Lub Dub


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…”

Inflammable Man

During the first year of my surgical residency, we were required to rotate through the Burn Unit.  The Burn Unit was an isolated six bed ICU with a twenty bed stepdown ward.  The unit had living quarters, and the burn resident was required to basically live in-hospital for the entire two month rotation.  Depending upon how early in the year you drew the rotation, the resident knew something between nothing and very little.  Nonetheless, the burn resident was the sole physician in charge of caring for the sickest patients in the hospital.  Thankfully, there was an expert crew of Filipino nurses who really ran the show.  It was a good thing, because the only attending supervision consisted of one of the staff plastic surgeons, Eli G*, weekly sticking his head into the airlock doors and calling out, “Everything going okay?”  The resident, overwhelmed with critically ill, septic, and dying patients would run to the door, yelling that “No, no everything was not okay, we need some help here, need to discuss operating on a couple of patients, Dr. G* “–to which G* would invariably turn a deaf ear and call over his shoulder as he strode purposefully away about the resident doing a great job and that he should feel free to call him if he was having any problems or needed any help with surgery.Dog Doctor253

I did the Burn Unit early in my first year, before doing any significant critical care rotations where I could have been taught something by a supervising Chief resident.  So I was basically completely incompetent to run the Burn ICU.   We had some great critical care nurses, but I had the misfortune of having a continuously full unit, with a bunch of big time, sick-as-shit “crispies.”   The patients would constantly die, but were immediately replaced by someone even toastier and sicker.  Most were alcoholics or addicts, homeless individuals who had managed to set themselves on fire in various ways.  It was late autumn, when every homeless Detroiter fired up their makeshift Sterno furnace, which usually promptly blew up or lit their Muscatel soaked clothing on fire.

A couple of weeks into the rotation, I was taking care of a fellow who had suffered thirty percent body surface area (BSA) burns when he fell asleep smoking and lit his mattress on fire.  Now this guy was relatively young, in his early thirties and, though an alcoholic, relatively healthy.  So I was kind of hoping I could get this guy out of my unit alive.  I was batting about .150 at the time.  Most of the patients, the ones with eighty percent BSA  burns or older than seventy years old with any significant burn at all, we were just kind of going through the motions because we knew they weren’t going to survive.  This guy, though, he came in with a survivable burn and talking, initially doing pretty well.  As usual, though, after a few days he started to go into DT’s (delirium tremens).  He became delirious, then septic, and finally ended up intubated on a ventilator.  We had had to sedate him due to the DT’s, and as he started to improve I stopped his sedation, but he didn’t wake up.  I waited a couple of days and finally called in neurology for a consultation.  I was still new and hadn’t had rule number four of the surgical residency program beaten into me–never, ever call a consult. So neurology, of course, orders an EEG to see if he’s still in there or if my expert care has already made the guy a vegetable.  About nine in the morning, after my initial ICU rounds, the tech comes in to  give the guy his EEG.  I’m around the corner in the stepdown unit when Filipino head nurse yells she needs “Geller Doctor STAT!”  I come flying back into the ICU to see the guy’s nurse doing chest compressions and yelling “V-tack,V-tack!” over and over again.  The EEG tech, who had just finished gluing about fifty electrodes to this guy’s head, decides he’s going to go on break now, maybe come back later.  You know, if the guy’s still alive and all.

Rule number three of the surgical residency was never, ever call a code.  The reason  for rule number three was the same as the reason for rule number four–the result would be a lot of crazy, dumb as a rock, medical residents gathering around your patient and ordering a lot of useless tests and medications that would inevitably kill off your patient.  Unfortunately, I was equally ignorant of rule number three.  So, upon seeing the nurse doing compressions and confirming that, yes, indeed, that was a pretty funky looking rhythm on the monitor, I picked up the phone and called a code.  “Bad, bad move, Geller doctor,” commented the head nurse when I hung up.  And she was right. Head Filipino nurse always right.

