Not just in the artery, though.  As luck would have it, Sweetness had managed to enter the subclavian artery extremely close to its takeoff from the aorta.  You know the aorta, the single largest blood vessel in the human body that carries the entire output of blood from the heart.  It tends to bleed very vigorously and fatally when injured.

Now, even that would probably have been kind of okay, if Sweetness at any point realized what was going on.  But this was a blind procedure, the usual cues had been taken away by his equally youthful anesthesia colleague, and Sweetness smoothly and confidently proceeded; still with no attending in sight.  Step three of the procedure is to gently and smoothly pass a dilating catheter over the guide wire, called an introducer.  The introducer is a gracefully tapering, somewhat flexible plastic straw that serves the function of gently stretching a hole in the wall of the blood vessel so that the catheter can be introduced.  I say ‘somewhat flexible’ because it is actually quite stiff–it has to be to perform its function.  It is, therefore, necessary to introduce this device with some degree of trepidation and finesse.  Sweetness had the finesse part down pat–it was the trepidation that was missing at this point.  Sweetness smoothly and expertly passed the introducer over the guide wire, a maneuver that he had performed without incident almost a hundred times before.  On this occasion, however, through a combination of bad luck, rushed technique, and inexpert assistance on the part of his anesthesia colleague, passage of the stiff-walled introducer device caused the root of the subclavian artery to be torn from its origin on the aorta.  This, of course, resulted in a large tear in the aorta.  The patient, already quite ill, proceeded to hemorrhage massively into his chest cavity.  The attending surgeon walked into the operating room just in time to see his patient, supposedly there to undergo a relatively minor procedure, receiving CPR on the OR table.

Oops.

Medical School, Part 2: The William O. Lombard Memorial Lecture on Flatus

As mentioned in Part 1, the medical school I attended was of the classic, old-school mode.  Like all the great medical schools before it, the “University Of” medical school required their students to spend the first two years of education reading approximately two million textbook pages and attending lectures and labs for over eight hours a day.  Our only clinical, real medicine experience during this time was in the personal discovery of hemorrhoids.  Classic.Minolta DSC

It was tough.  It was effective.  It was boring.  As one would expect of such a prestigious school, the students were smart and hard working.  Having succeeded in undergrad, a large number of the students found they could replicate their approach to their bachelors degree by skipping all the lectures and just reading like a madman, then acing the exam.  As a consequence, attendance was sparse.

The one year course on physiology was no exception.  The lecturer for this course was an elderly, white haired, world famous professor of physiology named Horace W. Rockport, III, or something like that.  He was the author of the most prestigious textbook of physiology at the time, a nine volume tome that was used in nearly every university.  He was a curmudgeon, to put it nicely.  Rockport would stride around the stage in front of the large lecture hall, emphasizing his points by banging his cane against the lectern or the whiteboard behind him.  Visual aids were not employed.  The idea was to sit and take in the grand wizard’s fountain of wisdom.

Rockport was not a shy man.  He lectured with great volume and authority, not only on physiology.  The great one would often include his pronouncements on politics, or society, or the world at large.  He began his lecture on lung physiology with the statement that, “Fully ninety percent of the world’s population performs no notable function other than the conversion of valuable oxygen to carbon dioxide.  That includes you people here, by the way.”  Great guy.

As the year went on, students began to realize that the lectures–besides being misogynistic, racist, and a bit loony–contributed nothing to their education that couldn’t be gleaned from the required reading of the great man’s textbook.  The audience grew more sparse.  This bothered Rockport not one bit, as he often pointed out that he was paid to talk, and he got paid the same no matter how many people were listening.  It became more hazardous to be in the audience, however.  The smaller numbers made for a more intimate experience despite the large auditorium, prompting Rockport to engage students directly, pointing his cane at somebody in the audience and questioning them vigorously.  This was okay when the questions concerned physiology, as we were prepared for that.  We weren’t prepared to answer questions about our parent’s possible infidelity leading to our conception, however.  Or why we thought ourselves smart enough to cure illnesses that God Himself had deemed appropriate to inflict on individual’s who, by this definition, deserved to suffer.  Tough questions.  The audience grew sparser still.

By the end of the academic year, there were about twenty of us left attending the lectures on a consistent basis, out of a class of just over one hundred.  This included the large German Shepard who attended every lecture accompanied his house mates from the medical student commune.  These students had to attend because they had drawn the responsibility of taking lecture notes for the class (at a cost of $100 to each student–I believe these guys went on to become entrepreneurs of narcotic prescription mills in various states).  And me, of course.  I was one of those guys that felt that I had to attend because on my schedule it said “Physiology Lecture 10:00-11:30,” so that’s where I was, usually trying to look inconspicuous somewhere in the middle rows.  I couldn’t sit in the back because the German Shepard did not like me one bit.

