Sunday, May 19, 2013

Common Sense


Has common sense been lost forever from the world healthcare? I ask this question because of a recent call I received about a patient of mine who had arrived in the ER hypotensive, hypoxic and fast approaching death. The ER doctor called me suspecting she had an intestinal obstruction. Then he told me her name: Linda X.
The name immediately resonated with me because I knew her well, having operated on her twice in the last year. I had first seen her when she was admitted with abdominal pain about a year before. She had a history of moderately severe COPD and was intermittently on home oxygen. Workup at that time revealed a mass in the head of the pancreas. She was not jaundiced nor obstructed at that time. CT Scan suggested her tumor was resectable, therefore her underlying medical condition was optimized and then she underwent surgery. At operation she was found to have adenocarcinoma of the pancreas with involvement of the superior mesenteric artery and vein, making the tumor unresectable. After surgery she was referred to the Medical Oncologist who gave her chemotherapy for 6 courses and then referred back to me to be reexplored. Although my past experience suggested that her tumor still would not be resectable, a second look represented her only chance for cure. She opted to proceed with surgery. The findings at the second operation were almost identical to the first. The tumor had not increased significantly in size, but also had not shrunk, a finding which was not very surprising.
It was Linda who was in the ER now, about 8 months after her second exploration. In addition to the suspected intestinal obstruction she also was found to have a pulmonary embolus, pneumonia, acute renal failure and was profoundly acidotic. The ER physician asked me when I would be taking her to surgery. My polite answer was “never;” I thought I heard a gasp on the other end of the phone.
“But, she’s obstructed and may have dead bowel, and she’s not a DNR,” he stated.
“She has unresectable pancreatic cancer which has not responded to any other treatment. What am I going to do? Keep her alive to suffer for an extra few days. I think you should just keep her comfortable and let her go peacefully,” was my reply.
He hung up, but did follow my advice, which was a bit of a surprise, someone actually thinking about the patient’s best interests.
I was involved with a similar patient many years ago, when I was Chief Resident in surgery. Allen came to our clinic with a carcinoma of the rectum. The diagnosis had been confirmed by colonoscopy and biopsy. He was having intermittent rectal bleeding and tenesmus. He did have moderately severe COPD, but his symptoms warranted surgery. He was further evaluated with a CT Scan of his abdomen and pelvis which revealed liver metastases. Still, surgery for palliation was indicated; besides, abdominoperineal resection was a good case for a Chief Resident. This was in the days before rectal cancers were treated with preoperative chemo/XRT. Allen was scheduled for surgery, but a few days before he was to undergo the procedure he was admitted to my service with shortness of breath. His chest X-ray revealed probable lymphangitic spread of his cancer, something that had not been apparent a few days earlier on his CT scan.
I sat and talked with him after the all the workup had been completed. I explained that he had a very aggressive cancer and that, even with chemotherapy, surgery and radiation, he had a very limited life expectancy. I asked him what treatment he wanted, explaining all the options from aggressive chemo to hospice. He asked for time to consider the options and, before he could make a decision, he suffered a cardiopulmonary arrest. At that moment, I had just finished a surgery and was in the PACU when I heard the all too familiar “Code Blue” for room 623, Allen’s room. I raced up the stairs and found the medical team doing a full resuscitation, about to intubate him. I pulled the senior medical resident aside and politely asked him to stop, explaining Allen’s condition.
“But there’s no DNR on the chart,” he protested.
“I know, but with his cancer his chance for long term survival is just about zero and all you will do is make him suffer,” I answered.
He finally agreed and Al was allowed to pass away. (sounds better than “die”).
Such scenarios occur on a regular basis. We physicians expend a great deal of time, effort and money caring for patients with hopeless conditions. I am frequently called to see elderly, bedridden patients with advanced Alzheimer’s for debridement of necrotic sacral or hip or ischial wounds. Often they have been ignored by their families until they have become too ill to stay in the Nursing Home and are sent to the hospital. Out of guilt or misplaced sense of duty, family members often want “everything done” even if it means making Grandma suffer and while doing nothing to improve quality of life. In such cases I will usually explain that the chances of the wounds healing are poor, but it usually falls to deaf ears. Most often, if the family insists, I go ahead with the procedure as it is low risk and does provide some small benefit.
Statistics show that a large portion of the health care dollar is spent on patients in the last six months or year of their life. In my book about surgery, “Behind the Mask”, I state that the problem with this statement is that physicians very often do not know which octogenarian with a perforated colon is going to walk out of the hospital completely recovered or succumb to overwhelming sepsis. However, in cases like Linda’s or Allen’s, the treating physicians should know that their prognosis is hopeless and that they should be kept comfortable and allowed to die with dignity.
Where does all this lead? The practice of medicine demands that physicians make medical decisions and judgments on a regular basis. It is our duty to explain options, risks and benefits to our patients and their families. Very often such discussions involve treatment options for life threatening illness and it is best that doctor, patient and family reach a decision together and that such decision be clearly documented. Ultimately it is the competent patient’s choice, not the doctor’s or patient’s family.
But, in a situation where the patient is unable to make the decision and an immediate decision is needed sometimes a doctor must exercise common sense and do what is right. This does not mean care should be withdrawn; rather it means that extraordinary measures which will only prolong suffering should not be instituted. Does this mean the doctor is playing “god?” I don’t think so. We physicians spend four years in medical school and even more years afterwards in residency. We should understand the disease processes we treat and should be properly equipped to exercise judgment in cases like the ones cited above. A little bit of common sense in such situations serves our patients and their families well.

