Stupid Doctor Tricks

It’s funny how our minds attempt to filter chaos until patterns are formed – often a night’s call will seem to have a running theme.  My previous post mentioned the recent “epidemic” of appendicitis.  Other nights, the ED seems to be running “2 for 1 specials” on small bowel obstructions.  Several months ago I was treated to an evening featuring a smörgåsbord of incarcerated hernias – inguinal, femoral, incisional, and Spigelian.  Medical school faculty dream of producing such clinical teaching opportunities for the students, while our ED seems to cough them up without any planning.

Last night’s lesson wasn’t so elegant – I swear I’ll never make THAT mistake again (more about that later)

The call started off with a lurch.  The Acute Surgery team had been inundated with 5pm consults, so the chief called for some pre-call assistance.  I headed across the street to the Psych Unit to see a consult for infected 3rd degree burn on a patient who used his forearm to extinguish a cigarette 3 days prior to admission.  I enjoyed the walk in the fresh air of the parking lot and brief respite from the insanity of the ED.  Hmmm… why doesn’t the ED have a foosball table and HD TV like the Psych Unit?

The patient was a repeat offender – he proudly showed me the scars from previous burns and how well he had healed them.  He really wasn’t worried about this new burn and didn’t know what all the fuss was about.  Rx: Keflex and we’ll debrid it when the cellulitis resolves.

Beep, beep, beep.  My intern was calling to tell me about one of those 5pm consults that had been admitted to the floor with a BP of 80/40.  The signout he got from the Acute team intern was “obstructed PTC catheter w/cholangitis – change PTC in am” and he decided to check that out.  Nice catch!  We started with the basics – IV antibiotics, externalize the drain, IVF and made preparations for the ICU.  Just as he arrived in the ICU, a medicine resident called me about a patient of theirs camping out in the ED for 3 hours with transfer to floor orders.  He was worried that his patient with RUQ pain, and elevated WBC had acute cholecystitis and might need a lap chole.  I checked her out.  He hadn’t told me that I would find a patient with altered mental status, fever, septic shock, acute renal failure, jaundice, large stone in the common duct and an 18mm common duct.  I called him back to tell him about her multiple diagnoses, including cholangitis, mentioned that she was dying, and said “I hope she is going to the ICU”.  Inexplicably, while I was placing a difficult Coude catheter in my other patient with cholangitis, Medicine managed to transfer her to the Cardiac ICU.  I met her there with bags of NS in my hands and the ICU charge nurse and myself brought her downstairs to the Med/Surg ICU.

Cholangitis #1 and #2 were now side by side and my guy looked like the picture of health in comparison.  He was responding to the IVF and antibiotics.  She required intubation, central line with fluids on pressure bags, and pressor support before we were ready for emergent ERCP.  Off we went to the ERCP suite!  After we got her prone on the table, I was called away to see a patient with a surgical site infection the intern had worked up.  I made sure that was squared away, called the chief and attending to update them on the night’s events, and headed back to the ERCP suite.  About 30 mins had passed.  The room was dark and no patient.  Hmmm…  I hadn’t heard a Code… that was awful quick.  I tracked back to the ICU to see what happened.

It became apparent to the GI attending that ERCP would be impossible when he visualized a Roux-en-y gastric bypass through his endoscope.  He asked the team present in the ERCP suite when they planned on telling him that detail.  The nurse knew she had gastric bypass, but thought there was some fancy way to do ERCP, so she hadn’t said anything.  The Medicine resident knew she had gastric bypass, but said he “didn’t know what kind” and if ERCP would be a problem, so he hadn’t said anything.

I knew she had roux-en-y gastric bypass – it was written on my H&P and dictated in my report.  I know, and knew beforehand, that ERCP would not be an option in this patient.  I even mentioned the gastric bypass to my chief when I rattled of her Past Surgical Hx, but somehow the words “gastric bypass” and “ERCP” failed to collide in my mind and produce the appropriate action.  Doh!

I briefly considered extinguishing a cigarette on my forearm as a memory aid for next time.

It’s funny how the mind works at 4am when you’re sleep deprived – filtering chaos and trying to form patterns .  My next thought was that I’d probably develop an infected burn and need evaluation by a surgical resident on call, who would then be called by his intern to evaluate a patient with cholangitis….  Nah!  That’s insane.

