First Death

I don’t dance. I have no rhythm and a tin ear. My attempts at dance, usually fueled by alcohol, amount to rocking back and forth or flailing about as if having some sort of bizarre seizure.

There’s a certain amount of irony in the fact that I married a classically trained dancer who realized after high school that she did not have the body habitus to be a prima ballerina and switched to nursing. Nevertheless, she regularly practiced with the American Ballet Theater the whole time she was in college at Georgetown. For her, trying to dance with me is an exercise in saintly patience combined with steel-toed shoes.

It’s different in the operating room. She has been my first assistant for twenty years and when we operate together, it’s as close to dancing together as we will ever get. There is a rhythm to surgery, a practiced flow of movement and action not unlike a dance. When two people have worked together for a long time, they learn to anticipate each other’s moves and respond without cues or conversation, just like practiced dance partners. It’s actually harder for a surgeon to be a good assistant than for a nurse or tech. Surgeons tend to want to control the operation and forget their job is to make the operating surgeon look good. It’s like both partners in a dance trying to lead at the same time. A good assistant, like a good dance partner, knows when to lead, when to follow and how to make the dance flow smoothly. They can’t make a poor surgeon look good, but they can make a good surgeon look great.

My wife and I dance well together in surgery, in part because we have always been on the same wavelength and in part because she has a natural understanding of physical movement. Her dance experience has given her a grace and economy of movement that never fail to excite and impress me. There is no one I’d rather have with me on a complex robotic or laparoscopic case. I’ve written about physician teamwork recently, and sometimes even my wife can’t bring to bear the skills I need in a difficult case, but those times are rare indeed.

Covering

It was early 1983, I was a fourth year resident, and I was in trouble. My program director, Dr. Fletcher, had called me to his office at three in the afternoon, an hour before preop conference, to talk to me about ‘recent events on the Gold surgery service’. My service. I knew what he wanted to talk to me about and as I waited outside his office, visions of my career as a surgeon swirling down the toilet filled my head.

Two days earlier I had lied to him about a patient. I had been covering for my Chief Resident. It wasn’t the first time.

The general surgery department at Bethesda was divided into three services: Blue and Gold for general surgery and Red for vascular surgery. Each service had three residents (Chief, Fourth Year and Second year), two interns and various medical students assigned to it. Each of the three Chief Residents ran one of the services on a rotation.

Dr. G. had been my Chief on Gold for three months. I figured I had only one month to go before I rotated to Red and would be done with G forever. These had been the worst three months of my life, worse even than my internship.

I found out early in the first week on Gold that G was a very smart guy who was totally unable care about other people. He was abrupt, demeaning, self-centered and perfectly willing to blame subordinates for his own errors.

Unfortunately, as I said, he was a very smart guy. He talked a great game and covered his ass well. He was extremely well read; he was up to date on the latest research and read extensively about any problem we encountered on the ward. Which was also part of the problem. He passed off rounding duties to me so he could read and research the disease processes we encountered. He sounded great when he presented cases in preop conference, but if asked about a patient’s current status, he had no clue.

More than once, I had stepped in and taken responsibility for errors in order to protect my junior resident from G’s finger pointing. It had cost me. Residents are graded on their performance quarterly and I knew my next evaluation would not be as good as the previous ones. My in-service exam scores had suffered because I was shouldering much of his work as well as my own and had little time to study.

Why did I do it? In part because I had been thoroughly indoctrinated in my first three years that patient care always came first. If G didn’t do the job, someone had to. That fell to me as the next senior resident. In part because I still believed that you kept faith with your team, both those above and below you.

The current trouble began three days earlier. We had admitted a 37-year-old man who was paraplegic and wheelchair bound from a service related back fracture. He came to the emergency room with a decubitus ulcer, a pressure sore, on his coccyx (tailbone). The ulcer was very deep with a 3 cm wide area of skin and soft tissue necrosis. The tissues were infected and foul smelling.

These are thankless cases. The surgery is not difficult but is unpleasant and unrewarding. The dead tissue needs to be debrided (cut away) and the wounds need to be left open to heal from the bottom up. Frequent, painful dressing changes need to be done daily for weeks.

G had been told specifically by Dr. Fletcher to take care of this patient himself. Apparently the patient was connected to the Admiral in command of the military medical school on the hospital campus making him a minor VIP.

G, true to form, passed the case to the junior resident. Usually it would be a junior case, but G had specific instructions to the contrary. I knew this, and took the case myself. At least the junior guy would be protected.

I booked the debridement for the next morning. Just as I finished and was escorting the patient to the recovery room, Dr. Fletcher called the OR and asked to speak to G. I took the call.

“Where’s Dr. G?” Fletcher asked.

“He’s tied up in the ICU and couldn’t do the debridement,” I lied. “The case was already booked, so I went ahead with it.”

Dr. Fletcher let that pass, and for a couple of days I thought he’d bought the story. I felt guilty, but the team was protected and the patient was doing as well as could be expected. Then came the message that Dr. Fletcher wanted to speak to me.

At three on the dot, Dr. Fletcher opened the door to his office and waved me inside. He sat behind his desk and I stood in front of it, not quite at attention. He told me to sit down.

“Dr. G says you took that case without his knowledge. Is that true?”

I was dumbfounded. I knew G could be a snake, but didn’t think he’d throw me under the bus like this. Still, I wasn’t willing to admit I’d covered for him.

“If he says so, sir. I knew he was busy and may have forgotten to tell him I was going ahead with the case.”

He looked at me for a second that seemed to drag on forever. Then he said, “Dr. G has been relieved. Cut the crap. You’ve been covering for him for months. Now, you can stick to your story and we’ll let it go, but you’ll be held back until the investigation into his behavior is finished. That may jeopardize your graduation from this program. Or you can tell me what really happened and you will then take G’s place as Chief Resident on Gold and on Blue next quarter until you start your own chief year. You’ll miss your Red rotation this year but will start on Red for the first rotation of your final year.”

I came clean with him, admitting that G had told me to do the debridement and that I’d been carrying most of the load on Gold for the past three months. I felt both relieved and guilty as I did so. It’s hard to explain, but I had a strong feeling that despite G’s problems, he’d been my Chief, part of my team, and I was betraying a trust by revealing his failures.

Dr. Fletcher seemed to understand my feelings. He thanked me and then said, ”Loyalty to a teammate is a good thing, but it can be taken too far. You covered for G when you knew it was wrong. I know you’re a better doctor than that. Which is why you’ll be taking over Gold service. Now go and get ready for preop. You’ll be presenting G’s cases.”

I went, the weight of Dr. Fletcher’s confidence feeling heavier than my shame at lying to him.

It was a routine Friday night trauma shift and the team was gathering for what sounded like a TINO – Trauma In Name Only; a rollover MVA with a single driver who self extricated and was walking around at the scene slightly confused but with no obvious signs of injury.

I was sitting at the x-ray computer station when the tech came up and said, “Excuse me Doc. I need to log on.”