Wednesday, May 15, 2013

A Great Tragedy

                               A Great Tragedy



I’ll never forget…

It was always there for me, like a great and faithful friend. Every morning I’d wait, full of anticipation and the expectation of being completely satisfied. I know what you might think. It was just an inanimate object, lifeless and cold. But it was a thing of comfort for me. Of course, it wasn’t the only thing in my world, but it gave me life, at least in a sense.
Let me spell it out more clearly for you. Every morning I would get up from my comfy bed, stretch and then come downstairs. After the usual morning constitutional I patiently waited, always calm, but also with the tremendous eagerness seething inside. I would sit and stare up at it as everything was prepared. First a little of this, then a little of that and a smidgeon more of this on top. When it was finally done I could never contain myself. I would jump up and down and then race to my designated spot.
After what seemed to be ages my dear friend would be set down in front of me and, finally, I could relax and commune with it in a way few people really understand. Afterwards we both felt satisfied, the emotional letdown was usually so great that I would have to settle down and take a nap. My treasured companion would go away for the rest of the day, but I knew we’d be back together the next day and the next and the next. As a matter of fact I couldn’t imagine any day when we would not be together.
Then came the great tragedy, the day we were parted forever. I remember it like it was yesterday. The morning was darker than usual, perhaps it was the clouds or maybe it was the time of year; there was thunder in the distance. All I know is that it was pitch black outside and the lights inside were dimmer than normal. My whole body shook as I was filled with a sense of dread and foreboding, but I wasn’t sure why. I felt a little better when my dear friend was brought out, looking as always, smooth and sleek. And, just like every morning, I sat patiently and waited. The were others there, sort of like a great fraternity of servant/friends, but those others didn’t matter to me. I only had eyes for my faithful companion.
I’m not sure how it really happened. All I know is I closed my eyes just for a second, nothing more than a blink and, in that brief moment, I was abandoned. A clumsy slip of the hand, followed by a crash and then a shattered existence. There were bits of glass and food scattered everywhere; nothing could be saved.
This can’t be I thought. How can I survive, surely I’ll starve… Pull yourself together. Take slow deep breaths. Maybe it’s all just a terrible nightmare. That’s right, pinch yourself and you’ll wake up and everything will be Ok.
But, it was real and nothing could stop the ache I felt in my heart … and stomach. All I could do was lie on the floor and let out mournful wails of sorrow. Only a miracle could save me from everlasting despair.
And, like a light from heaven, a miracle occurred. It was only few minutes, although at the time it was more like an eternity of suffering. A replacement came, quickly and silently. It was shiny and full to the brim with my favorite food. I couldn’t contain myself and ran up to greet it. First I nuzzled it with my lips and then I almost devoured it, finally licking it all over until its shiny metal gleamed like a mirror. It was at that moment I knew that this new and wonderful companion would be with me forever.
Stainless steel won’t break like glass.

