Futility and Rationalizations

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Last night I presided over the death of a child. To the world he was a young man of twenty, but as the paramedics rolled him into the trauma bay, pumping on his chest, I felt a momentary stab of panic. He was the same age as my youngest son, the same build, the same chocolate skin tone, and the same thin beard that my son wears so proudly. The moment passed before I recognized its source and I knew this was not my own son.

He’d been shot in the chest and other than a few gasping breaths at the scene had shown no signs of life in the twenty minutes it had taken them to get him to us.

We started the trauma code and massive transfusion protocols, but he didn’t respond. I placed a tube in his left chest and immediately got back almost 800cc of blood. His EKG stabilized from a chaotic series of spikes to a slow junctional rhythm at 46 per minute; still no detectable pulse, electrical activity only.

I called for the thoracotomy tray. ER thoracotomy is a dramatic, but ultimately futile gesture. Survival after such a procedure is uncommon. After 30 years in this business, I have three survivors. They are rare enough that I remember them all. This would not be my fourth. The bullets had shredded his pulmonary arteries and vena cava. All the fluid and blood we were pumping was pouring out as fast as it went in. I called off the code and his EKG went flat less than a minute later.

We never knew his name. The police had an idea but weren’t willing to say anything until they could confirm it. His parents didn’t hear about his death for several hours and I never met or saw them. When they finally arrived at the hospital, no one told me or asked me to speak to them. The wheels of the legal system were turning and other than carefully clinical statements to the detectives and an extensive dictation for the medical record, I said nothing more.

I am not good at giving families bad news. In this case, I was glad to leave it to a police officer. Nothing I could say would have helped and a clinical description of his injuries and the procedure would only cause more pain. I also know that what I just wrote is a rationalization of my own cowardice and inability to give comfort in the face of sudden loss. Whatever lies you have to tell yourself to get through the night, right?

Thirty minutes later, the team gathered in the same trauma bay for the next activation, a pedestrian struck by a car. The floor was clean, the sheets on the trauma gurney were fresh and white, the room was restocked and ready, like nothing had ever happened.

Age and the Trauma Surgeon

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I’m facing another Saturday trauma shift and feeling every bit my age. Trauma on a Saturday usually means no sleep and a steady stream of business. Back in the old days, when I was in my thirties, I could operate for 24 hours straight, catch a few hours of sleep and get up refreshed and do it again. Now it takes me a couple of days to recover from one of those marathon sessions.

My performance in the operating room isn’t affected. A number of studies have confirmed what every surgeon knows from personal experience: fatigue doesn’t significantly affect performance in surgery. And in the operating room, age and cunning always trump youth and enthusiasm. Older surgeons retain their edge over younger ones even when fatigued. There’s tremendous advantage in ‘been there, done that’. When the unexpected happens, the older surgeon spends less time thinking about his next move. He’s learned the hard way how to do things his mentors never taught him.

It’s after the drapes come off and the dressings go on and you have to write orders and notes and talk to the family that there is an advantage to the resiliency of youth. You can feel the energy drain away like someone pulled the plug. Error creeps in when you have to decide on medications and dosages and how to phrase a delicate question.

I tend to get short tempered and cranky. (Those who know me will now ask, “And how is that different from when you’re well rested”, so maybe I should say MORE cranky than usual). I have to think harder to remember names and dates and medications. And the after effects last longer these days.

So, I expect I’ll be up all night tomorrow night and be pretty much a zombie even when I’m awake all day Sunday. It’s hard on those around me. My wife is a surgical nurse practitioner and knows first hand the rigors of the job. She understands. My autistic son is now almost an adult and even he knows that Dad needs to nap, but he only has the weekend to spend time with me and it’s hard for him. And even though I try to be polite to others, my tolerance for stupidity and frustration is low and I’m liable to say things I’ll later regret.

So how much longer will I continue this work? I don’t know. Despite the fatigue and frustration, there’s nothing else like it. Trauma is like combat – often boring, but at times exciting beyond words and above all, addictive.

Cancer Care as a Business

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Cancer Care as a Business

My wife is a Primary Care Nurse Practitioner. She works with a very good Internist who gives her a lot of independence in managing her patients, but always backs her up when she needs advice. She is well respected by the specialists she refers to and has always been able to discuss a patient with any one of them. Yes, there is an element of selection there, since she tends to refer to the specialists who are willing to talk to her in the first place, but that is true for any Primary Care Practitioner, NP or MD.