I stood and he caught sight of my face. “Oh, hi Dr. Davis,” he said smiling. “I hoped you’d be on for my first shift. I just started here two weeks ago and this is my first time on nights.”

I smiled back, puzzled. He seemed to know me but I couldn’t place him. He wasn’t one of the regular techs and I didn’t remember seeing him at the other hospital where I work. His nametag read ‘Larry’, but that didn’t ring any bells.

He nodded and said, “I didn’t think you’d recognize me. Ten years ago, when I was sixteen you operated on me and took out half my liver.”

It came back to me then. He was a good foot taller and at least thirty pounds heavier, but now that he’d reminded me I knew him.

That night, ten years earlier, he’d been brought in after being hit by a car while skateboarding. He was in shock and going downhill fast.

We loaded him with volume, packed red blood cells, saline and later, plasma. This was before the institution of the massive transfusion protocol with its balance of red cells and plasma and automatic sending of components at timed intervals. We struggled to keep up with his falling vitals. His abdomen was getting distended and rather than risk him crashing in CT, I did a diagnostic peritoneal lavage. A catheter is inserted into the abdomen through a small incision in the umbilicus (belly button) and if you get blood back, it’s a sign of internal bleeding. Not a refined test, and these days, antiquated by the FAST ultrasound scan and the rapid acquisition CT, but back then it was often done if the patient was unstable. Blood bubbled up from my small incision before I could even insert the catheter.

We rushed off to the OR and explored his abdomen. He had cracked his liver through the central sinus, just behind the gallbladder.

Your liver looks like a homogeneous organ, but in fact is divided into right and left lobes by a band of tissue and a central vein just behind the gallbladder. Further segmental divisions are based on the branching of the portal and hepatic veins and although they are real, they are not as well defined. This boy’s liver was smashed. Most of the right lobe was hamburger and the large fracture through the central sinus was bleeding at an alarming rate.

I tried to suture individual vessels, to clip large bleeders and control the bile ducts, but he continued to bleed from almost every surface. Finally, 15 units of packed cells into the procedure, I packed the wound in the liver with bulky gauze pads, compressed the smashed tissue between several other gauze packs and closed the abdomen with the packs inside.

It’s called Damage Control Surgery. The concept is based on the Navy doctrine of Damage Control on combat ships. When a warship is damaged in action, it can’t retire to a nearby shipyard for repairs. The crew must patch the leaks and holes with anything at hand and jury rig systems to function well enough to continue the fight or sail away to safety. So too, when you get behind the physiologic curve in the OR, you need to patch the leaks quickly, staple off or tie off holes in bowel or bladder and bail out with a plan to return another day for definitive repairs once the patient is stable.

The packs controlled the bleeding and we moved him to the ICU. He got more fluid, blood components and most importantly he got warm. Heat loss in the OR is a major contributing factor to bleeding. By warming him up, replacing the losses and stabilizing his vitals, he lived to fight another day. 48 hours later, I took him back to surgery and removed the packs, controlled what was now minimal bleeding and removed much of the right lobe of his liver. There was very little new bleeding. He recovered over the next three weeks and left the hospital.

Flash forward ten years and here he is standing in front of me, twenty-six years old, and six and a half feet tall and obviously in the prime of his young life. He told me he had recovered fast enough that he stayed in his regular high school class and graduated on time. He learned to be an x-ray tech during a five-year tour in the Army after high school and had just moved back to Arizona with his wife and two daughters, aged two and three.

He still works trauma and general x-ray and we see each other frequently. It’s not often that I get to see the long-term results of what we do in the trauma bay, but this one is special to me. Larry is a good tech, a nice guy, and when his daughters have come to see him on the job, he looks like a good Dad. Seeing him banishes many of the feelings of futility that I have from time to time.

First Assist

When I was a fourth year medical student, I did my first real trauma rotation at Cook County Hospital. I had been exposed to trauma as a third year during my regular surgical clerkship and liked it. I was determined to spend some time on trauma during my elective rotations fourth year.

July fourth weekend I was following the trauma intern, Dr. T around. He was new. Internships start July first and the only difference between us seemed to be the M.D. after his name. Otherwise he was as clueless as I was.

About eight in the evening, all hell broke loose. Those were the bad old days on the west side of Chicago. The gangs had made some neighborhoods no-go zones for the cops. Cops jokingly referred to the ER at County, on the corner of Harrison and Wolcott, as ‘Firebase Harrison’.

There had been some kind of large-scale battle between gangbangers in Miles Square and the ambulances brought half a dozen critical patients within a few minutes of each other.

This was also in the days before close supervision of interns and residents. Usually the Chief Resident or the Third Year on trauma kept tabs on the interns and directed their activities. This day was different because the trauma unit was slammed with patients with gunshot and stab wounds.

The intern and I were told to evaluate the ‘stable head injury’ in Trauma Four. As we walked into the curtained off part of the ER labeled ‘Four’ we saw a young black man lying on his side facing us. There was a thin line of blood that had run down his neck but I saw no other sign of a head injury.

He frowned at us and said, “Are you the ones who are gonna take this thing outa my head?”

I walked closer and saw what he meant. Stuck in the back of his head, the curved end almost completely buried in his skull, was a crowbar. Protocol for impalements injuries is to leave the object in. Often the impaled object occludes the hole it has made in a major blood vessel, controlling the bleeding. Pulling it out may break that dam and cause major blood loss. The patient is taken to surgery with the object in place, anesthetized and only then is it removed. We got an x-ray (this was pre-CT scan days) and called the neurosurgeon.

He arrived a few minutes later and looked at our patient and the x-ray. He called the OR and booked a craniotomy, then turned to me and said, “You might as well scrub on this one. He won’t make it out of the operating room and Dr. T. is needed here”

Wait, what? Won’t make it out of the OR? But he’s awake and talking to us.

The neurosurgeon drew a tight circle around the tip of the crowbar. “This is the confluence of the venous sinuses of the brain, the superior sagittal sinus, the inferior sagittal sinus, and the transverse sinuses. All the blood the heart pumps through the brain drains through it. It’s essentially a huge vein, twice the size of your thumb with walls thinner than onionskin paper and only half as strong. Once it’s torn, it’s almost impossible to stop the bleeding.” He sighed. “Come on. You’ll be first assist on this one.”

I went eagerly. I think, in retrospect, I didn’t really believe him when he predicted the kid would die. All I could think about was the chance to first assist on a craniotomy. Two hours and six units of blood later, the patient died, just as the neurosurgeon had predicted.

I was stunned. He’d been awake and talking when he came into the trauma center. It wasn’t my first OR death, or even my first lesson in futility, but it was the first time I had scrubbed and assisted on a case where the patient died in the OR despite what were obviously the neurosurgeon’s best efforts.

I didn’t have the energy to change out of my bloody scrubs afterwards until the neurosurgeon came over and said, “You did a good job. You have steady hands and you didn’t freak out at the sight of that much blood loss. What are your plans after medical school?”

