Category Archives: Surgery

Never Say Oops in the OR

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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

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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.”

Medical School, Part One: Feeling Bad for the Patient

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Long ago I attended medical school in the midwest.  It was a public “University Of” school that enjoyed an excellent reputation, especially amongst the members of the school itself.  At the time (this was the early part of the last century), they claimed to be “the number six medical school in the country.”  I have no idea how they came up with this fact.  Suffice to say, they have spent every moment of the last one hundred years striving to overtake every institution above them on that imaginary list.IMG_1139

There was a unique dynamic in my midwestern state when it came to medical education.  In addition to “The University Of,” there was also a long established medical school in the city, as well as a brand new upstart medical school at the State University.  The State University already had a well respected veterinary school and one of the best osteopathic medical schools in the nation.  This fact led the brilliant State University administrators, faced with the task of naming the newly accredited allopathic medical school in a hip and distinctive way, to call it “The School of Human Medicine.”  I’m not sure what organisms the administrators thought their graduates from the osteopathic school were treating up to that point, by I’m assuming something distinct from animals or people–aliens, I guess.

This triumvirate of medical schools led to a great deal of competition on multiple levels:  for patients to care for in order to train their students, for prestigious residencies once their students graduated, and faculty.  It was a constant war, with faculty members being stolen back and forth amongst the three schools.  In response to this competition, each school developed its own unique personality.  “The University Of” simply made sure that everyone knew that they were the best and the most prestigious.  For a while they would spout the tag line “The Harvard of the Midwest,” until one marketing savant realized they could do better.  They then claimed that Harvard was just “The University Of” of the East.  You get the idea.  The urban medical school prided itself on its gritty reputation of training “real doctors,” emphasizing their large caseload inherent in a predominantly indigent population.  The State University emphasized their new, modern teaching approach. The curriculum incorporated an emphasis on compassionate care and alternate, New Age type approaches. The teaching method was also new and different.  Instead of the classic lecture for two years followed by two years of closely supervised clinical experience epitomized by the “University Of” format (and Harvard, of course), they developed a computer based, “teach yourself to be a doctor” curriculum.  It was very ahead of its time.  It was also a disaster.  The graduates of this system could always be identified by their inability to  pronounce any medical term over two syllables correctly, since they only interacted with a computer screen for two years.  They were cruelly mocked when they finally hit the wards.

This dynamic was exemplified in a joke popular in the state at the time.  A recent graduate from each of the medical schools is asked to evaluate a patient in the emergency room.  The patient is a seventeen-year old male with a one day history of worsening right lower quadrant abdominal pain, nausea, and fever.  Physical exam demonstrates exquisite tenderness over the appendix.  The first student, a recent graduate of “The University Of,” says, “I’m quite familiar with this type of patient.  I have read over a dozen journal articles on just this problem and given a Grand Rounds lecture on this exact condition.  This patient has acute appendicitis and needs an emergency appendectomy.”  “And how would you do that operation?” the “U of” graduate is asked by the professor.  He shrugs.  “No clue,” he says, “we don’t actually go to the OR.  That’s just technician stuff.”  The second student, from the urban training program, snorts derisively.  “The dude’s got a bad problem in his gut.  I’ve never read anything in a book about this, but I’ve taken care of twenty of these.  I need to get him to the operating room.”  “What’s your preoperative diagnosis?” the professor asks.  The urban graduate shrugs.  “Who knows?  Doesn’t matter.  Never let the skin of the patient stand between you and your diagnosis, that’s what we always say.”  Finally, the “State University” graduate is asked his opinion.  He looks distinctly uncomfortable when asked for his diagnosis.  Finally, he answers, “To be honest, I’ve never read anything about a patient like this.  As a matter of fact, I’ve never even encountered a patient with this problem during my education.  However, I do feel really, really bad for him. And I hope he gets better soon.”

