Just a quick note, I'm still here. Have had multiple family issues recently, combined with the practice being quite busy, haven't had time to post. Please be patient, more will be forthcoming.
Rusty
Wednesday, June 10, 2009
Tuesday, May 19, 2009
Update on Ms. Brown
For all of you wondering whatever happened to Ms. Brown, This is a quick update.
After 10 days of up and down progress, It became clear that she was in for a long, long, haul, and her chances of ever returning home were pretty much non existent. Even after 10 days of intense effort, she still couldn't hold her own blood pressure, and wasn't waking up after being off sedatives for 4 days. And so, after a long family conference, her family granted her peace, and withdrew support. She passed away shortly after, surrounded by her family, who alternately cried for her, and then shared her antics with each other and laughed. She died peacefully, bathed in the love of a caring family. While I never got to know her very well, her family will always hold a place in my heart.
Good night, and God's peace on you.
After 10 days of up and down progress, It became clear that she was in for a long, long, haul, and her chances of ever returning home were pretty much non existent. Even after 10 days of intense effort, she still couldn't hold her own blood pressure, and wasn't waking up after being off sedatives for 4 days. And so, after a long family conference, her family granted her peace, and withdrew support. She passed away shortly after, surrounded by her family, who alternately cried for her, and then shared her antics with each other and laughed. She died peacefully, bathed in the love of a caring family. While I never got to know her very well, her family will always hold a place in my heart.
Good night, and God's peace on you.
In and Out
OK, so I promised a further discussion of diabetes, but we're going to take a little detour to answer the Iconoclast's questions, because it raises several interesting topics, all of them pertinent to healthcare today.
First off, the Iconoclast asks if the sequential toe/foot/leg amps that occur with these diabetics is part of the high re-admission rates that are currently blamed for the high costs of medicine. The answer is: Yes. And No. Hey! That's dodging the question. Actually, what it means is that this population group of poorly controlled diabetics is a huge drain on the healthcare budget due to frequent admissions and significant complications, both with their diabetes as well as with their other medical conditions that are made worse by the diabetes. It's not necessarily the sequential amps that lead to readmission, but rather a continuous spectrum of problems that could often be managed as an outpatient in the general population. And that's something I need to clarify here, as well. When I dicuss diabetes, and diabetics, from a surgeon's perspective, what I'm talking is that group who do not maintain tight control over their disease. As a surgeon, the only diabetics who practice tight control of their blood sugars I know are social contacts and those that show up in my office for an appendix or gallbladder. Diabetics who monitor their blood sugars frequently throughout the day, and maintain their sugars in a very tight range approximating normal, don't have diabetic complications, certainly not at the level of the poorly controlled diabetic. This brings up the whole topic of self responsibility, but I'll save that for another time -- It has so many implications. Anyway, the sequential amputation of the diabetic is variable in it's progression, sometimes a toe every year or two, and ten years to the finale, other times, it's the massive debridement and a BKA less than a month later. So much depends on the patient's compliance with management, just how poorly and for how long they've been diabetic, how many other health problems they've got, and finally (but certainly not least), the patient's socio-economic support system. Sad but true, wealthy diabetics fare much better than poorer diabetics. While we have healthcare for everyone, there's still a lot of cost that isn't covered by any insurance or aid.
The Iconclast's second question is broader:
"what are the issues of readmission from your point -- poor hospital care, insurance/Medicare/Medicad refusing to pay for longer initial stays, poor followup by the home health care folks (part of the insurance issue probably), etc.?"
How about all the above? Poor hospital care is probably the least of all the reasons, at least in my world. Poor care from either the hospital or the doctors generally is a manifestation of external pressures, ie insurance carriers, pushing to have the patients out faster, sooner, quicker. Hospital readmissions were rare because we would keep the patient that extra day to make sure everything was working right. I've discovered a little line in the litany of the insurance providers from several of my battles to get the proper care for my patients. When I ask the medical director (a physician) his/her name, because I'm going to transfer care to them, since they are telling me what to do with the patient, their response is, "I'm not telling you what to do for the patient. You can do whatever you (and the patient) want to do. We're just not going to pay for it. " No fault insurance. They're not interfering with the management of the patient in any way. Of course, we all know the prices are so astronomical that you have no choice to follow their lead, but they're not telling you what to do.
Poor follow up by home health is generally not a reason. These people are dedicated to what they do, and as a general rule, their care is excellent. The actual care providers are in this for the same reason the hospital providers are in it, because they like caring for people. If anything, I say their strong devotion to duty and attention to detail may contribute to readmission just by seeing critical issues and alerting the docs in a timely fashion.
The third reason for high readmissions goes back to the poorly controlled diabetic we discussed earlier. Patients who don't take responsibility for themselves. These are self declared victims, and expect the world to serve them. "why didn't you get your prescription filled?" "The hospital didn't call it in." Or, our favorite, "I couldn't afford the ($4) copay" (while smoking 2 packs a day @ $4/pack). The other day, a patient in my office told me she hadn't been taking her meds because the pharmacy hadn't called the doctor for a refill, even after she had checked back twice. I asked her if she had called the doctor herself. Of course not. That's not her responsibility. Well, hell, if she's not going to take responsibility for her health, why the hell should I? Well, because I'm required to by law, for one thing. When she shows up in the ER, sick from her own irresponsibility, I will come in, no matter what the hour, and bust my ass to save her, and know that she's going to be in the hospital for weeks, on my dollar, because of her failure to take responsibility for her own health care. And that is the doozer of hospital readmissions, usually thru the ER, that contributes to the high cost of medicine.
And on that note, I will sign off, good readers.
Good night, and farewell.
First off, the Iconoclast asks if the sequential toe/foot/leg amps that occur with these diabetics is part of the high re-admission rates that are currently blamed for the high costs of medicine. The answer is: Yes. And No. Hey! That's dodging the question. Actually, what it means is that this population group of poorly controlled diabetics is a huge drain on the healthcare budget due to frequent admissions and significant complications, both with their diabetes as well as with their other medical conditions that are made worse by the diabetes. It's not necessarily the sequential amps that lead to readmission, but rather a continuous spectrum of problems that could often be managed as an outpatient in the general population. And that's something I need to clarify here, as well. When I dicuss diabetes, and diabetics, from a surgeon's perspective, what I'm talking is that group who do not maintain tight control over their disease. As a surgeon, the only diabetics who practice tight control of their blood sugars I know are social contacts and those that show up in my office for an appendix or gallbladder. Diabetics who monitor their blood sugars frequently throughout the day, and maintain their sugars in a very tight range approximating normal, don't have diabetic complications, certainly not at the level of the poorly controlled diabetic. This brings up the whole topic of self responsibility, but I'll save that for another time -- It has so many implications. Anyway, the sequential amputation of the diabetic is variable in it's progression, sometimes a toe every year or two, and ten years to the finale, other times, it's the massive debridement and a BKA less than a month later. So much depends on the patient's compliance with management, just how poorly and for how long they've been diabetic, how many other health problems they've got, and finally (but certainly not least), the patient's socio-economic support system. Sad but true, wealthy diabetics fare much better than poorer diabetics. While we have healthcare for everyone, there's still a lot of cost that isn't covered by any insurance or aid.
The Iconclast's second question is broader:
"what are the issues of readmission from your point -- poor hospital care, insurance/Medicare/Medicad refusing to pay for longer initial stays, poor followup by the home health care folks (part of the insurance issue probably), etc.?"
How about all the above? Poor hospital care is probably the least of all the reasons, at least in my world. Poor care from either the hospital or the doctors generally is a manifestation of external pressures, ie insurance carriers, pushing to have the patients out faster, sooner, quicker. Hospital readmissions were rare because we would keep the patient that extra day to make sure everything was working right. I've discovered a little line in the litany of the insurance providers from several of my battles to get the proper care for my patients. When I ask the medical director (a physician) his/her name, because I'm going to transfer care to them, since they are telling me what to do with the patient, their response is, "I'm not telling you what to do for the patient. You can do whatever you (and the patient) want to do. We're just not going to pay for it. " No fault insurance. They're not interfering with the management of the patient in any way. Of course, we all know the prices are so astronomical that you have no choice to follow their lead, but they're not telling you what to do.
Poor follow up by home health is generally not a reason. These people are dedicated to what they do, and as a general rule, their care is excellent. The actual care providers are in this for the same reason the hospital providers are in it, because they like caring for people. If anything, I say their strong devotion to duty and attention to detail may contribute to readmission just by seeing critical issues and alerting the docs in a timely fashion.
The third reason for high readmissions goes back to the poorly controlled diabetic we discussed earlier. Patients who don't take responsibility for themselves. These are self declared victims, and expect the world to serve them. "why didn't you get your prescription filled?" "The hospital didn't call it in." Or, our favorite, "I couldn't afford the ($4) copay" (while smoking 2 packs a day @ $4/pack). The other day, a patient in my office told me she hadn't been taking her meds because the pharmacy hadn't called the doctor for a refill, even after she had checked back twice. I asked her if she had called the doctor herself. Of course not. That's not her responsibility. Well, hell, if she's not going to take responsibility for her health, why the hell should I? Well, because I'm required to by law, for one thing. When she shows up in the ER, sick from her own irresponsibility, I will come in, no matter what the hour, and bust my ass to save her, and know that she's going to be in the hospital for weeks, on my dollar, because of her failure to take responsibility for her own health care. And that is the doozer of hospital readmissions, usually thru the ER, that contributes to the high cost of medicine.
And on that note, I will sign off, good readers.
Good night, and farewell.
Wednesday, May 13, 2009
Diabetes
OK, this is another post I started a couple days ago, and am trying to get finished. So let's give it a shot.
Today, along with a host of other tasks, I put a Hickman Catheter (a special central IV good for a couple of months) in a Diabetic with poorly controlled diabetes. It is to give IV antibiotics long term to treat osteomyelitis (infection of the bone) of his foot. I also debrided the complex, foul smelling wound on the outside of his foot. He'll be non weight bearing on this foot for the next 2-3 months while we try to heal this. If this doesn't work, he'll lose the foot. His kidney function is about 1/2 of normal, and odds are good that within a year or two, I'll be putting in some form of dialysis access. This is the real world of Diabetes.
Lee Iaccoca, in his autobiography, talks of his wife dying of diabetes, and his desire to try to promote education about this terrible disease. To the general public, diabetes means insulin shots, but not much else. To those of us in medicine, it is a whole category of patients. Type "cost of diabetes" in your google search box, and your mind will reel with the numbers. A recent study calculates the US cost of diabetes at $174 Billion. That's a pretty mind numbing number for me, sort of like the bailout figures. So I'll just talk about diabetes from a personal viewpoint.
There is an old, rather morbid joke we tell about diabetics. "What do you call a diabetic with 2 legs?" "Pre-Op." "What do you call a diabetic with 1 leg?" "Pre-Op." For surgeons, a diabetic means chronic, nasty, foot wounds. These wounds are a result of several factors. First, the chronically elevated blood sugars slowly destroy the sensory nerves. This happens from longest to shortest, so the first to go are the feet. So when a diabetic steps on a tack, or starts rubbing up a blister because their shoes aren't fitting properly, they don't feel the pain, and so, don't treat the early injury. Second, the diabetes is a disease of microvessels, the tiniest little vessels that supply blood to the tissues. Once again, the farthest vessels are affected first, ie, the feet. So when the diabetic has an injury, there is inadequate blood to the area to allow proper wound healing, and inadequate delivery of white blood cells to fight infection. Third, the high sugars essentially poison the white blood cells, impairing their ability to fight infection even more. Finally, diabetics have a very high incidence of what is, for lack of a better term, a complete collapse of the structure of the mid-foot, meaning the arch collapses, the bones of the ankle collapse to the middle, and the patient is left with a near crippling deformity of the foot, all the more prone to ulcers and pressure injuries. For the surgeon, it means months of treating these wounds, with pretty poor results, and more often than not, amputation. Sometimes this is in stages -- a couple of toes, then mid foot, then rear foot, then below knee. Other times, there's already a raging gangrene set up when we first see them in the ER, and the first cut is an above knee amp. It's frustrating, because we all know where the outcome lies, in a below knee amp, but the patient generally will not accept this early on in the process. What we, as surgeons, know, is that with the conservative approach, the patient will be non weight bearing for months, with multiple courses of antibiotics, hospitalizations, surgeries, and chronic pain. If we go almost directly to a below knee amputation (almost always successful), the patient can be up walking with a prosthetic in a matter of a couple of months. Today's modern BKA prosthetics allow fairly normal ambulation and activity, and most estimates suggest about a 25% increase in the effort of walking. Diabetes is the number one cause of amputations in my personal practice.
OK, I've got more to say, but I was up early doing an appendectomy, so I'm gonna get this posted, and in our next installment, we'll discuss diabetes and the kidneys.
Sleep tight.
Today, along with a host of other tasks, I put a Hickman Catheter (a special central IV good for a couple of months) in a Diabetic with poorly controlled diabetes. It is to give IV antibiotics long term to treat osteomyelitis (infection of the bone) of his foot. I also debrided the complex, foul smelling wound on the outside of his foot. He'll be non weight bearing on this foot for the next 2-3 months while we try to heal this. If this doesn't work, he'll lose the foot. His kidney function is about 1/2 of normal, and odds are good that within a year or two, I'll be putting in some form of dialysis access. This is the real world of Diabetes.
Lee Iaccoca, in his autobiography, talks of his wife dying of diabetes, and his desire to try to promote education about this terrible disease. To the general public, diabetes means insulin shots, but not much else. To those of us in medicine, it is a whole category of patients. Type "cost of diabetes" in your google search box, and your mind will reel with the numbers. A recent study calculates the US cost of diabetes at $174 Billion. That's a pretty mind numbing number for me, sort of like the bailout figures. So I'll just talk about diabetes from a personal viewpoint.