“General surgery at Bethesda Naval Hospital.”

“Cal Thomas is Chief of Neurosurgery there. If you change your mind and want to think about neuro, have him give me a call.” Then he turned and walked away. I changed and went to find Dr. T.

I never spoke to the neurosurgeon again, and although I worked under Dr. Thomas during my neurosurgery rotation three years later, I obviously didn’t change my mind.

 About five in the afternoon on a weekday trauma shift we got a call from Native Air, a helicopter medical transport service, about a seventeen year old they were bringing us with multiple fractures sustained in an ATV crash. The accident happened way up in the northern part of the state near St. Johns, a ranching community that borders the Navajo reservation. His vital signs were stable and they had medicated him for pain and would arrive in ten minutes.

 The trauma team assembled in the bay closest to the elevator from the helipad. About nine minutes later the elevator doors opened and the helicopter crew wheeled our patient in on their flight gurney.

 I took one look at the patient and cursed under my breath. He had a triangular face with a broad forehead and narrow jaw and chin. His chest was wide and deep, barrel-shaped is the term. His limbs were painfully thin with knobby joints and marked curvature of the long bones, those that weren’t already splinted. His eyes were striking – deep blue, and the sclera, the white of the eyes, were the color of a new robin’s egg. All the markers of Osteogenesis Imperfecta. What the hell was he doing on an ATV?

 Osteogenesis Imperfecta, also known as ‘brittle bone disease’, is a genetic disorder, a gene mutation that causes defective collagen synthesis. It may vary in severity but the classic expression causes weak bones that can break under the patient’s own weight. A sneeze can break ribs. A simple stumble can result in a broken hip or ankle. Patients usually end up confined to wheelchairs by their mid-teens, and although they may have a normal lifespan, the repeated fractures lead to short limbs and the characteristic facial appearance. So what monumental stupidity would lead someone who could break a leg just standing on level ground to get on an ATV and ride it around? Then he told me the machine had been a gift from his parents for his birthday, just a couple of weeks earlier.

 I almost went ballistic. This wasn’t just stupidity, this was child abuse. What kind of parent would willfully place a child with this disease in that kind of danger?

 It took a couple of hours to get his x-rays done, get all the fractures identified and splinted, talk to the orthopedic surgeon, and get his pain under at least marginal control. He had fractures of both femurs (the long bone in the thigh), five ribs on the right, the right radius and ulna (the bones of his forearm), and his left ankle. All were fragmented, would need operative repair, and were at high risk for nonunion (failure to heal).

 Just as we were getting him ready to go to the OR for the first of many expected procedures, the charge nurse told me his mother was in the waiting area. St. Johns is a long way from our trauma center and she had come by car rather than air. I stalked from the trauma bay, struggling to control my anger.

 I found her in the quiet room just off of the main ER. She was in jeans, heavy work boots, and a flannel shirt. Her hair was pulled back and her face was dirty with dark soil and sweat. I introduced myself rather coldly and outlined her son’s injuries, the plan for his immediate surgery, and some of the future procedures he would need. She listened calmly but there were unshed tears in her eyes.

 “He’ll be OK, won’t he?” she asked.

 “He’ll live, but he may not walk and there’s a good chance some of those bones won’t heal,” I said. Then my self-control broke. “How could you let him ride that thing?” I demanded.

 Then she did cry. “He was so happy,” she said. “Finally he could come down to the corrals and be with us during the day.”

 She explained that they lived on a ranch three miles from their nearest neighbor. Her son had an all-terrain wheelchair but the path to the corrals where they raised horses was too rough even for that. He had been confined to the house and front yard for several years while the rest of the family worked the ranch. He’d been terribly lonely. They knew the risk when they got him the ATV, but he had begged to be able to come down to the corral and watch her work with the animals.

 I was now ashamed of my outburst. I did my best to reassure her that her son was in the best hands and that we would do everything possible to help him. Then I showed her how to get to the preop area so she could see her child.

 Surgeons are acutely aware of risk. We make judgments every day about the relative risk versus benefit of our procedures, of the patient’s ability to tolerate an operation, of the chance that complications will outweigh potential benefits. Those are calculations that we try to base on our best understanding of physiology, our own abilities and the patient’s health. But sometimes we have to accept that the risk of our actions will be high but that the patient has no other option.  When the consequences of inaction are not acceptable, we (and our patients) must accept the risk and do our best

 There are other risk assessments that people make every day. We take risks when we love someone, when we get married, when we have children. A special risk assessment parents constantly face is the risk of harm to our children versus the need to allow them to learn independence and find their own freedom. What had it cost this mother to make that judgment and come up wrong? I hope I never have to learn that for myself.

Recovery and Hope

I saw a patient in follow up in the office today. She thanked me profusely for saving her life and told me the experience had changed her life. She wasn’t a trauma patient and I didn’t save her life. To be blunt, I kept her from dying from a complication of my surgical error.

 Her hospitalization was a twenty-day siege. It started out as an elective repair of a paraesophageal hiatal hernia. Her stomach was pushed up through her diaphragm alongside her esophagus along with her spleen and part of her transverse colon. It was a massive hernia and it was restricting her breathing and causing her pain whenever she tried to eat.

 It was a difficult and complex laparoscopic surgery and I thought it went as well as it could. But somewhere in the dissection, I made a small hole in her esophagus and didn’t see it during the surgery. It leaked and 24 hours later she was septic and dying. I rushed her back to the OR and fixed the leak, washed out her chest and abdomen and drained the area, but the die was cast. She started down the spiral of complication begetting complication until she ended up on a ventilator with a tracheostomy, in renal failure and needing multiple medications to maintain her blood pressure.

 I spent several nights in the ICU essentially running a continual resuscitation. Several times I expected her to die within the hour.

 Slowly things turned around. Her infection cleared, her pressure stabilized, we were able to wean the ventilator. After two weeks, the leak sealed and I could feed her. Ultimately she went to a skilled nursing facility and then home.

 I gently deflected her praise. I didn’t want to harp on the fact that it was a technical error that caused the trouble in the first place. She insisted that her time in the hospital had renewed her religious faith and she had returned to the Church, which she had left years earlier. She felt that her life was enriched by her experience. I thanked her for her praise and returned her hug a little guiltily.

 I see trauma patients all the time who survive life threatening injuries. I also have general surgery patients who are very sick from their disease process. I’m often impressed with how many of them deal with the experience. Some find renewed religious faith. Others find a renewed focus on their marriage or children or career. Many come away with nothing but pain and bitterness. Their experience is tragic and they see it as a continual burden.

 In trauma, a distressingly high number simply return to the risky lifestyle that got them in trouble in the first place – drinking and driving, drugs, riding motorcycles without a helmet, etc. We have a logbook of ‘repeat offenders’, patients who have been through the trauma bay more than once. Some four or five times.

