They say you never forget your first patient death. That wasn’t true for
me. I had been present at several deaths before the first that I truly remember. I started my first clinical clerkships late
in my second year of medical school at an inner city hospital. I was present for several ER and ICU deaths within my first
few days on the Medicine service. They were nameless old people for me. I had examined them on rounds with the rest of the
circus of students and residents, but hadn’t really connected with them except as clinical exercises.
That wasn’t the case with Anya. She was a bit older than I, almost thirty. She wasn’t classically beautiful,
but had a pale skinned, ethereal look that captivated me. She came into the hospital complaining of progressive shortness
of breath. She was faintly amused at my earnest but clumsy physical exam and the endlessly detailed medical history I dutifully
recorded. I listened to her lungs and percussed her chest and documented the diminished breath sounds on the left, the dullness
to percussion, and the asymmetry of her chest expansion when she took a deep breath. All signs of a pleural effusion, a collection
of fluid in the chest between the lung and the chest wall.
The pleural space isn’t
usually a space at all. Rather it’s a pair of slick membranes wrapping around the lung and the inner surface of the
chest wall allow the lung to move smoothly in and out as the chest expands and contracts. The lung itself is basically a big
balloon, or more accurately, a cluster of thousands and thousands of tiny balloons held together by blood vessels and tiny
air tubes called bronchioles. Unsupported, the lung will collapse under its own weight. What keeps it expanded is a vacuum
in the pleural space. The expanding chest pulls the lung outward causing it to fill with air, then collapses it as we breath
Anything that gets into that potential space between the lung and the chest wall
disrupts the vacuum and disturbs the mechanics of breathing. Air can do it, whether from a hole in the lung or a hole in the
chest that allows air in from the outside. This is called a pneumothorax and is commonly seen in trauma. An effusion is fluid
in the same space. Effusions may have many causes from trauma to infection to malignancy and the treatment is based largely
on the cause.
Anya’s effusion seemed puzzling to me, at least as a medical student, since
she was a slim, athletic young woman who said she enjoyed running, bicycling and rock climbing. I was accustomed to thinking
of effusions being due to heart failure or malnutrition or pneumonia, none of which seemed to apply here.
I stammered something to her about talking things over with my resident and asked if she needed the nurse. She smiled
and said she was fine and hoped I’d be back soon with some word about what we would do next.
her history and physical to my resident and he asked if there had been any x-rays taken. There was just a chest x-ray. He
opened her chart and ordered a mammogram, an upper GI series and a barium enema. Thoroughly confused, I asked why.
“She’s got cancer,” he said. “Come on. You’re going to do your first thoracentesis.”
I followed him back to her room, He spent a few minutes reviewing with her the history I’d taken and then asked
if he could reexamine her breasts. She nodded and he did a much more extensive exam than the shy, cursory one I had done.
“Did you notice the asymmetry?” he asked me, indicating the difference in size of the breasts. I had
but didn’t know what to make of it. I knew from my reading that there is often a distinct difference in size between
right and left breasts in some women and that it didn’t necessarily indicate pathology.
your left breast always been a bit larger?” He asked her. No, she said, the left had grown notably over the past six
The nurse brought in a tray of instruments and a liter sized glass bottle with
a tight rubber stopper sealed to the top.
The resident walked me through the thoracentesis –
drainage of the chest with a long needle. Under some local anesthesia, a large bore needle is directed through the skin and
muscle between the ribs in the middle of the back. Anya bore up stoically and when I got bloody fluid back, I was alarmed.
The resident said, “Good. Now connect the tubing to the needle and plug the other end into the bottle.”
I did as he directed and found that the bottle was a vacuum container, like a giant blood draw tube. Soon, we had
a liter of fluid out. The nurse switched the bottle for another one and we drew off another 800cc before the flow stopped.
By that time, Anya was breathing noticeably better. She thanked me.
I removed the needle from
her chest and applied a gauze pad. The nurse took the bottles and called for a lab pick-up.
in the hallway the resident said, “She probably has a diffuse breast cancer. That’s why her left breast is larger.
There is no mass. Most of the breast is replaced by the tumor. It’s easy to miss if you don’t notice the difference
in hardness between the two sides.” Her left breast was larger and I had noticed that it was firmer than the right.
The next day, the surgeons saw her and scheduled her for a breast biopsy and possible mastectomy. The fluid analysis
showed “malignant, poorly differentiated cells, consistent with breast primary”
came back from surgery in the evening, minus her left breast. I went to see her before I went home for the night. I was stunned,
but she was calm. I had little to offer her in the way of information or wisdom, but she talked for a while with me about
her parents and her cat. She asked if I had family and if they were in Chicago. It seemed surreal. We were having a normal
conversation, as if we had met at a social function and were getting to know each other. I think I fell in love a little right
I saw her off and on over the next six weeks as she was in and out of the clinic
and hospital getting chemotherapy. Chemo in those days was less effective and more toxic than the agents we use today. I stayed
with her a couple of times after evening rounds as she battled waves of nausea. We never touched other than in a clinical
way and our conversations were casual. I don’t know how she felt about me. I suspect she thought of me as a kind of
younger brother, or maybe a stray puppy she had picked up. I desperately wanted her to get better and be well again.