Today she needed a Hematology consultation on a woman she’d been following for several months. The patient has a refractory anemia and all of the usual lab evaluations have been inconclusive. She felt the patient needed a bone marrow biopsy and possibly more sophisticated lab evaluations.

Her patient was enrolled in a health plan run by BigHealth, the local healthcare juggernaut in our area. BigHealth owns seven local hospitals and another ten or so in other states. They have aggressively expanded their market share both through purchasing hospitals and practices and through exclusivity in their BigHealth insurance plans.

Recently they started a joint venture with FamousName, a well-known cancer hospital from another state, to run the BigHealth/FamousName Cancer Center. There really wasn’t a need for another oncology center in our area. The market was pretty well covered by two large oncology groups, both of whom offered Medical Oncology, Radiation Oncology and Hematology in a coordinated single referral. Plus, it was easy to pick up the phone and talk directly with one of their oncologists, discuss a patient, get some follow up or get an urgent consultation.

Enter FamousName. Their message was “We do it better”; not in so many words, but in their advertising and their attitude. They would offer all services, plus the advantage of a Team approach, combining Medical and Radiation Oncology with Oncologic surgery, nutritional consultation, and a Cancer Guide to shepherd the patient through the entire process. Nice idea, but a demonstrable advantage? I haven’t seen it. What I have seen is a longer referral process, significant delays in starting treatment, confused patients and a serious lack of approachability in the oncologists employed to deliver the care. Even the patients seldom see the Doctor. Most hands on care is done by Nurses.

So when my wife tried to call FamousName to talk to a Hematologist and explain the workup that had already been done for her patient (something she had always been able to do with the other oncology groups) she was shunted to a New Patient Coordinator. This person did not identify herself other than by first name and refused to connect her directly to a Hematologist. Instead, she took the patients name and insurance information and told my wife to fax over all labs and notes about the problem and their Internist would decide if it warranted a Hematology evaluation. Say what? Their Internist? What about the judgment of a Doctor of Nursing Practice in consultation with a Board Certified Internist with 20+ years of practice?

This is not a single incident. I have encountered the same stonewall routine when I have called personally to discuss a patient with an oncologist. I was connected to my patient’s Cancer Guide who told me she would answer my questions because the Doctor was in clinic that day.

This sort of thing may fly in FamousName’s main base of operations. They’ve been the Big Dog there for years. But out here, they have done little to attract referrals or court the local medical community. It has gotten so that no one wants to send them patients despite their Famous reputation. In order to keep their joint venture afloat, BigHealth has cancelled all their contracts with the local oncology groups giving FamousName an exclusive lock on all BigHealth patients. Now we have no choice about where to send our BigHealth covered patients.

Legal? Sure. Ethical? Maybe, if there is a definite advantage for the patient to see FamousName. But who will benefit most from a high-powered academic cancer team? The 35-year-old with a triple negative invasive breast cancer? Definitely. The 78-year-old with a Stage 1 ER/PR positive tumor? Not so much. In fact, the community was doing a pretty good job before FamousName arrived. Our oncology groups were up to date, participated in clinical trials, coordinated cancer care with surgeons and internists, and according to BigHealth’s own cancer registry, achieved better than average results compared to national standards. Once again, this was a business decision dressed up to look like innovative care and backed up by BigHealth’s dominant market share. Even then, we might have seen it as a positive. This is FamousName after all. But the arrogant attitude, the exclusivity and the inability to actually talk to one of their experts has generated hostility rather than acceptance.

31 years ago today

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Getting Married, Sort Of

I met my wife on the wards at Bethesda Naval Hospital during my surgical residency. She was a Navy nurse and it was definitely NOT love at first sight. She says I insulted her the first time I spoke to her. I didn’t see it that way, but given my personality at the time, it’s certainly possible.

Our mutual duties (she was the charge nurse on one of the main surgical floors) forced us into frequent contact and over time we came to trust one another’s abilities. She was a good nurse and a no nonsense leader.

By the end of my second year, I trusted her implicitly. She would often write routine orders during the night shift rather than awaken me for it, and then shove the charts under my nose before morning rounds and say, “This is what you did last night.” Of course, that meant that she trusted me as well to sign the orders. It could mean her license and a court marshal if I didn’t.

