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.