Difficult Doctors

Difficult doctor (def): a physician that disagrees with, or fails to immediately and graciously comply with, the expressed directive of any nurse manager or hospital administrator. [cf., Policy relating to the Reporting and Disciplinary Procedures for Difficult Doctors]

Many of you are painfully aware that our work environment has recently become–how best to phrase it?  Silly? Unpleasant? Challenging? Flat out, batshit crazy?  Yes, let’s go with that last one. (See Doctors Without Barbers). And I’m not even going to grace these new policies with any discussion, because they are so imbecilic as to not merit even this amount of attention.

(Doctor, you can’t leave the OR without a jacket. The short, paper one. No, no, no, doctor, not the full length disposable one.  Oh my god no, not the full length disposable yellow one, that’s only for isolation and an alarm will go off if you walk out of here with that on. Wear this one, it’s required, but make sure to take it off and replace it with the full length disposable one you had in your hand a minute ago if you step into the hallway with the brown guardrail to tell the family that your patient survived their operation, then take the full-length but not yellow one off and put the short coat back on when walking between the brown railed hallway and back to the OR, then remove the short coat before scrubbing for your next surgery but you can’t don a surgical mask after donning your coat because that would lead to shedding of dangerous skin cells onto the coat, rendering the entire environment a potential health hazard but you can’t go into the OR without a mask and you can’t walk down the hall with a mask dangling on your chest and you can’t walk down that hall to get a mask without the coat on so I guess you’ll just have to not operate any more today, okay? Sorry, doctor, it’s the policy. Have a nice day.)

Those in  the business know that I’m not making any of that up. Really.

Dread_Pirate_Roberts_by_bryanhumphrey

So, I received the following email recently from our hospital administrator:

Dear Surgical Physicians, Nurses, Techs, and all Operative Colleagues:

As you are aware, our policy for Surgical Attire is based on National Standards, and was developed to ensure our commitment to Patient Safety , which remains our core value.  In addition, proper surgical attire continues to be a major focus for both CMS and the State Department of Health.  Unfortunately, many of our sister hospitals (as well as hospitals in other systems) have found themselves in a position where physicians and staff members were not following policy to the specified level, and were subsequently placed on periods of Immediate Jeopardy, in which they were at risk of losing their Medicare and Medicaid funding.

We are doing everything we can as a hospital to follow our policy and avoid situations such as that.  I am attaching our Surgical Attire policy as a refresher of the expectations at [our hospital].  At the current time, I will remind you that ALL hair is to be covered, including sideburns and hair at the nape of the neck, as well as any facial hair (i.e. mustache).  Our strongest recommendation is that to make it most easy for you to comply, surgical hoods should be worn, often in conjunction with a surgical cap, to allow maximum of hair coverage with minimal effort.  Mirrors have been added around the operating theater to allow each physician and staff member to best police themselves.

You are all professionals, and your professional obligation is that you will comply with hospital policy.  We will be conducting periodic observations to make sure we are compliant.  I would ask that all staff please look to help any other physician or staff member who has not noticed that there is errant hair, or other non-compliance with the policy.

I am confident that we, as a hospital, and YOU as the Operative team, will be compliant and successful.

Sincerely,

[name deleted]

Vice President Medical Affairs & Chief Medical Office

 

So much of what is wrong with our current OR work environment is summarized in this completely nonsensical email.  Let’s discuss:

