Tag Archives: Medicine

Anesthesia is Hard-3

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The Subtle Science of Sedation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

Anesthesia isn’t Easy-1

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The Michael Jackson Edition

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

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

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

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

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

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

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.”

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.

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…”