Zoe is a six year old, slightly overweight Norwich Terrier.

Sunday, May 12, 2013

A Little Neglect...


Training in the medical fields emphasizes paying close attention to our patients and every little detail of their medical care. Medical students and residents are taught to take note of a patient’s appearance, demeanor, voice along with a detailed history and physical exam. When I walk into a patient’s room my assessment begins.

Such attention to detail becomes even more important after surgery is performed. As a resident I was taught to anticipate the worst, diligently search for signs of infection or poor healing and intervene as early as possible. Proper preoperative evaluation and post operative care are of paramount importance to successful surgical outcomes. Sometimes I thought that the actual surgery was de-emphasized, the implication being that anyone can perform an operation properly and it is the before and after care that mattered the most.

But, I’m not so sure…

Debbie was seen in my office with complaints of lower abdominal pain for almost one year. She had been worked up extensively with Abdominal and Pelvic CT Scan, Upper and Lower GI endoscopy, Pelvic Ultrasound and all pertinent blood and urine tests. Everything was normal. Cholecystectomy, Appendectomy, and Total Abdominal Hysterectomy and bilateral Salpingo-ophorectomy had been performed in the past. I discussed the options with her, offering to do a laparoscopy with the forewarning that it was very possible everything would be normal and her pain would persist. The surgery was performed, a few adhesions were lysed and all was well.

About two hours after surgery I was called by the recovery room nurse who informed me that Debbie was recovering satisfactorily, but she was requiring parenteral pain medication and wished to stay overnight. I gave her the appropriate orders and then went on my way to enjoy my weekend off.

Monday morning comes around and I’m called by the nurses about Debbie, asking if she can be discharged. Why is she still in the hospital? Then it hit me. I had failed to include her in my sign out to my partner. She was supposed to go home after surgery and I had forgotten to call my office and add her to my list after deciding she should stay in the hospital overnight. I went to see her first thing and found her sitting up in bed smiling.

“I feel just fine,” she informed me.

I gave a brief apology for neglecting her over the weekend and discharged her home. She had received proper nursing care over the weekend, her pain was better and, except for my own embarrassment, and a couple of extra days in the hospital, no one suffered. All the usual mental cogitating over post op care was not necessary in her case.

Then there are the patients we used to operate on at night at the county hospital where I trained. This hospital was a county hospital in the traditional sense, perpetually understaffed and underfunded. If we performed surgery at night, that is, after 7:00 pm there was no PACU nurse. These patients were taken to the ICU after surgery where there immediate post op recovery was spent parked in front of the ICU nursing station. This did not mean they were actually monitored by the ICU nurses. The often sparsely staffed surgical ICU sometimes had as few as four nurses for fifteen very sick patients. A healthy 23 y-o male who had just had his appendix out just did not measure up to a trauma patient with a pelvic fracture, bilateral chest tubes and severe closed head injury.

The nurses did check on these post op patients. This meant they walked by the stretcher every few minutes and made sure the patient was still breathing. This constituted close monitoring of the airway in a fresh post op patient. After the requisite 45 minutes the patient was sent to the surgical floor where there might be four nurses for forty patients. More benign neglect. Over the years I never became of aware of any patient who suffered from the arrangement.

I do have to report that the night time PACU (Post Anesthesia Care Unit, a fancy name for Recovery Room) situation changed with the start of my Chief Resident year. The new hospital CEO saw fit to include 24 hour Recovery Room nursing in his budget. Laurie was given the job. Laurie was the best ICU nurse we had. She understood surgical patients better than most of the doctors. She also did not mind taking it easy. It’s not that she was lazy; it was more that she didn’t do anything more than she was required. As the primary night time PACU nurse she spent most of time knitting. The occasional post op patient was attended to and then she went back to knitting. It was a win-win arrangement for all. Our night time patients were recovered properly by an excellent nurse and Laurie did a lot of knitting. It turned out to be even better. I soon learned that I could write an order, “Keep in Recovery Room overnight.” This was perfect for patients who had undergone big cancer operations or major vascular procedures. Most of them needed overnight observation in the perpetually understaffed ICU. Keeping them in the PACU gave them mostly one on one nursing and most often with the best nurse in the hospital. Laurie didn’t mind. The patients were almost always stable and she was still able to do a lot of knitting.