“As you are aware, our policy for Surgical Attire is based on National Standards”–actually, no, it isn’t.  It is an ungrammatical, unscientific, ad hoc mash-up of AORN policy recommendations, in-house silliness, and a good bit of complete nonsense.  It has no basis in JCAHO or Department of Health standards. It directly contradicts recommendations by many national and international scientific organizations, including the American College of Surgery Manual of Perioperative Care and a recent policy statement by the ACS. There is nothing about it that even approaches a rational scientific basis or accepted standards, national or otherwise.  It in no way represents any form of consensus of surgeons, nurses, or surgical technicians, either within the institution or at the level of representative organizations.  It was authored by a couple of nurse administrators who haven’t seen the inside of an operating room in decades while sitting in a hospital conference room with a few administrators lacking any clinical insight whatsoever and absent any physician, anesthesiologist,  or surgeon who might contribute rational insight into the process; i.e., dissent. The resulting policy was then filed in the Manual of Procedures and Policy without benefit of review by the Chief of Surgery, his designate, the OR committee, or as an agenda item at the surgical departmental meeting.  Or by the Chief of Anesthesia, or at the anesthesia departmental meeting. Or by the Chief of OB/Gyn, or at their departmental meeting. Or by the Chief of Orthopedics, or at the ortho departmental meeting. Of course it wasn’t, because the physicians affected would’ve pointed out that the document was nonsense. They would be “difficult.”

“developed to ensure our commitment to Patient Safety , which remains our core value”–unfortunately, your core value has been repeatedly demonstrated to be maximizing revenue. Capitalizing the phrase “Patient Safety” in all official emails does not make it your priority. You have an amazing capacity to re-interpret your institutional commitment to Patient Safety if this proves too expensive. It just so happens that arbitrary rules regarding surgical attire costs the hospital nothing.  And by the way, if you truly believe that the type of hat worn by a surgeon or OR nurse is an issue of patient safety, you really shouldn’t be allowed to come to work as a hospital administrator.

“Our strongest recommendation is that to make it most easy for you to comply, surgical hoods should be worn, often in conjunction with a surgical cap, to allow maximum of hair coverage with minimal effort.”–of course, this recommendation makes no sense, which is obvious to anyone who has actually set foot in an OR, and creates a situation in which you will be unable to operate, or keep from sweating into your patient’s wound (recent policy change takes away the ability to control OR room temperature without contacting an administrator), or breathe. We’re just interested in making it “most easy for you to comply.” Comply or die, whatever. Minimal effort.

“Mirrors have been added around the operating theater to allow each physician and staff member to best police themselves.”–I have no words.

“I would ask that all staff please look to help any other physician or staff member who has not noticed that there is errant hair, or other non-compliance with the policy.”–Please report your fellow workers to the authorities. You may be awarded the coveted “Employee of the Month.”

And more recently, yet another hospital email regarding this same subject ended with the following threat:

Please review the attached Guidelines for Operating Room Environment and Surgical Attire Policy.

Non-compliance with our policy will compromise the Hospital’s position with the DOH and may lead to financial penalty for the Hospital.   For physicians who are found to be in violation of our policy, a ‘non-adherence to policy that compromises patient safety’ note will be placed in the credentials file as part of their OPPE.

So, it’s okay that the OR nursing supervisor is “surprised” to realize that my hospital has no CO2 cylinders available when the tank goes empty halfway through my laparoscopic procedure, which results in no incident report, meeting, or repercussion of any sort, but if I fail to wear a disposable short coat while walking between the OR and the recovery room I will be cited as “compromising patient safety.”  A note will be placed in my permanent record.

Seriously.

 

Anesthesia is Hard-3

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

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.

Blind Man Blogging

I’m sure that you’ve noticed the lack of meaningful posts to this blog in the recent past, and I’m sorry that your lives have been sadly devoid of the warm glow that makes life worth living as a result.  (My wife assures me that you haven’t noticed.)  “We understand completely,” I hear the throngs acclaim, “how could we miss the recent evidence of the overwhelming effort that was obviously required to bring The Problem With God to fruition, now available at Amazon and for the Nook?” (They have no idea what I’m referring to, my wife informs me, trying to set my mind at ease.)  Or perhaps it was the press of getting ready for the craziness that is the holiday season, you conjecture.  (They don’t conjecture, my wife interjects, because they haven’t noticed.  If they noticed, they wouldn’t care, she reassures me.  And by the way, she adds, there is no ‘they’ anyway.  There is only the empty, black nothingness that lives behind my computer screen, she smiles.  She’s my rock.)eyeball5

While I certainly appreciate your willingness to excuse my lack of creative fecundity (or should that be, fecund creativity?), I feel compelled to explain the real reason for my paucity of posts.  I can’t see worth shit.