By my fourth year, she’d forgotten the insult (or at least forgiven it. She’s Sicilian. They never forget anything.) and we started dating. Within a few months, I’d asked her to marry me and she had said yes. That surprised both of us. My first marriage had left me with a cynical view of marriage and relationships in general. She had frequently said to anyone who’d listen that she would not marry a doctor, and most especially would never marry a surgeon. Sometimes God has a delicious sense of irony.

We planned a March 1984 wedding, as it fit into the surgical rotation schedule and we could get leave together for a honeymoon. I had started to badger my detailer in July of 1983 to get orders to Guam after my residency. By September I learned that Guam would indeed be my first duty station. Everything seemed to be going according to plan.

Then on the first of November I got a form letter requesting my spouses name, rank and service number so that accompanied orders could be cut. Accompanied orders meant that we would both go to Guam, rather than me spending two years alone there. It seems we had to actually BE married by the end of November, or the orders would be solo.

We scrambled around and got the marriage license. The 18th of November was a clinic day, which meant I had an hour and a half between morning and afternoon clinics to get married. Michele was off that day so all we needed was a witness.

I dragooned my junior resident, Rick Furman, a good friend from medical school and my best man at our church wedding in March, and we rushed up to the courthouse in Rockville, Maryland. Michele met us there. She was in a short red dress. Red is the Chinese color for good luck and she didn’t have a casual white dress.

We were ushered into the Justice of the Peace and he began the traditional civil ceremony. Then the pager went off.

Rick excused himself to go to the pay phone in the lobby to answer the page. This was pre-cell phone days. The JP waited until he returned. Michele and I struggled not to laugh. We weren’t taking this very seriously, I’m afraid.

Three more times as the JP struggled to get through the ceremony, Rick had to answer pages. By the third time, Michele was laughing out loud and had a hard time saying ‘I do’ with a straight face.

Finally the Justice said, “I now pronounce you man and wife. You may kiss your bride.”

Michele turned her face to me and I kissed her cheek. She was wearing bright red lipstick. I hate lipstick. To this day, I won’t kiss my wife if she’s wearing lipstick.

The JP signed the registry, but he looked a little reluctant. I’m sure he thought this was a green card wedding. But at least we had a proper marriage to show the detailers so they would cut our accompanied orders.

It’s been 31 years, and the adventure continues with love, passion, laughter and friendship.

It’s the 21st Century, Not the 19th

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It’s the 21st Century, Not the 19th

A little while ago, I was asked by one of my oncology colleagues to do a lymph node biopsy on one of his patients. The patient was a 67 year-old man with a cluster of enlarged lymph nodes in his right groin. His Primary Care doctor had rightly suspected lymphoma, a primary cancer of the lymph nodes, and referred him to oncology. The oncologist suspected lymphoma as well, and did CT scanning of the chest and abdomen that confirmed generalized enlargement of nodes in both places.

Lymphoma is a protean disease of the leukocytes or white blood cells. If the uncontrolled growth of leukocytes occurs mainly in the bone marrow, it manifests itself as leukemia. If the cancer occurs mainly in the lymph nodes, we call in lymphoma. It can arise from a number of different cell lines and the exact type of causative cell determines the specific diagnosis. It is important for the oncologist to know what type of lymphoma he is treating because that often determines what drugs are used.

Cell typing is done through a process called flow cytometry. I’m just a dumb surgeon and the biochemistry and immunology that go into this test are beyond my poor understanding. What I do know is that the pathologist needs a fairly large amount of tissue to do the test – about a cubic centimeter, say between the size of a grape and that of a peach pit.

I saw the man in my office and scheduled his biopsy or a few days later. At surgery, I took out a fairly large amount of tissue, partly to make sure the pathologist had enough, and partly to avoid cutting across a large node. That wasn’t because it would spread cancer but because nodes can bleed a lot and it’s better to take them whole if possible.

Cytometry requires fresh, unpreserved tissue. Nodes are sent fresh to the lab rather than dropping them in formalin in the OR. The more common reason we send tissue fresh is for a frozen section. That’s when the pathologist flash freezes the tissue with liquid nitrogen, cuts and mounts a slice, and looks at it immediately. We use this if we need a quick diagnosis. I hadn’t asked for a frozen section, but due to a mix up on the part of the cytologist or the OR nurse, one got ordered.