As I mentioned, the entire Burn Unit was an isolation ward.  It was entered solely through a double airlock door with all personnel being required to don isolation gowns, masks, booties, and hats prior to entering.  As the twenty man code team started to arrive, the head nurse stood just inside the airlock and insisted that everyone dress before entering.  This slowed things down considerably, and generally pissed off the medical residents anxious to save a life.  Meanwhile, I was in the process of trying to code my patient.  This one was supposed to live.  Now, even I knew the treatment of sudden ventricular tachycardia.  It’s  the application of a 700 joule jolt of electricity to the man’s chest.  So while the nurse continued CPR, I charged up the defibrillator to full power.  It may be worth noting that I had never done this before.  Actually, I had pretended to do it once on a mannequin.  So I was ready.  The first members of the code team, dressed in disposable paper bunny suits, started to arrive at the bedside as I applied the defibrillator paddles.  To her credit, the nurse momentarily paused in her chest compressions and indicated that this might not be a great idea.  I remember being somewhat annoyed by her lack of enthusiasm.  I was very excited to be defibrillating my first patient.

At this point, I must digress a bit to explain that, in order to perform an EEG, numerous electrodes are applied to the patient’s head.  By applied, I mean that they are glued to the scalp with a highly flammable compound called collodion.  While I was not familiar with the exact nature of collodion, I did like its smell.  Somewhat alcoholic in nature.  It’s rare that its flammability is much of an issue.

It is not difficult to properly apply a defibrillator.  It simply involves applying a special conducting paste to the paddles and then firmly pressing the paddles onto the patient’s chest.  The location for applying the paddles is conveniently pictured on the device itself.  It is traditional to loudly call out “Clear” just before pushing the little red button to deliver the jolt.  This gives the nurse the opportunity to move away from the patient so she does not also experience the 700 joule shock.  While I’m sure it was not a conscious decision, I elected not to bother with the conducting paste.  Like I said, first time was a manequin, no problem.

I yelled “Clear” as the the nurse yelled something about paste.  There was a flash, immediately followed by a strong burning smell.  The smell originated from two sources.  Initially, it was from the electrical burn I had caused my patient by not applying the paste.  This did not trouble me greatly, as I was a specialist in treating burns.  In addition, I was very pleased to note on the patient’s monitor that my jolt had been effective in converting his heart rhythm back to normal.  However, the nurse at this point indicated that I should perhaps take note of the patient’s head, which was now engulfed in flames.  It seems that the improperly applied paddles had arced, causing the collodion to catch fire.  I believe that Jeri-Curl, an alcohol based hair product popular amongst my patients at the time, may also have contributed.  In any event, as additional members of the code team joined the bedside, we all watched incredulously as the fire rapidly spread to the patient’s pillow and bedsheets.  It then spread to the tubing carrying pure oxygen to the patient’s ventilator.  This melted and began to shoot fire, flamethrower fashion, about the room.

The senior medical resident, a usually reserved Indian gentleman in his thirties, was the first to give voice to our general concern.  “Everybody out,” he screamed in accented English, “It is going to blow!”  Now, at this moment about half of the code team had made it past the head nurse and the double automatic airlock doors, dressed in highly flammable paper bunny suits, paper booties, paper hats, and paper masks.   These individuals, sensing the significant possibility of becoming one of my patients, turned and ran.  The remaining half, however, still oblivious to events unfolding within, continued enthusiastically to join our lifesaving efforts at the bedside.  The problem with automatic double airlock doors is that they only swing one way and rather slowly, at that.  Panic rapidly ensued.

It was at this point that a nurse kindly pointed out that perhaps I should do something, doctor-fashion, to address the rapidly progressing cataclysm.  I agreed enthusiastically, but was sadly at a loss.  As usual, the head nurse had already sprung into action.   Though somewhat trampled by the stampeding physicians still recreating a Keystone Kops routine at the airlock, she rapidly moved to the oxygen cutoff valve on the wall, disarming the torchlike ventilator.  Prior to that moment, I was quite unaware that such a valve existed.  It was, in retrospect, spectacularly convenient to have such a device.  Having extinguished the oxygen hose, she proceeded to soak a blanket in the bedside sink and throw it over the patient and myself, extinguishing the flames.  The patient woke up, ripped the tube from his airway, and began screaming and cursing out everyone in the room.

The patient survived.  He was discharged from Our Medical Center six weeks later.  His discharge diagnosis was “Second and Third Degree Burns, 48% BSA”  Hardly anyone noticed that his admitting diagnosis was “Second and Third Degree Burns, 30% BSA”.