Monday, March 24, 2008

Fact is stranger than fiction

    The endless parade of interesting, fascinating and odd characters with whom one interacts in this profession could literally provide fodder for a soap opera series. I find human behavior riveting. I might have been a psychiatrist but for one failing. As much as I like listening (which is a prerequisite for psychiatry), I just love talking. And in my anesthetized patients I have found a captive audience who can not interrupt me. The surgeons also make an appropriate audience because they aren’t going anywhere. The only drawback is that surgeons sometimes talk back (if they don’t know what’s good for them). I have a reputation for a passable sense of humor and use it to diffuse some of the tension in the OR. My wife, on the other hand, has no sense of humor as I have pointed out to her frequently. She, however, always makes the relevant point that she did marry me after all. I have yet to come up with an appropriate retort for that one.
     So, back to the patients. One night, after finishing the last of several urgent operations, I received a phone call from a very, very, very, very junior surgical resident (meaning: he started his residency that month). He was concerned about one of the patients who had undergone an emergency appendectomy earlier. He said, “The patient isn’t moving.” I then suggested, “Pronounce his death and let me get some rest for God’s sake.” “No,” he said, “it’s not that, he’s alive, he’s just not responding to me.” I thought to myself, “If I were your patient, and if I knew that you were the most inexperienced doctor in the hospital, I wouldn’t respond to you either.” No, I’m not that mean spirited, I didn’t actually say that to him, but I do get cranky at 3:30 AM when I haven’t gotten my beauty rest. “Oh, alright, I’ll be right up.
     I had not been involved with that particular patient’s anesthetic, so I asked the doctor who had, to meet me on the surgical ward. I found the resident and asked him to show me to the gentleman in question. I found a young Bedouin man lying in bed staring at the ceiling with his mouth open. After noting his normal breathing and skin color, I just had to have some fun with the resident (after all, it was 3:30 in the blessed AM). “Are you sure he’s not dead? He looks dead to me, did you take a pulse, did you measure his blood pressure, and have you informed the next of kin?” The look of abject failure made me feel sorry for the kid. “Don’t get yourself in a fit. He’s alive, I’m pretty sure of that. Now watch and learn.”
     “Ahmed, I’m Dr. ____. How are you feeling?”
     No response.
     “Is his name Ahmed?” I asked the resident.
     “No, it’s Faiz (not his real name to protect the patient’s privacy).” He replied.
     “Well, the first lesson is to always address the patient with his correct name.”
     “Faiz, can you hear me?”
     No response.
     I took Faiz’s hand and held it over his face. Faiz held his hand in the same position until I returned it to his side. Then, I positioned his other hand straight up, and again he held the position. When I bent the elbow, Faiz looked as if he were reading a menu in bed. Turning to the resident, “Do you understand what you have just witnessed?” I saw a complete blank on the resident’s face, but to save face he replied in the affirmative. “Don’t worry, you don’t have to know everything in your first week. It’s called catalepsy, look it up. It might be a reaction to the stress of being hospitalized and operated on.”
     “Call for a psych consult if you want. It’s not an anesthetic complication. It’ll probably pass in couple of hours anyway.” At this the nurse in charge of the shift got her hackles all up in a frenzy. “You take him back to recovery, it is an anesthetic complication. We sent you a perfectly fit patient to the OR and this is how you sent him back?”
     “OK, cool your jets, he left recovery completely conscious. There is no reason to move him back down to recovery.” I will spare the reader the barrage of epithets, threats, histrionics and general mayhem flung in my general direction. By this time the rest of the shift nurses were ganging up on me. I called for back up, “bring the senior surgeon on call here and let him decide.” He did, and it was not to the nurse’s liking. “I’ve been a nurse for 20 years and I’ve never seen anything like it.”
     “Just because you’ve never seen this phenomenon doesn’t mean it doesn’t exist.” I replied.
     This assault on her professionalism just inflamed the situation and I was subjected to another barrage of what she thought of me. I just don’t know when to shut up (but that’s why I went into anesthesiology in the first place remember?) Let’s just say that I was no longer her favorite anesthesiologist and leave it at that. “I’m standing firm by my decision. Call psych if you want. I’m going to sleep. Good night.”
     When morning came around, I groggily called the senior surgeon to ask about the patient. They had called for a psych consult, but by the time the psychiatrist had reached the ward, the patient returned to his normal state (which was apparently not so normal, as the surgeon confessed, that the patient had been hospitalized for a week with no diagnosis and had been acting strangely. The appendectomy was performed as a last resort because of increasing abdominal pain and no other obvious diagnosis. The said appendix was, as to be expected, completely normal.)


Thursday, March 13, 2008

The Soldier

My home computer has gone comatose. I formated, reinstalled windows (grrrr), prayed, threatened. Now it's just confused, but just as useless. This explains the lack of blogging. In addition, I'm doing a rotation in the pain clinic in another hospital. It involves quite a lot of commuting, so by the time I get home I only have time to help the Mrs. with the three musketeers. Unless, of course I'm on call. So if I find a rare quiet moment at work, I can blog there.
Last Thursday I drove from the center of the country back to Be'er Sheva to be on call in the ICU. There was a lot of activity surrounding an injured soldier. Both Treppenwitz and A Soldier's Mother mention him in their blogs. My first thought was how I miss the action and adrenaline of the emergency cases. 14 hours later, this feeling would pass. The chief of the ICU and the deputy chief stayed on until the wee hours of the night. Army medical corps officers were on hand to help getting drugs that were running low. Four nurses never left the side of his bed. The flurry of activity lasted all through the night. We all knew that the chance for survival was almost non-existent. But we never stopped working. The problem was uncontrolled bleeding. The vicious cycle of bleeding, consumption coagulopathy (depletion of clotting factors), hypothermia and metabolic acidosis was full blown. Each limb feeds on the others and all must be treated simultaneously. Thus the intense effort to try to save this young man.
For all of us he could be a comrade, a friend, a son. All of us felt it, and it was implicitly understood and unspoken. In this small country, almost everyone has lost a friend or a relative in battle or in a terrorist bombing. So everyone's son is our son as well. We might not know the same pain as the parents of this soldier but we will be acutely aware of it. And so, we never gave up trying.
At five in the morning, he started to bleed again. I ordered another set of units of blood, plasma, thrombocytes and clotting factors from the blood bank. The technicians in the blood bank were, to me, just disembodied voices on the phone. But they too had worked around the clock preparing the blood products. And when the bank was empty, they had more sent by taxi from the central blood bank.
By the time I finished morning rounds the soldier had received over 50 units of blood and hundreds of units of other blood products. I went home exhausted. Another doctor would take over.
The next morning I was in the clinic. I called the ICU to find out how the soldier was faring. He had died just minutes before my call. The feeling was one of frustration combined with emptyness, as if a huge hole had just swallowed his soul. Despite this, I wouldn't hesitate doing it all over under the same circumstances. Because. Because another man's son might have been my son.
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