Instead, I’ll just never make THAT mistake again!!

Where Textbooks and Skills Labs Fail

“No battle plan ever survives contact with the enemy.”

Field Marshall Helmuth Carl Bernard von Moltke

This week my service had an epidemic of appendicitis.  During this course of “Comparative Appendectomy” and the complexity of different attendings, various port placement strategies, and varieties of operative tools I realized this operation has yet to be properly described and illustrated.

Zollinger depicts the mesoappendix as a wispy filamentous membrane with an appendiceal artery and its branches gracefully tracing within.  He illustrates the acutely inflamed appendix as one might draw a water balloon swollen at one end.  There is no fat, no phlegmon, no appendix swollen 5 times its size. no friable tissue.

Where might I find a description of the technique of peeling away omentum, bowel, and fibrin in a phlegmon to reveal the appendix in all its glory?  How hard can I tug?  What am I grabbing?  What is this?

When the going gets tough, my attendings’ fail safe approach usually amounts to dividing the appendix with the endo GIA and then ligating the mesoappendix parallel to the axis of  the appendix, from proximal to distal, staying as close as possible to the appendix and out of trouble.  I haven’t found it described in a textbook, but I have a hunch the technique is widely practiced.

In my last case of appendicitis this afternoon I scrubbed out unsure if my operation had addressed the patient’s source of pain and leukocytosis.

The patient is HIV+ with a CD4 count of 700 and history of MI and gastric bypass initially presenting 1 day ago to the ER with complaint of 12 prior hours of constant vague epigastric pain.  Sublingual nitro and GI cocktail failed to relieve the pain.  WBC 12k.  CXR, EKG, Abd CT, GB u/s normal.  ED called Cardiology.  They admitted him in the evening and when troponins came back normal and an adenosine stress test the following morning was read as normal, Surgery was consulted for acute cholecystitis despite normal LFT’s, and all the normal admission images.  We reviewed the films with the radiologist – yep, nothing abnormal.  On our exam, patient states “pain 9/10″  no fever, VSS.  Pain right-sided mid abdomen with voluntary guarding, no rebound, no McBurney’s.

We discuss dx laparoscopy vs observation with trial of Cipro and Flagyl and my attending decides on the latter.   24 hours later his pain and physical exam is unchanged, still R mid-abdomen, no fevers.  His WBC is now 16k.  We make plans for dx laparascopy in the afternoon after clinic.  As the patient is being brought to the OR, our ID consultant pages me to recommend that we consider an appendectomy for acute appendicitis and they agree with our choice of antibiotics.  Thanks??

In the OR, there’s a small amount of exudate in right pelvis.   The parietal peritoneum overlying the R mid-abdomen is hyperemic – right where he said it hurt.  Appendix is anterior at McBurney’s point and appears almost normal.  Distal 2/3 normal caliber then proximal 1/3 expanding to twice diameter until it meets cecum.  The middle half of the thick section feels firm when I tap it with the grasper.  Proximal and distal to that, the appendix feels normal.  No gross inflammation except for the parietal peritoneum.  Looks a lot like Zollinger’s lap appy illustration.  When we retrieve the appendix with the endo-bag and look at it, we are underwhelmed.  The scrub nurse teases me for using TWO vascular loads on the endo GIA for such a “trophy” – I must confess that I didn’t have all the mesoappendix in the jaws, as I thought, when I fired the first time.  Remainder of abdomen and pelvis appears normal.

When the patient is wide awake, his pain is gone.  I guess Zollinger’s drawing was trying to tell me somthing about acute appendicitis after all.

Catching Up

It has been some time since I last posted.  Busy trauma rotation, holidays, ABSITE, killer call schedule – suddenly 3 months went by.  Many thanks to rlbates at Suture for a Living for giving me the elbow.