 In situations where the severe illness is a result of a surgical complication, I’m ambivalent about my role. I’m always honest about how the complication happened and what I could have done differently, but I try to keep the focus on getting the patient better, on fixing whatever is wrong. I have a duty to clean up my own mess and am not comfortable accepting any praise for doing so.

 My patient left the office happy. I was a bit troubled, but glad she had made a good recovery and had gained something positive from her illness.  

Going Home

She’s 17 years old and going home tomorrow. Today we are working with Social Service and Case Management to get all the equipment she and her family will need for her ongoing care – dressing supplies, a walker, crutches, a wheelchair and a raised commode seat.

She’s 17 years old and three weeks ago we amputated her right leg above the knee. Before that operation she went through six surgeries to try to salvage the leg.

She’s just an ordinary kid. Not a star athlete, not a great student. She likes horses and Harry Potter and boating with family and friends on Lake Saguaro. She wonders if she’ll be able to graduate from high school this year, if she’ll ever be able to swim again, if she will be able to work as a hairdresser, which was her goal after graduation.

It was a weekend night full of fun and a few really bad decisions. Underage drinking, driving too fast on the 101 and a fight with her boyfriend all played a part. I wasn’t on when she came in, but was involved in her care as the rounding surgeon for the trauma service off and on for the whole six weeks she was in the hospital.

Her right leg got caught on something under the dashboard when the car rolled. Her boyfriend, who was driving, was ejected and died at the scene. Her right knee was dislocated posteriorly and the tibia and fibula, the two bones of the lower leg were shattered. Most of the skin on the lower part of her leg was degloved, ripped off of the underlying muscle. There was serious talk between the orthopedic surgeon and the trauma surgeon of completing the amputation that night. But she was 17 years old and healthy. Instead they went to surgery and did what they could.

Posterior knee dislocations are particularly devastating injuries because of the high incidence of injury to the popliteal artery. It’s the blood supply to everything below the knee and is runs through a narrow space right behind the lower end of the femur and upper end of the tibia. It’s relatively fixed in place by the big muscle groups around the joint and so when the tibia moves backwards in a posterior dislocation it can shear the vessel in two just like a guillotine.

The first goal in a vascular injury like this is to stabilize the bones. The leg will tolerate up to four hours of warm ischemia time, longer if the tissue is chilled, but vascular repairs are sensitive and don’t tolerate twisting, kinking or tension. If the bones aren’t secured, any repair will fail.

Popliteal arteries are hard to get at. Direct repair is rarely possible. More commonly a piece of vein is harvested and used to jump across the damaged segment from good vessel above to good vessel below.

In this case, there wasn’t much good vessel above or below. The artery hadn’t been sheared cleanly but rather had been stretched until it ripped. That caused unseen damage to the intima, the lining of the vessel, for a considerable distance above the visible tear. The degloving had also disrupted the vessels below the knee so there wasn’t much to jump a graft to down there.

The orthopedic surgeon put on an external fixator, an erector set like device of rods and pins that screw into the bone and attach to a lightweight external frame that keeps the bone from moving. The vascular surgeon did a vein graft and the trauma surgeon pulled what skin he could over the open wound. A vacuum dressing completed the first procedure.

I saw her on ICU rounds a few hours later and knew she was in trouble. Her blood was still acidotic, too much lactic acid in circulation, a sign of tissue that wasn’t getting enough oxygen. There was no detectable pulse below the knee and her toes were purple. The vascular surgeon took her back to surgery an hour later, and again six hours after that. And again. And again. All the time moving his graft to different tiny vessels in the lower leg looking for one that would support enough flow to nourish the muscles. One by one they shut down and the muscles died. After 18 days in the ICU on multiple antibiotics, sodium bicarbonate to correct the acidosis and heparin to keep the vessels from clotting off, we had the difficult conversation with her and her family.

She’s going home tomorrow.

She is twenty-five and referred for evaluation of a thyroid nodule. As is often the case, this one was found incidentally when she had a sore throat. An astute primary care doctor thought she felt a mass and got an ultrasound. The nodule measured 2.3 cm and so by the accepted protocol for thyroid lumps, an ultrasound guided fine needle aspiration (FNA) was done. (A fine needle is used to suck up some cells from the mass and send them to pathology for analysis.)

Most thyroid nodules are benign – about 85%. But 15% are malignant and those are heavily skewed toward young women. The bulk of thyroid cancers fall into one of two categories. Papillary cancers are most common and are distinctive on FNA. Follicular cancers are less well defined and difficult to distinguish from benign follicular adenomas on FNA. Generally a finding of a follicular lesion on FNA of the thyroid leads to a thyroid lobectomy – removing the half of the gland where the tumor lives.

Her FNA showed a ‘follicular nodule of indeterminate nature’. In other words, the pathologist can’t tell me whether it is benign or malignant based on the needle aspiration. At her age, her risk of this being malignant is as high as thirty percent.

I sit down and talk with her about surgery. She listens as I outline the operation and it’s purpose. I tell her about the small risk of injury to her recurrent laryngeal nerves. They are the nerves that control movement of the vocal cords, one on each side. If one is injured, the cord on that side becomes flaccid and moves toward the middle. If both are injured, they won’t move and may even obstruct the airway requiring a tracheostomy. I assure her that the risk of such injury is only around 1% and that we have a device that allows us to monitor the integrity of the nerve during surgery.

She nods and asks “Will I be able to sing afterwards?”

I’m ready for this one. The stock response if I say “Yes” is to say, “ Gee that’s great because I never could before!”

I give her my stock answer, “Only if you could before.”

She gives me a funny look and says, “I’m an operatic voice major at the ASU School  of Music.”

Nothing like a little pressure.

In addition to the recurrent nerves, I must also worry about the superior laryngeal nerves. These enter the larynx at the top of the thyroid gland and under most circumstances are not considered very important. They cause the vocal cords to tense and flex and are responsible for pitch in the voice. A normal person who loses one or both won’t even notice until they try to speak for a long time or shout. Then the voice may be weak and breathy.

An Opera singer uses these nerves to add vibrato to their voice and to sustain notes, especially high notes.

With some trepidation, I take her to surgery and spend a lot of extra time on the dissection and identification of the small nerve trunks. Surgery goes well and her tumor turns out to be a benign adenoma.

A week after surgery she comes in for her postop visit. As she’s checking in, my medical assistant, who knows how worried I was about her nerves quietly asks her, “How is your voice?”

She steps back, straightens up, opens her mouth, and hits a high C that she sustains for a full 15 seconds. All the other patients in the waiting room break out in applause.

Rediscovering First Principles, or Grand Futile Gestures

Late night Saturday trauma, 59-year-old woman in a high speed head on collision. She was not restrained and ended up bend almost double, pinned under the steering wheel and dashboard of her car. Thirty minute extraction, seventeen minute transport time. We’re now three quarters of the way through that first golden hour when rapid intervention can still make a difference.