About three months after her initial diagnosis she came back to the emergency room with another effusion. I had moved
on to my Pediatrics rotation and was in the outpatient clinic seeing runny noses and rashes when the Chief Resident came looking
“Dr. P from oncology is looking for you,” she said. “There’s
a patient asking for you.” She gave Anya’s name. “Is she a relative?”
I said. “Just a patient I saw on my last rotation.”
She looked a little dubious.
Patients didn’t ask for medical students by name. She told me to finish with the child I was currently seeing, and then
go find Dr.P.
I did and the oncologist seemed to understand Anya’s request. He directed
me to her hospital room.
She looked terrible. She was skeletally thin and gasping
for breath despite the tube in her chest that drained reddish fluid into a complex of suction bottles at her bedside.
She smiled when she saw me and
said, “I didn’t want to go without saying goodbye.”
“Are they transferring
you to another hospital?” I asked and then wished I could take it back.
She just smiled again, shook her head,
and closed her eyes. I sat with her as she slept. About three in the
morning, she stopped breathing and was gone.
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.
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.
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.
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.
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.
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
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.
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.
up in the ICU and couldn’t do the debridement,” I lied. “The case was already booked, so I went ahead with
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.
he says so, sir. I knew he was busy and may have forgotten to tell him I was going ahead with the case.”
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
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.
The Night Market
This is a true story. I've taken some
literary license in the telling (I'm a writer. We do things like that) but the events are true and accurate. It’s
1979, 11:00 PM (23:00) and Bossa and I are in Singapore wandering the night market in Bugis Street. The street vendors have
been out since 10 or so, hawking everything from souvenir T-shirts to pirated cassette tapes to fake Gucci handbags. We’re
here for the food. The restaurants in the area close up at 10:30, then reopen in the form of steamcarts and propane powered
grills in the street at 11:00. Some of the most expensive places in town come to Bugis Street and sell their signature menu
dishes for a fraction of the restaurant price.
We find a likely collection of tables and take a seat. We order crispy
duck, kung pao chicken and an appetizer of fung gor dumplings along with a couple of Singha beers to wash it down. Bossa is
the Supply Corps Ensign for the battalion, about four years younger than I, the worldly and wise Medical Corps Lieutenant.
We’ve gotten a short R&R in Singapore during a flight layover from Subic Bay to Diego Garcia. Bossa is still trying
to live down the incident with the briefcase full of money from the last time we were in Singapore (another story). He’s
trying to look worldly himself rather than gawking at the exotic market that swirls around our table.
Just about midnight,
the bargirls appear, wandering and mingling through the crowd of diners, paying particular attention to westerners who look
like they have money. “Buy me drink, Sailor?” One of them catches Bossa’s eye and smiles at him. She’s
standing across the street from us, just outside of one of the bars that cater to Australians and off duty American sailors.
Bossa nudges me and points her out. She’s a bit tall for an Asian, but still only around an inch over my own 5 foot
six. She’s wearing a scarlet cheomsang, sleeveless, with a high Mandarin collar. The skirt is long but is slit along
the left side up to her thigh. She’s not buxom by any means but is curvy in all the right places. Her hair is cut short
in a bob that frames her stunningly beautiful face. She smiles at Bossa again and begins walking toward us.
Doc! She’s coming our way,” Bossa whispers.
“She’s a prostitute, Bossa.”
your point would be?”
“She’s only interested in your money.”
“Which I have plenty
of right now, so again your point would be?”
I sigh. “Dutifully warned. Use a condom. I don’t want
to see you at sick call with the clap. Have at it if that’s what you want.”
She stands in front of Bossa
and says in Malay accented English, “May I join you gentlemen?”
I’m surprised. This is a more subtle
approach than usual. Bossa stammers something and jumps to his feet, pulling out a chair for her. She and I exchange a brief
look and she correctly decides that Bossa is the better prospect. Bossa makes the introductions. She gives her name as Jade
and she shakes my hand with a light squeeze of her fingers. They are longer than I would have expected, but soft and her nails
are polished to a high shine. Bossa asks if she’d like a drink and she orders a gin fizz. Again a departure from the
usual overpriced ‘champagne’ that the bargirls push on their naïve marks.
I sip my beer as she and Bossa
get acquainted. Pretty soon they are snuggled close on his side of the table. Her hand is below the tabletop and from its
position it’s at least on his thigh, if not somewhere north of there. He’s grinning at me. He waves to the waiter
for another round and Jade has to shift her seat to allow the waiter to get past her. In that movement, the high collar of
her dress gaps open a bit and I catch sight of her cricoid cartilage, the prominent Adams Apple.
