Friday, June 27, 2008

The "eyes" have it.

The last on-call was full of action. But there is such a thing as too much of a good thing. The phone rang from the trauma room. In ten minutes a blast injury victim will be brought in. For the third time this month a Bedouin has "encountered" an unexploded shell. These are not citizens innocently exploding. These are criminals who knowingly risk life and limb and enter the army's training fields for one of two reasons: One is to strip old armored vehicles used as targets for their iron and sell it (iron prices have skyrocketed recently). The other is to try to retrieve explosive material from unexploded ordinance to sell to the terror organizations.
A 51 year old semi-conscious man was brought in. Full of shrapnel holes, right leg broken, a finger or two mangled, left eye looks like mush, pools of blood forming around him and most importantly an expanding hematoma in the neck. While the surgeons examine him I ask the nurses to prepare the intubation tray and as an afterthought, "have the emergency tracheotomy tray on standby and page the ENT guy to get here now!" The drugs are in and the patient loses consciousness. Opening the mouth with the laryngoscopy my instincts were right: the hematoma in the neck obliterated the anatomy so I can't see the vocal cords. I try a blind intubation and miss. The ENT guy runs in. "No go, you'll have to perform an emergency tracheotomy." The cricothyroid membrane identified, an incision made and the tracheotomy tube passed into the trachea. The patient is stable, there is no evidence of internal bleeding so we transport the patient to radiology for a total body CT. Except for the bleeding in the neck there is no evidence of additional bleeders. There is shrapnel all over the head and neck including two in the brain with no hematoma or edema, so no need for neurosurgery. In the operating room, two teams work simultaneously. The orthopedic surgeons internally fixate the broken tibia and the ENT surgeons explore the neck. They find lacerated lingual and facial arteries only millimeters from the carotid. A millimeter in the wrong direction and this man would have died even before being evacuated. More luck than brains, that's for sure.
It's midnight, I've been working on this guy for 8 hours. ENT and orthopedics are done. We transfer the patient to the ophthalmology OR (their special operating microscope can't be moved so we must bring Mohamed to the mountain in this case). The policy is to try to repair the eye even if it isn't functional, for aesthetic reasons. It's going to be a really long night. The surgeon begins the tedious process of suturing the eye with ophthamology's Amazing Invisible Sutures (tm). These sutures can't be seen with the naked eye and to tell the truth I don't believe that they are actually there. Oh wait, the TV monitor is hooked up to the microscope. They really are suturing what looks like a bowl of jello.
"That's the eye?" I ask.
"Yup, that's it."
"And it's going to look like an eye?"
"Yup, in about 3 or 4 hours."
(Talkative, aren't they?)
At three AM I literally can't keep my eyes open (ironic isn't it?). I drink some water, walk around look at the mush on the TV screen, hey, it's starting to look like something. Every time I sit down, I fall asleep. OK so I won't sit down.
Four AM, we've been at it for 12 hours. I call up to the general OR where they've been busy too. When we finish the next case, an amputation, we'll send someone to relieve you.
Five AM, hooray, they've finished the eye and my relief walks in. I run down the injuries and surgery that's been done. Now all that's left is to suture the eye lids ("only" 4 more hours of work.) "Good luck, I'm going to get some rest".
The next day is for recovery from the on call.
More or less rested, I come in to work. I've been assigned to urology. The first case: A five year old scheduled for uretheral implant (she has a double system from her left kidney and so she "leaks"). The problem: she was born with Transposition of Great arteries (that's where the main arteries arising from the heart, the aorta and the pulmonary, are reversed). She had corrective surgery, but she still has residual defects that might complicate major surgery. Everything goes well.
The next case is exploration of the retroperitoneum to excise a tumor. These operations are usually accompanied by significant bleeding. After inducing anesthesia I put in a big IV line and an arterial line. The surgeons are having a tough time exposing the tumor (previous operations resulted in adhesions), but finally expose it. There was about a 1.5 liters of bleeding but adequate fluid rescucitation and only one unit of blood later the tumor is out. While closing I administer morphine for post op analgesia. I wake the patient and extubate.
The surgeon (the chief of Urology, no less!) Thanks me. "It's good to have you on board, it gives us peace of mind which is important in such a tricky operation."
Wow! Surgeons are notoriously stingy with compliments, so this is a rare occurance.
It's nice to be appreciated.