Trunk Full of Human Tissue

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Simple elements of life can be a challenge for those pursuing training as a surgeon.  Getting home from work, for example.  In the days when the trainee was expected to take call in a busy hospital every two or three nights, the resident often was trying to drive home in a state of profound sleep deprivation.  This led to significant difficulties.  One of my fellow residents seriously injured her knee by crashing her car driving home after call.  She was on crutches for months, making standing at the OR table a bit of pain.  I can’t even count the number of times I was awakened by angry honking from the car behind me because I had fallen asleep at the wheel while waiting for a traffic light to turn green. I quickly learned to take the car out of gear whenever I stopped at a red light.  Once, I woke up to the sound of my car driving through an abandoned field–had no idea where I was or how I got there.  Most exciting was the time I fell asleep while driving down the merge ramp to the expressway, in the driving rain in the middle of the night–woowee, that was a hoot. You really snap awake when you realize that you are looking at headlights instead of taillights in front of you at sixty miles per hour.Boston City Flow

I found that the only reliable way to get home without falling asleep was to drive as fast as physically possible.  This not only generated the adrenaline necessary to keep my eyelids up, it also shortened the critical period of vulnerability.  Stop signs became optional after one in the morning.  Red lights became optional after three.  You get the idea.

Unfortunately, the police forces of the various localities I drove through were not amused by my technique.  Soon after I adopted my Steve McQueen attitude toward commuting, I began to accumulate significant expenses in the form of moving violations.  While many cops are sympathetic to physicians in training, very few are willing to forego writing the ticket when you just blew through a red light at eighty in a thirty mile per hour zone.  It got to be way too expensive.  I think I was making somewhere in the range of $25,000 a year at the time, and traffic tickets (my kind at least) were over a hundred bucks a pop; they were popping at the rate of one or two a month.  You do the math.

As a result, I had to slow down again.  This worked for a bit, but then one spring evening I fell asleep at a red light and rolled back into the car behind me.  No real damage, but unfortunately the car was driven by a state trooper.  Troopers never let you off without a ticket.  It’s because they have to wear that ridiculous hat, I think.

So driving slow wasn’t working, either.  I needed a solution, as I was facing a problem that would continue for another four years.  At the time of my encounter with the state trooper’s bumper, I was on the transplant service.  One morning, as I was trying to stay awake during attending rounds, I saw my salvation.  It was a styrofoam box just outside the OR, waiting to be tossed in the trash; one of the containers used to hold a kidney being transported between hospitals for transplantation.  The box is about the size you’d expect to hold a St. Bernard, because it needs to hold the ice to keep the kidney cold.  It is impressively marked with multiple labels proclaiming in large, authoritative fonts:  RUSH:  HUMAN TISSUE FOR TRANSPLANT.  I excused myself from rounds (fake page gambit, always handy) and took possession of the box, promising the janitor I’d toss it for him.

From that day on, I never drove anywhere without my HUMAN TISSUE box in the trunk.  Back in Steve McQueen mode, I was again getting pulled over with fair regularity.  Now, however, I greeted the officer with the explanation that I had no time for him, I was driving like this because I had to get a kidney to the hospital for transplant.  This usually elicited quite a bit of skepticism, requiring me to pop the trunk.  Which I would do with profound irritation, pointing at the box and saying, “Okay, believe me now?  Because I gotta get this to {insert name of hospital in general direction I was heading at time I was pulled over) so a little girl will live to see another birthday.  Or is making your ticket quota on my ass more important?  Your call, officer.”  I admit, I usually laid it on a little thick.  What can I say, I was tired. Always tired.

This worked without fail.  I never got another ticket for the rest of my residency.  Only problem was the one time I really gave the cop such a hard time (I was really, really tired) he insisted on giving me an escort all the way to the hospital.  I had to thank him and actually carry the box into the ER as he watched.  I couldn’t leave until he pulled away.

Still better than another hundred bucks down the drain.  Besides, that little girl needed that kidney.