I scrubbed an interesting case this week.  We had a consult on a 70F with a GIB.   Endoscopy showed a bleeding ulcer and the GI doc couldn’t get control.  He thought it was in posterior D2.  In the OR we opened the duodenum at D2 and no ulcer, but lots of blood.  We extended our enterotomy proximally and finally found the ulcer in the posterior (slightly superior) wall of the duodenal bulb.   The 1.5 cm ulcer had perforated the duodenum and we were looking at what appeared to be the anterior wall of the common bile duct.  The bleeding was coming from the mucosal edge of the duodenum and the ductal vessels lying in the 3-o-clock position on the CBD.  We controlled the bleeding and then considered how to put her back together.  We had a long enterotomy in the duodenum and the ulcer was in a bad position.  What to do , what to do, what to do??

After much discussion and some intraoperative consults, we proceeded by extending our enterotomy through the pylorus and into the anterior stomach until the ulcer was now lying along the midpoint of a very long enterotomy beginning at D2.  We did a small triangular duodenectomy around the ullcer with the superior margin of the ulcer at the apex and the base being defined by the long enterotomy.  The apex now became the superior corner of a modified Jaboulay gastroduodenostomy and thus we closed the defect.  It was very cool – like an elegant plasctics case.  We finished off with a truncal vagaotomy, CBD T-tube, and G and J-tubes.

Brain Dead

I have been very busy lately with no time for blogging.  I was on a vascular rotation and now trauma.  The actions of CORE (Center for Organ Recovery and Education) this week made me re-consider my commitment to organ donation, as expressed on my driver’s license.

We had a young trauma patient die from brain death this week and the parents wanted to donate his organs.  The patient was healthy and CORE planned to take everything – organs for 7 to 9 recipient patients.  That was two days ago.  They waited almost 48 hours to arrive for procurement after brain death was declared and by then, a stable healthy homeostatic donor had been transformed into an unstable donor on the verge of coding with diabetic ketoacidosis, lactic acidosis, acute renal failure, and shock liver, to name a few.  They kept re-scheduling and re-scheduling and delaying.  The original procurement was to take place hours after being pronounced.  I fear the recipients didn’t get the best organs they could have had because of the poor management by CORE.

This isn’t the first time I have witnessed this substandard performance by CORE.

Several months ago a family decided to donate from a young healthy patient.  After 24 hours, no representative from CORE had even managed to arrive and begin the process or talk to the family.  The family became frustrated that their son’s body was being kept on life support and there seemed to be so little interest in getting things done from CORE’s end that they opted to withdraw care and he was de-listed as a donor and allowed to expire.

With the chronic shortage of organ donors, WHAT A WASTE!!!

My Donorcycle (aka motorcycle)

The last paragraph of my post Reflections From Call generated some comments on the dangers of riding a motorcycle.  Working in the biosphere of health care, I frequently hear similar comments.  Perhaps I should take up smoking for stress relief and really give people something to worry about.  OK, so I am unabashed in my commitment to ride.

Here’s a stock picture of the motorcycle I own.

Yamaha Virago 250cc

My bike has saddle bags and a windshield.  It’s pure joy to ride.  On days off or on long summer evenings after work I love taking the back roads, smelling the scenery and feeling the cool of the shadows – a very immersive experience that is missed when traveling by car.  I may travel the same routes, but each trip is a unique experience dependent upon the weather, season, and time of day.  I wear a full face helmet, leather jacket, and gloves for safety and to keep my experience with insects to a minimum.

I am not the first to write about the exhilaration and psychological benefit derived from riding. Last year another surgical resident introduced me to Zen and the Art of Motorcycle Maintenance by Robert M. Pirsig.  Pirsig wrote:

“You see things vacationing on a motorcycle in a way that is completely different from any other. In a car you’re always in a compartment, and because you’re used to it you don’t realize that through that car window everything you see is just more TV. You’re a passive observer and it is all moving by you boringly in a frame. “

“On a cycle the frame is gone. You’re completely in contact with it all. You’re in the scene, not just watching it anymore, and the sense of presence is overwhelming. That concrete whizzing by five inches below your foot is the real thing, the same stuff you walk on, it’s right there, so blurred you can’t focus on it, yet you can put your foot down and touch it anytime, and the whole thing, the whole experience, is never removed from immediate consciousness”

If you are a fan of Charles Swindoll, on the back cover of Laugh Again you will find a picture of him and his wife on their Harley.  In the introduction he wrote:

“Who says becoming a responsible adult means a long face and an all-serious attitude toward life?….Who says a responsible senior pastor and radio teacher can’t hop an a Harley with his sweetheart of almost 40 years and roar around town now and then?”