Oh! I think. She catches
my eye and sees the look on my face. She knows I know. She makes a kissing motion with her lips and I smile and look away.
She returns her attention to Bossa and I order another beer, struggling with my conscience, struggling not to laugh out loud.
After a few more minutes, they get up and start across the street toward the bar where Jade first emerged onto the sidewalk.
She give me a smile and a wink. Bossa doesn’t see that. He just grins and give me a thumbs up.
I learned later
about kathoey like Jade, a Thai word that means literally ladyman. They range from the equivalent of an American drag queen
to true transsexuals who are waiting for their gender change operations while living full time as women.
a quarter of an hour later, a big grin on his face.
“Where’s Jade?” I ask as innocently as possible.
“She had to go home. Sick mother or something. It’s Ok. I paid her already.”
“Did you two…”
I leave it hanging.
“Best oral sex I ever had.”
Probably the only one you ever had, I think, but keep
my mouth shut.
I never told him, even when he bragged to the wardroom a few days later. I still laugh about it. I’m
an evil man.
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.
was sitting at the x-ray computer station when the tech came up and said, “Excuse me Doc. I need to log on.”
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.
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
We rushed off to the OR and explored his abdomen. He had cracked his liver through the central sinus, just behind
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.
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.
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
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
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.
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.
be OK, won’t he?” she asked.
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.
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.
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.
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
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.
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.
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.
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!”
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.
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?”
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
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.
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.
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.
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 5th 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.
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.
It Never Gets Easier
You'd think the
mowing the grass in your own front yard would be a relatively risk free afternoon activity. Sure you need to be a little careful
with a blade spinning at 3500 RPM, but modern dead man clutches make accidental injury unlikely. Sometimes, even the mundane
can turn deadly. Last Saturday I was on Trauma call and a page came through for an incoming trauma code, car vs pedestrian
incident, intubated in the field, unresponsive. I was expecting the usual combination of head and extremity injuries that
we often see when people are hit by moving cars. Instead, my patient was a 60 year old man with no obvious external signs
of trauma, unconscious and intubated with no responses to any stimulation. His pupils were 5mm, not dialated but not normal
and fixed, meaning they didn't contract in response to a bright light. This is a bad sign, usually indicative of severe
brain injury, bordering on brain death, unless the patient has gotten paralytic drugs, say for a surgery or intubation. "Did
he get drugs in the field?" I asked hopefully. "No, doc. He took the tube without bucking or gagging, no drugs needed."
Again a bad sign.
Then we got the whole story. He had been mowing his
front yard, near the sidewalk, when two cars got involved in a minor fender bender in front of his house. As one of them tried
to avoid the accident, it went up on the sidewalk and as it was hit by the other car, its rear fender brushed against my patient.
It was a low speed impact. The car was almost stopped when it clipped him. But speed is less important than force in this
case and since force is dependent on mass, the man was knocked down by the barely moving car. Had he fallen to the grass,
he would have had nothing more than a bruise on his thigh. Instead, his head struck the engine housing of the mower. The engine
cut off as soon as his hands left the deadman clutch, but the engine is made of tempered steel and aluminum, both much harder
than the human skull.
We hurried him off to CT where the scan confirmed
a basilar skull fracture with a massive intracranial hemorrhage. His brain was already starting to herniate. That means that
the pressure of the bleeding in his skull was pushing the base of his brain into the opening that allows the spinal cord to
exit. Herniation = death. The neurosurgeons rushed him off to surgery to take the top of his skull off and give the brain
room to expand upward instead of down.
He's still not responding and may
be brain dead. Now I have to talk to the family about organ donation and eventual withdrawal of care if the flow studies show
his brain is indeed dead. They're obviously in shock. His son keeps saying "He was only cutting the grass".
I'm not religious, or even particularly spiritual. Incidents like this are why. What
possible plan could include dying in a freak event while doing something as mundane as yard work? This job never gets easier.
The Purple Man
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
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
My purple man did well in radiology and is now being
monitored in the ICU for any further signs of bleeding. I love technology.
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”
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.
A Saturday Trauma Shift
Under ‘Better To Be
Lucky Than Smart’:
An 18 year old male attempting to break the ‘car surfing’ distance record (I didn’t know they kept
such records) at mile three was struck in the eye by a bug (no goggles), lost his balance and fell off the car striking his
head on the pavement (no helmet either). Despite an occipital skull fracture and a subdural hematoma, he’s awake and
alert and talking. He’s likely to survive to attempt the record again.
‘No Cure For Stupid’:
A thirty-year-old male, passenger in a car that spun out on the freeway and struck the guardrail. He was unhurt in
the crash, but when the police approached he got out of the car, jumped over the guardrail and fell fifteen feet to the bottom
of a ravine. He broke his heel and his femur (thighbone) and required a crane to extricate him from the ravine. It seems he
had a bag of illegal oxycontin in his pocket and didn’t want the cops to find it. It didn’t occur to him to simply
toss the bag out the window and retrieve it later. To add insult to injury, the cops say they wouldn’t have searched
him anyway since he wasn’t driving and was unhurt in the original accident.