“Keep Calm And Carry Speed”

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For a very long time, my favorite aphorism was “Don’t panic.”  I am a big fan of Douglas Adams, obviously.  My son and I often threaten his Mom that we’re going to get the phrase tattooed on the back of our right hands, which she no longer considers amusing.  It has always seemed an apt phrase and good advice for us both.  Certainly as a surgeon who specialized for a long time in trauma care, it served.  It also seems appropriate for my son, who is a percussionist.  It seems that unlike any other type of musician, percussionists are constantly coping.  A classical violinist or horn player, performing a difficult piece in a crowded concert hall, is rarely faced with an unexpected technical challenge. They play.  Percussionists, on the other hand, are frequently moving between multiple instruments, changing mallets on the fly, adjusting to alterations in tempo, tuning in mid performance. It makes me nervous just watching, but he loves it.  Every performance is a challenge in real time, every note played is heard without fail by everyone in the hall.  Certainly, “Don’t Panic,” has served him well throughout his career, as it has my own.cropped-156595748-alonso-ferrari-austin_custom-a3b7a8d98fcee01986148e35e0ef3b39c800a9c6-s4.jpg

“Don’t Panic” is good advice in difficult circumstances.  Whether you are faced with a patient bleeding out from a gunshot wound, a conductor who botches the crescendo, or a lethally morose robot (Hitchhiker’s reference), one must first cope.  But not panicking is not sufficient.  In life, as in surgery or musical performance, staying calm in the face of adversity is but the first step.  The real trick, as the famed Formula One driver, Kimi Raikkonen, so elegantly stated in the title of this post, is to keep moving. When faced with a difficult challenge, a sudden catastrophe, the realized mistake–it is necessary to move forward.  Carry speed.  It is almost never helpful or appropriate to stop suddenly, ruminate on why the illness has happened to you, regret the decision/marriage/investment.  In racing, a difficult situation is transformed into disaster by standing on the brakes, every time.  The host of Top Gear, Jeremy Clarkson, once said, “Speed has never killed anyone, suddenly becoming stationary…that’s what gets you.”  Carry speed.

Of course, just moving straight ahead is rarely sufficient to overcome difficult circumstances.  As you are moving through trouble, the driver must see further ahead, fighting the natural tendency to become too focused on what is immediately in front.  “The car goes where the eyes are looking.”  Look down the road farther.  Create space, change course, adapt, use a different technique–DO something.  In surgery, the experienced surgeon knows that the answer is almost always “Make a bigger incision.”  Better exposure, a wider approach, seeking control of the disastrous injury by extending into areas of normal anatomy is almost always the safest course.  Stopping, pausing to consider, trying to figure out why one’s usual techniques have failed; these things do nothing to stop the bleeding.  And there’s only so much blood one can lose before it really doesn’t matter any more.

There are a number of similarities between racing and surgery.  The need for constant focus is the most concrete.  In both pursuits, even a momentary lapse by the operator is often detrimental, and can at times be disastrous.  Team work, skilled colleagues, luck–all are paramount in both avenues of pursuit.  Even the aphorisms seem interchangeable:

“Slow hands in the fast parts, fast hands in the slow parts.”  The routine parts of the operation, opening and closing, can usually be accomplished by an experienced surgeon expeditiously.  Care must taken, however, when maneuvering around the pathology.

“Slow in, fast out.”  Approach the pathology deliberately, intelligently choose your position as you enter the critical phase of the resection–this will make the performance of the actual maneuver straightforward, allowing an easy, controlled exit.

“The fastest line is not always the quickest.”  In surgery, as in racing, it is sometimes much more efficient to take additional time in the approach, allowing the next maneuver to be performed more optimally.

“Drive your own car.”  You can only be responsible for your own actions.  What all the other guys are doing–the other drivers, the anesthesiologist, the other patients, the officials–is out of your control.  Do what you do to the best of your ability, let the others take care of themselves or the patient.