It’s true.  I’m writing this by sensing the individual letters by pressing my nose against the screen.  (Consonants smell like toast, vowels like fruit.  The letter ‘y’ smells like wet dog.)  Obviously, this is a slow and inexact practice.  Actually, this post would’ve gone up three days ago except the ‘save’ button smells exactly like ‘delete.’

Here follows a tale of yearning, fear, and cosmic payback; certain to stimulate your need for schadenfreude and ‘thank-God-it’s-Geller-and-not-me-or-someone-I-really-care-about’ relief that is so especially appropriate for this holiday season:

Yearning:  I have worn glasses since I was seven years old.  My mother actually claims that I was born wearing glasses, which made for a particularly painful delivery for which I was never properly appreciative.  I don’t believe this, however, as one of my most profound childhood memories is of that exact day in the third grade at Einstein Elementary School when I joined the rest of my fresh-faced classmates in lining up for eye exams in the cafeteria during recess.  How clearly I recall the looks of sad compassion on the faces of the grownups as they shook their heads and announced that I had failed my exam.  Failed!  That was the exact term they used, the word they checked off on the mimeographed form they made me hold all day, staring at it (cruelly blurry, all those mimeos were blurry), finally carrying it home to present to my disappointed parents.  They shook their heads in consternation and I burst into tears at the kitchen table.  It was the first test that I had ever failed.  Not to worry, my parents reassured me, you can just wear your bother’s hand me down glasses.

Since that day, I have worn glasses.  I never complained, despite seeing the world through someone else’s corrective lenses.  Since I didn’t know any better, I accepted the distortion of the world about me, the crazed funhouse mirror appearance of the adults looming over me, the facial expressions of those I loved always looking like something out of that Twilight Zone episode that gave everyone nightmares.  (In the Eyes of the Beholder, I think it was called.  This will prove ironic.)  A lifetime of watching my glasses fly across the room whenever some perceived insult led to a slap in the face, of watching my glasses fly onto the infield grass of the Matterhorn ride at Disneyland (a story for some other time), of a hard packed snowball with my glasses in the middle thrown into the windshield of the principal’s car as it sped from the parking lot.  The principal returned my glasses but he was not happy about it, not one bit.  And they never quite fit right after that.

For just shy of a half-century I happily accepted my facial appendage. I must admit, however, that I yearned to see the time on the bedside clock every morning.  I yearned to actually see through a telescope, a microscope, an otoscope, an opthalmoscope, and not just to pretend I could see what everyone else could see.  I yearned for clarity.  But I always kept this yearning to myself.  And I never let this yearning get so out of control that I ever, ever considered getting contacts.  Never.

Fear:   The entire concept of contact lenses horrifies me.  The name horrifies me. I mean, the “contact” the name refers to is your eyeball.  I don’t do eyedrops, no way in Hell I’m sticking a piece of jellied plastic in my eye unless it’s kicked up by the rear wheel of a passing cement truck.  I’ve cleared out my eye doctor’s waiting room on several occasions because of the screaming elicited every time he tries to measure my intraocular pressure.  “Just a puff of air,” my ass.  That thing is a medieval torture apparatus.