But, I am straying away from the topic of neglect.

Finally, there is the case of Mike. Mike came to our hospital after leaving AMA (Against Medical Advice) from an academic hospital down the road from our community hospital. He had been admitted with a bowel obstruction and most of the work up had been done at the other facility. The short version is that he had a large mass in his right colon that was causing his obstruction; biopsy revealed carcinoma of the colon. Mike had grown frustrated waiting to have surgery; therefore he left and showed up in our ER.

After obtaining his records from the other facility his surgery was scheduled for the next day, Sunday morning. He had a large tumor growing into his abdominal wall and multiple enlarged lymph nodes in the mesentery, without any obvious distant disease. He had en bloc resection which included a right hemicolectomy with all the enlarged nodes along with resection and reconstruction of the abdominal wall. He was taken to the ICU post operatively with a nasogastric tube, arterial line, foley catheter and IV lines. He was very stable in the immediate post operative period.

I made rounds early the following morning; he was still recovering well and I gave orders to transfer him out of the ICU. He asked me how long he would be in the hospital. I responded “about five more days depending…”

“But doc, I need to leave. My dog is tied up in my back yard and I need to feed him.”

I thought for a moment. “Isn’t there anyone you can call who will feed him?”

“He’s one mean pit bull, doc. No one can go near him but me.”

This created a bit of a dilemma for me, (I have six dogs of my own) but I could not let him leave. I left his bedside and was seriously trying to think of a solution to this problem when Mike solved it for me. I received a call from the ICU nurse. Mike had gotten out of bed, pulled out his NG tube, art line, IV’s, insisted the foley be removed and signed out AMA. He was already gone and no amount of talk could have changed his mind.

I shook my head and silently hoped he would be OK. Well, two weeks later Mike showed up in my office, looking remarkably fit and well.

“Doc, I haven’t felt this good in years,” he reported.

“Are you eating OK?”

“Anything I want.”

“Going to the bathroom?”

“No problem.”

He had gained ten pounds, his wound was healing well; he was a true surgical success. I removed his staples and set him up to see the Medical Oncologist, still marveling at his recovery without any of the usual post operative gyrations. He had done all of his post operative care based on how he felt and he was his own best doctor.

I think there are lessons to be learned from all this, ones that I have incorporated into my practice over the years.

First, and most important: do the best operation you can do. A properly performed surgery will usually be successful no matter what is done afterwards.

Second: listen to the patient. They will tell you if they are ready to eat or go home or if there is a complication brewing.

Despite everything that is happening in the world of medicine these days there is still some truth in the term “healing arts.” The science of medicine has come a long way from the days of Hippocrates, but medicine will never be reduced to simple algorithms and protocols until humans are constructed on assembly lines. And, although we are taught to be vigilant and to pay close attention to detail, a bit of benign neglect from time to time can be a good thing.

Wednesday, May 1, 2013

Post OP Orders


1. S/P Right Colon Resection

2. Diet: Consult Dietary for recommendation

3. IV: consult Nephrology.

4. VS: Per Routine

5. Monitor Intake and Output. If urine output is low, consult Nephrology

6. PCA pump per Pain Management

7. Antibiotics per Infectious Disease

8. Consult GI for recommendation for proton pump inhibitor

9. Foley catheter to gravity, D/C in am if OK with Urology

10. AM lab per Medicine

11. Consult Physical Therapy for ambulation per their recommendation

12. Consult Cardiology for Beta Blocker administration

13. Hematology to see for DVT prophylaxis

14. If patient develops temp above 99.0 0r WBC above 10,000 consult Infectious Disease

15. Consult Cardiology if patient complains of chest pain

16. Critical Care Consult while patient is in ICU

The Age of No Reasoning