Her vitals were all over the map in the ambulance, heart rate swinging between the low 60’s and up to 120. Her blood pressure would be normal one minute, then drop to the 50’s the next.

In the trauma bay we had the low end of that swing. We placed another large bore IV and started pouring in fluids and O negative blood. Her blood pressure briefly rose to the high 90’s. She opened her eyes and looked at me. She said, “I can’t breathe. Help me.” And then she died.

Her blood pressure went away completely, not recordable. Her heart rate, which had been 120, fell to 40 and the pattern changed from normal sinus to a junctional rhythm (the last ditch effort of a dying heart to keep going).

It’s called PEA – pulseless electrical activity. The electrical system of the heart is still firing but no contraction is taking place either because the heart is empty or because it can’t fill. I bet on the latter and call for the thoracotomy tray.

ER thoracotomy is a dramatic event. It’s also usually futile. Survival after opening someone’s chest in the ER is less than 10% under most circumstances. A few centers report better results with penetrating trauma. But almost universally the survival with ER thoracotomy for blunt trauma is zero. My personal experience in thirty years is two survivors, one penetrating and one blunt.

I open her chest through a left lateral incision through the space between the 5^th and 6th ribs and extend it across the sternum. Her pericardium, the membrane around her heart, is filled with clot and it s squeezing the heart so it can’t pump. I open the pericardium and evacuate the clot and her heart fills and starts to beat.

Yes! I think, watching the ventricle fill and contract. Then I see the same blood that filled her ventricle rush out of the aortic valve annulus and the darker blood pouring out of the hole in her superior vena cave. She’s avulsed her heart from the superior mediastinum – ripped it off of the major vessels in the upper chest. In about twenty seconds the heart fasciculates and stops.

First principles  - mortality for ER thoracotomy in blunt trauma is 100%. But she opened her eyes and spoke to me. Sometimes you need to make a grand futile gesture, just so you can sleep at night

Patient's satisfaction is one of the new buzz words in our current ongoing struggle with the American medical care system.  Physicians and hospitals are rated on patient satisfaction surveys and our reimbursement through Medicare is intimately tied to these ratings.  But what does patient satisfaction really mean?  More importantly how accurate are the measures that are being used to determine patient satisfaction?  The current survey which is standardized and distributed to all patient's leaving the hospital, is not individualized for each physician that the patient saw during her hospital stay.  Rather an aggregate score is assigned to all of the physicians who were involved in the patient's care.  The patient simply answers a scaled questionnaire on how well the doctor listened to you, how well you were treated with respect by the doctor, and how well the doctor explained your medical problems and procedures.  The doctor in question however is not identified.  This means that if several doctors were involved in the patient's care, the one that was the most memorable to the patient will be the one that is rated.  He or she may be memorable because they were particularly good, or particularly bad.  Anyone else involved in that care is tarred with the same brush.

I was recently reminded of the vagaries of patient satisfaction when I saw a patient in my office in follow up.  This was a woman who had had a particularly complex surgical problem, and had a very difficult and demanding operation.  She was not in the best of health and was a poor candidate for the surgery in the first place.  I was very proud of my efforts, since the surgery was exceedingly difficult but went very well.  Furthermore her postoperative care was top-notch and she had no significant complications.  When I saw her in my office however she was quite angry and upset.  She swore she would never again go back to that hospital, and thought that it was one of the worst experiences of her life.  I was taken aback.  I had put forth extra effort doing a complex bit of surgery and then taking care of a very sick woman and was expecting a modicum of gratitude or at least appreciation.  I had spent a good deal of time prior to the surgery describing its complexity, and informing her of the very high risk nature of the procedure.

I dug a little deeper to try to discover the source of her anger.  It turned out that she had multiple complaints about the physical plant of the hospital, the cleanliness of her bathroom, the quality of the food, and the promptness of the nursing staff in dealing with her requests and demands.  These are all things that I consider peripheral to her care but to her were quite central to it.

I was reminded of the importance of patient perception after a recent airplane trip.  I flew from Phoenix to San Jose for a training course.  The flight itself was uneventful other than some high altitude turbulence.  We took off and landed safely and arrived on time.  I was nevertheless somewhat unhappy at the end of the flight because there had been a long delay in boarding, I was forced to sit in a middle seat rather than an aisle seat, and they were out of my choice of beverage.  Completely lost on me was the fact that we had just flown hundreds of miles at 35,000 feet where the outside temperature was 50°below zero and there was not enough oxygen to sustain life.  We had passed through an area of turbulence with very little incident and had landed safely and on time.  I was completely discounting the skill and training of the pilot, the people who maintain the aircraft, and the air traffic controller who guided us safely to our destination.  These are all very complex interactions with involving multiple people all of whom have highly skilled jobs to do.  For me a safe flight and on time arrival was simply the expectation.  My expectations were not met with respect to boarding, seating, and my beverage choice.  I'm sure that to the flight crew and pilot, these are all things that were quite peripheral to a safe flight, and my complaining about them now seems somewhat petty.

It may not be fair, but we need to remember that peoples’ experience is based on a point of view, and not necessarily on the complexity of the interaction going on around them.  My patient was upset about things that directly affected her and her comfort.  It was her expectation that she would have a safe and successful surgery and that the people caring for her would do their jobs properly.  Where her expectations were not met, there was certainly room for improvement, but in the overall importance of her hospital stay and they were relatively minor. To her, however, they were the defining aspects of her experience.

The Purple Man

Friday afternoon trauma shift and we get a call about an incoming trauma – 67 year old man restrained driver, hit from behind at high speed; brief loss of consciousness, complaining of chest and back pain.

He arrives a few minutes later, awake and alert, complaining of back pain midway between his shoulder blades. He is diaphoretic (cold clammy sweat) and says he is having a little difficulty breathing. What is immediately obvious is that his face is purple. Not the purple of a bruise or contusion, but the purple of venous congestion, like when you hold your breath and strain until you turn blue. The discoloration stops at his collarbones and he is normal to a little pale in color below that. His blood pressure is normal to a little high and his pulse is in the 80’s – not terribly elevated.

Facial cyanosis in the settling of trauma is a sign of something very bad going on in the chest. It is caused by impaired venous return – blood flows into the head and face but can’t get back out – and implies an obstruction in the superior vena cava. With penetrating trauma, this could be due to a wound to the cava with a clot occluding it. In blunt trauma it is more likely due to a big hematoma from a torn aorta pressing on the vena cava and blocking it. Even though this man’s pulse and blood pressure are reasonably normal, we may be sitting on a ticking bomb.