Rockport announced the topic of the final lecture with great solemnity, even going to the trouble of writing the title on the white board: “William O. Lombard Memorial Lecture on Flatus.”  He began his lecture with a lengthy and touching tribute to Lombard, a fellow physiologist who had evidently devoted his entire professional career to researching every aspect of the physiology of gastrointestinal vapors.  For some reason which I still do not understand to this day over forty years later, I thought the great wizard was making a joke.  I don’t know why I thought this, as the man had never displayed the slightest sign of a sense of humor during the entirety of the preceding academic year.  “What a sap,” I chuckled appreciatively from the middle rows.  I guess I thought that Rockport meant to contrast the greatness of his own career with that of lesser, mortal physiologists.  I was wrong.  Turns out that Lombard was his friend, or father-in-law, or something.  Never found out exactly what the connection was, but the “sap” comment was noted.

Rockport stopped dead in his tracks.  “Who said that?” he demanded, scanning the large lecture hall.  “It was Geller,” the owners of the German Shepard said.  “Right there, in the middle row.”  Evidently, they felt the same way as the dog.  Rockport rounded on me, jabbing violently from the stage with his cane.  “You think this topic funny, Mister Geller?” he demanded.  Yes, I didn’t say, I find this topic rather ridiculous.  But I just sat and tried not to nod.  “You think the scientific investigation into the nature and physiology of intestinal gases is unimportant?  Not worth your time or study?  Is that what you think, Mister Geller?”  By this time Rockport had come to stand just in front of me, standing at the very edge of the stage and stabbing out with his cane, trying to hit me.  I was, I thought, a safe distance away.  Unless he decided to throw the cane.  Or jump from the stage to attack me.  He had turned bright red and looked like either was a distinct possibility.

“Let me tell you, Mister Geller,” he continued.  “Let me tell you what kind of doctor you’re going to be, unless I can help it.  You, sir, are going to be the kind of doctor that thinks you know enough to get by.  That you don’t need to master the details, do you, Mister Geller?  You’re going to be a gastroenterologist, I think.  Yes, Mr. Geller, a gastroenterologist.  A doctor that makes oodles and oodles of money shoving rubber hoses up the arse of your patients, all day, dozens of times a day, every day.  Getting paid lots and lots of money to shove colonoscopes up the rear end of society’s elite, every day.  And one day, Mr. Geller, one day you’ll be looking up some poor patient’s arse with your fancy colonoscope and you’ll see something!  Do you know what you’ll see, Mr. Geller?”  I had to shake my head at this point, as it was clear he wasn’t going to move on until I did.  “You are going to see a nice fat, juicy polyp, that’s what you’re going to see.  A nice fat, juicy colonic polyp, Mr. Geller.  And I know you’ll want to take out that juicy polyp, Mr. Geller, because you can charge a lot of money to take out the colonic polyps of our society’s elite colons.  So you’ll position your colonoscope, and you’ll ensnare the nice, juicy polyp with your electric cautery snare, Mr. Geller, and you’ll tell your pretty young assistant to turn on the current to your electric snare.  And do you know what will happen then, Mr. Geller?  Do you know?”  I had to admit that I did not know.

“No, Mr. Geller, you will not know.  You will not know that flatus contains 2% methane gas, a highly inflammable compound.  You will not know this simple physiological fact, Mr. Geller, because you think it unimportant.  Laughable, even.  You will not appreciate the significance of the fact that the gas within your patient’s colon is highly inflammable.  You will not.  And because you are an idiot, Mr. Geller, do you know what will happen?”  I think I might have been smiling at this point as I admitted that I really did not know.  “Your patient, Mr. Geller, will EXPLODE!  Yes!” he said gleefully, “Your high society, polyp possessing patient will explode in your face!  Pieces of your patient will spray across the endoscopy suite, bits of flesh will spatter the walls.  And then do you know what will happen, Mr. Geller?”  I shook my head.  The dog may have barked at this point, I wouldn’t be surprised.  “Then, Mr. Geller, the poor patient’s widow will sue you for medical malpractice.  And then a jury will pronounce you guilty of being a stupid, ignorant git.  And then your malpractice insurance company will cancel your policy.  You’ll be out of a job, Mr. Geller.  Out on the street, destitute!  That’s what going to happen to you, Mr. Geller, because you don’t respect science!”

“If that does happen, Professor Rockport,” I said, “I’ll still be sucking your precious oxygen.  And I’m pretty sure you won’t be.”