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
The other night, my wife got a call from a relative that she hadn’t spoken to in quite a while. The woman called during dinner, of course. Why people capable of calculating compound interest on their mortgage while separating two warring children armed with steak knives and making dinner for a family of six can’t manage to wrap their heads around the entire concept of time zones is beyond me, but she was happy to hear from her. When she hung up, my wife said, “I really should call her more often.” Meaning, ever.
This got me to thinking about all the people I know and care about that I just don’t seem to hear from anymore. Dinner was being reheated anyway, so I had some time to think about this. It occurred to me that I really hadn’t had a good conversation with my Dad, for instance, in a very long time. I love my Dad, and I remember when we used to talk pretty much every day. My wife gave me a strange look when I brought this up with her, however, pointing out that my Dad had died almost twenty years ago. Like this was a good excuse.
[Brief Aside: One of my Dad’s favorite sayings was, “Man who trip over same rock twice, deserve to break his neck.” He’d often admonish me with this gem told in a solemn fake Confucius accent, in way of educating me about some mistake I’d made for the sixth or seventh time. The frequency with which he used this aphorism prompted me to write a very short story in fifth grade about a dashing young knight who tripped over a rock in the road. He was stuck, turtle fashion, by the weight of his brilliant armor, but helped back to his feet by a passing Good Samaritan. The next day, however, when the incautious knight tripped over the very same rock, resulting in the same predicament, the next passer-by was a robber who killed the knight by breaking his neck and stole his money. As I recall, Mr. Barno, my fifth grade teacher with breath so bad two students dropped out of school that year to pursue a life of crime, wrote in his comments something to the effect that I should seriously consider pursuing a career in accounting. Thanks for that, Mr. Barno–hope you’re resting peacefully.]
There are dozens of good friends and beloved relatives with whom I’ve lost contact. It’s inevitable, I guess, as we get older and get busy with our own, hectic lives, and these other folks just keep moving away or dying. It makes it tough to keep in touch. It’s probably my fault, to be honest. I mean, I’m one of those folks that’s pitifully inattentive to maintaining contact with old friends and relatives. I don’t think I’ve made a long distance call or attended a seance in a really long time. And while I hate to admit it, there has been more than one occasion when I’ve returned from a long, tough day at work and looked at that little flashing red light on the answering machine and said, “No way.” Then I just delete those suckers without even listening. It’s true. So it’s entirely possible that my Dad left some kind of message, just touching base, and I erased it. It bothers me, now that I think of it, because if he left a call back number and I just deleted the thing, no wonder he’s so ticked off that he never called back.
On the other hand, it’s at least as likely that’s it’s their fault. I know how tough it can be to pick up the phone. My wife and I were recently traveling in Ireland, and we kept trying to use the cellphone to call back to a friend of hers here in the States. But who can figure out whether to put the one in front of the number or not, do you include the 01 country code, and all that other jazz that makes it just about impossible if you’re over fifty to make these things work? (Which is why we almost always travel with a child, just in case we have some technical issue.) Most of these people are really, really old now. A lot of them passed away before we even had cellphones or Skype. What do we expect?
I like to think that they’re probably too busy to call, anyway. Most of my parents’ friends are dead, and I wouldn’t be surprised if they’re so busy yelling at one another over how their partner screwed up the bidding for their great bridge hand that the subject of how the kids are doing just hardly ever comes up. Or Samba lessons, or something. Time just gets away from you, I know. Dad’s probably still upset I moved so far away that’s he’s waiting till I move back into his neighborhood to stop by. He hated that drive from Michigan to Long Island, no way he’s coming all the way back from the dead unless someone gives him a damn good reason.
Or maybe it’s just because they’re dead. I don’t know. Wouldn’t kill you to call, though.
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.
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.
During my Chief Residency (fifth and last) year of surgical training, I was working at the large academic hospital for a three month rotation. During this rotation, I was in charge of a general surgery service with an emphasis on oncology surgery. This was a plum rotation for the chief, for we got to perform large operations just about all day, every day.
While finishing a particularly satisfying distal pancreatectomy with my attending, my junior resident came into the OR, excused himself for interrupting, and told me that he had received a request for a consultation in the Medical ICU to “rule out acute abdomen.” This phrase, when voiced by any member of the Medical ICU resident staff, uniformly portended disaster. I instructed him to find the third year resident on our team and for them to go check things out. I went back to closing with the help of the intern while my attending broke scrub to do whatever attendings did between cases. Once closed, I left instructions for the intern to write postop orders and, donning white lab coat, took the elevator up to the MICU to check out the consult.