‘No Good Deed Goes Unpunished’:
A twenty-year –old male was the designated driver for a buddy’s 21st birthday celebration. He
did his job, stayed sober and safely delivered all the partygoers home before heading for home himself. He fell asleep at
the wheel and drove the car into a dry canal, shattering his second lumbar vertebra. He has no sensation below mid-thigh and
can’t bend his legs. Fortunately, the neurosurgeons stabilized his spine and say he has a reasonable chance at a full
Under ‘Only in Arizona’:
An amateur cowboy was practicing his
roping skills for an upcoming rodeo. He dropped his loop around a practice post, cinched it up tight and went to wrap his
end around the pommel of his saddle. For some reason, the horse reared, the rope wound around his thumb as well as the pommel
and sheared his thumb off at the base. The rope then broke, the end whipped back under tension and caught him in the right
eye, rupturing the globe (eyeball). He fell from the horse breaking some ribs and the horse stepped on him breaking his femur.
Four major injuries from a single freak event.
Every shift is a new adventure.
and M (not the candy)
am going to present a case at the Morbidity and Mortality conference. M&M is a time-honored surgical tradition that, ideally,
is an open forum for surgeons to give and accept criticism, dissect their errors and try to understand why adverse events
happened. Surgery is not an exact craft. It’s not like working on an engine or a malfunctioning computer. Every case
is different and presents different opportunities to excel or to trip over your own feet.
cases that I’ll have to discuss aren’t important. Suffice it to say, there was room for improvement in my management.
That’s okay. As my friend, the late Troy Brinkerhoff used to say, ‘Every day’s a school day’. We learn
by doing, and sometimes by screwing up.
M&M is part of a larger process of peer review. I know
the ability of physicians to police themselves has been seriously questioned of late, but in the setting of a peer review
meeting, or M&M conference, surgeons tend to be their own harshest critics.
The process of reviewing
and discussing another surgeon’s complications can be gut wrenching. We all share a common set of experiences from our
training, and after a few years in practice, a common case log of operations performed and problems managed. A few key words
about a patient’s history or the appearance of an x-ray convey a host of potential difficulties and complications that
it would take several minutes to describe to the non-surgeon.
Sometimes that shared experience
leads to sage nods of understanding when a difficult case is presented. Yes, we understand. We’ve been there and but
for the grace of God it could be one of us dealing with this complication (And thank God it’s you and not me). Other
times it leads to forehead smacking what-the-hell-were-you-thinking condemnations.
The key to good
peer review is an atmosphere of mutual respect and a commitment to confidentiality. Case discussions under the umbrella of
peer review are protected from discovery. Nothing we say to or about one another can find its way into a malpractice suit.
That may seem a bit cold at first blush. We are talking about patients who have been harmed by a complication of our surgeries.
But if we are to be honest and fearless in our examination of these problems, we can’t be looking over our shoulders
for a subpoena if we admit to an error in judgment or a lapse in attention.
Does it always work
that way? Of course not. Honest criticism sometimes degenerates into acrimony. Competing groups use the peer review process
to bludgeon one another. But by and large, the system functions. Relations are patched up and the job of a department chairman
is to protect the integrity of the M&M conference. Especially when its his own dirty laundry that’s about to be
I did an urgent laparoscopic cholecystectomy today on a young woman who called the office with a sudden worsening
of her gallbladder symptoms. By the time we got her to the OR preop area, she was pale, diaphoretic (cold and sweaty) and
writhing in pain. Her gallbladder was sick but not infected and she had a stone stuck tight in her cystic duct, the tube that
drains the gallbladder. The stuck gallstone was probably what caused the sudden worsening of her symptoms.
I had originally seen her in the office
late in July, just before I went on vacation. She was having episodes of upper abdominal pain once or twice a week and had
gallstones diagnosed by ultrasound. She's an otherwise healthy thirty year old who had stones diagnosed on a pregnancy
ultrasound and symptoms that started four months after the recent birth of her third child--pretty typical history. She took
no prescription medications but did take a handful of herbal and vitamin supplements daily and told me she stayed away from
processed foods in favor of a 'natural' diet. That should have tipped me off, but it didn't
at the time.
The surgery went well, although the stone was wedged pretty tightly and I did an x-ray of the common bile duct, the
main tube that drains bile from the liver, just to make sure no other rocks had gotten away from us.
When I talked to her family after surgery,
her husband asked if the 'purge' had worked. I asked what he meant and he told me she had read about a gallbladder
purge that was supposed to get rid of stones 'naturally' and had tried it a couple of days before. The increased pain
and the stuck gallstone now made sense.
These purges are touted on various websites as a natural cure for gallstones. There are several popular ones, but
they all involve a fast of several days followed by a large dose of olive oil or similar fatty meal. The idea is to make the
gallbladder 'expel' the stones. These purges are at best a bad idea and at worst dangerous.