In all seriousness, we do all sorts of death-defying feats daily (it’s called living).  I survived my shower this morning.  Some of my countrymen were not so successful.  My son and I walked home from his football game last night.  Many more Americans succumbed in their pedestrian efforts.  I plan to get in my death trap auto later today.  The automobile is king of highway carnage, yet we calmly, willingly enter this potential coffin-on-wheels without a second thought.  In the past 24 hours I survived countless potential attempts on my life – terrorists, lightening, violent crime, stairs, and eating to name a few.  I also survived my motorcycle commute – twice!!  Adding to this danger, my own body is slowly, imperceptibly, relentlessly conspiring against me.  Perhaps one of my own cells has already managed to throw off the control of p53.

p53 in action

Yes, avoiding riding a motorcycle will protect you from its associated dangers just as avoiding tobacco will help keep your cells under the control of p53.  I take trauma calls and know well the potential harm.

In reality, all our decisions have cost/benefit outcomes and most of the time we ignore them.  Did your life flash before your eyes as you approached the stairs?  Humans aren’t often rational about which ones we choose to worry about and which ones we ignore.  Our present leaders convince us to worry about terrorists, but would assert that air travel is a safe means of transportation – certainly safer than auto.  Yet, airplane accidents kill more Americans than terrorists and we continue to worry about the terrorists as we board the plane.  Shouldn’t the “In the event of a water landing…” safety talk be striking terror in passengers’ minds? Yet, look around the plane and few are paying attention.  (For reference, the lifetime odds of dying in an airplane accident are about 5 times less than a motorcycle accident.)

I am frequently bringing ideas of potential morbidity and mortality into the conscious thought of my patients.   Usually, they weren’t concerned with such things until someone called Surgery.  It is my job to help patients attempt an on-the-spot cost-benefit analysis for proposed surgery in the form of the informed consent process.  Infection, bleeding, injury to adjacent structure, failure of procedure to correct problem, anesthesia complication, drug reaction, need for further surgery, need for blood transfusion placing you at risk for hepatitis and HIV, heart attack, stroke, blood clots, prolonged hospital stay, and death.  Attend a few M&M’s and you will get the picture.

What are the average odds my motorcycle will make me dead?  How does that compare to my car?  What’s my informed consent look like?  While using StumbleUpon last week, I came across some information from the National Safety Council.  Here are some lifetime mortality odds for several things mentioned in this post:

• Car 1 in 247
• Pedestrian 1 in 631
• Motorcycle 1 in 938
• Pickup truck or van 1 in 965
• Hospitalization 1 in 1308
• Aerospace 1 in 5552
• Drowning in bathtub 1 in 9377
• Terrorism odds are much less and are estimated here

The complete tabulated NSC data can be found here.

So motorcycles aren’t killing that many Americans compared to, say, walking.  One could also rationalize that they ride a motorcycle for the same reason people drive SUV’s.  The odds of dying are about the same.  Obviously these numbers are population-based statistics.  Personal habits, the local environment, and other factors can have large effects, but rational people generally recognize that SUV’s kill fewer people than 2-door specks.  What’s unusual is that most people don’t consider motorcycles to be in the same category as SUV’s when talking about odds of dying.

There’s the potential risk, so what are the benefits, if any, of riding my motorcycle?  I previously mentioned the psychological benefit I derive for stress relief.  It’s also cheap transportation.  I filled up yesterday – $4.50.  Can’t remember the last time I filled up, but I think it was about a month ago.  Additionally, my bike is environmentally friendly at 66mpg highway or street.

Sensible, responsible, and fun.  Does it get any better?  Oh yeah, the black leather jacket…!

House Call

I live in a small village (population 4366 in 2007) and most residents are within a few minutes walking distance of each other.  Thus, everyone in the village is practically my neighbor (see Luke 10:25-37 for the full concept of neighbor).  There is a neighbor down the street who is post-op from orthopedic surgery and was discharged last week with home Lovenox injections.  Neither she nor her husband were comfortable administering SQ injections, so another neighbor has been going over to do it twice per day.  The alternative to home Lovenox is driving to the hospital twice per day – quite an ordeal for this elderly patient status post knee surgery.

