Friday, October 30, 2009

Bastards

There can be no simpler example of why the new healthcare "reform" bill has nothing to do with reform whatsoever than this :

...Pelosi’s bill has an anti-tort-reform measure. On pages 1431-1433 of the 1990 spellbinder, there is a financial incentive for states to try “alternative medical liability laws.” But look — you don’t get the incentive if you have a law that would “limit attorneys’ fees or impose caps on damages.” That’s what the trial lawyers get for the millions spent in supporting the Democratic party, and that’s what tort “reform” in the Alice-in-Wonderland world of health-care legislation amounts to. States will be strong-armed into repealing existing caps in order to get the Fed’s money. Sweet, huh? Well, unless you thought the aim was to reduce medical costs. No, this will go a long way toward ensuring that tort lawyers remain rich, malpractice insurance remains high, and unnecessary defensive medicine remains a fixture of the health-care system.
Read it for yourself. As I have said before, Obamacare Delenda Est. These are unscrupulous, dishonorable people bent on controlling every aspect of your lives in order to maintain their power and positions. I am afraid I don't have enough control to add anything short of a very long stream of expletives. Disgusting.

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.

Wednesday, October 07, 2009

How Doctors Think? Oh, my...

Call me a nonconformist -- everybody else does. Yeah, I was the guy with long hair and a ZZ Top beard in college during the height of the "preppy" era. I even went so far as to sew an Izod alligator onto my flip flops just to be annoying. I suppose I haven't really changed. That's why I don't have a whole lotta use for books that paint physicians (or any group, for that matter) with a brush as wide as a '57 Caddy. How Doctors Think, for example, really is more a collection of one man's opinions (like this blog) than a complete investigation into what goes into everyday issues that make us doctors tick. Don't get me started on this guy, either, whose deeply flawed study on checklists in the OR has unfortunately been adopted as Gospel without being objectively repeated and verified.

So, how exactly do I think, you may ask. The stream of consciousness in my head that passes for rational thought is populated by all of those doctors that influenced me along the way --- their images and words just fly by so fast at times I have a hard time keeping up. Here's a little preview of a typical day for me.....



Me, pissed off that we are yet again not starting on time in the OR.

Ma'am, we are surgeons and we are here to operate. We're just waiting for a starting time. That's all.




Me, talking to an administrator.

You're hiding... hiding behind rules and regulations. ...Logic? My God, the man's talking about logic; we're talking about universal Armageddon! You green-blooded, inhuman...




Me, seeing someone who presents a difficult diagnostic dilemma.

I think we may go mad if we think about all that.





Me, irritated at one of my more senior partners showing up late.

Someone get that dirty old man out of this operating theater.




Me, when audible bleeding is found in a trauma patient.

Work faster, Doctor!





Me, irritated at the patient who assumes that I take every Wednesday afternoon off to golf.


Oooh, cutie pie, eh?






Me, at 2:12AM, explaining for the 4,693rd time to the same night shift RN that, yes, this truly is an emergency and I need to get this patient to the OR right now.

Look, mother, I want to go to work in one hour. We are the Pros from Dover and we figure to crack this kid's chest and get out to golf course before it gets dark. So you go find the gas-passer and you have him pre-medicate this patient. Then bring me the latest pictures on him. The ones we saw must be 48 hours old by now. Then call the kitchen and have them rustle us up some lunch.


Me, beating myself up while waiting on a CT to see if I may have missed a diagnosis, second guessing myself over a possible error in judgment, or while I'm just plain worried about a patient.

You bubble-headed booby! You realize what you've done?!




Me, finding an abdomen full of stool from perforated diverticulitis.

You put me right off my fresh fried lobster, do you realize that? I'm now going to go back to my bed, I'm going to put away the best part of a bottle of scotch...




Me, talking to myself when I'm getting ready to start a case.

With a knife in your hands?






Me, trying to be patient when I have a full day of complicated cases lined up and a new scrub tech student in the room.


And then give me at least ONE nurse who knows how
to work in close without getting her tits in my way.




Me, seeing a drunk and abusive idiot just brought to the ED after his third MVA in as many months.

Oh, a wise guy, eh, I gotta good mind to hand you a ticket. Where's your driver's license?




Me, cautiously entering a no mans land of inflammation and adhesions in a multiply operated upon belly.

Is it safe?... Is it safe?






Me, meeting with the hospital CFO.

Silence, you ninny.






Me, scalpel in hand, ready to get to work.

Nurse: Everything''s ready.
Moe: We''ll make an incision like this.
Curly: No, we''ll make an insertion like that.
Larry: No, we''ll make an excursion like this.
All Three: Tic-tac-toe!




Me, hoping for a break from taking trauma call.

There's a CATCH...Sure. Catch-22. Anyone who wants to get out of combat isn't really crazy, so I can't ground him.



Me, getting some insight on how best to proceed in a difficult case

Sir! I have a plan!






Me, exasperated with some supercilious JCAHO reviewer.

Laugh-a while you can, monkey-boy!







Me, to my partner, trying to break the tension in a difficult case.

If this guy knew the clowns who were operating on him, I think he'd faint.





Me, dragging my ass out of bed at 5AM to make rounds before the 7AM meeting that precedes the 8AM start of a full OR day.

Now come along with me, you ludicrous lump, there's much to be done!





Me, wondering yet again if I made the right career choice.

I been in the right place
But it must have been the wrong time
I'd of said the right thing
But I must have used the wrong line
I been in the right trip
But I must have used the wrong car
My head was in a bad place
And I'm wondering what it's good for


Me, with my end-of-the-day martini.

Wonderful stuff, that Romulan Ale...I only use it for medicinal purposes.





Me, when asked if I'd like a refill on said martini.

Soitenly!





For those of you too young to know, these are direct quotes from (in order) Hawkeye Pierce in M*A*S*H, Dr. McCoy in Star Trek, Dr. Zhivago, Hawkeye Pierce, Dr. Phibes, the Three Stooges, Trapper John in M*A*S*H, Dr. Smith in Lost in Space, Hawkeye Pierce, Dr. Phibes, Trapper John, the Three Stooges, Dr. Szell in Marathon Man, Dr. Smith, the Three Stooges, Dr. Daneeka in Catch 22, Dr. Strangelove, Dr. Emilio Lizardo in Buckaroo Banzai, Trapper John, Dr. Smith, Dr. John, Dr. McCoy, and the Stooges.