There is an old, rather morbid joke we tell about diabetics. "What do you call a diabetic with 2 legs?" "Pre-Op." "What do you call a diabetic with 1 leg?" "Pre-Op." For surgeons, a diabetic means chronic, nasty, foot wounds. These wounds are a result of several factors. First, the chronically elevated blood sugars slowly destroy the sensory nerves. This happens from longest to shortest, so the first to go are the feet. So when a diabetic steps on a tack, or starts rubbing up a blister because their shoes aren't fitting properly, they don't feel the pain, and so, don't treat the early injury. Second, the diabetes is a disease of microvessels, the tiniest little vessels that supply blood to the tissues. Once again, the farthest vessels are affected first, ie, the feet. So when the diabetic has an injury, there is inadequate blood to the area to allow proper wound healing, and inadequate delivery of white blood cells to fight infection. Third, the high sugars essentially poison the white blood cells, impairing their ability to fight infection even more. Finally, diabetics have a very high incidence of what is, for lack of a better term, a complete collapse of the structure of the mid-foot, meaning the arch collapses, the bones of the ankle collapse to the middle, and the patient is left with a near crippling deformity of the foot, all the more prone to ulcers and pressure injuries. For the surgeon, it means months of treating these wounds, with pretty poor results, and more often than not, amputation. Sometimes this is in stages -- a couple of toes, then mid foot, then rear foot, then below knee. Other times, there's already a raging gangrene set up when we first see them in the ER, and the first cut is an above knee amp. It's frustrating, because we all know where the outcome lies, in a below knee amp, but the patient generally will not accept this early on in the process. What we, as surgeons, know, is that with the conservative approach, the patient will be non weight bearing for months, with multiple courses of antibiotics, hospitalizations, surgeries, and chronic pain. If we go almost directly to a below knee amputation (almost always successful), the patient can be up walking with a prosthetic in a matter of a couple of months. Today's modern BKA prosthetics allow fairly normal ambulation and activity, and most estimates suggest about a 25% increase in the effort of walking. Diabetes is the number one cause of amputations in my personal practice.
OK, I've got more to say, but I was up early doing an appendectomy, so I'm gonna get this posted, and in our next installment, we'll discuss diabetes and the kidneys.
Sleep tight.
Sunday, May 10, 2009
Updates
Good evening. Tonight's will be a short post, as I've still got some chores to do around the house. It has been an interesting day, and I've got some updates for you all.
In "The House of God," a satirical novel detailing an intern's hellish year, our hero, Roy G. Batsch, is taught by the iconic senior resident (The Fatman), "the less you do to the little old ladies, the better they do." My 95 yr old is backing this theory. When last we talked about her, she was knocking on death's door. I didn't expect her to live through Friday night, much less the weekend. In talks with the family, we had decided comfort measures only. Well, yesterday afternoon, she looked better. Today, she was awake and alert, not complaining of any pain, and hungry. I shot an Xray, and her bowels have decompressed. She's still FOS (Full of S******), but has managed to squeak through this latest crisis. With her doing so much better, we're going to try to get her cleaned out, and maybe give her another year. With her colon no longer looking like the Hindenburg, I can give her cathartics from above, and try to move all that CaCa south.
Ms. Brown is also still with us. Over night, she started having some arrythmias, and is now being followed by the cardiologist as well. She continues to soak up the fluids, and is trying hard to pee. Her prognosis remains grim, but she's dodged some bullets so far. I'm currently waiting for a call with updates on her labs, tweaking them several times a day is necessary.
And now, if you all will excuse me, I'm going to sign off, and go pay some bills. They're never ending, ya know.
In "The House of God," a satirical novel detailing an intern's hellish year, our hero, Roy G. Batsch, is taught by the iconic senior resident (The Fatman), "the less you do to the little old ladies, the better they do." My 95 yr old is backing this theory. When last we talked about her, she was knocking on death's door. I didn't expect her to live through Friday night, much less the weekend. In talks with the family, we had decided comfort measures only. Well, yesterday afternoon, she looked better. Today, she was awake and alert, not complaining of any pain, and hungry. I shot an Xray, and her bowels have decompressed. She's still FOS (Full of S******), but has managed to squeak through this latest crisis. With her doing so much better, we're going to try to get her cleaned out, and maybe give her another year. With her colon no longer looking like the Hindenburg, I can give her cathartics from above, and try to move all that CaCa south.
Ms. Brown is also still with us. Over night, she started having some arrythmias, and is now being followed by the cardiologist as well. She continues to soak up the fluids, and is trying hard to pee. Her prognosis remains grim, but she's dodged some bullets so far. I'm currently waiting for a call with updates on her labs, tweaking them several times a day is necessary.
And now, if you all will excuse me, I'm going to sign off, and go pay some bills. They're never ending, ya know.
Happy Mother's Day
Well, good morning. It's been a busy 24 hrs since I last posted, and I'm sure you're anxious for an update on Ms. Brown. It was yesterday afternoon when she and I met in the OR for the second time. As of this morning, she's still alive, and when I'd last checked on her last night, she was producing a little urine. A lot rests with her spirit now. If she's a fighter, she'll go home, if not, she'll go Home. So let's get to it.
It was close to noon yesterday by the time I got to the ICU to check on Ms. Brown. I had taken a couple of phone calls on her the previous evening, and tweaked a few labs, and then again yesterday morning I'd gotten a few calls and once again made some changes to get her a little more tuned up for the OR. When I see her at noon, she's sedated, but will respond slightly if she's stimulated. She's off the medicines that are supporting her blood pressure and her vitals look pretty good. I'm concerned because her urine output has dropped significantly over the last few hours. Her kidneys took a hell of a hit with the sepsis and hypotension (low blood pressure) and I suspect Acute Tubular Necrosis (ATN, essentially, shock kidney). I've asked the nephrologist (kidney specialist) to see her. I also discuss her with the hospitalist who is following along. I then have a sitdown conversation with the family about the surgery today, plans, and prognosis. They have made her a Do Not Resuscitate with the exception of what we are doing now-- the ventilator and medicines we are using now. I don't argue with this, because it's the right decision. If she has a cardiac event, no matter what reason, her chances of leaving the hospital alive are less than one percent. As I'm waiting for the team to collect and get her to the OR, I finish my rounds. Hopefully, when I finish up with Ms. Brown, I'm done for the day.
In the OR, we get off to a much better start. She's already intubated and sedated, and she's now had a full 20 hrs or so of aggressive fluid resuscitation, and when anesthesia is induced, she holds her pressures much better. We peel away the dressings and prep and drape the abdomen. Within a minute, I'm back in the abdomen. It's a good choice to second look, the culprit of yesterday's persistent odor has declared itself. I find two spots of necrosis on the right colon, both about the size of a silver dollar, maybe a little bigger. One is near the cecum, the other is on the transverse colon, close to where I cut across the colon the day before. Another guilty party is also now here-- her gallbladder has that green-black color that tells me it's died too. It's got to come out, too. I'd love to leave her some colon, and if she was young and healthy, I might try resecting just these two spots. If she was young and healthy, she would be here in the first place. I remove the remaining colon, along with a few inches of the small bowel. The gallbladder comes out next. It's actually pretty easy getting the gallbladder out when the colon's not there to get in your way. I wash out the abdomen with another 4 liters of saline, then run the bowel again from the ligament of trietz (where it starts), to the terminal illeum (where it joins the colon). It all looks good. With the removal of the colon, I've now got good exposure of the duodenum (the first 5 inches of small bowel, which runs from the stomach to the ligament of treitz), and it's also healthy. I create a hole in the abdominal wall and pass the end of the bowel through. This will be the ileostomy, the permanent end of her GI tract. I take another run down the bowel to make sure I don't have any twists in the gut or in the vessels feeding the gut, and then do a formal closure of the fascia. The skin I leave open, with a wet to dry dressing that will have to be changed twice a day until the wound heals from the inside out. If I were to close the skin, she would almost definately develop a wound infection, and she doesn't need anymore setbacks. I then mature the ileostomy, that is, I open up the end of it and fold it back on itself to create a "rosebud" that will project far enough away from the skin to keep the stool off it. The bowel contents coming out of the small bowel tend to be more caustic, and if it's chronically on the skin around the ileostomy, she'll develop a nasty rash and skin breakdown, not too different from a bad diaper rash. As I open up the illeum, I find another marker for just how tenuous her condition is. The lining of the small bowel has necrosed (died). If I thought I'd find something better farther up, I'd reopen and move farther up the small bowel, but I suspect this is going to be the pattern for most of her bowel. Since the wall of the bowel is still alive, and looks to have some degree of blood flow, I mature the ostomy and we get her back to the ICU. It's now up to her. I expect that this necrotic lining will slough off in a few days to a week, leaving healthy pink tissue behind. All I can do now is support her, watch, and wait. After tucking her in, I finally head home.
About midnight, I went in for an appendectomy. It was around 3 this morning when I climbed back into bed. Now that I've finished updating you all, my kind readers, I'm heading back to the hospital. It's time to check on Ms. Brown, my appy from this morning, and a host of other players. My biggest priority today: Remember to call Mom and wish her happy mother's day.
Have a wonderful mother's day.
It was close to noon yesterday by the time I got to the ICU to check on Ms. Brown. I had taken a couple of phone calls on her the previous evening, and tweaked a few labs, and then again yesterday morning I'd gotten a few calls and once again made some changes to get her a little more tuned up for the OR. When I see her at noon, she's sedated, but will respond slightly if she's stimulated. She's off the medicines that are supporting her blood pressure and her vitals look pretty good. I'm concerned because her urine output has dropped significantly over the last few hours. Her kidneys took a hell of a hit with the sepsis and hypotension (low blood pressure) and I suspect Acute Tubular Necrosis (ATN, essentially, shock kidney). I've asked the nephrologist (kidney specialist) to see her. I also discuss her with the hospitalist who is following along. I then have a sitdown conversation with the family about the surgery today, plans, and prognosis. They have made her a Do Not Resuscitate with the exception of what we are doing now-- the ventilator and medicines we are using now. I don't argue with this, because it's the right decision. If she has a cardiac event, no matter what reason, her chances of leaving the hospital alive are less than one percent. As I'm waiting for the team to collect and get her to the OR, I finish my rounds. Hopefully, when I finish up with Ms. Brown, I'm done for the day.
In the OR, we get off to a much better start. She's already intubated and sedated, and she's now had a full 20 hrs or so of aggressive fluid resuscitation, and when anesthesia is induced, she holds her pressures much better. We peel away the dressings and prep and drape the abdomen. Within a minute, I'm back in the abdomen. It's a good choice to second look, the culprit of yesterday's persistent odor has declared itself. I find two spots of necrosis on the right colon, both about the size of a silver dollar, maybe a little bigger. One is near the cecum, the other is on the transverse colon, close to where I cut across the colon the day before. Another guilty party is also now here-- her gallbladder has that green-black color that tells me it's died too. It's got to come out, too. I'd love to leave her some colon, and if she was young and healthy, I might try resecting just these two spots. If she was young and healthy, she would be here in the first place. I remove the remaining colon, along with a few inches of the small bowel. The gallbladder comes out next. It's actually pretty easy getting the gallbladder out when the colon's not there to get in your way. I wash out the abdomen with another 4 liters of saline, then run the bowel again from the ligament of trietz (where it starts), to the terminal illeum (where it joins the colon). It all looks good. With the removal of the colon, I've now got good exposure of the duodenum (the first 5 inches of small bowel, which runs from the stomach to the ligament of treitz), and it's also healthy. I create a hole in the abdominal wall and pass the end of the bowel through. This will be the ileostomy, the permanent end of her GI tract. I take another run down the bowel to make sure I don't have any twists in the gut or in the vessels feeding the gut, and then do a formal closure of the fascia. The skin I leave open, with a wet to dry dressing that will have to be changed twice a day until the wound heals from the inside out. If I were to close the skin, she would almost definately develop a wound infection, and she doesn't need anymore setbacks. I then mature the ileostomy, that is, I open up the end of it and fold it back on itself to create a "rosebud" that will project far enough away from the skin to keep the stool off it. The bowel contents coming out of the small bowel tend to be more caustic, and if it's chronically on the skin around the ileostomy, she'll develop a nasty rash and skin breakdown, not too different from a bad diaper rash. As I open up the illeum, I find another marker for just how tenuous her condition is. The lining of the small bowel has necrosed (died). If I thought I'd find something better farther up, I'd reopen and move farther up the small bowel, but I suspect this is going to be the pattern for most of her bowel. Since the wall of the bowel is still alive, and looks to have some degree of blood flow, I mature the ostomy and we get her back to the ICU. It's now up to her. I expect that this necrotic lining will slough off in a few days to a week, leaving healthy pink tissue behind. All I can do now is support her, watch, and wait. After tucking her in, I finally head home.
About midnight, I went in for an appendectomy. It was around 3 this morning when I climbed back into bed. Now that I've finished updating you all, my kind readers, I'm heading back to the hospital. It's time to check on Ms. Brown, my appy from this morning, and a host of other players. My biggest priority today: Remember to call Mom and wish her happy mother's day.
Have a wonderful mother's day.
Friday, May 8, 2009
A Long Day
Some days are physically exhausting, others are mental exhausting. Today was the latter. There are days when I might do 7 cases, and feel tired at the end of the day, but mentally feel fresh. Today, I did 5 cases, and am mentally wiped. It really hinges on 3 patients.
It started with a consult, an elderly lady in her 90's with a probable bowel obstruction. Doing routine surgery on 90+yr olds isn't routine, doing it for an acute problem is even less encouraging. Even better, she has family working in the hospital, which, for me, makes her family for me as well. After shooting Xrays, it appeared she had a blockage in the colon (large intestine). Surgery would be a colostomy (a bag on the abdominal wall), and possibly removing the blockage, depending on what it really was. Up until this acute event, this lady had been pretty active and living independently. But even a perfect operation was probably going to leave this woman bedridden-- at 95, she just doesn't have the reserve for even a little set back. I spent a long time talking with family about her, including my least favorite question, "If this was your mother, what would you do?" I'm sorry, but it's not my mom, and that's exactly why I can't answer that question. I've known my mom all my life, and have visited with her over the last 6 months, and so know exactly what her quality of life is, and exactly what her wishes are. I've "known" the patient for 2 hrs, and have no clue as to her spark, her drive, her wishes except for what her children have told me. I can't answer the question, not honestly. Besides, my professional curiosity and drive makes me want to go find out what's wrong, and fix her. In the end, the family decided on comfort measures only. This is a good and merciful decision, and I agree with it. But the whole event leaves a little hole in me.