There came a day, however, when the yearning for clarity was joined by a dangerous disability to see certain items at night; things like moving cars, traffic lights, and pedestrians.  A certain small dog, I think.  Enough is enough, I believed.  I deserve, I need, to see!  This feeling was only strengthened by an unfortunate episode in the operating room recently.  I had the privilege to operate upon an optholomologist.  Nothing major.  As he was lying on the OR table before surgery, I engaged him in lighthearted banter, in the fashion of reassuring him and setting him at ease.  (Doctors are the worst patients.)  I’m thinking of having surgery soon myself, I said to him conversationally.  Really, he asked, what kind of surgery?  Well, I admitted, these cataracts are really starting to bother me and I was thinking–the guy sat bolt upright on the table.  “You can’t see?” he asked me.  “I think we should cancel this surgery.  You should not be telling me such things.  I think we should reschedule.”  I’m pretty sure he was kidding.  It didn’t really matter anyway, since at that moment the anesthesia hit him and he fell back, unconscious. I don’t think he remembered the conversation afterwards.

It bothered me though.  He might be right.  I should be able to see.  I want to see.  So I went ahead with the cataract operation.  The world went dark.

Cosmic Payback:  The surgery went fine.  Before the operation I told the anesthesiologist, a friend of mine, that if I’m awake, I’m screaming. (Doctors are the worst patients.)  When I eventually awoke face down in the parking lot, my old milky, calcified lens had been plucked from its dusty lair and replaced with a shiny new piece of plastic.  Never felt a thing.  The next day, my blurry ophthalolomomolologist was pleased with the result.  [Brief Aside:  It is my theory that while constantly smiling and chipper, all opohthlolkmologistolists are secretly angst ridden and angry because even they really have no idea how to spell the name of their profession.]  I was also fairly pleased, except for the little inconvenience that I couldn’t see a thing.  “Yeah,” he explained, “that’s to be expected.  You’ll need to wear a contact lens in the other eye for a month until we operate on that one.”  “I’m sorry,” I said, “I thought you said something just now about contact lenses.  So much for my other senses taking up the slack, huh, doc?”  “No, really,” Blurry Bob confirmed (I don’t think I actually called my opthalcomologist that to his face, I was just upset and it seemed an appropriate moniker at the time.  I may have called him “The Butcher of my Eyes” once or twice, though.  Like I said, I was blind, and upset.)  He explained the dark, arcane science of quantum optical physics that made no sense to me but ended with the cosmic certainty that my glasses were now useless.  My mind could not reconcile the new view from my left eye, soon to be perfect in viewing things on the horizon but only magnified fuzziness anywhere within shouting distance, with the lifelong image from the right eye, nice and sharp up close but gelatinous and unformed beyond the end of my arm’s reach.  An insurmountable dichotomy that will destroy my mind, he explained.  “We’ll just set you up for contact lens instruction.”  Yeah, right.

I stumbled into the optician’s subterranean lair and began screaming at “Hello.”  The instruction did not go well.  While the instructor was nice and patient (at first, though with a disturbingly evil, maniacal laugh), I knew she was starting to get a bit testy with my lack of ability to shove my hand in my eye when she suggested that my wife, a veteran contact lens user of decades, could do it for me.  Sure, that sounds like fun.  Then they started to talk about “plungers” and showed me a rusty ice pick she uses to remove “a displaced lens,” whatever that means.  Something about the lens ending up behind my eye and stuck to the frontal lobe of my brain.  Hers was a unique and effective teaching technique.  I left sightless, wounded, and with a jelly blob folded into my one good eye.  But I’m still reluctant to let my wife of thirty years scrape this thing off my eyeball.  She is enthusiastic to help, however.

I can’t wait to get the other eye operated on.  In the meantime, I’m coming up with reassuring new explanations when my patients ask why I was just led into the OR by a seeing eye dog.