The second neighbor became ill, so she called my wife for help.  My wife is quite squeamish with all things medical and since I was at home when the call came I volunteered.  I jumped at the chance to join the ranks of early American physicians – the house call!  I’ll admit I’m a bit of a romantic – we live in a 150 year-old house.  My wife, seeing my enthusiasm, teased me by saying I would be perfectly happy sewing up lacerations on our kitchen table and having a walk-in clinic in our living room.  I start wondering if physicians ever visited this house and under what circumstances.  I can almost see the gray-haired doctor hunched over the candlelight in the kitchen….

My wife joined me for the walk over – as we had never met this neighbor.  The smell of a crisp fall evening, the 19th century houses, and the quiet of the village street interrupted only by the sound of our steps allowed me a few more moments of rumination upon that old doctor in my kitchen.

I gave her the injection after washing my hands in her kitchen sink.  We made small talk, of course discussing her post-op course.  She was complaining of muscle stiffness, but ambulating well with her walker.  I told her I expected the stiffness to resolve over the next week and encouraged her to continue her prescribed activities.

They were both very grateful that a person they didn’t know, moreover a doctor, would come by.  As we left, her husband tried to pay me.  I thanked him for his generosity, but I refused payment.  He still wanted to pay me for my time and explained how unusual it was that I should help out someone whom I didn’t know.  I still refused payment and we left on a happy note after I jokingly reminded him that he had perfectly described my usual practice at the hospital.  It’s unusual to me if I KNOW my patients beforehand.

Seriously, I thought, this house call WAS remarkably normal for me.  Their living room had become the clinic.  Although I wasn’t the operating surgeon, I had a chance to assess the post-op discharge planning.  Here was a routine follow up appointment.

In response to DRG’s and cents-on-the-dollar reimbursement, patients are asked to do more at home and through clinic.  However, my neighbor wasn’t fully prepared to take on the role that 21st century American medicine demanded.  Our system leaves it to the family and neighbors to provide that touch of 20th century American medicine to fill the gap.  Professional home health services are often the last resort on the discharge plan because that costs more money.  The plan for home Lovenox might easily have fallen through with a different patient under these circumstances, but, overall, my neighbor was doing well.

As my wife and I walked home I thought about my other neighbors.  Did they have a doctor in their kitchen?

Resident’s Role

The ACGME (Accreditation Council for Graduate Medical Education) is the private, non-profit council that evaluates and accredits medical residency programs in the United States.  Surgical residents are required to complete certain numbers of cases during residency and each case is logged by the resident at the ACGME website.  Currently, I am doing an endoscopy rotation and my concern, in addition to the joy of learning, is performing enough EGD’s (esophagogastricduodenoscopy) and colonoscopies to meet the requirements.

The question of my week is, “So, how many cases have you done?”  This is often asked by other residents and faculty.  Faculty are usually trying to confirm that the resident’s time on a rotation is bearing fruit in the form of measurable training opportunities.  The intra-resident discussion, however, has many angles.  Frequently the conversation turns into a series of “fish stories” to see who holds the record.  This week my numbers were not high enough to satisfy a senior resident, so I had to hear about that.  This prompted an interesting discussion.

I log cases in which my hands come into contact with the patient and some instrument to perform a procedure.  If I only watch the endoscopy, I don’t log it – same as if I only watch a surgery.  It is true that watching and imagining procedures does improve motor skills, but I am not convinced that those activities should be part of the case log.  There is a higher level of skill development when “doing” and the ACGME is measuring “doing”.

Not all residents see it that way.  To some, if they watch a scope, they were there learning, so they log the case.  There is a concern with having enough numbers to provide documentation of adequate training for attaining hospital privileges and some feel that only logging cases “performed” will not document the full extent of their training in this area.  The rationale:  more thorough documentation demonstrating the depth of excellent training – seeing and doing.

On the other and, it is my belief that the ACGME set the case numbers with the knowledge that seeing procedures will occur as part of the process.  Otherwise, what does completion of an accredited surgical residency mean if meeting the case goals implies a questionable or inadequate level of training, but further documentation of watched cases dispels that?