The second strike comes with my third case in the OR. This is a very pleasant gentleman, who, in the parlance, "has been rode hard and put away wet." He's lived a rough life, and he's a hell of a lot older than the birthdays he's had. He comes to my office by cab, as he has no real support in the community. He came to my office with a whole litany of illnesses, all pretty much real. His complaint to me was rectal pain and bleeding-- severe pain that would leave him unable to walk after a bowel movement. I'm the third doctor he's seen in 5 yrs, he's had two colonoscopies, and no improvement. I've run several tests as an outpatient, looking for some of the less common sources. A look at his bottom in the office is difficult because it is so tender, and so today I'm going to do a colonoscopy, rectal exam under anesthesia, and probably a hemmorhoidectomy. The colonoscopy is challenging because the prep wasn't very good, but the rectal exam shows the real problem. An anal cancer, extending from the outer skin adjacent to the anus across the anal ring to the lining of the rectum. He also does have significant hemmorhoids, but fixing those is now out of the question. I biopsy the tumor for to get a definative tissue diagnosis, and send him to recovery. Anal cancer has been in the news recently, as Farah Fawcett has advanced anal cancer. I'm left frustrated. Once again, I couldn't fix his problem, will have to give him the bad news when he's back in my office, and I know that, with his overall health and poor socioeconomical support, he's not going to do well.
I finish up my last case, and head to hospital B to see one more sick patient. Ms. Brown is a patient I've seen in my office for abdominal pain. She's a vasculopath, someone with severe peripheral arterial disease, and I suspect she's got some mesenteric ischemia (inadequate blood flow to the gut), that's causing her pain. She's also getting worked up by a vascular surgeon for a blockage in one of the arteries to the brain. She roled in to the ER this morning with 10 out of 10 pain and looking septic, going into kidney failure, with a lactic acid level of 8.8 (normal less than 2). A CAT scan suggests she's got small bowel that has died. This is not a good prognosis. (Are you seeing a pattern in my patients here?) I route her straight to the OR, after talking with the family about options and risks. From the clinical picture and the CT, I'm worried I'm going to find the entire gut dead, or so much so that she won't be able to live without IV nutrition. To add to my happiness, she's had a couple of operations in the past, so I might have to fight my way through a thick web of adhesions to evaluate anything. In the OR, we almost lose her on induction (starting anesthesia). My first break comes on the way in-- after a few minor adhesions, the belly is free. I almost immediately smell it. Dead gut. It's a distinct odor, and anyone who's ever worked in an OR recognizes it immediately. I run the small bowel, and come up empty. Nothing. Where is it? I check the right colon. It's a little pale, but it's not the problem. I switch to the patient's right side to look at the left colon, and Bingo! The colon from the splenic flexure down to the pelvic brim is green-gray in color. This is where the problem is. It also fits with her surgical history that I'd reviewed a week earlier. I mobilize the colon from it's various attachments, fire a stapler-cutter across the two ends of the dead area, and pass it off the field. I wash out the abdomen with 5 liters of saline, and run the bowel again. The cecum (the point where the small bowel and right colon join) still looks pale, but otherwise, nothing. But I can still smell dead gut. But there's little else I can do right now. I run a fast whip stitch to close the fascia, put a damp dressing over the open skin incision, and get her back to the ICU. We'll resuscitate her hard overnight, hope her kidneys kick in, and bring her back tomorrow for a second look. I'll create a colostomy at that time as well. By the time I finish up writing orders in the ICU, dictating the op note, talking with family, and a last check on her (collectively called, "tucking her in"), it's close to 830p. I've kept her alive for the time being, but I don't have that warm feeling of success. I question if I've extended her life, or prolonged her death. Only time will tell. I had planned to visit with some friends this evening, about an hour up the road. I call and cancel my plans, and head home. Tomorrow I'm on call, and it will be busy.
Good night
It started with a consult, an elderly lady in her 90's with a probable bowel obstruction. Doing routine surgery on 90+yr olds isn't routine, doing it for an acute problem is even less encouraging. Even better, she has family working in the hospital, which, for me, makes her family for me as well. After shooting Xrays, it appeared she had a blockage in the colon (large intestine). Surgery would be a colostomy (a bag on the abdominal wall), and possibly removing the blockage, depending on what it really was. Up until this acute event, this lady had been pretty active and living independently. But even a perfect operation was probably going to leave this woman bedridden-- at 95, she just doesn't have the reserve for even a little set back. I spent a long time talking with family about her, including my least favorite question, "If this was your mother, what would you do?" I'm sorry, but it's not my mom, and that's exactly why I can't answer that question. I've known my mom all my life, and have visited with her over the last 6 months, and so know exactly what her quality of life is, and exactly what her wishes are. I've "known" the patient for 2 hrs, and have no clue as to her spark, her drive, her wishes except for what her children have told me. I can't answer the question, not honestly. Besides, my professional curiosity and drive makes me want to go find out what's wrong, and fix her. In the end, the family decided on comfort measures only. This is a good and merciful decision, and I agree with it. But the whole event leaves a little hole in me.
The second strike comes with my third case in the OR. This is a very pleasant gentleman, who, in the parlance, "has been rode hard and put away wet." He's lived a rough life, and he's a hell of a lot older than the birthdays he's had. He comes to my office by cab, as he has no real support in the community. He came to my office with a whole litany of illnesses, all pretty much real. His complaint to me was rectal pain and bleeding-- severe pain that would leave him unable to walk after a bowel movement. I'm the third doctor he's seen in 5 yrs, he's had two colonoscopies, and no improvement. I've run several tests as an outpatient, looking for some of the less common sources. A look at his bottom in the office is difficult because it is so tender, and so today I'm going to do a colonoscopy, rectal exam under anesthesia, and probably a hemmorhoidectomy. The colonoscopy is challenging because the prep wasn't very good, but the rectal exam shows the real problem. An anal cancer, extending from the outer skin adjacent to the anus across the anal ring to the lining of the rectum. He also does have significant hemmorhoids, but fixing those is now out of the question. I biopsy the tumor for to get a definative tissue diagnosis, and send him to recovery. Anal cancer has been in the news recently, as Farah Fawcett has advanced anal cancer. I'm left frustrated. Once again, I couldn't fix his problem, will have to give him the bad news when he's back in my office, and I know that, with his overall health and poor socioeconomical support, he's not going to do well.
I finish up my last case, and head to hospital B to see one more sick patient. Ms. Brown is a patient I've seen in my office for abdominal pain. She's a vasculopath, someone with severe peripheral arterial disease, and I suspect she's got some mesenteric ischemia (inadequate blood flow to the gut), that's causing her pain. She's also getting worked up by a vascular surgeon for a blockage in one of the arteries to the brain. She roled in to the ER this morning with 10 out of 10 pain and looking septic, going into kidney failure, with a lactic acid level of 8.8 (normal less than 2). A CAT scan suggests she's got small bowel that has died. This is not a good prognosis. (Are you seeing a pattern in my patients here?) I route her straight to the OR, after talking with the family about options and risks. From the clinical picture and the CT, I'm worried I'm going to find the entire gut dead, or so much so that she won't be able to live without IV nutrition. To add to my happiness, she's had a couple of operations in the past, so I might have to fight my way through a thick web of adhesions to evaluate anything. In the OR, we almost lose her on induction (starting anesthesia). My first break comes on the way in-- after a few minor adhesions, the belly is free. I almost immediately smell it. Dead gut. It's a distinct odor, and anyone who's ever worked in an OR recognizes it immediately. I run the small bowel, and come up empty. Nothing. Where is it? I check the right colon. It's a little pale, but it's not the problem. I switch to the patient's right side to look at the left colon, and Bingo! The colon from the splenic flexure down to the pelvic brim is green-gray in color. This is where the problem is. It also fits with her surgical history that I'd reviewed a week earlier. I mobilize the colon from it's various attachments, fire a stapler-cutter across the two ends of the dead area, and pass it off the field. I wash out the abdomen with 5 liters of saline, and run the bowel again. The cecum (the point where the small bowel and right colon join) still looks pale, but otherwise, nothing. But I can still smell dead gut. But there's little else I can do right now. I run a fast whip stitch to close the fascia, put a damp dressing over the open skin incision, and get her back to the ICU. We'll resuscitate her hard overnight, hope her kidneys kick in, and bring her back tomorrow for a second look. I'll create a colostomy at that time as well. By the time I finish up writing orders in the ICU, dictating the op note, talking with family, and a last check on her (collectively called, "tucking her in"), it's close to 830p. I've kept her alive for the time being, but I don't have that warm feeling of success. I question if I've extended her life, or prolonged her death. Only time will tell. I had planned to visit with some friends this evening, about an hour up the road. I call and cancel my plans, and head home. Tomorrow I'm on call, and it will be busy.
Good night
Ol Clet
I wrote this post about a week ago, but then tabled it. It seems I have a lot of memories of patients who have passed away. But Clet deserves mention.
I thought I would continue with some memories from my practice of the people, patients, and friends that have made a difference. In many cases, the line between patient and friend has blurred over a couple of years of caring for a patient. Clet was one of these people who was both a patient and a man I considered my friend.
I thought I would continue with some memories from my practice of the people, patients, and friends that have made a difference. In many cases, the line between patient and friend has blurred over a couple of years of caring for a patient. Clet was one of these people who was both a patient and a man I considered my friend.
Clet came to me after a biopsy by his primary doctor. The biopsy had turned up an extremely rare kind of cancer, not quite skin cancer, not quite a neuro cancer. Even after fairly extensive searches by myself as well as my oncologist and radiation oncologist, we never really had a good handle on how to treat this thing, mainly because it was so rare there were no organized studies on treatment. All of the literature was based on case reports, "I treated one of these cancers," type items. So none of us were really sure how to best treat this. In addition, Clet was pushing 80, so using a highly toxic regimen really didn't make a lot of sense either, as the treatment would be worse than the disease.
Clet and his wife were much like the Green's, both upright by leaning on the other. They came to every appointment together, sometimes with one of their children, other times, just the two of them, but always together. I quickly learned that despite a neuro condition that slowed his speech considerably, Clet was sharp as a tack, with a wonderful sense of humor. My office staff planned on a little extra time for Clet, they knew it took him a bit to get out what he had to say.
After first doing a wide excision of the skin lesion, I then followed Clet as the wound healed. As soon as we had healing, he underwent a course of radiation to the site, and, for about a year, he did well. He then showed up back in my office with a lump in his armpit. A biopsy showed this was a recurrence, and he underwent another round of radiation. It was during this period that Mrs. Clet fell and broke a hip. She recovered nicely, and after a short stay in assisted living, they were back home again, and, Oh, the tales Clet told. Both of them were using walkers now, and they quickly discovered that they couldn't pass in the hallway of their home-- one or the other had to turn around and go back. So they developed the habit of calling an all clear down the hall before starting down to avoid these one lane tie-ups. Since Clet was a good half foot taller than Mrs., it made for a hilarious tale when he got up in the middle of the night to take care of business and grabbed the wrong walker.
Over the course of another year, I followed Clet, meeting more and more of his family as different sons, daughters, nieces and nephews helped shuttle he and Mrs. back and forth. He asked me about my children, and I kept up to date on the comings and goings of his extended family. Eventually, the cancer returned, and now it was in the vital organs. Once again, I found myself visiting with Clet, now in the hospital. I was there with Clet on the day he passed away. Up until the end, Clet's humor never let up, and he continued to cheer up those around him. Clet's was a funeral I attended, as he had passed from patient to friend a couple of years ago. Although I had done very little to treat him over the last year -- his disease was now in the realm of oncologists and radiation therapy -- his family told me that he treasured his visits with me, and that mine was the opinion he valued most. With his slow speech, Clet could have been someone I rushed through and never got to know. So often I think of him, and how grateful I am that I didn't miss this wonderful person in my life.
Thursday, May 7, 2009
Doctor humor
Four surgeons were talking about their favorite patients.
The first surgeon spoke up and said, "I like operating on librarians, because when you get in there, everything is organized alphabetically and with the dewey decimal system."
The second surgeon then spoke up. "I prefer electricians, because everything is color coded inside."
The third surgeon also had his preference. "My favorite patient is a mechanic, because they understand when you've got a few parts left over."
The three surgeons looked at the forth surgeon. "What's your preference?" they asked.
"Me? I like operating on lawyers." Needless to say, his associates were aghast. "Lawyers!?! Why in the hell would you prefer to operate on lawyers?"
"Simple," he replied, "They're heartless, gutless, and spineless, and the ass and the mouth are interchangable."
The first surgeon spoke up and said, "I like operating on librarians, because when you get in there, everything is organized alphabetically and with the dewey decimal system."
The second surgeon then spoke up. "I prefer electricians, because everything is color coded inside."
The third surgeon also had his preference. "My favorite patient is a mechanic, because they understand when you've got a few parts left over."
The three surgeons looked at the forth surgeon. "What's your preference?" they asked.
"Me? I like operating on lawyers." Needless to say, his associates were aghast. "Lawyers!?! Why in the hell would you prefer to operate on lawyers?"
"Simple," he replied, "They're heartless, gutless, and spineless, and the ass and the mouth are interchangable."
Wednesday, May 6, 2009
Stress management
Lately, my significant other's daughter has been asking to get her belly button pierced, something pretty common these days. The request got me thinking about a time, oh, so many years ago, when another shining example of our finest graced my trauma bay. It was, of course, during my residency, when so many of my favorite tales have come. So come now and listen, while I tell of stress management, trauma style.
Kelly (for lack of any other name) was a young lady of about 20 yrs when I met her. It was a mid morning trauma, a little unusual, since most trauma is mid night. She and her 18 yr old boyfriend had been drinking and smoking, ahhh, something, and had had a little mishap in their van. Well, actually, not so little. They rolled it over. Of course, they weren't wearing seatbelts, and so they wound up in our trauma room, with me taking the head on Kelly-- that is, trying to get a history from her, assessing the airway, trying to keep her calm. As the clothes were cut away, it became apparent that Kelly had a penchant for piercing-- There were 6 or 7 earrings in each ear, a stud in her tongue, and both nipples were pierced. And don't forget, this was 10 yrs ago, when piercing was much less common. Interestingly enough, with all these different piercings, Kelly just about came unglued with.... You guessed it. The IV. She pretty much freaked out, even with all the self administered sedation. Because we were going to the CAT scanner, all of the metal hardware had to come out-- A learning experience in itself, and one that I still find useful. She wasn't happy about this, either, as she was sure all of her holes would close up. She went through the scanner, got Xrays of her spine, and everything else she said hurt, and after everything was cleared, she got a bed for the night to detox.