“Make room for trouble.”  Try to see the crisis developing ahead, rather than being forced to react once it happens.  Create space in anticipation, extend your line around a car that looks loose entering a turn–if he goes into a spin, the added space may get you past safely.  Same thing in surgery–anticipate that the infected artery may not hold your stitches, may fall apart as you try to clamp it.  Extend into another body cavity if you have to:  if you can’t get control of the bleeding infected aneurysm in the groin, go into the belly to get control.  Anticipate and extend.

Finally, Churchill (though not a racer or a surgeon, he managed to always say it best):  “When going through Hell, just keep going.”

Equanimity

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In surgery, as in many fields of endeavor, it is never a good idea to panic.  We strive for equanimity, the ability to remain calm and effective despite surprising or difficult circumstances.  We never curse or say “Oops” after cutting the wrong structure or getting sprayed in the face by an unanticipated fountain of blood, for instance.  The well trained surgeon merely says, “Well, that’s interesting,” or something similar.  (Anesthesiologists know that when the surgeon says that something is interesting, it’s time to start transfusing blood pretty rapidly.)  This particular personality trait was drilled into me throughout my surgical training, but never so effectively as by my senior resident and mentor, Ben Jeffries.  Ben at the time was new to our program, having been tossed out of the Johns Hopkins surgery residency as part of the pyramid system they use and because he wasn’t a dick.  You gotta be a dick if you’re going to succeed in the Hopkins surgery program.  Fact.  Anyway, Ben was a skilled surgeon and a positive influence in our program after he joined us in his third year of training.  We still stay in touch.IMG_1154

A lot of what we do in surgery is done because that’s the way we do it.  Of course, what we do is based upon careful scientific research.  How we do it, however, is often done because we do it that way.  Not always the best way, as it turns out.

The surgical procedure of tracheostomy is frequently performed upon critically ill patients in the intensive care unit who require long term support on a ventilator.  It is dangerous and uncomfortable to maintain a breathing tube down the patient’s throat for longer than a week or two, so the patient is eventually scheduled to undergo the routine procedure of making a surgical opening in the windpipe, the trachea, and inserting a special tracheostomy tube.  This tube is much more comfortable for the patient and is less prone to becoming blocked or dislodged.  Research has proven over and over again that it is a valuable surgical procedure.

Research has not clearly addressed just how this valuable procedure is to be accomplished, however.  A couple of options are available to the surgeon about to embark upon the procedure of tracheostomy.  The safest and most enjoyable manner for all concerned, surgeon and patient, is to perform the tracheostomy in the operating room.  Everything is more fun in the OR.  In the OR, the surgeon is surrounded by skilled, helpful personnel, a trained anesthesiologist is carefully managing the critically ill patient’s respirations and sedation, the lighting is optimal, and every tool one can possibly need is readily available.  So, of course, we often don’t do tracheostomies in the OR.  We frequently perform this surgical procedure in the patient’s bed in the ICU.  This is much more efficient–which means, it’s much cheaper.  Can’t honestly think of any other reason.

As part of my surgical training, I rotated through a very busy community hospital.  This hospital had a large, pleasant Pulmonary Intensive Care Unit, the PICU, which cared for patients who required ventilator support because of emphysema, lung surgery, or other severe pulmonary illness.  These patients often required tracheostomy.  On this occasion, I was a second year resident, having been a doctor for about eighteen months.  My service was consulted to perform a “trach” on an elderly, robust man who had been requiring high levels of ventilator support for over a month.  He was overdue for the procedure and our attending, an ebullient thoracic surgeon named “Tex” Dallas, felt we should get this done ASAP.  Tex was a skilled, flamboyant thoracic surgeon, who had the practice of wearing a cowboy hat while doing hospital rounds.  Nobody knew why he had to leave Texas, but he cut a loud and colorful swath through the Midwestern surgical society while he was here.  Tex told Ben, my senior resident, to get the trach done “today” in the PICU and he’d staff the procedure.  Which meant that Tex would be flirting with the PICU nurses (one of whom would go on to become a skilled physician and my wife) while we did the procedure at the bedside.