I am concerned that an attempt to log watched cases amounts to grade inflation and residents may be under peer-pressure to “keep up with the Jones” – no one wants to have the program director take an interest in their “low” case numbers compared to their peers.

When filling out the log, the resident is asked to identify his/her role.  There is no role of “Observer”.  The choices are:  “Surgeon Chief” exclusively for cases logged during the chief year, “Surgeon JR” for cases logged as the primary operating resident, “1st Assistant” for residents who helped (the case thus logged doesn’t count towards numbers, but is captured to show hands-on skill development), and “Teaching Assistant” for senior residents who take junior residents through a case while the attending watched or assisted.

Under which role should I log observed cases, if I were to begin that habit?  I don’t think they good enough for Surgeon JR.  But what if they are?

The esteemed Jonathan Swift School of Medicine might advocate a new model for surgical education.  They could announce the great day of telemedicine for surgical residents has arrived!  Stay home and watch these videos, then take this test, and the diploma will be in the mail.

My program has a virtual reality colonoscopy trainer.  I could log those cases vs. the ones I watched on an HD video screen because, at least, I DID something.  Isn’t that somewhere between watching a scope and doing a “live” scope?  Should I log a laproscopic case the next time I catch one on Discovery Health?

Adding further stress to the system, this year the ACGME increased the number of required endoscopies, among other cases.  Of course, the work hours to accomplish more cases remained the same.  There is much discussion in Surgery about the work hour restriction; the ACGME is very concerned with surveillance to prevent residents from working 80+ and deflating their logged hours to “comply”.  I don’t hear much concern that the other side of the equation may be equally susceptible to manipulation – case inflation.

Mathematically:  Cases/Work hours = Educational Efficiency.  If one is able to reduce work hours and maintain case numbers, presumably menial tasks are eliminated and residents use the time bonus to study, feel more cheerful, and see their families.  Win-win.  Educational efficiency and quality of life increase.  Unfortunately, there are limits and this single equation’s view from 30,000′ is a crude estimate of reality.  Still, if work hours are locked to provide a more equitable living situation for residents, the only way to improve educational efficiency is to increase cases numbers.  Do more with less.

Doing more with less tempts the inner capitalist and we may strive to wring ever more efficiency out of the system, but at what cost?  There has to be a cost to this kind of thinking, otherwise we wouldn’t be in our present economic catastrophe and NASA, too, might have avoided a crash (Mars Orbiter).

The efficiency equation only looks at one part because it assumes a case is a case is a case.  Once all the unnecessary tasks are eliminated to make room for more cases, something has to give, if, yet, more cases are to be counted.  Case inflation necessarily decreases case quality in order to provide further “efficiency” in this equation.   The pursuit of efficiency above all else risks the “Wal-Mart-ization” of surgical education, namely, bottom-tier, high quantity product.  Where is the balance?

I think the sober-minded person keeps the ideas of retained quality and fairness in tension with promises of greater efficiency.  Henry Ford put it this way:

“There is one rule for industrialists and that is: make the best quality of goods possible at the lowest cost possible, paying the highest wages possible.“

Certainly Wal-Mart, our present economic troubles, and case inflation all fall short of this ideal balance of quality, fairness, and efficiency.

Each time I log my cases the Website prompts me to “Please select a value” for the field of “Residents Role”.  I consider my role and carefully choose the correct value.  I probably won’t break any records for most cases, but…

“If gold rust, what shall poor iron do?” – Chaucer

Please select a value

Twist And Shout!!

A GI attending I am working with has great playlists on his iPod.  Music plays in the background as I continue to work through the paces of learning to control an endoscope.  I start out the case and get 5 minutes before he takes over.  I get to continue into “bonus time” if am making good progress.  At this point, I can reliably get past the sigmoid colon.

In my earlier post on this topic I envisioned smooth sailing would follow.  Not so, well, kinda.  It’s usually a straight shot up the descending colon to the splenic flexure.  Now, I am learning the art of the splenic flexure and transverse colon.  I have only made it to the cecum once.  The scope is curved like a question mark once the transverse colon comes into view; at this point, advancing the scope through the rectum produces pitching and yawing motions at the point of the camera instead of the usual forward progress.  Suddenly, the skills I learned to rely on for navigating the sigmoid are of little help here.