Thursday, June 12, 2008

No, not that four letter word, the other one

T. from Anesthesioboist submitted an excellent thought provoking post on the 4 letter "F" word, no not that one, the other one. This isn't a spoiler, the post was featured on the latest SurgeXperiences blog carnival on this very site (just scroll down) so I assume most of you have read it. I agree completely with her but would like to add my 2 own shekels worth.
The word is fear. And doctors aren't supposed to fear...anything. But fear is there. Sometimes it's "normal", for example, fear of failure, fear of causing a patient pain, fear of losing a patient (all the more acute in the case of children) etc. But perhaps fear isn't the only emotion we are denied, there is also anxiety. I believe that some fear, especially when faced, is healthy, it spurs us to be better doctors, to increase our knowledge to improve our proficiency. But too much fear and anxiety can be counterproductive and even dangerous - it paralyzes the mind when quick action is warrented, for example, during an emergency.
This can happen during anesthesia, on the ward, on the street, anywhere. At our institution, anesthesiologists are part of the code team which responds to cardiac arrest, and we do on-calls in the mobile intensive care ambulance. So I have quite a few emergencies under my belt. In addition, I am an ACLS (Advanced Cardiac Life Support) course instructor. This is mandatory in many institutions for doctors. One of the most important points that I convey is the the necessity for keeping a cool head when others around you aren't. During an arrest, which is the quintessential emergency, the worst thing to do is to show indecision and fear. It is natural to feel anxiety at such a moment, but, I teach my pupils, the tempest inside should remain there at least during the event. I point out that very few people are actually born with nerves of steel. Fear can be, and should be mastered for such situations. To paraphrase Shakespeare, "Some men are born cool, some achieve cool, and some have cool thrust upon them." Remaining cool during an emergency obviously relies on inborn character traits. But most people can actually learn and perfect cool and this ability improves as one acquires more experience and proficiency.
During a code it is important not to bark orders to the junior members of the team whether doctors or nurses. These may be at various stages of training and experience and an abusive, vain, humiliating team leader may scar them for life (causing them to be useless until pension).
After a code, it is essential, in my opinion to gather the code team and have a short feedback session, and yes, even talk about feelings. I came to this conclusion after a case where I was on call in the ambulance and we were dispatched to take over for EMT's performing CPR on a homeless man in a hostel. The ambulances here also include volunteers, many of whom are high school students. There is some wisdom in teaching the lay public basic life support, but we never take into account that these children are still developing not only physically but also emotionally. Upon arrival at the scene, it was obvious to me that the patient was not responding and that I would soon "call the code" (i.e. cease rescustitation). I allowed both teams to continue for a few more moments so that the younger members could get some valuable experience in rescusitation techniques. While the paramedic was writing up the report, I noticed one of the volunteers crying. I asked the EMT in charge of her what was the matter. He said that she felt that the man died because she didn't perform adequately.
I took her aside and asked her what was wrong. Through a monsoon of tears she let out all of her feelings of failure and inadequacy. When the torrent abated, nose blown and tears wiped, I told her that first of all, she did everything that was expected of her and she did it correctly. Secondly, from my examination, I could tell that the victim was a drug addict. Life had dealt him a lot of bad luck, or he had thrown his life away. Either way it was not her, or our, fault that he died. We just have to do our best. I told her that it was ok to feel bad, it meant that she is sensitive to others' suffering, and that in itself is not a sign of weakness, it is a rare trait. I emphasized that there is no shame in feeling what she feels. Everyone has a niche in this world. And she has quite a few years left to discover hers. I offered her two choices: 1. To accept what happened, to realize that a tragedy happened to that man and to go on. Or, 2. Leave the ambulances and volunteer in some other activity and under no circumstances should she feel less of herself for doing so. My intention was to provide her a way out while maintaining her dignity. I found out a few weeks later that she had left the ambulance service.
Since then, I always gather the team for a feedback session.
Hubris, in medicine, is the original sin. The only thing that disgusts me more than incompetence in a physician is vanity. Hubris is born of fear. Fear of exposure, fear of failure and fear of showing weakness. When you see a vain person, scratch the surface (one may need an ice pick) and you will discover a coward. Not a coward in the sense of external bravery, but one who won't face his/her own failings. Such a person has stopped growing, learning and improving. When that happens, our greatest fear, of harming our patients, is most likely.