Why? First, a few words about the gallbladder
and what it does. The gallbladder stores bile. When we eat, especially a meal rich in fat, the stomach and intestine secrete
a hormone called cholecystokinin (CCK) which causes the gallbladder to contract and push a big slug of bile into the common
bile duct and through it into the intestine. Bile acts like detergent to break fat into smaller globs that the digestive enzymes
can work on. People have gallbladders because for most of human history, food supplies were unreliable. Especially for our
hunter-gatherer ancestors. They might eat a large meal one day and then little or nothing the next. An organ to store bile
during fasting and mobilize it in response to a meal prevented crippling diarrhea from poorly digested fat.
When we eat every
day, which most people in this country do, and especially when the quantity and quality of our food doesn't vary much,
the gallbladder can languish. It has nothing to do. That may be why some gallbladders form stones. We don't really know.
But we do know that healthy gallbladders don't allow stones to form in the first place. So if you have gallstones, your
gallbladder isn't working very well.
Purges try to take the normal physiology of the gallbladder and use it to pass the stones out into the bile duct
and thence into the intestine. Sounds nice, but in practice, only small stones can pass this way. And, because the bile duct
is a low pressure/low flow system, even then they often get stuck. A larger stone will just wedge itself into the duct and
jam up there, causing unrelenting pain and setting up the potential for an infection or even a ruptured gallbladder.
I see five or six
patients a year who come to my office or to the ER acutely ill after one of these purge attempts. Often they were referred
to a website by a helpful friend, or worse, had the purge prescribed by one of those charlatans who call themselves 'Naturopathic
Physicians'. Just because it's natural, doesn't make it safe. (Hemlock is a natural substance but it wasn't
very good for Socrates.) You may know a friend or a friend of a friend of a friend's second cousin who 'cured'
gallstones this way, but that doesn't make it a good idea.
On the other hand, it doesn't hurt my business to have a patient who
is convinced in such a graphic way that they need an operation. Olive oil cocktail, anyone?
Win One, Lose One
Sometimes the magic works and sometimes it doesn't. Last night was like that. About midnight a young woman came
in with a stab wound to the groin. Paramedics said it was a five or six inch blade that entered her groin in the crease between
the upper thigh and the abdomen. There was a lot of blood at the scene and her blood pressure was low--50 over nothing. There
was about a pound of gauze covering the entry wound and it was saturated.
The groin is a busy place. Both the femoral artery and
the femoral vein, the main vessels into and out of the leg run through the area where she'd been stabbed. The distinct
crease in the groin is created by the inguinal ligament. This is a tough band of tissue about an inch thick that provides
the point of attachment for all the abdominal muscles. Put a hook through it and you can lift the whole body off the ground.
The vessels run under it and that makes them hard to get at.
The first rule of arterial injuries is proximal and distal control. Get
the vessel above and below the injury and put your clamps on there. Trying to get control of a bleeding vessel at the site
of injury is usually a losing proposition. Especially when the blood is flowing as fast as your kitchen faucet. But getting
proximal control in the groin can be a challenge. Sometimes you have to get at the artery and vein from inside the abdomen.
This time, I got
lucky. The injury was just below the inguinal ligament. Not enough to get good control, but enough so that by cutting the
ligament, I could get at the artery and vein from the leg side and not have to open the abdomen. Lucky for her, too, because
as fast as we could pump blood in, it was gushing out of the wound. Once I got a vascular loop on the vessels (a soft rubber
tie that closes off the vessel without damaging it), we could catch up on the blood loss and call the vascular surgeon to
do the definitive repair.
The other vascular injury patient wasn't so lucky, but that was his intent in the first place. I am always ambivalent
about gunshot wounds to the head, especially when they are self inflicted. Outcomes are rarely good. Most through and through
wounds aren't survivable. Death, or at least brain death, is the norm. Even those people who survive almost never regain
a quality of life near to what it was before the wound.
This was a thirty year old man who shot himself with a nine millimeter
pistol. Entry wound in the right temple, exit wound behind the left ear with brain matter herniating through the wound. He
was hypotensive with a blood pressure of 70/40. Paramedics said he was breathing spontaneously on scene and had some purposeful
movement, so we were committed to treating him as a salvageable patient.
We pumped in volume, dressed the wounds with a turban-like
pressure dressing and I called the neurosurgeon. He was pretty pessimistic about the patient's chances. Through and through
wound in a bad zone of the brain, but even then, there was donor potential to think about. It sounds cold, but Donor Network
is one of our first calls in cases like this. I shipped the patient off to CT scan to assess the amount of brain injury. At
that point his pressure was up to 110/70 and he was breathing on his own. His pupils were fixed and dilated and he didn't
respond to pain. He was probably dead and his heart and lungs just didn't know it yet.