Learning this skillset reminds me of learning to dogfight in F-15 Strike Eagle on my Commodore when I was a kid.  On an EGD, getting into the duodenum is similar to executing an Immelman Turn.  You fly through the greater curvature, pull up on the stick to the pylorus, and as the tip passes through the pylorus, you execute a hard right turn rolling the image over.  Keep your nose level through the roll and the duodenum comes into view.  It really is quite exhilarating when you pull it off!!

Reflections From Call

Being on call is terribly overwhelming.  I feel overwhelmed not from inability to do the work, instead the physical, mental, and emotional demands give me little room to gain perspective or reflect and come to terms with the amazing and horrible things that happen during a 24 hr call.  I was on call from Sunday 6am to Monday 6am, so Monday morning all I could focus on was finding my bed.  Today is when the reality of the call begins to hit.

The recap:  Two patients coded.  One of them died.  There was one trauma code.  I took a patient to the OR and did several bedside procedures.  I saw seven or eight (I can’t remember) patients in the ER and half of them went home – the rest were admitted.  If you asked me to order those cases chronologically, I couldn’t do it.  It remains a blurred composite of twenty four hours with sharp details at critical moments.  The background is filled with miscellaneous interventions on SICU patients; taking phone calls from patients at home with questions; answering nurse questions, requests, and concerns; and the ever-critical search for food or elusive cat nap.  That is the aseptic, clinical view of “getting the job done”.

The “trench warfare” version starts with a Code being called overhead.  The Medicine residents run to the codes.  Surgery walks.  Medicine carries out the ACLS protocol while Surgery offers advice and provides procedural expertise, if needed.

I walk into the room with CPR in progress.  The patient is blue and huge – probably over 300 lbs.  End-stage COPD in PEA (pulseless electrical activity).  A nurse says they have been expecting him to code all day and, despite his poor prognosis, the patient and his wife want “everything done”.  We go about our sad ritual of a full code on a lost cause.  I want to yell at the guy, wherever he is,

“Do you want THIS???!!!  Are you happy, because we’re doing everything?”

I ask the medicine resident how long we shall persist and if they need vascular access.  She shrugs her shoulders to the first question, but the second question is easier to answer.  They want a line.

During a procedure I become so focused on the task that everything around me disappears and time stands still.  Now I’m jabbing a 6″ needle into the patient’s groin trying to stab his femoral vein.  I get in and get dark red blood back, but I can’t thread the wire because I keep loosing access from movement – the chest compressions add a degree of difficulty.  I repeat this several times with the same result while the medicine intern retracts the abdominal fat away from his thigh so I can see.  No success.  The chief takes over and gets the line in.

After the procedure, I “come up for air” – mentally check back into the big picture.  CPR is still in progress and now he’s intubated.  No change except the patient’s abdomen is bigger and there’s no condensation in the ETT (endotracheal tube)  Somehow, only the chief and I notice this.  I can’t hear much for breath sounds due to the patient’s obesity and lung disease.  I think the ETT is in his esophagus.  There’s bleeding from his lips – no doubt a difficult intubation on a good day.  I’m so focused on airway that it takes me about 30 seconds to notice nobody is doing chest compressions.  I pull my stethoscope out of my ears – back to the loud world.

“What’s going on?  Did you get a pulse?”

They called it.  Time of death….  We did everything  No time for reflection.  The ER is calling and they think some little kid has appendicitis.

Later in the night, or is it early morning, a young girl comes in mauled by her pet.  The dog latched onto her arm and wouldn’t let go even when a man began hitting it on the head with a hammer.  The girl sufferred 10 minutes of this torture.  Finally, several adults were able to pry the dog’s jaws open.  I want to kill the dog and slap the adults.  I picture a dog grabbing my daughter and me shooting it with my gun before 60 seconds have elapsed.  I could have sawn the dog’s head off with a hacksaw before 5 minutes were up.  10 minutes?  I could have wrapped plastic trash bags around the dog’s snout and suffocated it sooner than that.  For doctors, the knowledge to save life is also the knowledge to efficiently end it.  I wish they had the knowledge to quickly dispatch the dog for this girl’s sake.