My residents were at the bedside of the patient in question and explained that, as expected, the gentleman was an elderly, sick-as-shit individual, currently hanging onto the merest shade of life with the help of infusions of every medication the medical intensivists had available. It was also obvious, from a cursory review of the patient’s medical record, that he had begun the process of dying almost ten days earlier due to impaired blood flow to his bowel. Though that diagnostic possibility had eluded the medical intensivists, today the rather clear-cut evidence of full blown gangrene of the bowel had pushed them to think fondly of their surgical colleagues for assistance. Almost any internist will call a surgical consult when the patient is screaming at the top of his lungs about how much his belly hurts. Of course, the initial reaction to this event had been for the internists to promptly sedate, paralyze, and intubate the individual, six days ago. Connecting the patient to a ventilator always makes the screaming stop. Now that the patient had deteriorated to the point of imminent demise, and it was impossible to examine the patient or take a medical history, they had called the consult.
Though unable to perform at this point a meaningful bedside exam, my residents had reviewed the laboratory tests of the past several days, about eighty of which clearly indicated progressive gangrene of the bowel. They had also reviewed the three CT scans which had been obtained during the past eight days, each documenting the clear progression of gangrenous changes of the bowel. They also reviewed the medical student’s ICU admission note, cosigned but undoubtedly unread, that listed as number 14 on the differential diagnosis list “Ischemic gangrene of the bowel.” My third year resident had circled that, written “You think?” next to it with a smiley face. I instructed my team to get a consent for surgery from some family member and have him down in the OR after my next case. I told them that if they didn’t screw this up, I’d staff the two of them on it and let my fellow Chief do the last case in my room He’d be thrilled and they were thrilled at the prospect of doing a real operation.
Two hours later, I was finishing my next case when the intern came in to tell me the consult patient was in OR 7, being prepped by anesthesia. I said great, good work, I’ll be right over.
I came into the OR just behind an EKG machine being wheeled in by the circulating nurse. Mr. Really Sick MICU guy is on the OR table with an anesthesia attending and two anesthesia residents buzzing around him. There’s a nurse anesthetist who looks about sixteen years old sitting at the head, working the controls. I stand in the door as I watch one of the residents start to hook up the new EKG machine, a most unusual thing to do.
“What’s up?” I ask innocently, to no one in particular.
“EKG’s screwed up,” Anesthesia Resident Number One replies.
“Unusual,” I comment sagely.
“Happens,” he replies, supersagely.
“Is his pressure okay?” I ask.
“Can’t get a pressure off the cuff, too edematous,” Anesthesia Resident Number Two informs me.
“Hmmm,” I reply. ‘How about the a-line?” I inquire, pointing at the monitor.
“Waveform’s damped, haven’t been able to flush it. Probably kinked,” Number One again.
“Hmmmmm,” I reply. I approach the patient and can’t help but notice that the second EKG tracing is not very impressive either. I gently palpate the patient’s groin for a pulse. Nothing.
“Excuse me,” I say to the nurse anesthetist, who is listening to the patient through an esophageal stethoscope. She looks up and pulls the earpiece out to listen to me. “Excuse me, but do you hear lub, dub?”
“What?” she asks smiling, pleasantly confused by my question.
“Do you hear lub dub, lub dub? You know, like a heartbeat?”
“Actually, no,” she responds rather sheepishly, “Good breath sounds, though”–more brightly.
“Okay,” I announce loudly, making a show of looking at my watch, “I’m pronouncing at 3:42. He’s dead.” All motion stops. Awkward silence. Anesthesia attending sputters to life–“What are you talking about?”
“He’s dead,” I deadpan.
“What do you mean?”
“I mean that you have been giving anesthesia to a dead person for–how long have you been in the room?” to the circulating nurse.
“Twenty minutes or so,” she answers.
“Twenty minutes or so,” I conclude. I smile. I really shouldn’t have smiled.
Anesthesia attending goes ballistic. “Call a code!” he yells as he starts to pull all the covers off the patient. “Start CPR!” to Residents One and Two. All hell starts to break loose. “Get a code cart in here!” Multiple anesthesia attendings and residents begin to flood in through various doors.
“Hey, come on,” I beseech, fairly loudly over the din. “He’s been dead for almost half an hour–you’re going to start coding him now?” Awkward silence re-ensues. “3:42. Dead. Elliot–” to my third year, “call the next of kin. See if you can get an autopsy.” And I’m outta there, stealing back my case from my fellow chief resident.
Surprisingly, it takes a full two days before I’m told the Chairman wants to see me. “You wanted to see me, Dr. W*?”
“Yes, Evan. How are you? How’s your lovely wife, Sheri?
“Great, thanks. How’s yours?
“Great, thank you for asking.” I’m looking at a report on his desk. Upside down I can make out (all capitals) LUB DUB. Underlined twice, with quotes. “Say, Evan, just wanted to speak with you about a note I received from the Chairman of Anesthesia. You might remember a case from a couple of days ago…”
the Goat Rodeo blog 