Ben and I prepared the patient for his tracheostomy by setting up the instruments that we borrowed from the OR.  We recruited the Respiratory Therapist to help, as there comes a point in the operation when the tube already in the trachea and supporting the patient’s respirations, called the endotracheal tube, needs to be removed from the patient’s mouth so that the surgeon can put in the new tracheostomy tube.  This role is usually filled by a trained anesthesiologist or anesthetist in the OR, of course.  We, as I mentioned, weren’t in the OR.  But the Respiratory Therapist was enthusiastic and anxious to help, especially since she’d never seen this done before.  Ben and I instructed her on when and how we’d like her to remove the tube when we said so.  She nodded enthusiastically.  This was exciting.

Ben and I got started.  The patient was cooperative as we had given him a small dose of sedative, his breathing being entirely supported by the ventilator anyway.  The operation started well, with Ben letting me do everything while he held the tissue out of the way with retractors.  This was critical, as the patient had a bull like neck and the hole to reach his trachea was therefore deep and narrow.  And since we weren’t in the OR with all the special lighting, a little dark, as well.  Tex was sitting at the nursing station, which was around the corner from where we were working, watching the patient’s vitals on the monitor and trying to convince the stunningly beautiful nurse to join him at lunch after the procedure.  (Did I mention that I married the woman about a year later?)  The operation was going smoothly and we had the surface of the trachea cleanly exposed in the depths of the wound.  Ben turned to the Respiratory Therapist standing at the patient’s head, watching with fascination.  “Ready to remove the tube?” he asked her.  She nodded enthusiastically.

At this point, it is necessary to carefully cut into the trachea and create a small window in which to insert the new tube.  As I began this maneuver, Ben suggested that I take care to avoid the small blood vessel just adjacent to the point we had picked for our window.  While it wasn’t a conscious decision (in the dark depths of the wound I couldn’t see from my angle what he was referring to), I ignored his advice and instead severed the vessel just as I cut into the windpipe.  The wound immediately filled with blood.  “That’s interesting,” Ben said.  I was speechless.  “Okay, it’s out,” the Respiratory Therapist said.  We both turned to look at her.  She was smiling as she displayed the endotracheal tube she had removed from the patient.  “Really?” was all Ben said.

Ben and I bravely suctioned and retracted in our efforts to expose the trachea so that we could get a tube into the patient.  At this point, the patient was not receiving any oxygen or any type of respiratory support.  He had, at best, a couple of minutes to live unless he was reconnected to the ventilator.  The blood welling up from the wound became progressively darker as we struggled.  Listening to the EKG monitor, we could hear the patient’s heart rate slowing as he lost oxygenation.

“You boys okay back there?” Tex called from around the corner, watching the pulse slow on the monitor at the nurse’s station.

“Just fine, Dr. Dallas,” Ben called back.  We were not fine.  We were completely fucked, actually.  The wound was so deep that we needed two hands to hold the tissue out of the way, leaving only two hands to suction the bleeding and operate–about two hands short of what we needed.  We couldn’t see shit.  The patient was rapidly deteriorating.  The Respiratory Therapist was looking over, fascinated.  “That’s a lot of blood,” she commented helpfully.  The patient’s heart rate continued to slow.

“Boys?” Tex called from the desk.

The patient’s heart stopped.  He was in arrest.  I looked up at the monitor.  Flatline.  Ben took the tracheostomy tube from me and jabbed it blindly into the wound.  “Ho-ly Shit!” we heard Tex shout from around the corner.  Ben hooked the tube up to the ventilator, having no idea whether the tube was actually in.  It must have been in place, however, because in the next few seconds the patient’s heartbeat reappeared and quickly came up to normal.  Tex came skittering around the corner and pulled up short at the foot of the bed, looking at the monitor.

“That’s pretty weird,” Tex said, scratching his head.  “Poor bastard was looking a little dead there for a bit.  That monitor must be fucked up.  You boys all good here?”