A few minutes later, I got a call from
the CT scanner. The patient had dropped his pressure and there was massive bleeding soaking through our dressing. The scan
was done, so we hustled him back to the trauma bay. I took down the dressing and found blood gushing from the exit wound behind
the left ear.
First rule of bleeding control: stick your finger in the hole. I did and knew immediately that the ball game was
over. I could feel the jet of bleeding from the internal carotid artery hitting my fingertip. Unlike the artery in the groin,
the internal carotid at that point is encased in a boney canal. There's no way to get at it. Imagine a fire hose encased
in concrete. Imagine trying to get at the hose by chipping away the concrete without making more holes in the hose. It can't
be done. I could plug the hole with my finger inside his skull, but that just diverted the flow to other branches in the face
and nose and all the blood started leaking from there.
I called the neurosurgeon who was looking at the scan from a remote monitor.
He could see that the bullet had blown away the carotid canal in the skull and had taken out most of the frontal part of the
brain as well. We decided that further efforts were a waste of time and blood products. I'd never be able to get him stable
enough for transplant harvest. We stopped pumping in blood and the end came within a few minutes.
Why hadn't the bleeding been immediately
obvious when he came in? I think his pressure was low enough that a clot formed in the injured carotid. Sometimes it's
better if an artery is completely divided rather than slice halfway in two. A completely divided artery will contract and
narrow the hole, maybe enough to allow a clot to form. The partially cut artery can't close the hole and it keeps bleeding.
I think when we resuscitated this patient and pushed his pressure up to 110, it blew the clot out of the end of the artery
and he started bleeding again.
Object lesson--not all bleeding can be controlled, but all bleeding stops eventually.
Sometimes, my job involves playing
traffic cop, or referee when two different specialists have competing interests in the same trauma patient. As the trauma
surgeon, I have ultimate responsibility for decisions on care, even when it isn't care that I personally am delivering.
we got a man in from a motorcycle accident with a complex pelvic fracture. He had what's called an open book fracture.
It's a disruption of the pubic symphysis, the joint in the front of the pubic bone, as well as a disruption of the sacroiliac
joint in the rear. Think of it as the splits taken to the extreme. This disrupts the plexus of blood vessels around the pelvic
ring and often causes massive bleeding. It can also tear the bladder or rectum and spill their contents into the pelvis or
The treatment for the bleeding is to reduce the fractures-pull the separated bones back together again. We can use
a metal frame and screws placed into the bone through small incisions, or a simple binder around the hips. The bleeding isn't
the kind you can fix with ties or sutures. It's rapid bleeding in a tight dark box with no easy ends to tie or tissue
to sew. Fortunately, if you close the box, by pulling the bones together, you may create enough pressure to slow or stop the
blood loss. The last thing you want to do is open that box by making an incision in the abdomen or pelvis. It's like taking
the top off of a shaken up bottle of soda.
So my orthopedic colleague wants to place a binder on this gentleman and
monitor him in the ICU, aggressively replacing blood and components until the bleeding is controlled. Then he can operate
to fix the fractures.
But in this man we also had a ruptured bladder. Worse, the rupture was into the peritoneum, the abdominal cavity,
and was bathing the intestine in urine. The treatment needed is an operation to repair the tear. But that involves opening
that bloody box and releasing the pressure.
Now I have a Urologist and an Orthopedic Surgeon glaring at me, a charge
nurse who wants to know if she should call the OR or the ICU and a patient whose blood pressure is starting the slow slide
that means we're falling behind on his volume replacement. DO we delay surgery and risk infection, sepsis, and possible
death? Do we go to the operating room and repair the bladder and risk releasing the pressure keeping the bleeding down to
a manageable rate? My decision, my job.
After some consideration, I decided that the risk of infection from a bladder
rupture outweighed the bleeding risk. Urine itself is sterile, but it is a chemical irritant to the bowel and is a pretty
effective anticoagulant. Enough urine in the pelvis and the blood won't clot anyway.
We started some bigger IV line,
ones that we could pump blood through as fast as it would run through the tubing. I helped the urologist. The bleeding was
alarming. the suction ran continuously making a sound like water running down a drain. The anesthesiologist did a great job.
She pumped in ten units of packed red blood cells, ten units of plasma, two platelet packs and two rounds of concentrated
clotting factors (called cryoprecipitate). That's on top of almost five liters of saline. We fixed the bladder and the
orthopedic guys placed an external fixator-a frame to pull the pelvis together. We made a stop in the angiography suite after
surgery where the radiologist embolized some big bleeders. By placing a catheter in the bleeding vessel, they can inject small
plugs that block the bleeding vessels and help control the bleeding as well. By the time we made it to the ICU, the patient
was stable, the bladder was fixed and the pelvis was reasonably stable. He's facing a lot more surgery, but should recover.
point of this story is that this was a team effort. A lot of different people had to do things as a team to get the result
we did. I couldn't do it myself. I don't have the training to fix the bones, and although I could fix the bladder,
the repair wouldn't be as good as the urologist's. He does that work every day. My primary role
here, and in a lot of other, less intense traumas is to prioritize the interventions and make sure that the competing interests
don't sabotage each other.