The following morning, she was sober, sore, and ready to go home. Since she was pleasant, I took the plunge and inquired. "Explain to me, please. You come into the trauma bay with piercing everywhere, but you freaked out when we started the IV." She explained that she didn't like needles. Uh-huh. Still brave, I asked if she had managed to get all the hardware back in. She told me the tongue stud was OK, but her nipples had already closed. But then it got better (and hence this blog's title). She explained to me that the Native Americans had been using piercings for relieving stress for thousands of years. She continued on, telling me that it was a well known fact that women carry a great deal of stress in their breasts. Finally, she proudly informed me that every since she had had her nipples pierced, she had been so much more relaxed, and her life just seemed so much less stressful.
I kid you not.
I have related this story several times over the years, and asked several very stressed women I have met if they would be interested in testing this theory, but to date, have had no one offer to explore this approach to stress management.
May your evening be stress free.
Good night.
Kelly (for lack of any other name) was a young lady of about 20 yrs when I met her. It was a mid morning trauma, a little unusual, since most trauma is mid night. She and her 18 yr old boyfriend had been drinking and smoking, ahhh, something, and had had a little mishap in their van. Well, actually, not so little. They rolled it over. Of course, they weren't wearing seatbelts, and so they wound up in our trauma room, with me taking the head on Kelly-- that is, trying to get a history from her, assessing the airway, trying to keep her calm. As the clothes were cut away, it became apparent that Kelly had a penchant for piercing-- There were 6 or 7 earrings in each ear, a stud in her tongue, and both nipples were pierced. And don't forget, this was 10 yrs ago, when piercing was much less common. Interestingly enough, with all these different piercings, Kelly just about came unglued with.... You guessed it. The IV. She pretty much freaked out, even with all the self administered sedation. Because we were going to the CAT scanner, all of the metal hardware had to come out-- A learning experience in itself, and one that I still find useful. She wasn't happy about this, either, as she was sure all of her holes would close up. She went through the scanner, got Xrays of her spine, and everything else she said hurt, and after everything was cleared, she got a bed for the night to detox.
The following morning, she was sober, sore, and ready to go home. Since she was pleasant, I took the plunge and inquired. "Explain to me, please. You come into the trauma bay with piercing everywhere, but you freaked out when we started the IV." She explained that she didn't like needles. Uh-huh. Still brave, I asked if she had managed to get all the hardware back in. She told me the tongue stud was OK, but her nipples had already closed. But then it got better (and hence this blog's title). She explained to me that the Native Americans had been using piercings for relieving stress for thousands of years. She continued on, telling me that it was a well known fact that women carry a great deal of stress in their breasts. Finally, she proudly informed me that every since she had had her nipples pierced, she had been so much more relaxed, and her life just seemed so much less stressful.
I kid you not.
I have related this story several times over the years, and asked several very stressed women I have met if they would be interested in testing this theory, but to date, have had no one offer to explore this approach to stress management.
May your evening be stress free.
Good night.
Tuesday, May 5, 2009
Successes
Well, we're back, after a short hiatus--this doctoring business takes up a lot of time, ya know. I was thinking back to some more of my successes, and what keeps me in the business, and I started thinking about Bob (another pseudonym, of course). Bob and I did not meet on the best of terms, at least, not for him, and they were pretty crazy for me. It all started one bright spring day a few years ago.
I was in the OR that day, and was just about to start a case, when one of the anesthesiologist came into my room and asked if I could come down to room one, where, "I might be needed." I walked into the room to find about 4 anesthesia providers at the head of the table. This was an immediately clue that there was trouble, especially as none of them was sitting down. The patient had been undergoing cystoscopy, where a lighted tube with a camera is inserted into the bladder to look for disease, or, in men, to assess and treat the prostate. Somewhere, a hole had been formed, connecting the bladder to the abdominal cavity, and about a gallon and a half of fluid had been pushed into the peritoneal (abdominal) cavity. This was bad for a couple of reasons. First, the fluid was NOT isotonic, that is, the same as the body's normal fluids in its electrolyte composition, and so all of the patient's electrolytes were waaaaaay out of wack, lethal in and of itself. Second, all this fluid led to what is called, "Abdominal Compartment Syndrome." What this means is that the abdominal pressure had been pushed up to the point where all the veins in the abdomen returning blood from the organs and lower extremities were compressed and no longer returning blood to the heart. In addition, this distended the diaphragm up into the chest space, severely compromising the patient's ability to breath. This patient was in a bad, bad, bad way-- a hell of a lot closer to dead than alive. Anesthesia was getting an airway in to assist with the breathing, the urologist was working on getting the bladder decompressed, and that left everything in between to me. What I found was an abdomen the size of a prize winning pumpkin, and at least as firm. I had a dull thud when I tapped on it, telling me it was all fluid. He needed help, and now. I first tried placing a 5mm trocar (a tube used for laparoscopy) to see if i could drain this fluid off without a major intervention. I got a few drops, but it obviously wasn't working, and time was running out. I grabbed a prep stick and sloshed over the abdomen, and yanked on a gown and gloves while the crew got a sterile drap over the abdomen. A midline incision from top to bottom and into the abdominal space took less than a minute, and shortly, we had about a gallon of fluid spilled on the floor and on my shoes. Immediately, anesthesia reported a decrease in pressures on the lungs. He was now getting enough oxygen. Within a minute, his blood pressure rebounded, and along with the BP, his heart rate stabilized. After washing out the abdomen to help prevent any further electrolyte problems, I left the patient in the hands of the urologist, who still needed to work on the bladder, with plans to follow up on the patient the following day in the ICU. I still had a patient waiting for me back in my room. I had spent a total of 20 minutes in the room.
The next day, as I rounded on the patient, I discovered a new problem: His abdominal closure had broken down, and he was in danger of his bowels falling out. It was another trip to the OR to re-close the abdominal wall. It was a lot more pleasant this time, we took our time and spent about an hour and a half rechecking the abdominal contents for any other injuries, cleaning up the edges of the muscle layer, and closing the abdominal wall, using a couple of extra tricks I'd learned doing gastric bypass surgery many years earlier. He did well, and eventually was discharged. On frequent follow up appointments, we learned that we shared a few common interests, including our cynism and slightly off kilter sense of humor, and we have been friends ever since. "Bob" will recognize himself when he reads this, I'm sure. Our discussions on the medical system (he once worked for medicare) have colored several of my commentaries. He thanked me for saving his life, which was really a little embarrassing for me. I mean, what do you say? So I said, "Ahhh, it was nothing. Anybody could have done it." Maybe this isn't exactly right, but this is what surgeons do, I just happened to be the one who was available. But it does help to think about this now and then, especially when the other side of being a doctor (a mistake) occurs, and I question if I really belong in this field.
Well, it's time for me to get back at it, so I'll sign off now. See ya next time.
I was in the OR that day, and was just about to start a case, when one of the anesthesiologist came into my room and asked if I could come down to room one, where, "I might be needed." I walked into the room to find about 4 anesthesia providers at the head of the table. This was an immediately clue that there was trouble, especially as none of them was sitting down. The patient had been undergoing cystoscopy, where a lighted tube with a camera is inserted into the bladder to look for disease, or, in men, to assess and treat the prostate. Somewhere, a hole had been formed, connecting the bladder to the abdominal cavity, and about a gallon and a half of fluid had been pushed into the peritoneal (abdominal) cavity. This was bad for a couple of reasons. First, the fluid was NOT isotonic, that is, the same as the body's normal fluids in its electrolyte composition, and so all of the patient's electrolytes were waaaaaay out of wack, lethal in and of itself. Second, all this fluid led to what is called, "Abdominal Compartment Syndrome." What this means is that the abdominal pressure had been pushed up to the point where all the veins in the abdomen returning blood from the organs and lower extremities were compressed and no longer returning blood to the heart. In addition, this distended the diaphragm up into the chest space, severely compromising the patient's ability to breath. This patient was in a bad, bad, bad way-- a hell of a lot closer to dead than alive. Anesthesia was getting an airway in to assist with the breathing, the urologist was working on getting the bladder decompressed, and that left everything in between to me. What I found was an abdomen the size of a prize winning pumpkin, and at least as firm. I had a dull thud when I tapped on it, telling me it was all fluid. He needed help, and now. I first tried placing a 5mm trocar (a tube used for laparoscopy) to see if i could drain this fluid off without a major intervention. I got a few drops, but it obviously wasn't working, and time was running out. I grabbed a prep stick and sloshed over the abdomen, and yanked on a gown and gloves while the crew got a sterile drap over the abdomen. A midline incision from top to bottom and into the abdominal space took less than a minute, and shortly, we had about a gallon of fluid spilled on the floor and on my shoes. Immediately, anesthesia reported a decrease in pressures on the lungs. He was now getting enough oxygen. Within a minute, his blood pressure rebounded, and along with the BP, his heart rate stabilized. After washing out the abdomen to help prevent any further electrolyte problems, I left the patient in the hands of the urologist, who still needed to work on the bladder, with plans to follow up on the patient the following day in the ICU. I still had a patient waiting for me back in my room. I had spent a total of 20 minutes in the room.
The next day, as I rounded on the patient, I discovered a new problem: His abdominal closure had broken down, and he was in danger of his bowels falling out. It was another trip to the OR to re-close the abdominal wall. It was a lot more pleasant this time, we took our time and spent about an hour and a half rechecking the abdominal contents for any other injuries, cleaning up the edges of the muscle layer, and closing the abdominal wall, using a couple of extra tricks I'd learned doing gastric bypass surgery many years earlier. He did well, and eventually was discharged. On frequent follow up appointments, we learned that we shared a few common interests, including our cynism and slightly off kilter sense of humor, and we have been friends ever since. "Bob" will recognize himself when he reads this, I'm sure. Our discussions on the medical system (he once worked for medicare) have colored several of my commentaries. He thanked me for saving his life, which was really a little embarrassing for me. I mean, what do you say? So I said, "Ahhh, it was nothing. Anybody could have done it." Maybe this isn't exactly right, but this is what surgeons do, I just happened to be the one who was available. But it does help to think about this now and then, especially when the other side of being a doctor (a mistake) occurs, and I question if I really belong in this field.
Well, it's time for me to get back at it, so I'll sign off now. See ya next time.
Monday, April 27, 2009
So Why do I Stay in Medicine?
A friend called me the other day. He has been following my blog since I started, and asked me, "If it's such a pain in the ass, why do you stay in it?" This got me to thinking that very question. There are alot of smart ass answers I could give, at least as many dumb ass answers, and just a few really good answers. In the end, it comes down to this: I like to help people, to make a difference in their lives. I also just like people, which is sort of an oxymoron in surgeons, as we are notorious for not being people persons. I'm quite sure it costs me in the short run, since I don't mind spending a little more time with my patients, especially the ones with complex or difficult diagnoses. I'm always interested in what my patients do for a living, and have come across a few careers I've never heard of. Here in the midwest, it's mostly farming and agriculture, but I've also treated a rock star or two (just passin thru), college professors, engineers, soldiers, pilots, and train engineers. If you give a person a little time, just about everyone out there has a story, and all of them are interesting. Here today are a couple of tales from my past, reasons why I stay in this.
Mr Green was an elderly gentleman, approaching the end of his time here on earth, but still plugging. He and his wife, in much the same condition, lived comfortably in an assisted living center, and like so many elderly couples, stayed upright pretty much by leaning on each other. Tug either one out, and the other would probably just fall right over. They had been married for something close to 60 yrs, and when I met Mr. Green, Mrs. Green was admitted to the hospital across town with pneumonia, and in the ICU. I really met Mr. Green by accident. He developed severe abdominal pain, and went in to the ER at the other hospital. His CAT scan looked bad, but the hospital was full, and so he was transferred to our hospital, and I caught him. I did emergency surgery on him almost immediately, and then took him back in a couple more times to wash out the abdomen. Because of his bad lungs and heart, he soon had a tracheostomy, a tube in his neck into the windpipe to ventilate him through. Meantime, his family, bouncing between two hospitals, had transferred Mrs. Green over to our hospital. The two of them had rooms side by side in the ICU, and for about a week, the nurses would move one or the other over to the other's bedside for several hours each day. They would sit and hold hands, and it was obvious the love and devotion that existed there. Within a week, Mrs Green came off the ventilator (breathing machine), and was transferred out of the ICU. Mr. Green, while sicker, was slowly working his way off the vent as well. On Friday morning, however, Mr. Green took a nosedive, and it was necessary to ramp up the vent support. It quickly became clear that he was becoming septic, that an infection had set in somewhere. About noon, word came down from the floor on Mrs Green. Mrs. Green had passed away sometime between breakfast and lunch, probably from a heart attack or stroke. She had been DNR (Do Not Resuscitate), so, while the family mourned, they also rejoiced in her return home. That evening, I met with the family on Mr. Green, who had been deteriorating all day. They were thinking about withdraw support, but wanted to wait until after Mrs. Green's funeral, which would be within the next few days. They didn't want two funerals right on top of each other. I suggested they consider withdrawing support sooner, and having a joint funeral. I could see the idea quickly take hold, as they realized the meaning of this to their parents, as well as to all of the surviving family. They decided to wait until the following afternoon to withdraw support. Mr. Green had the last word. About 4am the following morning, he passed away peacefully. When I talked with the ICU nurse, she reported that his pulse had been slowing for several hours, and at almost exactly 4am, it simple stopped, the EKG went flatline. I didn't speak with the family again, as Mr. Green had already been picked up by the funeral home by the time I arrived at the hospital later that morning. One of my nurses was from the Greens' hometown, and attended the funeral, she said it was beautiful. I reflected that Saturday, as I made my rounds, on the Grace of living together for nearly 60 yrs, and going Home within 24 hrs of each other. Surely the Hand of God was present here.