The aorta is the main artery flowing out of the heart to the rest of the body. As it exits the heart, it sweeps up toward the neck but makes a 180-degree turn while still in the chest and then goes down along the spine toward the abdomen. That sweeping curve from upward to downward and right to left is called the arch and it gives off both right and left carotid arteries to the brain and the innominate and subclavian arteries to the right and left arms respectively. Through most of this turn, the aorta is pretty firmly fixed to the spine and muscles by tough bands of tissue. There are a couple of places where it is more mobile. One is just above the heart for about a centimeter as it leaves the annulus of the aortic valve. The other is as the aorta completes its turn and heads down toward the abdomen. At that point it is anchored by the ligamentum arteriosum, the remnant of the ductus arteriosus, a fetal structure that bypasses the lungs before they are inflated by the baby’s first breath. It is at these fixed points that the aorta can tear through shear forces caused by a sudden, violent acceleration or deceleration.

Tears of the aorta can be catastrophic and immediately (or within a minute or so) fatal, or they can be contained temporarily by the tissue surrounding the aorta. This containment may last minutes to hours, but eventually if fails as clots begin to break down and catastrophic bleeding develops.

When a patient survives to reach the trauma center with this type of injury, they are like a bomb waiting to go off. I have no way to know or predict when the containing clot will fail and so time is of the essence.

After a few quick minutes examining the patient for other injuries, we hustle him off to CT for a scan of his chest. Sure enough, he has a contained tear in the middle of the descending aorta – the part heading down to the abdomen. There is a large clot containing the tear and pressing on the cava which lives right next door.

This is a job for Cardiovascular surgery. Only a few years ago, we’d be hustling this patient off to the OR for a thoracotomy and direct repair of the injury. But not today. Today we are going to the interventional radiology suite. These injuries can often be treated with covered stent grafts, similar to the stents that are put in coronary arteries, only much bigger. The stents are cylindrical metal frames that are collapsed around a balloon. They are passed under fluoroscopy up the aorta from the groin, positioned at the tear, and then the balloon is inflated which expands the stent to its full diameter. When the balloon deflates, the stent remains in place and covers and reinforces the tear. Very high tech and slick, and it saves the patient a big cut on his chest. Once the tear is covered, the clot can be allowed to break down naturally and the cava opens up.

My purple man did well in radiology and is now being monitored in the ICU for any further signs of bleeding. I love technology.

Joe's Legs

I was a young resident on my trauma rotation, eager to do procedures and save lives, when we got a call from the paramedics. They were bringing in a man with a head injury and lower extremity paralysis.

As the resident, I ran the initial trauma evaluation. My attending was in his office, two floors up and I was supposed to call him after my initial assessment or if the patient was unstable.

When the paramedics arrived they presented the few known facts they had – the man was found down under a viaduct with a large gash on his head. He was homeless and smelled strongly of alcohol and a number of other less savory substances. His ‘friends’ could only tell the paramedics “Joe got hit in the head and can’t move his legs”.

Joe was only semiconscious. He would snore and sputter; he would arouse to shouted words or pain but only said a few nonsense words before becoming somnolent again. I considered intubating him because of his depressed level of consciousness, but he seemed to be protecting his own airway adequately and if we sedated him, we’d not be able to assess his neurologic exam.

We loaded him with IV fluids, sewed up the 15-centimeter scalp laceration, and badgered him repeatedly to move his legs. The only coherent thing he said was “Can’t”.

This was in the days when CT scanners were relatively new and exotic pieces of technology. Scans could take as long as 30 minutes to complete (compared to 30 seconds today) and we didn’t get them on everyone. Before ordering one, I had to call my attending. I outlined the presentation and physical findings for Dr. Cochran and told him I suspected a central brain injury was responsible for Joe’s paralysis, even though it was bilateral and symmetrical, an unusual way for a brain injury to present. I wanted to do a CT scan.

Dr. Cochran came down and looked Joe over. He turned to the nurse and ordered Narcan, a narcotic antagonist that can temporarily reverse the effects of drugs like heroin, codeine, morphine, etc. A few minutes later Joe opened his eyes. He was still confused and somnolent but was definitely more alert than before.

Dr. Cochran shouted at Joe in his gravelly voice, “Move your legs, sir.”

Joe said, “I can’t”

Dr. Cochran then asked the key question. “When was the last time you could move your legs?”

Joe said, “Oh man, I haven’t moved them in five years. Not since I broke my back.”

Dr. Cochran just said, “Cancel the CT.” and walked out of the trauma bay.

Object lessons that I have never forgotten: 1) Just because a patient is drunk, doesn’t mean he doesn’t have other substances on board. Joe was also a heroin addict and Dr. Cochran had noticed the needle tracks on his arms. Narcan reversed the heroin enough to get a better history. Which leads to the second lesson, 2) Always get as complete a history as possible before ordering a bunch of hi-tech tests.

Joe sobered up and the paramedics found his wheelchair and brought it to us a couple of hours later.

How Surgeons Think, Part 2

A long time patient of mine was admitted by the Hospitalists five days ago with a bowel obstruction. He has known metastatic colon cancer and has trouble with intermittent obstructions for some time, probably due to tumor. I admitted him for the same problem just after Thanksgiving and he got better as 80% of obstructions do. We talked then about surgery. The bottom line in this situation is that when the obstruction doesn't resolve or when it becomes a recurring issue, surgery is an option. With tumor you never know. You may or may not be able to fix the blockage. If the tumor is too extensive you may do an operation for no gain. I told him I would discuss it with him again if the symptoms became unbearable and he wanted to try an operation.

He went home but didn't fully recover. Every few days he'd have obstruction symptoms again. He'd stop eating for a day, get better and start back on a diet only to have trouble again several days later.

This admission, the Internists plugged him into IV nutrition, and resolved his pain and nausea. They then dithered for five days, trying again and again to advance his diet before deciding to send him home on home IV therapy. For some reason, the Hospitalist on call New Year's day decided to call me to see him before discharge so I could arrange to see him in the office.

I sat down with him and layed out the options. He clearly wasn't getting better with waiting. His choices were to have surgery in hopes of relieving his blockage or do nothing and enter hospice. The options are easy to present, the choice is very hard. But up until our conversation, none of the doctors caring for him had laid the choices out clearly for him. He chose to risk the operation. I canceled his discharge and he's scheduled for Monday.

The difference in approach to this patient was very clear. From the admisssion five days earlier it was clear to me that he was going nowhere. No amount of time or medication would resolve the problem. A clear presentation of options was needed so that a very hard choice could be made. But someone needed to articulate tose options for the patient. None of the internists could or would do that.

A Surgeons Day

It was a quintessential General Surgery day. An elective line up that started with a complex abdominal hernia repair, followed by a thyroid lobectomy, a laparoscopic cholecystectomy (removing a gallbladder with the laparoscope) and finishing with a robotic laparoscopic Nissen fundoplication (fixing a hiatal hernia and wrapping the esophagus to prevent acid reflux). Halfway through the second procedure, an internist friend of mine called me. Bad sign--he never calls personally unless it's a disaster.

"Are you busy?" he asks. Another bad sign. He's not given to small talk and that kind of lead-in means he needs a favor.