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
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
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.
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?
Should We Insure Everyone
Guarantee Healthcare to Everyone?
In the current media blitz about healthcare reform, the idea that everyone should be provided with some sort of healthcare
coverage is accepted as axiom. The only question considered valid is how to expand coverage to one and all. "NO ONE SHOULD
DIE FOR LACK OF HEALTHCARE!" is the rallying cry.
But is this the proper business of a government such as ours? Is it proper
for a limited government to intrude in people's lives in such a fundamental way? Is it even permitted under our constitution?
That last statement echoes some of the arguments of the more radical Right, but is still a legitimate question whose answer
has implications beyond just healthcare.
So, first: Is healthcare a basic right? If so, why? Under what definition of 'rights'? And if we accept this
as a right, what about food, shelter, clothing? Aren't they basic rights as well? Where is the 'crisis' in government
provided food or fashion accessories? If we are to talk about rights to healthcare, we are accepting that some level of care
must be provided without any obligation on the part of the recipient. After all, a right is not something you have to buy.
It's yours already. You don't pay for your rights to worship in the church of your choice, or speak your mind in open
debate or vote in a public election. So why should you pay for healthcare?
Historically, rights were defined in very broad terms
and, in the American tradition, were endowed by the mere fact of being human, by our 'Creator'. They were 'inalienable'
and one needed to be constantly on guard that a despotic government did not usurp or infringe on those rights. Our Declaration
of Independence and Constitution speak eloquently about various rights and responsibilities. The main thrust of both documents
is to guarantee individual freedom and LIMIT the ability of government to infringe on that freedom. That's why the Bill
of Rights is mostly written in the negative--'Congress shall make no laws...' 'Rights shall not be infringed...'
and so on. Nothing in there about the government being obligated to provide any rights to the citizens, only prohibitions
on taking rights away. So where does this supposed right to healthcare come from? Yes, we can't be deprived of life or
liberty without due process, (hence the obligation on the government to provide CRIMINAL defense), but no mention is made
of illness or economic adversity. There is no constitutional right to care; only, perhaps, a right not to be arbitrarily denied
care based on race, religion, creed etc.
Much is said of a 'moral obligation' to provide healthcare. But how does a government incur a 'moral'
obligation? And how can it impose that obligation on a segment of its citizens? Moral obligations are questions of individual,
not collective, responsibility. A devout Muslim is morally obligated to pray five times a day. Not being Muslim, I chose to
pray when it suits me. A Jew is morally obligated to avoid eating pork. Not being Jewish, I like bacon with my eggs. I feel
a moral obligation to treat patients in my office regardless of their ability to pay. I cannot impose that obligation on my
peers or the labs, hospitals and pharmacies that I use. No government has the right (see above) to impose a moral obligation
upon me to provide a service to another person if I choose not to provide it. This is not the same as laws that impose obligations
on us to behave in certain ways. Those are prohibitions on destructive behavior that infringes on the rights of others. A
government can COMPEL me to do certain things against my will, but that not the same moral obligation. If I choose to disobey,
I can be deprived of my fortune, my liberty or my life, even if I believe I am morally in the right. (Which is why I pay my
income taxes despite my belief that they are inherently immoral). If individuals believe in a moral obligation to provide
healthcare to those without it, let them band together with like minded fellows and do what they can to provide it. Don't
use the instruments of government to compel me to do their work for them.
So, in my opinion. there is no legal or moral OBLIGATION
for the government to provide medical care to individual citizens, any more than there is an obligation to provide everyone
with food or clothes or a house or a car. We may, as a Republic, decide that it is desirable to provide these things for our
citizens, but that is not the same as an obligation. That is a question of economics and politics, not morality.
Despite media hand
wringing and political hyperbole, people are not dying in the streets for lack of universal healthcare. Any full service Emergency
Room in this country is obligated by law and usually by hospital charter to provide lifesaving care regardless of ability
to pay. It doesn't mean you won't get a bill afterward, but you won't be denied care for a life-threatening condition.
No one is bleeding out on a street corner because the ER wouldn't take care of them. The real tragedies are more subtle.
People who are faced with a sudden crisis, such as a diagnosis of cancer, who have no insurance to pay for treatment that
could save their life. Or who feel they must compromise their care in the interest of keeping a job or a family obligation.
It would be nice to have a system that doesn't force those choices. But are these situations any more tragic than the
family whose home and possessions are destroyed by a fire or a tornado? Where is the hue and cry for universal homeowners
insurance? What about the small tragedies--the man who loses a job because his employer went out of business or the car that
breaks down preventing a single mother from going to a job interview. Do we insulate people from all of the misfortunes of
life because they have a 'right' to not suffer from misfortune? No. This country has a tradition, possibly a myth
but a common myth that binds us together, of self-sufficiency and personal responsibility. It's why the current system
of care evolved the way that it did in the first place.