I didn't think much about the Greens again, until 5 months later. I was heading out to a fall festival on a beautiful fall day, and stopped in a little town to grab a soda and stretch my legs. A gentleman in the convience store looked vaguely familar, and, obviously, he recognized me from somewhere. He quickly cleared the mystery, he was Mr. Green's son. He told me of the funeral, and how very grateful the family was for all I had done for them, and that they still talked of me, the hospital and staff, and those final weeks. While I had been feeling tired after a long week in the hospital, I left that store rejuvenated, and with a new feeling of accomplishment. It's been close to 5 yrs now, and I still reflect on the Greens and their family. I can only hope that when my time here ends, it will be with such a feeling of completeness and closure.
Mr Green was an elderly gentleman, approaching the end of his time here on earth, but still plugging. He and his wife, in much the same condition, lived comfortably in an assisted living center, and like so many elderly couples, stayed upright pretty much by leaning on each other. Tug either one out, and the other would probably just fall right over. They had been married for something close to 60 yrs, and when I met Mr. Green, Mrs. Green was admitted to the hospital across town with pneumonia, and in the ICU. I really met Mr. Green by accident. He developed severe abdominal pain, and went in to the ER at the other hospital. His CAT scan looked bad, but the hospital was full, and so he was transferred to our hospital, and I caught him. I did emergency surgery on him almost immediately, and then took him back in a couple more times to wash out the abdomen. Because of his bad lungs and heart, he soon had a tracheostomy, a tube in his neck into the windpipe to ventilate him through. Meantime, his family, bouncing between two hospitals, had transferred Mrs. Green over to our hospital. The two of them had rooms side by side in the ICU, and for about a week, the nurses would move one or the other over to the other's bedside for several hours each day. They would sit and hold hands, and it was obvious the love and devotion that existed there. Within a week, Mrs Green came off the ventilator (breathing machine), and was transferred out of the ICU. Mr. Green, while sicker, was slowly working his way off the vent as well. On Friday morning, however, Mr. Green took a nosedive, and it was necessary to ramp up the vent support. It quickly became clear that he was becoming septic, that an infection had set in somewhere. About noon, word came down from the floor on Mrs Green. Mrs. Green had passed away sometime between breakfast and lunch, probably from a heart attack or stroke. She had been DNR (Do Not Resuscitate), so, while the family mourned, they also rejoiced in her return home. That evening, I met with the family on Mr. Green, who had been deteriorating all day. They were thinking about withdraw support, but wanted to wait until after Mrs. Green's funeral, which would be within the next few days. They didn't want two funerals right on top of each other. I suggested they consider withdrawing support sooner, and having a joint funeral. I could see the idea quickly take hold, as they realized the meaning of this to their parents, as well as to all of the surviving family. They decided to wait until the following afternoon to withdraw support. Mr. Green had the last word. About 4am the following morning, he passed away peacefully. When I talked with the ICU nurse, she reported that his pulse had been slowing for several hours, and at almost exactly 4am, it simple stopped, the EKG went flatline. I didn't speak with the family again, as Mr. Green had already been picked up by the funeral home by the time I arrived at the hospital later that morning. One of my nurses was from the Greens' hometown, and attended the funeral, she said it was beautiful. I reflected that Saturday, as I made my rounds, on the Grace of living together for nearly 60 yrs, and going Home within 24 hrs of each other. Surely the Hand of God was present here.
I didn't think much about the Greens again, until 5 months later. I was heading out to a fall festival on a beautiful fall day, and stopped in a little town to grab a soda and stretch my legs. A gentleman in the convience store looked vaguely familar, and, obviously, he recognized me from somewhere. He quickly cleared the mystery, he was Mr. Green's son. He told me of the funeral, and how very grateful the family was for all I had done for them, and that they still talked of me, the hospital and staff, and those final weeks. While I had been feeling tired after a long week in the hospital, I left that store rejuvenated, and with a new feeling of accomplishment. It's been close to 5 yrs now, and I still reflect on the Greens and their family. I can only hope that when my time here ends, it will be with such a feeling of completeness and closure.
Friday, April 24, 2009
Trauma revisited
It's hard not to come back to the trauma bay when you want great stories to entertain and impress. For many of us, if we could just do the trauma bay, and not have to deal with the riff-raff the next day, we, too would probably love trauma. In the "old days," ie, before lightening fast, very accurate CT scanners, the trauma bay was a lot more fun, too, because so much blunt trauma offered a chance to cut-- there was just no other way to see what was going on in that belly. Now, we can run the more or less stable patient through the Scanner, and rule out just about all of the operable trauma. Don't get me wrong, this is Great for the patient, it just sucks for the anxious, up and coming trauma surgeon who desperately wants to cut a hole in someone. And this is where penetrating trauma comes in, otherwise known as The Knife and Gun Club. While there are few outside sources of penetrating trauma, about 99% comes in the form of people trying to do away with other people, and the forementioned other people trying to prevent this. Predominantly, GangBangers. And this is where our tale takes us tonight. Now, keep in mind, GangBangers wear their surgical scars as badges of honor, and most of us who had any kind of KGC in their training have seen not just repeat, but 3peat customers. Their biggest fear, as they roll into the trauma bay, is, "Am I gonna get a bag?" referring to a colostomy, standard surgical treatment when someone rolls in with a hole in the colon.
Please let me insert a little disclaimer here. Gang violence, and the decay of the inner city, and urban violence, are all terrible blights upon the very fabric of our society. I do not make light of these serious problems. But, I can't fix these problems, and I don't think the government can fix these problems. The cure, when it comes, will come from within, very much like peace eventually came to Ireland when the civilians said, "enough is enough, STOP" In the meantime, those of us in the trauma bay can either cry or laugh. Since most of us have a pretty dark sense of humor, most of us laugh. And with that disclaimer, let's go live to the action:
Victim: "I'm shot! I'm shot! I'm shot!"
Doc: "Where? How many shots? Was the shooter in front or behind you?"
Vic: "My stomach! I don't know! I donno, I didn't see no one. I'm Shot! I'm Shot!"
Doc: "Slow down, take a deep breath. Let me see your belly. Do you hurt anywhere else?"
Vic: "I don't hurt no where else. Oh S**t, am I gonna get a bag, Doc?"
Doc: "I don't know yet. You're gonna feel a finger in your bottom, now" (to check for blood)
Vic: "YOU GONNA WHAT!!!???"
Doc: "OK, you've got some blood in your stools. We're gonna get some xrays, and then go
straight to the OR. We're gonna put a tube in your penis, now" (check for blood, and
monitor urine output)
Vic: "YOU GONNA WHAT!?!?!?!?!?"
Doc: "The xrays don't look good, you're shot pretty bad, we're going to the OR now"
Vic: "When you gonna take this tube out?" (referring to foley catheter in bladder)
Doc: "Sir, you've been shot, and are in rough shape, we're going to the OR now.
Vic: "When you gonna take this tube out?"
Doc: "Sir, we need to operate. You could die"
Vic: "When you gonna take this out?"
As you can see, the foley catheter pretty much ends any productive conversation. But, another member of the team has arrived, the police detective, who's job it is to arrest whoever did this. And so our discussion continues:
Officer: "Hey, Leon, didn't I just arrest you last week?"
Vic: "Yeah, but I got out again"
Off: "Leon, did you see the shooter?"
Vic: "Ahh, man, I didn't see nothing"
Off: "Well, did you even get a look at this guy?"
Vic: "Man, it was some dude. I ain't never seen him"
Off: "So just some dude. You sure you've never seen him? Maybe pick him out from some
mug shots?"
Vic: "Man, it was some dude. I ain't never seen him before."
About this time, we role Leon out, heading for the OR, and, if we're lucky, some really great surgery. And, if Leon is lucky, some really successful surgery.
All of us in the trauma bay know "Some Dude." He is, by all know accounts, the meanest, baddest, shooting-est character out there. If local law enforcement could remove just this single individual, the gun fire in the KGC would almost cease to exist. Of course, we all know we'll get to meet someone pretty close to his description within a day or so, when Leon's boys ask Some Dude to take out one of the rival gang's members. When he shows up in the trauma bay, yep, you guessed it: It was Some Dude. Damn, he is one bad asssed boy.
Please let me insert a little disclaimer here. Gang violence, and the decay of the inner city, and urban violence, are all terrible blights upon the very fabric of our society. I do not make light of these serious problems. But, I can't fix these problems, and I don't think the government can fix these problems. The cure, when it comes, will come from within, very much like peace eventually came to Ireland when the civilians said, "enough is enough, STOP" In the meantime, those of us in the trauma bay can either cry or laugh. Since most of us have a pretty dark sense of humor, most of us laugh. And with that disclaimer, let's go live to the action:
Victim: "I'm shot! I'm shot! I'm shot!"
Doc: "Where? How many shots? Was the shooter in front or behind you?"
Vic: "My stomach! I don't know! I donno, I didn't see no one. I'm Shot! I'm Shot!"
Doc: "Slow down, take a deep breath. Let me see your belly. Do you hurt anywhere else?"
Vic: "I don't hurt no where else. Oh S**t, am I gonna get a bag, Doc?"
Doc: "I don't know yet. You're gonna feel a finger in your bottom, now" (to check for blood)
Vic: "YOU GONNA WHAT!!!???"
Doc: "OK, you've got some blood in your stools. We're gonna get some xrays, and then go
straight to the OR. We're gonna put a tube in your penis, now" (check for blood, and
monitor urine output)
Vic: "YOU GONNA WHAT!?!?!?!?!?"
Doc: "The xrays don't look good, you're shot pretty bad, we're going to the OR now"
Vic: "When you gonna take this tube out?" (referring to foley catheter in bladder)
Doc: "Sir, you've been shot, and are in rough shape, we're going to the OR now.
Vic: "When you gonna take this tube out?"
Doc: "Sir, we need to operate. You could die"
Vic: "When you gonna take this out?"
As you can see, the foley catheter pretty much ends any productive conversation. But, another member of the team has arrived, the police detective, who's job it is to arrest whoever did this. And so our discussion continues:
Officer: "Hey, Leon, didn't I just arrest you last week?"
Vic: "Yeah, but I got out again"
Off: "Leon, did you see the shooter?"
Vic: "Ahh, man, I didn't see nothing"
Off: "Well, did you even get a look at this guy?"
Vic: "Man, it was some dude. I ain't never seen him"
Off: "So just some dude. You sure you've never seen him? Maybe pick him out from some
mug shots?"
Vic: "Man, it was some dude. I ain't never seen him before."
About this time, we role Leon out, heading for the OR, and, if we're lucky, some really great surgery. And, if Leon is lucky, some really successful surgery.
All of us in the trauma bay know "Some Dude." He is, by all know accounts, the meanest, baddest, shooting-est character out there. If local law enforcement could remove just this single individual, the gun fire in the KGC would almost cease to exist. Of course, we all know we'll get to meet someone pretty close to his description within a day or so, when Leon's boys ask Some Dude to take out one of the rival gang's members. When he shows up in the trauma bay, yep, you guessed it: It was Some Dude. Damn, he is one bad asssed boy.
Thursday, April 23, 2009
Where the money goes
I talked a week or two ago about how doctors get paid by the insurance companies, but yesterday, someone started spouting off around me about "overpaid doctors," and how rediculous doctors' rates are, and so I'm back around the topic. Just a little rundown on the cost of doing business. We're gonna take out a gallbladder, and then follow the money. So get out your calculators, and follow the bouncing bill.
My charge: $2200
Medicaid pays: $1000 (-$1200)
Office costs: ~50% (-$500)
Malpractice: $100 (-$100)
My Income Tax: ~35% (-$140)
Total: $260
Hours/Pt: 4hrs
equals: $65/hr
Hell, I can make that working on the assembly line! And I didn't include in that the monthly payments on my student loans, which is equal to the mortgage on a nice 3-4 bedroom, 3 bath home.
It amazes me that Americans are willing to pay to watch somebody play baseball, football, basketball, etc, for millions of dollars per year, or shell out $10 a ticket for a movie with an actor/actress making$20 million dollars per movie, but they think that their doctor is overpaid, even though s/he has at least 7 yrs of education beyond college, at a cost of roughly $100,000, and is available 24 hrs a day, 7 days a week, 52 weeks a year.
There is a constant buzz in the hallowed halls of congress, and elsewhere, about the Right to Healthcare. Could someone please point out for me the specific text in the declaration of Independence, the Constitution, or some other founding document, where this is specified? I found, right up front in the first 10 amendments, the right to legal representation, but I don't see anyone working to control the cost of legal care --Hell, I sure can't afford a lawyer, not on my pay. I also see, in the Declaration of Independence, the Right to the Pursuit of Happiness. As I took my hippocratic oath, did I surrender this Right in exchange for the care of my patients?
Oh, well, it has become late, I was up early, and spent 10 hrs in the OR, I'm gonna hit the sack, tomorrow is another day.
My charge: $2200
Medicaid pays: $1000 (-$1200)
Office costs: ~50% (-$500)
Malpractice: $100 (-$100)
My Income Tax: ~35% (-$140)
Total: $260
Hours/Pt: 4hrs
equals: $65/hr
Hell, I can make that working on the assembly line! And I didn't include in that the monthly payments on my student loans, which is equal to the mortgage on a nice 3-4 bedroom, 3 bath home.
It amazes me that Americans are willing to pay to watch somebody play baseball, football, basketball, etc, for millions of dollars per year, or shell out $10 a ticket for a movie with an actor/actress making$20 million dollars per movie, but they think that their doctor is overpaid, even though s/he has at least 7 yrs of education beyond college, at a cost of roughly $100,000, and is available 24 hrs a day, 7 days a week, 52 weeks a year.
There is a constant buzz in the hallowed halls of congress, and elsewhere, about the Right to Healthcare. Could someone please point out for me the specific text in the declaration of Independence, the Constitution, or some other founding document, where this is specified? I found, right up front in the first 10 amendments, the right to legal representation, but I don't see anyone working to control the cost of legal care --Hell, I sure can't afford a lawyer, not on my pay. I also see, in the Declaration of Independence, the Right to the Pursuit of Happiness. As I took my hippocratic oath, did I surrender this Right in exchange for the care of my patients?
