Equanimity

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 which 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.

Evidently, My ICU Has A Helluva Skylight

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.