"What's up?" I ask. He jumps right in. He has a patient in the ER with abdominal pain and a CT scan showing a perforated colon. Probably diverticulitis, but there's a lot of spillage and free air in the abdomen. Free air means that air from the intestine is leaking into the abdominal cavity and showing up in places where air doesn't belong. The implication of free air is that the leak is large and the body can't wall it off. Peritonitis usually follows. So far, a pretty standard presentation for a perforated diverticulum of the colon, serious but not disastrous.

"What's the rest of the story?" I ask. After an apology for dumping this on me, he fills in the details. The patient has emphysema. She has poor oxygen saturations on a good day and now is hypoxic, blue, hypotensive and getting emergently intubated as we speak. She is on high dose steroids for her lungs and her rheumatoid arthritis. She has had two strokes and a blood clot in her lung and is on Coumadin, a powerful blood thinner. Her INR, a measure of her prolonged clotting time due to the drug, is 4.5 (normal clotting is 1).

Surgeons hate Coumadin. It's hard to control and not easily reversed in an emergency. We also hate steroids. They inhibit the immune system so patients are more susceptible to infection. They delay wound healing so patients on high doses are at risk for wound breakdown. This lady is a train wreck. She would not be a candidate for an elective procedure under any circumstances, but this is no longer an elective situation.

I finish the thyroid operation, which fortunately was not a cancer, speak to the family, and then hustle over to the ER. Mrs. G. is now intubated and has a couple of large bore IV lines in. My internist friend has started antibiotics, gotten some blood typed and crossed (with her coagulation profile, we're going to need it), and started pressors (drugs like epinephrine that raise the blood pressure) because she's now in septic shock. Dr. K. is one of the good ones; an internist who follows his own patients when they are admitted and who is comfortable with seriously ill people. The only thing I add is a dose of recombinant Factor VII.

Factor VII is a clotting factor in the coagulation cascade. It used to be precipitated from donor blood and is used for hemophilia. It's now manufactured by recombinant DNA technology and is free of human pathogens. It's also beastly expensive and dispensed by the microgram. An off-label use is in the severely bleeding patient and as a temporary reversing agent in patients on Coumadin. It buys you a couple of hours before it metabolizes away and the blood stops clotting again. We use it as a bridge in situations like this where anticoagulated patients need an immediate operation. There are other agents that can be used, but they are all either expensive or take a long time to work.

I bump myself (delay my other cases and use the room and anesthesiologist for this case) and we rush off to the OR. The operation is pretty straight forward. I take out the perforated segment of colon, oversew the downstream end as a blind rectal pouch and bring out the upstream end as a colostomy. We close the abdomen with some retention sutures, extra heavy sutures, through the big abdominal muscles. Two hours, five units of packed red cells and four units of plasma later, we transfer the patient to the intensive care unit.

I'm now two hours behind schedule and have the hardest part of my day coming up. The laparoscopic cholecystectomy is easy and the patient is a young healthy woman. She does well and will go home from the recovery room.

The robotic case is much different. Robotic surgery is a misnomer. Remote teleoperation surgery is more accurate. The robot does nothing on its own. It is a tool, an extension of my hands. I sit at a console, several feet away from the patient and operate the arms and manipulators of the robot with fingertip controls. My head is in a hood with binocular eyepieces that give me three dimensional vision through the robot's two cameras. It's just like having my head inside the patient, up close to the area where I'm operating. The drawback is the complete lack of any tactile sensation. Even with the regular laparoscopic instruments, I can still 'feel' what's going on. Not the same as with my fingers but like the feel you get using chopsticks to eat. You can tell the texture of the food, it's size and resistance to tearing. Regular laparoscopic surgery is similar. I can tell if tissue is hard or soft, weak or sturdy by the feedback sensation through the instrument. Not so with the robot. It's all visual.

Robotic cases are stressful. Even after fifty or so, I still feel stressed while operating. I don't schedule more than one a day and would prefer not to have other hard cases on the same day. This day, I've already been stressed and am not looking forward to the robot. Fortunately, my patient is a healthy man and is reasonably thin. The case starts well and by fifty minutes in, we have the robot docked, the instruments in and I move to the console to start work.

That's when the pages from the ICU start. Mrs. G. is still bleeding, soaking through her dressing and leaking from the edges of her colostomy. Her INR is 3; better than before but still too high. I order more plasma and some vitamin K. Fresh Frozen Plasma (FFP) is full of clotting factors and helps reverse the Coumadin. So does Vitamin K. (Coumadin blocks vit K in the manufacture of the clotting factors by the liver).

Throughout the robotic operation, I field calls from the ICU. My mind has to be able to split attention between the operation at hand and the resuscitation of my critical patient in the ICU. I also maintain a low level of situational awareness for the room around me--what my assistant nurse is doing, how the monitors of the patients pulse and BP read, whether the anesthesiologist is relaxed or busy--all these things are there in the background.

The robot surgery goes well. We finish in a little under three hours--about par for that type of surgery. I'm convinced it would have gone faster without the interruptions from the ICU, but don't worry much about it. It's a decent time and I feel like I still know what's going on with Mrs. G. I write post op orders and talk to the family before returning to the ICU.

Mrs. G has stabilized somewhat. She's off the pressors and the oozing seems to have slowed down. Her saturations are terrible, but survivable and probably as good as she ever gets. More importantly, her base deficit (a measure of acid in the blood) is less than -3, which means she's delivering oxygen to her tissues adequately. The shock seems to be clearing and her INR is down to 1.5. Now we only have her lungs and kidneys to worry about. But at least I can go home. It's nine P.M. and I've been in the hospital since six in the morning.

It's not that this day was so special. Quite the contrary. Many days are less busy, some more so. The day was not unusual for me or for many of my colleagues, which is why we are becoming dinosaurs. Few choose to go into surgery these days, fewer into General Surgery. That broad range of skills and orientation is slipping away, replaced by specialists who concentrate on single organ systems or disciplines. I don't know if this is a good or bad thing. Specialists can concentrate on the latest knowledge and techniques but sometimes miss the bigger picture. I still think the ability to shift gears rapidly between a routine schedule and an emergency and then back again still has value, though. I just don't see very many successors in the current training programs.

How Surgeons Think

I was on trauma call recently and an unfortunate young man was brought in after being run over by a car. He was riding his bicycle home from a local pub, (blood alcohol .2) when he lost his balance and fell. He landed in the traffic lane rather than the bike lane or sidewalk and was run over by a car. The wheels went over his pelvis and abdomen. He arrived at the trauma unit in serious trouble with a nasty pelvic fracture, a dislocated hip, multiple broken ribs, a punctured lung and a distended abdomen. He was in shock and having trouble breathing and in severe pain. We quickly determined that the problem with his breathing was the hole in the lung and the resulting pneumothorax (Air in the chest cavity that compresses the lung and restricts breathing) Easy fix with a chest tube, a tube passed between the ribs into the space between the chest wall and the lung to suck the air out and reinflate the lung. Sixty seconds after placing the tube he was breathing better.