Oh, well, it has become late, I was up early, and spent 10 hrs in the OR, I'm gonna hit the sack, tomorrow is another day.
Saturday, April 18, 2009
Sex and Trauma, or, Love in the Fast lane
Ok, so a day or two ago, I promised tales of trauma from days old. So, I'm gonna dig deep into my repressed memories from my residency for a story of love (sorta) in the fast lane.
I need to expand on the trauma experience a little to make this a better story, first. Medical students LOVE trauma. It is exciting! There's blood, and violence, and fast past action -- all the making of a great hollywood movie. Nurses LOVE trauma. See above explanation. Residents..... HATE trauma. that's becuase after the med students go off rotation, and the nurses go home after shift, the resident is still stuck babysitting the trauma patient. And while, on occassion, a clean, wholesome, pleasant person comes through the doors of the trauma bay, the majority, at a ratio of about 20 to 1, are drunk, obnoxious, rude Assholes. They are uncooperative and belligerent in the trauma room, usually stink to high heaven with booze and tobacco, and, now a days with CAT scans and other imaging techniques, not even a good chance for an operation. Additionally, once they get to the floor, they tend to be demanding and rude, telling you about all that "they" are paying for the hospitalization (Oh, Ooops, you're on Medicaid, or, more likely, not even insured, so NO pay) and how they're going to "sue your ass" because they didn't get the breakfast of their choice. There was also the charmer who lay on the backboard bucking and thrashing and telling me he was "gonna get me. I got friends. We're gonna get you." This settled down when I leaned over real close and personal like, and explained that one more buck, or one more threat, and I was paralyzin' his ass and stuffin a tube down his throat. Amazin how nicely that worked. And on and on and on. Attending level surgeons either love or hate trauma, it just depends on whether they have residents or not. You can guess which group loves it. So, as a resident, a rotation on trauma is pretty much just a detour through hell, with all the unsavory characters and then some in Dante's Classic Road Trip Novel.
So enough ground work. Suffice to say, Trauma sucks. So here it was, a lovely spring morning, with morning rounds done, and settling into chasing down Xrays, CAT scans, and the various reports thereof from the previous nights customers, when the trauma pager went off. (On an aside, we kept all of the trauma pagers set to the same tone, and threatened other residents who used it for their personal pagers-- I still hate that tone. It causes flashbacks for me) It was a class 2 trauma from a motor vehicle accident. The patient was a direct flight from the scene, and, by report, was already intubated. There was a death at the scene, always a bad sign. When he hit the table, it was clear he had a pretty significant head injury, but really no other life threatening injuries. We drew blood, got in the appropriate lines and tubes, and prepared to get the whole body CAT scan to determine how bad the coconut was cracked, and see if anything else was damaged. 'Bout that time, the social worker came in. The social workers showed up for all the traumas, their job was to round up the family, friends, posse, whatever, and keep them informed what we were doing, and assist us with communications. Well, this one was a doozy. She let us know that his mother, along with his wife, girlfriend, and mother of his baby, were in the waiting room. "Ummm, how many people is that, exactly?" Yep. Four different people. "Oh, they all know each other? And get along?" OK. Needless to say, there was great wailing at the fall of the patriarch. We explained the plan of action, and promised to keep them updated.
Back in the trauma room, the State Police had arrived. It turned out that the death at the scene was actually the girlfriend's roommate. We, the collective trauma team quickly peppered the trooper for details of the accident, so as to better predict our patient's injuries. As it turns out, our patient was moving at a high rate of speed (in more than one way), when he drifted across the centerline to go head to head with a Semi. He had survived only because of an "airbag" Turns out, his pants were around his ankles (I don't recommend this when driving), and the girl was naked on his lap (I really don't recommend this while driving), when he became,,,, ummmm,, distracted, and lost control of the vehicle. The story, as it developed, was that apparently the girl was "auditioning," for a place in the family. Apparently, parking on a quiet street, or just renting a room, wasn't an option. Pity. As the story went on, after the initial show of great concern and caring, and as it became apparent that he was not going to snap out of the acute brain injury too quickly, all of these ladies disappeared. Patient X did come off the vent, and even woke up to some extent. He spent several months with us, as he had no home with out the ladies, and no extended care facility or nursing home would take him (did I mention, no insurance?) After about six months living in the hospital, as the nursing staff and residents became more and more aware he was faking a good deal of his deficit, he finally was sent home. The police dropped the vehicular homicide charges, since he was deemed incompetent to stand trial.
Makes for a kinda crappy ending, huh? Well there is a post script to the story. Around 3 years later, as I was finishing up my residency, one of the floor nurses who had cared for/put up with him showed me a newspaper clipping. It turned out that Patient X had continued to have "problems" after his return home, thereby avoiding the homicide charge. He had no memory of the event, couldn't comprehend the seriousness of the charges, and apparently even had significant problems with short term memory. This all collapsed one day when he was out walking his dog, who showed little respect for the neighbor's lawn, this let to a shouting match between the two men, followed by threats by Pt. X, who then went home to get a gun to carry out his threat. He returned, with said gun in pocket, to be met by a couple of the local law enforcement officers, and was promptly tossed in jail. The last I heard, this was the event the law had been looking for to prove competency, and he was headed to trial. And so too, ends my tale of Sex and Love in the fastlane.
Seein' as I'm on call tonight, I'm gonna hit the sack, as it's likely I will get woke up about once an hour for the rest of the night.
Sweet dreams, all.
I need to expand on the trauma experience a little to make this a better story, first. Medical students LOVE trauma. It is exciting! There's blood, and violence, and fast past action -- all the making of a great hollywood movie. Nurses LOVE trauma. See above explanation. Residents..... HATE trauma. that's becuase after the med students go off rotation, and the nurses go home after shift, the resident is still stuck babysitting the trauma patient. And while, on occassion, a clean, wholesome, pleasant person comes through the doors of the trauma bay, the majority, at a ratio of about 20 to 1, are drunk, obnoxious, rude Assholes. They are uncooperative and belligerent in the trauma room, usually stink to high heaven with booze and tobacco, and, now a days with CAT scans and other imaging techniques, not even a good chance for an operation. Additionally, once they get to the floor, they tend to be demanding and rude, telling you about all that "they" are paying for the hospitalization (Oh, Ooops, you're on Medicaid, or, more likely, not even insured, so NO pay) and how they're going to "sue your ass" because they didn't get the breakfast of their choice. There was also the charmer who lay on the backboard bucking and thrashing and telling me he was "gonna get me. I got friends. We're gonna get you." This settled down when I leaned over real close and personal like, and explained that one more buck, or one more threat, and I was paralyzin' his ass and stuffin a tube down his throat. Amazin how nicely that worked. And on and on and on. Attending level surgeons either love or hate trauma, it just depends on whether they have residents or not. You can guess which group loves it. So, as a resident, a rotation on trauma is pretty much just a detour through hell, with all the unsavory characters and then some in Dante's Classic Road Trip Novel.
So enough ground work. Suffice to say, Trauma sucks. So here it was, a lovely spring morning, with morning rounds done, and settling into chasing down Xrays, CAT scans, and the various reports thereof from the previous nights customers, when the trauma pager went off. (On an aside, we kept all of the trauma pagers set to the same tone, and threatened other residents who used it for their personal pagers-- I still hate that tone. It causes flashbacks for me) It was a class 2 trauma from a motor vehicle accident. The patient was a direct flight from the scene, and, by report, was already intubated. There was a death at the scene, always a bad sign. When he hit the table, it was clear he had a pretty significant head injury, but really no other life threatening injuries. We drew blood, got in the appropriate lines and tubes, and prepared to get the whole body CAT scan to determine how bad the coconut was cracked, and see if anything else was damaged. 'Bout that time, the social worker came in. The social workers showed up for all the traumas, their job was to round up the family, friends, posse, whatever, and keep them informed what we were doing, and assist us with communications. Well, this one was a doozy. She let us know that his mother, along with his wife, girlfriend, and mother of his baby, were in the waiting room. "Ummm, how many people is that, exactly?" Yep. Four different people. "Oh, they all know each other? And get along?" OK. Needless to say, there was great wailing at the fall of the patriarch. We explained the plan of action, and promised to keep them updated.
Back in the trauma room, the State Police had arrived. It turned out that the death at the scene was actually the girlfriend's roommate. We, the collective trauma team quickly peppered the trooper for details of the accident, so as to better predict our patient's injuries. As it turns out, our patient was moving at a high rate of speed (in more than one way), when he drifted across the centerline to go head to head with a Semi. He had survived only because of an "airbag" Turns out, his pants were around his ankles (I don't recommend this when driving), and the girl was naked on his lap (I really don't recommend this while driving), when he became,,,, ummmm,, distracted, and lost control of the vehicle. The story, as it developed, was that apparently the girl was "auditioning," for a place in the family. Apparently, parking on a quiet street, or just renting a room, wasn't an option. Pity. As the story went on, after the initial show of great concern and caring, and as it became apparent that he was not going to snap out of the acute brain injury too quickly, all of these ladies disappeared. Patient X did come off the vent, and even woke up to some extent. He spent several months with us, as he had no home with out the ladies, and no extended care facility or nursing home would take him (did I mention, no insurance?) After about six months living in the hospital, as the nursing staff and residents became more and more aware he was faking a good deal of his deficit, he finally was sent home. The police dropped the vehicular homicide charges, since he was deemed incompetent to stand trial.
Makes for a kinda crappy ending, huh? Well there is a post script to the story. Around 3 years later, as I was finishing up my residency, one of the floor nurses who had cared for/put up with him showed me a newspaper clipping. It turned out that Patient X had continued to have "problems" after his return home, thereby avoiding the homicide charge. He had no memory of the event, couldn't comprehend the seriousness of the charges, and apparently even had significant problems with short term memory. This all collapsed one day when he was out walking his dog, who showed little respect for the neighbor's lawn, this let to a shouting match between the two men, followed by threats by Pt. X, who then went home to get a gun to carry out his threat. He returned, with said gun in pocket, to be met by a couple of the local law enforcement officers, and was promptly tossed in jail. The last I heard, this was the event the law had been looking for to prove competency, and he was headed to trial. And so too, ends my tale of Sex and Love in the fastlane.
Seein' as I'm on call tonight, I'm gonna hit the sack, as it's likely I will get woke up about once an hour for the rest of the night.
Sweet dreams, all.
Wednesday, April 15, 2009
Nursing: Old versus New
A couple of days ago, I promised to tell you the tale of the beaurocrats. The world of nursing is a great example of where the number crunchers and bean counters have overwhelmed the world of medicine and driven this noble, caring profession into a squirrel cage rat race doing more secretary work than patient care.
Let's take a look at "old nursing" vs "new nursing".
Old Nursing: Bring meds to patient, bring dinner, spend 10 min talking with patient and learning what they're scared of, a little about their family, spend time teaching about the next day's test. Pt's upset and nervous, you give a back rub to help them relax. Total time spent with patient: 50 min. Total time on paperwork: 10 min.
New Nursing: Run meds in, confirm patient ID with armband (because you really haven't had a chance to get to know them all. Spend 10 minutes on computer documenting you gave the meds, and did so with all of the appropriate safeguards. Nurse's aide brings in dinner. You run in to glance at tray to estimate how much they ate. Spend 10 more minutes documenting how much patient ate. Nurse's aide repostions patient. You spend 10 minutes documenting frequent repositioning of patient. Drop off a brochure with patient about tomorrow's procedure. Spend 10 minutes documenting you gave patient brochure. Nurse's aide lets you know the patient is anxious. You talk to patient for 2 minutes to confirm this. Call the doctor, get order for sedative, give to patient. Spend 20 minutes documenting anxiousness, call, and meds. Total time with patient: 10 min. Total time documenting: 50 min.
And on and on and on and on and on and on and on it gooooooooeeeeeeeesssssss.
How did we get here?
The beauracrats came along with "a better way"
"Healthcare is a disaster" "Our system is Failing" "Too many errors" "Systems will make it all better"
Beauracrates, with no knowledge of healthcare, nursing, medicine, or just simply caring for another human being decided they could do it better. And to acheive that, you must have DATA. So now, instead of caring for the patient, the nurses create data. This proves what good care they are giving. Of course, even as the beaurocrates were making healthcare better, they were already upsetting the balance of personel within the system. With all this DATA coming in, it was necessary to hire people to collect the DATA, and people to store the DATA, and people to analyze the DATA, and even more people to supervise the people who process the DATA, and pretty soon there were 5 and 6 people for every one person actually, physically, caring for the patient. Current estimates now are for 20+ people in healthcare who never actually provide care to the patient, either directly or indirectly, for every one person who provides actual, hands on care to patients. Recent estimates suggests that for every dollar the consumer spends on healthcare, about 17 cents reaches the doctor. Another 10 to 15 cents go to nurses and other allied health care salaries. More goes to administration, bean counters, and a host of others whose jobs is to file claims, check claims, scour the charts to make sure they are in compliance with a dozen different regulatory agencies, make sure everything is signed, dated, and complete. But, do you know where a little over half of your dollar goes? The insurance company. And is health care any better? I doubt it. Now that we document the living hell out of everything, our nurses spend less time than ever with the patients, leaving more and more of the patient care to "nurse extenders," aka, nurses' aides or "patient care technicians," basically someone who does all the hands on work like checking vital signs, feeding, bathing, bedding, bedpans, call lights, etc, leaving the nurse free to pass meds, run IV's, and, least we forget, DOCUMENT. Don't get me wrong, I work with a host of wonderful, caring, dedicated nurse extenders. But they lack the training to recognize subtle signs and changes in a patient headed for trouble, and so the call to the doctor warning of trouble is often that much more delayed. Too many times, I've rounded in the morning, looked at the flowsheet (the list of vitals, ins&outs, etc), asked the nurse why I wasn't notified of an obvious change or trend, and she had not even seen the flowsheet. This isn't evil people. It's good people, caring people, who've had their job defined and redefined, and redefined again, by people who've never provided patient care before. (The lawyers are part of this, but that's a whole other day. Gotta stay focused)
Ok, it's getting late, and I've rambled on again. Tomorrow, tales of trauma past, just for the fun of it.
Good night.