“No problem,” Ben said.  “All good.”

Tex bent down to pick up his hat that had flown off as he ran around the corner.  As he bent down, he noticed the half-inch deep puddle of blood under the bed and lapping at our shoes.

He straightened up, smiling.  “Nice job, boys, nice job.  Now don’t make that pretty young nurse have to clean up after you boys now, you hear?”

“Of course not, Dr. Dallas.  We’re better than that.”  Ben smiled at him.

Not much better, though.

The Zen of Surgery and Bicycle Repair

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I spent summers during high school and the first half of college working as a bike mechanic.  I love bicycles, and since I’ve always been the kind of racer with all the natural gifts to consistently finish last, I spent a lot of time fixing and tuning other people’s bikes.  The guys who taught me how to fix bikes were professional, passionate mechanics, dedicated to their craft and absolutely, batshit crazy.  As a young and impressionable adolescent, I was schooled in the ways of life, women, and bike repair by this motley gang.  Amongst other things, they taught me how to kill a fly twenty feet away in midair by creating a flame thrower from a large squeeze bottle of WD40 and a butane lighter.  They also taught me how to put out a fire in a confined space filled with flammable liquids.  And how to swear. Minolta DSC After the first year working with these proud professionals, I began to realize the difference in approach possessed by certain mechanics.  When I was confronted by a difficult challenge, I’d seek advice from one of the older, wiser mechanics.  Of course, they were all older and wiser.  Often, this mentor would advise me to simply remove the malfunctioning part and replace it.  Quick and easy.  However, a couple of the more senior, seasoned mechanics, the guys who were still doing this after many years (with brief interruptions doing time in jail due to other, part-time occupations), would show me how to actually fix the offending part.  Often, this repair would involve the deft application of a hammer and screwdriver, or a hammer and wrench, or hammer and an awl.  Always a hammer, deftly applied.  The repair was elegant, effective, and a lot cheaper than replacing the whole part. It wasn’t long before I realized that there was a world of difference in the approach these two types of completely competent mechanics would take to a difficult problem.  Both would end up with a perfectly functioning bicycle.  The “replacement mechanics,” however, cost the shop and the customer a lot more money.  These guys were also the ones who always were in need of some special tool or wrench, the little used tools that were always squirreled away somewhere.  They spent a lot of time looking for the exact tool that was needed to remove a bottom bracket or a gear cluster.  The other guys though, the “fix-it mechanics,” never seemed to need more than a hammer and a couple of basic tools to make the most intricate repair on the most expensive Italian racing machines.  And they did it cheaply, quickly, and half the time while hung over or higher than a kite.  This impressed me.  I always strove to be a “fix-it mechanic” whenever I could.  I also built myself a damn nice racing bike from all the parts the “replacement mechanics” chucked into the broken bin.  Still consistently ended up last. Many, many decades later, I have found the same phenomenon amongst surgeons; surgeons of every type and specialty.  I can truthfully say that it is very, very rare to find a truly incompetent surgeon.  In my nearly thirty years of practice, I can think of only one, as a matter of fact.  Oh, I’ve run into a lot of surgeons that I wouldn’t let operate on my dog, don’t get me wrong.  Many surgeons are arrogant (see Mommas, Don’t Let Your Babies Grow Up To Be Surgeons post on this blog), lack any semblance of beside manner, or are incapable of admitting when they screwed up.  Some lack good judgement or have personal issues.  But not truly incompetent.  When faced with a sick patient needing surgery, almost every surgeon that has successfully completed an accredited residency will manage to do the right thing. But like in the bike shop, they don’t all do the same right thing. I remember a case during my training that illustrates the point.  I was a fourth year resident on the trauma service.  In my training program we saw a lot of trauma, so by the fourth year we were fairly competent in patching up holes in people made by various firearms.  On a summer Sunday morning, a young man was brought to our ER with a recently acquired gunshot wound to the flank.  I forget the exact story, but I can confidently say that the young man was simply shopping for groceries with the several hundred dollars rolled up in his pants, given to him by his grandma, when he was jumped in the alley by two dudes.  It was always two dudes, because the victim would’ve blown away a single attacker and gone on to the grocery store to buy his grandma’s groceries, no problem.  Pretty much the same story every time. Anyway, this otherwise healthy seventeen year old comes to the ER bleeding pretty impressively from his flank wound and in shock.  My Chief is tied up with a list of operations left over from the night before so he asks the attending to staff me on the case.  Usually, this would be a great opportunity for me as almost every attending surgeon at this hospital was an expert in trauma care and a great teacher.  Almost every one.  On this morning, I have the bad luck to be staffed by a newly hired attending, a young general surgeon fresh out of residency/trauma fellowship at a very prestigious Midwest academic medical center.  Unfortunately, it was the kind of medical center that doesn’t see a lot of penetrating trauma.  The kind of program that writes a lot of textbook chapters, publishes a lot of esoteric medical papers, but doesn’t do a lot of operating. My attending, Dr. Maisy Blue, is not happy.  