Economics is the reality check in all the healthcare buzz. Plain and simple,
no matter how you crunch the numbers, there just isn't enough money in the system to pay for the current level of care
for all citizens. Period, end of story. Either you come up with more money or you reduce the level of care. There are no other
choices. There is not the level of 'fraud' in Medicare that will save the billions the administration claims. Preventive
medicine won't do it , nor will the magic of the electronic medical record. One way or another, the money paid out will
have to decrease. You can cut payments to doctors. We're an easy target, but a limited one. Make the practice of medicine
too restrictive or poorly paid and no one will do it. You can cut services. Not politically palatable,
but for a while you can get away with blaming it on greedy doctors and hospitals who won't provide the same level of service
for less money. Or you can have long waiting lists for specialty care and hope people die or get discouraged before their
turn comes. No matter what, though, you ultimately get the care you pay for.
Most of these points are not new. Nor are they necessarily
practical. I don't claim to be an expert on practical healthcare policy. I have opinions that are shaped by my experience
and political philosophy. What I do in my own practice is my decision and my business, not the business of some government
bureaucrat. For what it's worth, I take all insurance plans, even the ones that pay poorly. I don't turn people away
if they have no insurance. I don't usually provide free care, but I do have my office manager try to work out a payment
scheme that will be acceptable to the patient. For cancer surgery, I do what has to be done a worry about payment later. I
believe in personal responsibility and expect even my indigent patients to pay something toward their care. I have little
patience with people who feel entitled to my services simply because they feel they need them.
I encourage anyone reading this screed
to scroll down to my piece on the economics of private practice. Unfortunately, I believe that the solo private practice of
surgery is all but dead. I am an anachronism, a living dinosaur in the medical world. My only remaining goal in my practice
is to hang on for a few more years until my youngest son is out of school and my long term employees are able to collect on
their pensions. Then I will join the ranks of those clamoring for the services of those that follow behind me. Heaven help
ECONOMICS OF PRIVATE PRACTICE
I am a surgeon in private practice. I will say right up front that I make a good living. I have been at this for
better than 25 years and it has taken me a long time to build the kind of practice that can sustain itself through referrals
from my primary care colleagues. My practice is a business. I have expenses and fixed costs just like the plumber or the guy
who runs the tire store.
I am paid primarily by insurance companies or by the government through Medicare or AHCCCS (Arizona's
form of Medicaid for the indigent). Patients rarely pay more out of pocket than a token copay - anywhere
from ten to ninety dollars depending on their health plan. Most of the insurance companies peg their payments to Medicare,
even for non-Medicare patients. Rates for each service are expressed as a percentage of Medicare,
ranging from 95% to 140%. Since 1989, Medicare payments to surgeons like me have fallen by 20%. I make less per procedure
today than I did in 1989, in static dollars, not inflation adjusted. I make up for it by increasing volume. I'm working
more for less pay than ever before.
Surgeons are paid under something called 'global fees'. I get one payment for seeing the patient in the office,
determining what operation, if any, he needs, doing the surgery and 90 days of follow-up after surgery. Whether I see him
once or a dozen times the pay is the same. If he spends one day or twenty in the hospital after surgery, the pay is the same.
there is no adjustment for the patients preoperative health. The healthy 30 year old woman with a bad gallbladder is the same
as the 58 year old man with high blood pressure, diabetes and heart disease as far as the insurers are concerned. (Or Medicare
for that matter.)
Payment is mailed directly to me most of the time. The average turn around for a 'clean' claim is 45 days.
It may be as long as 90 days. There are no late fees or extra charges if the payment is delayed.
For self-pay patients, I charge 140%
of Medicare and discount the fee for prompt payment. I do not charge interest and do not send patients to collections if they
show good faith by keeping in touch and making even token payments. (I once had a man pay his entire bill in quarters over
a period of five years; one roll of quarters every two weeks.)
I have a number of fixed expenses: 1)Office rent, expendable supplies,
phones, copiers, computers, internet etc costs about $6000 per month or $72k per year. 2) I pay $76,000 per year in malpractice
insurance. I have never been sued. 3) I have two full time and one part time employees. Their salaries and benefits come to
almost $100k per year. 4) Additional but necessary expenses- answering service, transcription service, cell phones, yellow
page adds, my own health insurance add up to $65k.
Before I take any money home, I have to make over $300k. That's a lot of operations. And in addition, any retirement
funding comes from my own pay. I don't have an employer making payments into a pension or a 401k plan. Ditto, disability
insurance, health insurance etc.
So when politicians talk about how much doctors are paid, think for a minute about the last time you called a plumber
in the middle of the night. Last time I did that it cost $125 just to get him out of bed. I get $95 to go into the Emergency
Room at 2 AM to evaluate an elderly woman with acute abdominal pain and a list of other medical problems as long as your arm.