I was mildly surprised when the pathologist called into the room as I was completing the skin closure. I took the call because the room nurse said he was very insistent and sounded excited.

“What’s going on, Joe,” I asked as I came on the line.

“This node is full of caseating granulomas,” he said. “What’s this guy’s story?”

I was stunned. Caseating granulomas are the signature sign of tuberculosis. (Caseating means cheese-like and that’s what the inside of the nodes looks like – Brie cheese.)

This type of groin node used to be common a hundred and twenty years ago. Even a hundred years ago, it was a consideration when a patient presented with a groin mass. In 2014, TB is a Third World disease that is unfortunately making a comeback in this country. Even then, it’s more commonly seen in the lungs. Nodal involvement outside of the chest is rare.

This patient didn’t fit the profile of the usual TB patient. He wasn’t a recent immigrant, he wasn’t immunocompromised, he wasn’t an alcoholic or drug addict, and he wasn’t malnourished. He was a retired firefighter from Minnesota. So where had he gotten TB and why was it disseminated to his lymph nodes?

We still don’t have a good answer to that question. This was sort of a good news/ bad news scenario for him. On the one hand, he doesn’t have cancer. On the other hand, disseminated TB is a life threatening disease that takes a year or more to cure, if at all. TB has become resistant to some standard therapies and the drugs themselves have serious toxicities. He’ll need close monitoring and may need to be isolated for a while until we can be sire that he’s shedding the bacteria in his sputum and other secretions.

I’ve encountered this disease a few times in my career, but always in places like the Philippines or the outer South Pacific islands, places where TB is still endemic. I didn’t expect it here in my comfortable suburban practice. I’m glad the order got mixed up and the lymph node was examined immediately. At least now we have cultures and can check sensitivities to the standard drugs. Hopefully the man will do well.

Complications

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Complications

Yesterday I readmitted two patients to the hospital with surgical complications. One was a man who had a colon resection six weeks ago. He has had the ‘dwindles’ since discharge. He’s lost weight, has no energy and no appetite. A CBC done yesterday showed his white blood cell count was elevated and a metabolic panel shows impending renal failure. I suspect he has an intrabdominal abscess despite the fact that he has no fever.

The second patient is three weeks out from a complex incisional hernia repair that involved reconstruction of her entire abdominal wall with placement of a large sheet of surgical mesh under the muscle layers. She is a morbidly obese diabetic and has developed a wound infection. If the infection reaches the mesh, I’ll have to remove it, undoing her entire repair.

Complications are a fact of life in surgery. No matter how good a surgeon you are, no matter how carefully you manage patients, something will go wrong once in a while. As my Chief was fond of saying, “If you do big surgery, you get big complications.” Intellectually I know this. But days like yesterday try my soul.

The first thing I ask myself when a patient has a complication after surgery is, “What did I do wrong?” Did I make a technical error? Did I miss some critical sign or lab value? I’m not comfortable until I’ve looked for those things, and even then feel that I must have missed something. This is the default mode for most surgeons I know. That type of thinking is built into our training. The ritual of the Morbidity and Mortality conference emphasizes taking responsibility for everything that happens to your patient. Only then can your peers grant you absolution for your mistakes. I suspect most of us tend to be hyper-responsible pessimists at heart or we wouldn’t have selected this career in the first place.

The Wise Woman (my wife) tells me that taking responsibility for things I can’t control is arrogant, a form of narcissism that imagines that I am able to control the forces of random chance. I understand her point and accept it. My difficulty is separating those things I can control from those I can’t.

Both of these people had issues before surgery, and that’s another truth I must concede. Trauma is a high-risk practice but even my general surgery practice tends toward the high risk/low reward type of procedures. I’m not sure if that’s a complement to my surgical skill or just because I’m willing to operate on people whom others have turned down. These people are more likely to have postoperative problems that the healthy thirty-year-old gallbladder patient. So perhaps the failing isn’t in technical skill or in postop care but rather in judgment and patient selection.

Whatever the root cause of this particular round of surgical complications, I’m still the one who has to clean up my own mess. That is a responsibility any surgeon must accept before he places a knife on the patients skin. Acknowledging the responsibility doesn’t make it any easier to face my patients on rounds in the morning, but at least it helps me sleep at night.