His blood pressure was still low but it responded transiently to a shot of IV fluid. Better to replace lost blood with blood, so we gave him two units of O negative. Wonderful stuff, blood. O neg is often called 'universal donor' blood because it lacks the major antigens that cause most transfusion reactions. You can give it with reasonable safety to any blood type without waiting for a cross match. The blood boosted his pressure to a safe range and bought us time.

A quick exam and a plain x-ray of the pelvis showed a complex pelvic fracture and a dislocated hip. You can lose a lot of blood into a fracture like that. It could account for his shock. But his abdomen was tender and distended and he was still having episodes of low blood pressure. He just looked like he had blood in his belly. I thought about going to CT scan, but another dip in the pressure decided the issue. We were going to the operating room.

At surgery, I found very little free blood in the abdomen. But under the colon on the left side, where the left kidney lived there was a tell-tale stain of bright red. The bleeding was in the space behind the intestine called the retroperitoneum. Dangerous stuff lives back there: the kidneys, the pancreas and the great vessels--the aorta and the vena cava, the largest blood vessels in the body. Bleeding back there can make a noise when it cuts loose. (Literally, turn on a faucet and listen to the sound it makes splashing into the sink. Bleeding from one of those vessels can sound like that). Surgeons say a brief prayer before entering that area.

I opened the area where the blood was, taking care to stay close to the big vessels so that I could get control of them if I needed to. The bleeding was coming from the artery and vein that supplied the left kidney. A vascular clamp on the root of the renal artery slowed things down and bought time to dissect out the artery and vein and assess the kidney. Unfortunately, the artery had been torn off of the hilum of the kidney, the place where the vessels and the ureter enter the substance of the organ. (Imagine a kidney bean; the hilum is the dent in the side of the bean) That's not a repairable injury. I might be able to jump a graft from the aorta, but there wasn't enough vessel on the kidney side to sew to and the substance of the kidney around the hilum had been crushed to hamburger. No other choice really. The kidney had to come out.

That's a hard decision to make on the fly. This was a healthy young guy with no medical problems. He had an intact right kidney and clear urine in the catheter we placed before surgery. I had the anesthesiologist give a little blue dye in the IV and within seconds the urine turned green so I knew the right kidney worked (A one shot IVP or a CT would have been better but we didn't have time and I was concerned about giving contrast) He'd survive just fine with one kidney, but taking the left one out still felt like a failure.  I went ahead anyway. The rest of the procedure was routine and after closing the abdomen, we went to CT and got good pictures of the head, neck and pelvis. The right kidney is working fine. He's still sick, his lung is damaged and he has a lot of toxic byproducts from the crush injury to his muscles in his system causing problems for his heart and kidney.

I am still second guessing the decision. It's an occupational hazard. I still believe it was the right thing to do. The interesting thing is the reaction of the various specialists  who are involved. My fellow trauma surgeons listen to the description of the injury and nod and say "Good call". The intensivist (a pulmonologist, or lung specialist, by training) asks if I called in a vascular surgeon or urologist to help make the decision. I didn't. Aside from it being O-Dark-Thirty in the morning, the answers would have been the same. Why spread the pain around? The answer, of course, is spreading the responsibility. Internists are accustomed to medicine by consensus. Get multiple opinions and decide on a course of action that all agree upon. Surgeons tend to take individual responsibility for action. I may ask for input if I'm uncertain, but in the end, I'm ultimately responsible for the outcome.

As Dr. Blalock, the father of pediatric cardiac surgery, said back in the 1940's "The mark of the surgeon is the ability to make irrevocable decisions on the basis of incomplete information."

AN O.R. TALE

She was 94 years old and had been labeled demented. She was admitted through the Emergency Room because she had stopped responding to the caregivers at the assisted living center. The ER doc checked her out and found that she was again extremely hypercalcemic--her blood calcium was too high. Normal range is 8 to 10 mg/dl. Hers was 13. This wasn't her first trip for this problem. In the past two months she had been admitted three times with calcium's over 12. The Hospitalists would tune her up with saline and diuretics, treat her with Sensipar, a drug that lowers calcium, and send her out, only to have the cycle repeat. Either she wasn't taking her meds, or they weren't working to keep her stable. After all, she's demented; she may not be able to take her meds properly.

This time, the Hospitalist who admitted her was a friend of mine. She's an Internist who is old enough to remember the days before DRG's and 'best practice guidelines'. Those guidelines say that for patients over 80, the best management for hypercalcemia is medication. Rather than simply follow the guideline. she worked the patient for hyperparathyroidism.

The parathyroid glands control calcium in the body. Most people have four glands, two on each side of the neck. Once in a while, one of those glands will stop responding to the feedback mechanisms that control the production of parathyroid hormone (PTH). It then becomes an adenoma, a benign tumor that keeps churning out PTH, no matter what the calcium--a condition called hyperparathyroidism.

The old lady's PTH was 380, over ten times normal. And her parathyroid scan, a nuclear medicine study, showed a probable adenoma on the right side. So my friend the internist called me. My first response was 'You've got to be kidding'. Did she really expect me to operate on the woman? When I first saw the patient, she could barely put two words together and those didn't make sense. She was so thin and frail a strong wind would blow her away. And yet, my friend insisted that her mind seemed clearer when her calcium was below 10 and her family was in favor of either surgery or completely withdrawing care and letting her go. So I reluctantly agreed.

We went to surgery . I did a focused operation on the right and removed one of the biggest parathyroid adenomas I have ever seen. Her PTH went from 380 preop to 36 in the recovery room and ultimately fell to 16. Her six hour postop calcium was 10.5 and she did surprisingly well with the anesthesia. I felt pretty  good about it.

When I went into her room the next morning, I thought I was in the wrong place. In bed was a bright animated elderly woman happily eating oatmeal. Her first statement to me was 'When can I go home? I have things to do.' She was a totally different woman. One of the effects of hypercalcemia is mental depression that can simulate dementia. It's called metabolic encephalopathy and had been the problem all along. Not only did we fix her high calcium, we fixed her brain, too.

Happy ending, right? So I go out and get her chart, feeling on top of the world. I open the chart and find the dreaded Green Sheet. A missive from the Medicare case manager. 'Dear Doctor, Best practice guidelines recommend medical management of hyperparthyroidism in patients over 80 years of age. Surgery is not approved treatment for patients in this age range. You must have prior authorization for surgery or payment will be denied.' So my friend and I save this woman from spending her remaining days drooling in a corner and Medicare is going to shake its bureaucratic finger at us and refuse to pay for her care?  I hate to be pessimistic (well, a little. Surgeons are natural pessimists), but I see this as a preview of where the regulation of healthcare is headed. Follow the guidelines. Forget your experience, your training, your gut. Just follow the book. It was that gut instinct that made my friend the internist work our patient up and then push me to operate on her. How long will we be able to keep that kind of intuitive thinking in medicine?