Let's take a look at "old nursing" vs "new nursing".
Old Nursing: Bring meds to patient, bring dinner, spend 10 min talking with patient and learning what they're scared of, a little about their family, spend time teaching about the next day's test. Pt's upset and nervous, you give a back rub to help them relax. Total time spent with patient: 50 min. Total time on paperwork: 10 min.
New Nursing: Run meds in, confirm patient ID with armband (because you really haven't had a chance to get to know them all. Spend 10 minutes on computer documenting you gave the meds, and did so with all of the appropriate safeguards. Nurse's aide brings in dinner. You run in to glance at tray to estimate how much they ate. Spend 10 more minutes documenting how much patient ate. Nurse's aide repostions patient. You spend 10 minutes documenting frequent repositioning of patient. Drop off a brochure with patient about tomorrow's procedure. Spend 10 minutes documenting you gave patient brochure. Nurse's aide lets you know the patient is anxious. You talk to patient for 2 minutes to confirm this. Call the doctor, get order for sedative, give to patient. Spend 20 minutes documenting anxiousness, call, and meds. Total time with patient: 10 min. Total time documenting: 50 min.
And on and on and on and on and on and on and on it gooooooooeeeeeeeesssssss.
How did we get here?
The beauracrats came along with "a better way"
"Healthcare is a disaster" "Our system is Failing" "Too many errors" "Systems will make it all better"
Beauracrates, with no knowledge of healthcare, nursing, medicine, or just simply caring for another human being decided they could do it better. And to acheive that, you must have DATA. So now, instead of caring for the patient, the nurses create data. This proves what good care they are giving. Of course, even as the beaurocrates were making healthcare better, they were already upsetting the balance of personel within the system. With all this DATA coming in, it was necessary to hire people to collect the DATA, and people to store the DATA, and people to analyze the DATA, and even more people to supervise the people who process the DATA, and pretty soon there were 5 and 6 people for every one person actually, physically, caring for the patient. Current estimates now are for 20+ people in healthcare who never actually provide care to the patient, either directly or indirectly, for every one person who provides actual, hands on care to patients. Recent estimates suggests that for every dollar the consumer spends on healthcare, about 17 cents reaches the doctor. Another 10 to 15 cents go to nurses and other allied health care salaries. More goes to administration, bean counters, and a host of others whose jobs is to file claims, check claims, scour the charts to make sure they are in compliance with a dozen different regulatory agencies, make sure everything is signed, dated, and complete. But, do you know where a little over half of your dollar goes? The insurance company. And is health care any better? I doubt it. Now that we document the living hell out of everything, our nurses spend less time than ever with the patients, leaving more and more of the patient care to "nurse extenders," aka, nurses' aides or "patient care technicians," basically someone who does all the hands on work like checking vital signs, feeding, bathing, bedding, bedpans, call lights, etc, leaving the nurse free to pass meds, run IV's, and, least we forget, DOCUMENT. Don't get me wrong, I work with a host of wonderful, caring, dedicated nurse extenders. But they lack the training to recognize subtle signs and changes in a patient headed for trouble, and so the call to the doctor warning of trouble is often that much more delayed. Too many times, I've rounded in the morning, looked at the flowsheet (the list of vitals, ins&outs, etc), asked the nurse why I wasn't notified of an obvious change or trend, and she had not even seen the flowsheet. This isn't evil people. It's good people, caring people, who've had their job defined and redefined, and redefined again, by people who've never provided patient care before. (The lawyers are part of this, but that's a whole other day. Gotta stay focused)
Ok, it's getting late, and I've rambled on again. Tomorrow, tales of trauma past, just for the fun of it.
Good night.
Tuesday, April 14, 2009
Well, we're back again. Getting late, so this is sort of a wrap up. That was, without question, the biggest abscess I have ever seen. It extended the length of the thigh, and had 1.5 liters of pus in it. And it was under pressure, shot 2ft when I cut into it. Don't try this at home kids, I'm a professional. I'll plan on taking him back to the OR for the next few days to try to get this thing really cleaned up, and then it will have to heal from the inside out, because any attempt to close it would simply lead to another abscess.
It was a busy day. I started rounds in hospital B, then office for about 5 hours, then to hospital A to do a quick case, which of course then took twice as long. I'm on call today, so by the time I had finished the case, I had three consults to see back at hospital B, so off I went. I saw this big abscess and got it routed towards the OR, then saw the other two cases, and lined up most of their management, then down to the OR, and finally back up to the floor to finish off the second two consults. I'm now home as it approaches 11p, and this is definately a short blog night. A while ago, I promised the expose' on the beauracracy, but I'm afraid it's going to have to wait a little longer.
I did notice, glancing at the last post, that I talked about abscesses as most surgeons' first case, as it was mine. Now, how is this so? Pretty simple. As I said earlier, abscess tend to come in at night. This is when staffs are lower, activity is minimal, and residents can take a little time to teach the enthusiastic student. So here ya are, on your second night of call on surgery service, already almost falling over because you were up at 0300 that morning to round on your patients, and it is now around midnight. The resident sent you down to the ER a couple hours ago to see this patient, and do the history and physical, and now the junior resident, and then the senior resident, has seen the patient, and the two of them have talked about you, and decided you really are bustin your chops, and they throw you a bone. Your first procedure. Sit here. Hold the scapel like this (Oh my God, they're letting me touch the scapel!) Cut here. Course, they forget to warn you about that pressure thing, so a half second after the, "cut here," you're falling off the stool backwards as you try to dodge the pus squirting out. But it doesn't matter. You've cut your teeth, you've drawn blood. You're hooked. Never again will treating the common cold be enough for you. You're A SURGEON now.
Good night,
It was a busy day. I started rounds in hospital B, then office for about 5 hours, then to hospital A to do a quick case, which of course then took twice as long. I'm on call today, so by the time I had finished the case, I had three consults to see back at hospital B, so off I went. I saw this big abscess and got it routed towards the OR, then saw the other two cases, and lined up most of their management, then down to the OR, and finally back up to the floor to finish off the second two consults. I'm now home as it approaches 11p, and this is definately a short blog night. A while ago, I promised the expose' on the beauracracy, but I'm afraid it's going to have to wait a little longer.
I did notice, glancing at the last post, that I talked about abscesses as most surgeons' first case, as it was mine. Now, how is this so? Pretty simple. As I said earlier, abscess tend to come in at night. This is when staffs are lower, activity is minimal, and residents can take a little time to teach the enthusiastic student. So here ya are, on your second night of call on surgery service, already almost falling over because you were up at 0300 that morning to round on your patients, and it is now around midnight. The resident sent you down to the ER a couple hours ago to see this patient, and do the history and physical, and now the junior resident, and then the senior resident, has seen the patient, and the two of them have talked about you, and decided you really are bustin your chops, and they throw you a bone. Your first procedure. Sit here. Hold the scapel like this (Oh my God, they're letting me touch the scapel!) Cut here. Course, they forget to warn you about that pressure thing, so a half second after the, "cut here," you're falling off the stool backwards as you try to dodge the pus squirting out. But it doesn't matter. You've cut your teeth, you've drawn blood. You're hooked. Never again will treating the common cold be enough for you. You're A SURGEON now.
Good night,
It's Live, Tuesday night!!
Well this isn't going to be a very long post, I'm waiting to go to the OR with a case of pus. As a matter of fact, my evening is awash in pus, seeing as, as soon as i finish opening an draining this huge collection of pus, I've got to more abscesses waiting for me up on the floor. AAAAhhhh, the joy of the general surgeon, Pus. The never ending call of the general surgeon is, "Don't let the sun go down on pus under pressure!" Unfortunately, a more appropopriate call would be, "Don't let the sun come up on pus under pressure!" since it seems I do 90% of these after dark. Tonight is a little bit of an exception to the rule, none of my 3 cases is in a really stinky, private place, like a butt crack, or next to the anus, which is usually where I find these pleasant little things. The perirectal abscess holds a special place in so many surgeons' memories, because, invariably, it seems this is the very first procedure any of us ever did in med school.
Well, I gotta run, they're calling for me from the OR.
More later.
Well, I gotta run, they're calling for me from the OR.
More later.
Saturday, April 11, 2009
Ya think your mechanic will go for it?
So I promised you yesterday I would tell you about how to pay your mechanic. So envision this: You take your car into the shop because it's got a funny noise coming out of the right front. The mechanic puts it up on the rack, uses the really fancy machine, you know, the one that goes "BING!" He then looks in a couple of big books in his office, and finally tells you the gloopa joint is bad and will need replacing. After you give him the go ahead, he pulls a new gloopa joint off one of his store shelves, replaces it, and finally presents you with the bill. It's a doozy, $2000. After he hands you the bill, and your keys, you tell him, "Great job. I'll get this money to you in about 3 or 4 months. About 3 months later, you finally pay him. But there's a hitch: In the interval, you've talked to all your friends who have ever even heard of a gloopa joint. All of you agree that $2000 seems pretty high, and so you send him a note with the payement: Dear Rusty, I have reviewed your charges for the gloopa joint, and, in keeping with the Usual and Customary Charges, for gloopa joints, I'm sending you $1000. Thanks for the work. HEY!!! Wait!! You can't do that!! Oh Yeah?? Welcome to my world. Wanta make it even better? OK, try this on. It's now 2am on a Sunday morning when your gloopa goes giddy. So you call your mechanic up, get him out of bed, and have him fix it, right then and there. Well, hell, that should be good for at least time and a half, right? Nope. Same half off discount. Hell of a racket, huh?
Let's sweeten it up again, and we'll take a little more off the ticket. In almost every state in the union (about 45 out of 50), in order to get a license to practice medicine, you must show proof of malpractice insurance. It's mandatory. What does this mean? There isn't much effort on the part of the malpractice carriers to give you a good deal. At this point in my career, with no claims against me, I am currently paying around $45,000/yr in malpractice coverage. And it gets better. Doctors have to deal with what is called "Tail Coverage." What this means is that if I go shopping around and find a better deal, or, for that matter, decide to move out of one state for another, maybe with better rates, I must either purchase a rider on my new insurance, increasing the price by several thousand dollars a month, or buy "tail coverage" from the previous carrier. This "tail coverage" is to cover any occurances that might be filed against me after I'm gone. I looked into this last summer when I moved from one state to another. My tail coverage, if I had purchased it, would have been about $135,000. One lump payment. OK, let's swing that back around to your car with the squeaky gloopa joint. You've been with Mexican Family for a few years, but just for the heck of it, you do a little shopping around, and you figure out that you can get the same insurance from State Barn. You go ahead to make the switch, and then get a bill from Mexican Family equal to about 5 yrs of insurance that you have to pay, in case some one files a claim against you for running over Rover 2 yrs ago. AND YOU MUST BUY IT. That's what tail coverage is.
About a year ago, United Healthcare was running an ad campaign that said, essentially, "we're doing all we can to keep the cost of medicine down." This coming from a company who's CEO's salary is in the 8 to 9 figure range. Have ya noticed who's building the biggest, fanciest buildings these days? I (and the entire medical field) are providing care for less than ever before. Gallbladder surgery, once a two week stay in the hospital, is now done as an outpatient. You can get your appendix out and go home the next day, where it used to be at least a week. Have a heart attack 25 yrs ago, and you'd be in the hospital for a month, now you're likely to be heading home within a week, depending on the severity. So, here I am, providing care more efficiently than ever before, your premiums are higher than ever before, and where is all the money? You tell me.
Next up: The beauracracy strikes.
Let's sweeten it up again, and we'll take a little more off the ticket. In almost every state in the union (about 45 out of 50), in order to get a license to practice medicine, you must show proof of malpractice insurance. It's mandatory. What does this mean? There isn't much effort on the part of the malpractice carriers to give you a good deal. At this point in my career, with no claims against me, I am currently paying around $45,000/yr in malpractice coverage. And it gets better. Doctors have to deal with what is called "Tail Coverage." What this means is that if I go shopping around and find a better deal, or, for that matter, decide to move out of one state for another, maybe with better rates, I must either purchase a rider on my new insurance, increasing the price by several thousand dollars a month, or buy "tail coverage" from the previous carrier. This "tail coverage" is to cover any occurances that might be filed against me after I'm gone. I looked into this last summer when I moved from one state to another. My tail coverage, if I had purchased it, would have been about $135,000. One lump payment. OK, let's swing that back around to your car with the squeaky gloopa joint. You've been with Mexican Family for a few years, but just for the heck of it, you do a little shopping around, and you figure out that you can get the same insurance from State Barn. You go ahead to make the switch, and then get a bill from Mexican Family equal to about 5 yrs of insurance that you have to pay, in case some one files a claim against you for running over Rover 2 yrs ago. AND YOU MUST BUY IT. That's what tail coverage is.
About a year ago, United Healthcare was running an ad campaign that said, essentially, "we're doing all we can to keep the cost of medicine down." This coming from a company who's CEO's salary is in the 8 to 9 figure range. Have ya noticed who's building the biggest, fanciest buildings these days? I (and the entire medical field) are providing care for less than ever before. Gallbladder surgery, once a two week stay in the hospital, is now done as an outpatient. You can get your appendix out and go home the next day, where it used to be at least a week. Have a heart attack 25 yrs ago, and you'd be in the hospital for a month, now you're likely to be heading home within a week, depending on the severity. So, here I am, providing care more efficiently than ever before, your premiums are higher than ever before, and where is all the money? You tell me.
Next up: The beauracracy strikes.