Saturday, June 7, 2008

SurgXperiences Blog Carnival

Welcome to the June 8, 2008 edition of surgexperiences.

So, I've taken the plunge and am hosting my first blog carnival. Many moons ago I was a philosophy major so I asked bloggers to submit posts with a more introspective and philosophical approach to medicine. I'm pleased to report that the SurgXperiences bloggers have met the challenge.

James Moore presents ... your angel is simply watching. posted at Spiritual Passages Part of a series on dying and life after death, This fascinating post describes near death experiences and what they are.

Øystein Horgmo , a medical cinematographer, presents Detachment posted at The Sterile Eye. Muses on remaining "detached" when witnessing the suffering and misfortune of others.

Jeffrey Leow provides a lesson on the eponyms associated with the famous Jean-Marie Charcot in: Charcot and Reynold posted at monash medical student.

Chris cites a recent article in: Everything I needed to be a surgeon I learned in kindergarden posted at Made A Difference For That One: A Surgeon's Letters Home From Iraq, saying, "It describes several hospitals that experienced decreased malpractice claims and settlement amounts after adopting a policy of full disclosure of complications and apologizing to the patient. It surprises me that anyone would ever follow a policy of concealment and refusal to apologize. " He points out that this is also called: Lying

Charles H. Green refers to the same New York Times article in
What Malpractice Suits Teach Us About Trust posted at Trusted Advisor Associates
He points out another interesting facet, "In other words, the motives of an apology are immediately undercut for the sake of a self-oriented outcome. The apology becomes impure: input is destroyed for the sake of an output. Lowered malpractice costs are no longer a byproduct, they become a goal. All sincerity is lost. And malpractice rates will go up, but with a higher-still level of cynicism."

David Khorram presents Carl Talk and the Folly of Aid posted at
Marianas Eye. This post deals with some of the pitfalls of working for aid organizations.

T. discusses The "F" Word posted at Notes of an Anesthesioboist. What's the "F" word? You'll just have to read the post to find out, won't you?

On the lighter side,
bongi prolifically (is that a word?) provides two posts:
gee thanks and small cut, big surgeon? posted at
other things amanzi. Bongi's wit is self evident.

In I'd like to donate my organs... at The Paper Mask,
Sheepish ponders options for organ donors when their organs are not suitable for transplants.

D. Singh points out the danger of putting one's medical information online in
Google Health Launched. Can We Entrust our Health to Google? posted at Internet Marketing Blog, saying, "Google has entered into the fray of online health record service via a simply branded service, Google Health. Google Health aims to empower us in managing our health information. Google Health proposes to store all this information in a secure and private environment. It even promises that it won’t sell our data."

For those who still need their fix of practicality, rlbates, another prolific blogger sent in two posts: High Pressure Injection Hand Injuries and Abdominal Wall Reconstruction posted at Suture for a Living.

Ian Furst too, offers practical advice in Wait Time & Delayed Care: Block Booking for Procedural Patients posted at Wait Time & Delayed Care, saying, "It's about how to block book for procedural patients and control their wait time. Thanks Ian."

I hope you enjoyed this edition of SurgXperiences blog carnival. Thanks for the submissions and keep blogging!
I have to make a confession: I took advantage of the Instacarnival [beta] feature. Made things a whole lot easier. Hah!

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