Never Say Oops in the OR

 

As a first year surgery resident, you don’t get to do much operating.  Mostly minor procedures and the simplest OR cases, especially the ones the more senior residents have no interest in, like removing skin lesions or biopsies, that sort of thing.  One of the most common surgical procedures left for the first year residents was the insertion of the chronic indwelling venous access catheter, an implanted device to facilitate infusion of medications, long term antibiotic therapy, or long term IV nutrition.Minolta DSC

This was not only a straightforward procedure, it was a very common procedure at the main University hospital we trained at.  Our service performed this operation over a dozen times a week.  As such, it wasn’t long before even the first year residents felt comfortable in the procedure.  And as first year surgical residents, it wasn’t much longer before we were feeling pretty cocky about our skill in performing this seemingly straightforward procedure.  Of course, as first year residents we had not yet internalized one of the most important tenets of all surgery:  There are no small operations.  Even the most routine procedure, the most mundane biopsy, can go horribly wrong if not approached with the respect deserved by every patient.

Towards the latter part of our first year, the residents spontaneously devised a kind of competition.  As we got really experienced in the procedure, it got to the point where we could  comfortably complete the operation in less than fifteen minutes.  When it went well, that is, which was about 95% of the time.  A couple of us were so “good” that we could occasionally complete the entire operation in about seven minutes.  So an informal competition started up amongst the first years, a hypercompetitive lot by nature, to see who could complete the operation the fastest.  It got to the point where the real objective of the resident was to have the catheter in and be suturing the closure before the attending finished scrubbing, so you could tell him when he walked in not to bother gowning up.  Attendings loved not bothering to gown up.  More time for coffee and chatting up the nurses.

It’s not hard to see where this is going.  The operation of inserting a chronic venous access catheter has nine distinct steps for its successful completion.  I know this, because as we first year residents began operating faster and faster, we managed to screw up each and every one of them.  As was the tradition in our residency program, every time a new screw-up was committed, it was named for its original perpetrator.  My class was instrumental in naming every possible screw-up related to chronic venous catheter insertion.  For the decades that followed our completion of the program, an errant first year resident could be heard being admonished by his attending not to “pull a Geller” or any one of the numerous other maneuvers we invented.  (A complete list of all the named maneuvers is available upon request, but I must pause here just to mention the Schwarma maneuver, in which the very last stitch at the conclusion of the operation is deftly passed right through the catheter, necessitating starting the procedure all over from the beginning.  Schwarma was asked to leave our program after his first year and went on to father many children during his career as a cruise ship physician.)

Step one of the procedure involved introducing a long, large-bore needle into the subclavian vein, a very large vein (about as thick as your little finger) that lies just under the clavicle (collarbone) in the upper chest as it carries blood back from the arm to the heart.  Unfortunately, this was a blind procedure in those days, made a bit more challenging by the fact that the subclavian artery, a large pulsatile structure carrying the entire blood supply to the arm, lies immediately adjacent to the target vein.  And the lung, an organ that really doesn’t like being stabbed by needles as it tends to collapse like a punctured balloon, is located immediately behind the target vein.  Inadvertent puncture of each of these anatomic structures had been accomplished thousands of times by countless surgical residents for decades.  We, therefore, were already trained in the precautions necessary to avoid these structures.  We were much more creative.

As I said, back in those dark old days of my training, this was a “blind stick.” (Currently, technology has progressed to allow real time ultrasound guidance of the procedure.) As a blind procedure, the surgeon is reassured that he had struck the correct anatomic structure with his needle by seeing the gentle return of dark red, venous-type blood from the hub of the needle when the syringe was disconnected.  It was appropriate, however, to quickly cover the hub of the needle with your finger so as to prevent air from being  sucked into the low pressure venous system.  This is called an air embolism and can immediately lead to a cardiac arrest or stroke.  This was to be avoided, having already been done many times as well.  One afternoon, towards the end of our first year, one of my first year colleagues named Dr. Sweetness was performing this procedure, smoothly and confidently proceeding before his attending came in the room.  Actually, he had begun before his attending was even in the operating suite, not that unusual at the time but a sign of cockiness for a first year resident.  Sweetness was pretty cocky at this point, as were we all.  Dr. Sweetness inserted the needle and was immediately rewarded with a flash of blood.  Rather than carefully consider the nature of the blood return, however, he immediately assumed it to be venous and clamped his finger over the hub of the needle.   Like I said, he was moving pretty fast.