Friday, April 10, 2009
Breaking the intern
Well, here it is, 8:00p, and I'm home for the day. I'm on call today and through the weekend, I've already cleared my pager twice, about 40 calls so far. I started the day with rounding at one hospital, removing a gallbladder (a "lap chole"), several scattered patients in my office, and rounds and a couple of consults at the other hospital. All in all, a moderate day, hopefully the pager will settle down and I'll get a decent night's sleep. Lately, when on call, my pager has managed to wake me about once an hour throughout the night. Really smart doctors, one's who go into fields where they don't take call, have studied this. They took healthy volunteers (read: poor college students), hooked them up to monitors, and everytime they started to fall into dream sleep, they'd wake them up. Within a few days, they were pretty much fried, bleary eyed, drooling, unable to concentrate, mean and crabby. Call is pretty much the same thing. In residency, where they take medical school graduates and teach them to be real doctors, call was traditionally 1 in 3, or if you really had it bad, 1 in 2. This led to the dunkin donuts man syndrome, where you eventually run into yourself going out the door as you're coming in. It was perpetuated by the same logic that has killed freshman and rookies for a hundred years-- I survived, you can survive, get over it. What this means in real terms is that starry eyed dreamers who were going to save the world and make it a better place for mankind had this attitude beaten out of them, until they simple look to morning's light as a sign they are still alive. I entered my training in the days of old. I reported for duty July 1 at 0600. I got home around 1000p that night. This went on for 3 days, and then, glory to God, my chief told me I could have the 4th off. I fell asleep at 1030p that night, about 15 minutes after I walked through the door. My pager went off at midnight after just an hour and a half of sleep. As I looked at my pager and the clock showing midnight (exactly), I thought, what kind of rotten trick is this to play on the intern? It wasn't. I wound up covering a trauma for back up while the regular trauma team took care of other patients. I finally had that patient tucked in to a bed in the SICU (Surgical Intensive Care Unit) around 400am, and was back in my bed by 5a. so much for the 4th, I slept through half the day. When I returned to work the following day, I launched into what would turn out to be two and a half months without a day off, working 16 to 18 hr days, with call (ie, up all night) every third day. I completed the rest of my training on pretty much this schedule, though there were the occasional rotations where call dropped to one in four or, rarely, one in five.
My senior year dawned a new light. There was change in the air. The government, acting in the best interest of the people, were enacting tough new standards for resident education. These new rules limited residents to an 80 hr workweek, and forbid working more than 30 hr straight. Being in a very forward looking residency, we started working by these rules in January of my last year. It made for a rather nice year, and I wound up my residency taking call about once a week. These rules were enacted after a couple of highly publicized deaths involving residents that were severely sleep deprived and trying to care for patients. There was a great deal of debate involved in these changes being made, much of involving "continuity of care," meaning decisions on your care are made by someone who knows every detail about you, what's been done, what hasn't, the drugs you're on, your allergies, your spouse's name. It was finally decided that continuity wasn't as important as being bright eyed and bushy tailed, and so the new hours were instated. So what's the post script? Several studies done since the change have shown no improvement in deaths or complication rates, or an actual worsening.
More fun for those of us who made it through, we take comfort in knowing that, having been there, we can do it again when we are faced with no options in our private practice, which is still pretty common in much of the country. While there have been plenty of times in the few years since entering practice I would have really loved to have quoted those resident hour rules back to the ER doctor calling me, the simple truth was, if I didn't stay up, or get out of bed, to take care of little Tommy's appendix, it wasn't going to get done. "Sorry folks, I know little Tommy's hurting pretty bad, but, hey, I just hit the 24 hr mark, and I won't be able to operate for the next 10 hrs. I sure hope his appendix doesn't rupture before I'm allowed to operate again. People reading this in big cities may not appreciate this, but in the rural communities which make up pretty much all of the midwest, one or two surgeons covering everything within a hundred miles is not unusual. And this shortage is only going to get worse, as fewer and fewer young doctors chose this lifestyle. In most fields, as the number of trained individuals available to fill a position decreases, the pay for those individuals goes up. Not so in medicine. For the last 5 or so years, every year dawns with the theat of huge medicare cuts. There have been reprieves every year, but this reflect more just that there was no cut in funding, not that an appropriate cost of living increase took place. If the government is so short on cash, why aren't they cutting congressional salaries, perks, and pensions?
OK, my pager is going off again, so I think I'll wrap this up here. Next up: Paying your mechanic the way your insurance company pays me. And other dirty tricks you don't know about.
My senior year dawned a new light. There was change in the air. The government, acting in the best interest of the people, were enacting tough new standards for resident education. These new rules limited residents to an 80 hr workweek, and forbid working more than 30 hr straight. Being in a very forward looking residency, we started working by these rules in January of my last year. It made for a rather nice year, and I wound up my residency taking call about once a week. These rules were enacted after a couple of highly publicized deaths involving residents that were severely sleep deprived and trying to care for patients. There was a great deal of debate involved in these changes being made, much of involving "continuity of care," meaning decisions on your care are made by someone who knows every detail about you, what's been done, what hasn't, the drugs you're on, your allergies, your spouse's name. It was finally decided that continuity wasn't as important as being bright eyed and bushy tailed, and so the new hours were instated. So what's the post script? Several studies done since the change have shown no improvement in deaths or complication rates, or an actual worsening.
More fun for those of us who made it through, we take comfort in knowing that, having been there, we can do it again when we are faced with no options in our private practice, which is still pretty common in much of the country. While there have been plenty of times in the few years since entering practice I would have really loved to have quoted those resident hour rules back to the ER doctor calling me, the simple truth was, if I didn't stay up, or get out of bed, to take care of little Tommy's appendix, it wasn't going to get done. "Sorry folks, I know little Tommy's hurting pretty bad, but, hey, I just hit the 24 hr mark, and I won't be able to operate for the next 10 hrs. I sure hope his appendix doesn't rupture before I'm allowed to operate again. People reading this in big cities may not appreciate this, but in the rural communities which make up pretty much all of the midwest, one or two surgeons covering everything within a hundred miles is not unusual. And this shortage is only going to get worse, as fewer and fewer young doctors chose this lifestyle. In most fields, as the number of trained individuals available to fill a position decreases, the pay for those individuals goes up. Not so in medicine. For the last 5 or so years, every year dawns with the theat of huge medicare cuts. There have been reprieves every year, but this reflect more just that there was no cut in funding, not that an appropriate cost of living increase took place. If the government is so short on cash, why aren't they cutting congressional salaries, perks, and pensions?
OK, my pager is going off again, so I think I'll wrap this up here. Next up: Paying your mechanic the way your insurance company pays me. And other dirty tricks you don't know about.
Thursday, April 9, 2009
Welcome to Doc's Page
Aaaahhhhh, the end of the workday. I hope. My day started with rounds 12 hrs ago, and, if all goes well, is now done for the day. I've poured a glass of my favorite adult beverage, and am going to sit and relax for a little while before attacking the mail and a dozen other chores around the house.
But let me introduce myself. I am a General Surgeon, living and working in a small community in the Midwest. While that may seem a little vague, so it must be if I am to do with this blog what I intend, which is to tell the tales of my life and work (mostly work), some sad, some maddening, some comical, I must maintain a certain degree of anonymity so as to avoid a dredded breach of confidentiality and a certain HIPPA violation. (More about HIPPA later) I'm quite certainly going to wind up on some political soapboxes along the way. The opinions expressed here are quite certainly my own, please feel free to disagree at any time. It's a well known fact in the medical community that if you want two opinions, ask two doctors. You'll get them.
More importantly, though, is a desire to journal the life of a surgeon, and the factors that shape us and our work, the issues that drive us nuts, the things that we really want to say, but don't, because you'll get pissed off at us and walk out of our office. I certainly want to highlight some of the absurdities that the lawyers, politicians, beaurocrats, and insurance companies have propagated upon the unknowing public, much to the expense of the public, both in money and in health. I also want to try to show you all just what is involved in being a doctor today--for instance, the fact that my pager just went off, even though I'm not on call tonight. Most people today have an impression of medicine derived from one part Marcus Welby, 3 parts "ER", 4 parts "Grey's Anatomy," and 5 parts "House". Second page in 5 min. Hang on a second.
OK, I'm back. Well let's see. I vaguely remember Ol Doc Welby, saintly, always there, all knowing. What a great age that was. Oh, and that was also before Medicaid and lawyers. Truly a golden age, but alas, now gone.
ER. ER hit the airways the year I started Med School. Every Friday morning, my classmates and I would sit around and analyze the previous night's adventures, compare them to our cases and studies, and unaminously assign last night's disease du jour to one of our patients. It was haled as "gritty," and "realistic", and in those early days, I guess it was. But I haven't watched it in years, and what little I've heard of it certainly doesn't impress me as real.
Grey's Anatomy. Have never seen it, haven't ever seen anything that suggested it was worth wasting an hour of my time. What little I have heard and seen of it, screams "soap opera!" And, hey, hospitals make for great soap operas.
House. Another show I've never seen a full episode of, and what I have seen was probably sitting in a surgeon's lounge, waiting to start a late evening Appendectomy. Pertinent observations-- Ooops, hang on, another page. OK, observations. 1) House is an arrogant, pushy ass, and would be kicked out of any current day hospital as a "disruptive physician," a label that would just about end his medical career, no matter how good he is. 2) House has managed to get miracle, just developed cures from drawing board to patient in a single episode. That's damn good, considering it takes the standard pharmaceutical company a company several million dollars and several years to do the same thing.
What does this all mean? That people really have no clue about what a doctor's life really is. And that's what I'm going to try to show. OK, I'm back just took another page, and a phone call from another doctor, to discuss a patient with no good answers. As a matter of fact, this is a great case to open a discussion of a doctor's life.
Ms. Green (no, not her real name), is a 90 year old lady. She's pleasantly demented, which medically savvy people will recognize as meaning, "she's clueless, but she doesn't cuss, spit, or try to hurt you." She was admitted several days ago with nausea and abdominal pain. The cat scan done at the time suggested that she has some intestines that are not getting enough blood, and are almost dead, or are getting no blood, and are dead. From a clinical perspective, she certainly doesn't look that sick. But by the book, she probably should be operated on, to determine if this really is the case, and, if so, to remove the dead gut. But here's the glich. She won't survive the operation. Oh, sure, I'll get her off the table, and into the ICU, but she won't leave the hospital alive. Now, she's just had another cat scan, and it shows a slightly less pretty picture. So the question is, what should I do when the family says, "save her. do everything. spare nothing." Am I doing Ms. Green any favors? I certainly don't think so. Am I practicing "responsible" medicine, trying to make the most effective use of your taxpayer's dollar? I don't think so, either. I know what I'm going to do, I can only pray that the family agrees with that course, and I don't wind up doing CPR on a 90 yr old lady who will not leave the hospital alive.
OK, I'm going to get to those chores and mail I mentioned about an hour ago. Next installment (if I remember): How I got here, or, the breaking of a starry eyed intern.
But let me introduce myself. I am a General Surgeon, living and working in a small community in the Midwest. While that may seem a little vague, so it must be if I am to do with this blog what I intend, which is to tell the tales of my life and work (mostly work), some sad, some maddening, some comical, I must maintain a certain degree of anonymity so as to avoid a dredded breach of confidentiality and a certain HIPPA violation. (More about HIPPA later) I'm quite certainly going to wind up on some political soapboxes along the way. The opinions expressed here are quite certainly my own, please feel free to disagree at any time. It's a well known fact in the medical community that if you want two opinions, ask two doctors. You'll get them.
More importantly, though, is a desire to journal the life of a surgeon, and the factors that shape us and our work, the issues that drive us nuts, the things that we really want to say, but don't, because you'll get pissed off at us and walk out of our office. I certainly want to highlight some of the absurdities that the lawyers, politicians, beaurocrats, and insurance companies have propagated upon the unknowing public, much to the expense of the public, both in money and in health. I also want to try to show you all just what is involved in being a doctor today--for instance, the fact that my pager just went off, even though I'm not on call tonight. Most people today have an impression of medicine derived from one part Marcus Welby, 3 parts "ER", 4 parts "Grey's Anatomy," and 5 parts "House". Second page in 5 min. Hang on a second.
OK, I'm back. Well let's see. I vaguely remember Ol Doc Welby, saintly, always there, all knowing. What a great age that was. Oh, and that was also before Medicaid and lawyers. Truly a golden age, but alas, now gone.
ER. ER hit the airways the year I started Med School. Every Friday morning, my classmates and I would sit around and analyze the previous night's adventures, compare them to our cases and studies, and unaminously assign last night's disease du jour to one of our patients. It was haled as "gritty," and "realistic", and in those early days, I guess it was. But I haven't watched it in years, and what little I've heard of it certainly doesn't impress me as real.
Grey's Anatomy. Have never seen it, haven't ever seen anything that suggested it was worth wasting an hour of my time. What little I have heard and seen of it, screams "soap opera!" And, hey, hospitals make for great soap operas.
House. Another show I've never seen a full episode of, and what I have seen was probably sitting in a surgeon's lounge, waiting to start a late evening Appendectomy. Pertinent observations-- Ooops, hang on, another page. OK, observations. 1) House is an arrogant, pushy ass, and would be kicked out of any current day hospital as a "disruptive physician," a label that would just about end his medical career, no matter how good he is. 2) House has managed to get miracle, just developed cures from drawing board to patient in a single episode. That's damn good, considering it takes the standard pharmaceutical company a company several million dollars and several years to do the same thing.
What does this all mean? That people really have no clue about what a doctor's life really is. And that's what I'm going to try to show. OK, I'm back just took another page, and a phone call from another doctor, to discuss a patient with no good answers. As a matter of fact, this is a great case to open a discussion of a doctor's life.
Ms. Green (no, not her real name), is a 90 year old lady. She's pleasantly demented, which medically savvy people will recognize as meaning, "she's clueless, but she doesn't cuss, spit, or try to hurt you." She was admitted several days ago with nausea and abdominal pain. The cat scan done at the time suggested that she has some intestines that are not getting enough blood, and are almost dead, or are getting no blood, and are dead. From a clinical perspective, she certainly doesn't look that sick. But by the book, she probably should be operated on, to determine if this really is the case, and, if so, to remove the dead gut. But here's the glich. She won't survive the operation. Oh, sure, I'll get her off the table, and into the ICU, but she won't leave the hospital alive. Now, she's just had another cat scan, and it shows a slightly less pretty picture. So the question is, what should I do when the family says, "save her. do everything. spare nothing." Am I doing Ms. Green any favors? I certainly don't think so. Am I practicing "responsible" medicine, trying to make the most effective use of your taxpayer's dollar? I don't think so, either. I know what I'm going to do, I can only pray that the family agrees with that course, and I don't wind up doing CPR on a 90 yr old lady who will not leave the hospital alive.
OK, I'm going to get to those chores and mail I mentioned about an hour ago. Next installment (if I remember): How I got here, or, the breaking of a starry eyed intern.
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