Her arm is a mess and she is hysterical.  Pieces of SQ fat and muscle are hanging out of a dozen holes in her arm.  The dog got into the flexors and the extensors of her forearm, but the worst damage is to her extensors – she can’t extend her fingers.  At least she has circulation and sensory intact.  I knocked her out with morphine and Ativan and loosely re-approximated the wounds until Hand Surgery could evaluate her in the morning.  Her mom watched me suture, told me more details, and cried.  A two year old was at the scene watching the attack – thank God the dog didn’t grab her.  I hope she never remembers what she saw.

Another Code is called overhead.  This one is in my ICU.  I walk over.  It’s not my patient – some Medicine disaster quit breathing.  The nurses are placing an oxygen mask over his face and watching the pulse ox.  His breathing is agonal.  I suggest bag-valving him since he’s not moving air.  His sat comes up and he starts breathing again.  Medicine doesn’t want any lines.

I head off to the call room for an attempt at sleep.   This is my third attempt in 24 hrs.  On the previous two, the ED called as I entered the room.  All is quiet this time.  It’s 4:30am, so if I’m lucky I’ll get about an hour before the teams call for morning report.

Pager wakes me up from some bizarre dream.  4:45am.  Medicine is calling.

“The guy that Coded?”….”Yeah, OK I’ll be right over”

The respiratory Code from earlier is now intubated and in cardiogenic shock.  They can’t get a BP on the cuff, can’t get an ABG, and need central venous access for pressors.  Only palpable pulse is his carotids and his wrists are bloody and brusied from a dozen or more radial artery attempts.  The Medicine resident is trying another radial art line.

It’s procedure time and I hate art lines!  I decide to try to place a femoral artery line in a groin with no palpable pulse, but I don’t have much else for options.  I get a weak Doppler signal, so I triangulate my mind on where I imagine the source.  A few dry sticks and then I get dark blood back – probably femoral vein, but on a guy this sick it could be arterial blood.  I decide he isn’t THAT blue and go lateral.  Bright red pulsing blood!!  The wire goes about 15 cm and then comes to a grinding stop.  I pull it out and get pulsatile flow.  I try re-threading the wire, but it still gets stuck.  I reason it’s probably stuck due to atherosclerosis since the artery is only about 2-4 cm deep.  Given the patent’s medical problems, his arteries are probably fossilized and have stalactites hanging from the ceiling.  I go for it.  I pull the needle, thread the catheter over the wire, pull the wire out – the moment of truth!

Bright red pulsatile flow through the catheter!  I draw a gas, the nurse hooks up the pressure transducer, and there is an excellent waveform.  BP is 50/30, but I am elated.  Now, the Medicine resident can quantify how badly he wants that central line.  Triple lumen in the IJV (internal jugular vein) coming up!  Would you like fries with that?  On the heels of my success and given the patient’s critical condition, I consider going for a blind IJ.  I figure his CVP is sky high and he has the JVD (jugulovenous distension) to prove it.  Plus, I have palpable carotids.

Nah!  I go conservative and grab the ultrasound.  The line is a breeze – you could drive a truck down his jugular vein.  The Medicine resident is appreciative of the ultrasound-guided demonstration becasue they don’t get much experience with lines.  I take the opportunity to do some line teaching.  It’s 5:45am and the teams will be calling any second.  My last duty on call is to review the CXR on my line.  I stop by radiology on my way out the door to my motorcycle.  The central line is in perfect position.

First Post

I finally got my NY State Medical License today.  What an ordeal!  I have been waiting for them to process the paperwork for over 2 months.  I needed it 2 months ago for a rotation in NY, which I had to cancel.

Currently, I am learning endoscopy and enjoying my time away from hospital patient care duties – its a nice break of routine.  The pager never beeps and I work humane hours.  I still take call, but it is easier when you have time to decompress.  I have seen more of my wife and children in the last week than I usually see in a month.

The technique of endoscopy is challenging – I imagine similar to learning to fly.  The attending hands me the scope properly centered on the lumen of the colon and within seconds I have converted the image on the screen to a close-up of the colon wall pressed against the lens and struggling to gain control over the unwieldy beast!  If I can just make it through the sigmoid colon… clear sailing.

There is an old saying in surgery:  “If it looks easy, it’s difficult.  If it looks difficult, it’s impossible”