Friday, October 30, 2009

The Sickth Sense

Every once in a while, I run across an old friend or meet someone new, and after they compliment me on marrying well above my pay grade, the conversation turns to work. "What type of doctor are you" is a very frequent question, and I admit I don't have an answer that is terribly complete and accurate. "I'm a general surgeon," I usually say, adding "that is a very nonspecific name for what I do." Because I have much difficulty describing my profession, I usually throw out a laundry list of things that may cause a patient to come see me --- colon cancer, thyroid mass, gallstones, hernia, stabbing, car crash, etc. It is sometimes easier for me to describe one part of what I do, rather than the whole chalupa. So, here's a little bit of what I do for a living:

I see (near)dead people.

When on call, the types of not so sick, ill, very ill, or desperately sick patients I may be asked to see may include
  • a person having an acute myocardial infarction who has severe belly pain
  • a young lady 3 weeks postpartum with gallstone pancreatitis
  • a previously healthy lady 3 days postop from a difficult hysterectomy, tachycardic, tachypneic, with peritonitis and a plummeting white blood cell count
  • one of my own patients with severe shortness of breath a few days out from an uncomplicated colon resection
  • an elderly gentleman with a small bowel obstruction
  • an elderly lady 4 days out from a total hip replacement with Ogilvie's syndrome
  • a patient on a ventilator with sepsis from pneumonia who may or may not have an intraabdominal catastrophe
  • a patient pancytopenic from chemotherapy with a GI bleed
  • a middle aged person involved in a high speed MVA, white as a ghost and with a blood pressure approaching levels seen in invertebrates
  • the passenger in the same MVA who is hemodynamically stable but complaining of back pain and tingling in their toes
  • a patient on chronic narcotics complaining of abdominal pain well out of proportion to their examination
  • a patient with severe Clostridium difficile colitis and diarrhea with a WBC count in the 20s
Which of these patients needs surgery now? Later? At all? Who needs a CT, an angiogram, transfer to the ICU, an endoscopic evaluation? Who is at risk to die in the immediate future if surgery is delayed? Who has a high risk of death if taken to the operating room? And, who are you gonna call to make those decisions? Me, or somebody like me.

So, what do I do in these situations? Once again, there is not a simple explanation. Obviously, the patient has to be seen and all available information reviewed --- history, labs, imaging studies, etc. But I suppose that there is also a difficult to define aspect to evaluating these types of patients, which is not tangible or quantifiable. It is the need to see a patient and relatively quickly determine "how sick" they are.

Call it a 6th sense -- or Sickth Sense -- if you like.

Am I an expert at this, a true Clever Hans of the hospital? Oh, not in the least. But I am better at this now than I was, say, 15 years ago when I started practice. No doubt, this is a skill that hopefully I have honed a bit over the years. Medical problems in surgical patients such as a postoperative MI, pulmonary embolism, aspiration pneumonia, etc. require careful evaluation and care, but most of the time can be distinguished from acute surgical emergencies.

Am I always right? Not to sound Clintonesque, but that sort of depends on what your definition of "right" is. Let me give you an example. Let's say that the elderly gentleman with a bowel obstruction also has chronic lymphocytic leukemia, making his WBC count unreliable in determining acute illness. And let's say his abdominal exam is questionable, and he's a bit more tender than I'd like to see. And let's also say that he states he's miserable, hasn't felt this bad ever in his life, and can't get comfortable. With this scenario, a trip to the OR is very reasonable --- pain out of proportion to his exam can indicate that some of his small intestine may not be viable at this point. But let's say a simple bowel obstruction was found and corrected, and all of his bowel was healthy, and even that perhaps with time the obstruction would have resolved without surgery. Was his surgery necessary? Was it the "right" decision to go to the OR?

Yes! And, perhaps, no. If such a patient were to suffer a postoperative complication, such as a wound infection, pneumonia, or MI, then we tend to second guess ourselves. Our "sickth sense" is not infallible, and it is often much more difficult to not take someone to the OR than it is to go ahead. An old surgical aphorism that describes this impetus is

Never let the skin get between you and a diagnosis.

About as subtle as a rocket launcher, that one. I prefer to look upon these situations as comparative ones --- what is the worst thing that could happen if we take this patient to the OR versus what is the worst thing that could happen if we don't? Most of the time, we have to come down in favor of surgery, as patients with intraabdominal disasters don't tend to do well when watched.

In short, if I am going to be wrong, I'd rather it be a "sin of commission" rather than a "sin of omission."

I'll freely admit it, I have sinned plenty in this way. But have mercy and please cast no stones at this poor sinner. After all, I'm already spending plenty of time in atonement in the hospital's equivalent of purgatory ---- the Emergency Department.