Step two of the procedure is to insert a flexible  guide wire through the needle into the patient’s venous circulation, actually passing the wire near the chambers of the heart.  I should digress at this point to mention that it is important not to insert the entire wire into the vein, but rather to hold onto its end.  My fellow resident, Dr. Napoleon, failed on one occasion to follow this simple rule.  He neglected to maintain control of the end of the guide wire, which he smoothly and accidentally introduced completely into the patient’s vein, where it proceeded to pass downstream into the heart and lodge there.  This trick, thereafter known as the Napoleon maneuver, necessitates immediate abandonment of the planned operation and stat consultation with a cardiologist for percutaneous fluoroscopically guided extraction of the rogue guide wire.  This also required a very embarrassing conversation with the patient and his family, a conversation that never failed to upset the attending surgeon.

But I digress.  Sweetness smoothly introduced the guide wire and maintained control of its end throughout.  He did not, however, appreciate the fact that he had introduced the guide wire into the subclavian artery, not the vein.  In and of itself, this would not be remarkable, for as I mentioned, this particular maneuver had been done literally thousands of times.  Usually, however, the operator was immediately aware of the error when, upon removing the syringe from the end of the needle, bright red blood (not deep purple as it should be) sprayed like a fire hose into your face.  At that point, the surgeon need only fight the urge to curse or say “Oops”  (“Never say ‘Oops’ in the OR”) and remove the needle from the wrong vessel, then to hold pressure until the body’s natural tendency to recover from our screwups takes effect.  No permanent harm, no foul, as they say.  Unless, of course, you don’t realize what you’ve done.

This particular patient also had the unfortunate combination of low oxygen saturation in his blood stream and low blood pressure introduced by the inexpertly administered anesthetic provided by the first year anesthesia resident.  Therefore,  Sweetness didn’t realize he was in the artery.  Not just in the artery, though.  As luck would have it, Sweetness had managed to enter the subclavian artery extremely close to its takeoff from the aorta.  You know the aorta, the single largest blood vessel in the human body that carries the entire output of blood from the heart.  It tends to bleed very vigorously and fatally when injured.

Now, even that would probably have been kind of okay, if Sweetness at any point realized what was going on.  But this was a blind procedure, the usual cues had been taken away by his equally youthful anesthesia colleague, and Sweetness smoothly and confidently proceeded; still with no attending in sight.  Step three of the procedure is to gently and smoothly pass a dilating catheter over the guide wire, called an introducer.  The introducer is a gracefully tapering, somewhat flexible plastic straw that serves the function of gently stretching a hole in the wall of the blood vessel so that the catheter can be introduced.  I say ‘somewhat flexible’ because it is actually quite stiff–it has to be to perform its function.  It is, therefore, necessary to introduce this device with some degree of trepidation and finesse.  Sweetness had the finesse part down pat–it was the trepidation that was missing at this point.  Sweetness smoothly and expertly passed the introducer over the guide wire, a maneuver that he had performed without incident almost a hundred times before.  On this occasion, however, through a combination of bad luck, rushed technique, and inexpert assistance on the part of his anesthesia colleague, passage of the stiff-walled introducer device caused the root of the subclavian artery to be torn from its origin on the aorta.  This, of course, resulted in a large tear in the aorta.  The patient, already quite ill, proceeded to hemorrhage massively into his chest cavity.  The attending surgeon walked into the operating room just in time to see his patient, supposedly there to undergo a relatively minor procedure, receiving CPR on the OR table.

Oops.

“Keep Calm And Carry Speed”

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

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

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

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

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

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

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

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

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

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

Equanimity

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.

The Zen of Surgery and Bicycle Repair

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

Evidently, My ICU Has A Helluva Skylight

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.