It is early on a sunny Sunday morning and she was planning on spending the morning in the call room “catching up on work”; she is quite distressed that the Chief has “dumped” this case on her.  As we explore the patient’s abdomen, we discover that he has a through-and-through gunshot wound to the kidney with a collection of blood (hematoma) rapidly expanding within the capsule enveloping the kidney.  The good news, though, is that the bullet has only injured the single kidney and otherwise exited the young man without incident.  Pretty straightforward case, one that I’d participated in on a fairly recent occasion.  I confidently outlined my plan to isolate the blood vessels carrying blood to the injured kidney, to be followed by repair of the organ.  “No way,” Dr. Blue, counters, appearing quite uncomfortable with my plan.  “He’s lost too much blood already.”  She is clearly distressed as we watch the hematoma expanding. “It’s going in the bucket.  He’s got another one, right?”  I quickly check to make sure that this young man is not one of the few individuals born with only one kidney and confirm to her that he indeed does have another, uninjured kidney, but– No ‘buts’ about it, Dr. B has already begun to dissect the capsule surrounding the injured kidney, resulting in a large gush of bright red blood.  She clamps her hand around the kidney, holding pressure.  “Take it out, Geller,” she instructs.  Which I do, clamping and tying the necessary blood vessels.  Once freed, Dr. Blue ceremoniously plops the kidney into a stainless steel basin.  “Done,” she pronounces.   “You can close with the medical student, right?”  No problem.  Young man did great, went home to his grandma three days later with a really cool scar and one perfectly good kidney.  Which should do him nicely for his whole life, really.  Unless somewhere down the line he gets kidney cancer, or has the bad luck to get shot in the other flank.  Should be fine. I just would rather fix it, that’s all I’m saying.

Evidently, My ICU Has A Helluva Skylight

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True Stories From The Front Lines Of Medicine

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

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

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

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

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

“Heaven,” he says, smiling.

“I’m sorry?  What was that?”

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

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

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

“What did you give this guy?”

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

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

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

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

“Oh.”

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

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

“Yeah.  Everything. Get everything, stat.”

“Huh?”

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

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

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

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

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

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

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

“I’m sorry?  Fine with what?”

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

“Killing off your Dad, you mean?”

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

“If he were still alive, you mean?”

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

Just wish I was.

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

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

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

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

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

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

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

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

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

The CTSF shrugs, “Fine.  Thirty minutes.”

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

“What was that?” I ask the CTSF

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lub Dub

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

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

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

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

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

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

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

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

“Unusual,” I comment sagely.

“Happens,” he replies, supersagely.

“Is his pressure okay?” I ask.

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

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

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

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

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

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

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

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

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

“He’s dead,” I deadpan.

“What do you mean?”

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

“Twenty minutes or so,” she answers.

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

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

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

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

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

“Great, thanks.  How’s yours?

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