Sunday, August 3, 2014

I Wonder...


I’ve been practicing surgery for more than twenty five years. Over these many years I’ve had innumerable interactions and encounters with patients, nurses, doctors and other health care professionals. Sometimes I’m left scratching my head in wonder and amazement. This is not always a good thing.
A few years ago Martha, a patient of one of my partners, called on a Sunday morning, which also happened to be July 4th. She had a colostomy created along with what’s called a mucus fistula following surgery for a colon perforation a few years before. A colostomy means that the colon (large intestine) was brought out to the skin level so that stool passes into a bag instead of taking its normal course to the rectum and out through the anus, a common practice when patients require emergency colon surgery. A mucus fistula means the other end of the intestinal tube is also brought out to the skin where a small amount of mucus will drain intermittently. Such mucus fistulas usually only require a light gauze dressing, not a complete stoma appliance.
Back to Martha. She was concerned because she was out of bags for her colostomy and she needed to change it and the medical equipment stores were closed. She gave me a brief rundown on her history and assured me that besides needing a new a new bag everything else was OK.
I gave some thought about what she should do. We don’t keep such appliances at our office, so I couldn’t help her directly and it was true that the medical supply shops were closed. All I could think to do was to send her to the hospital where one of the nurses could fix her up. I advised her to go to the ER and then I called and spoke with the head nurse in the ER, explaining the situation and asking if she could do the patient a favor and find her a colostomy bag to get her through the holiday weekend.
I didn’t give the matter a second thought, assuming the nurses would be able to accommodate the desperate patient without any fuss. But, I was wrong. Three hours later I get a call from the ER doctor informing me that Martha was there and he had just eyeballed her. Now he was asking me about my concerns. At first I didn’t remember her, but the lightbulb went off in my head and I told him:
“Oh, she just needs a new colostomy bag. She called me a few hours ago and I spoke to your head nurse about her.”
There was a long pause and then the ER doctor replied, “She has two colostomies and nothing is coming out of one.”
“Oh, that’s just a mucus fistula. I wouldn’t expect her to have much drainage from it. Just get her a bag and she’ll be fine,” I reassured him.
“Do you think I can talk to your partner who did her surgery? Because if she has a colostomy something should be coming out,” he deduced, again.
“Well, he’s usually not available on the weekends when he’s off, but Martha will be fine if you just fix her up with a colostomy bag.”
“Unless, I can speak with your partner I feel I’m obligated to do a CAT Scan,” he reiterated more forcefully. “Colostomies should have some drainage and I don’t see anything coming out.”
I was beginning to get a little annoyed.
“Did you actually talk to the patient?” I asked. “Did she tell you what the problem is?”
“I did talk to her,” he replied, his frustration also beginning to surface, “and she told me just what you said. But, she could be confused and a colostomy should have something coming out. I really think I should do a CAT Scan.”
I realized I was going nowhere fast.
“OK, OK, do what you have to do. I haven’t seen her and you have. I’ll see if I can get a hold of my partner.”
I realize that once the ER doctor saw poor Martha he was responsible for her care and he was only trying to practice good medicine, at least from his perspective, but he really broke a few rules. He didn’t listen to the patient, he assumed an elderly patient must be confused if she didn’t tell him what he expected to hear, he ignored his consultant and refused to consider anything but his own inaccurate diagnosis. This also is an example of relying too heavily on CAT Scans for diagnosis, while refusing to utilize any clinical judgment.
In the end, Martha got her bags and a completely unnecessary CAT Scan of her abdomen and pelvis. That particular ER physician was fired about a month later, my encounter being only one of many similar episodes. It made me wonder how some people make it through medical school and residency.
I had another incident today that made me stop and think. I was called to consult on a patient at one of the Long Term Acute Care (LTAC) facilities. LTAC’s are hospitals for patients who are not sick enough to be in a regular acute care hospital, but are too sick for a nursing home. I consult at these facilities when necessary to evaluate surgical problems.
Mitch was a complicated patient who had undergone major intra-abdominal surgery and had numerous drains which had been placed to treat abscesses which had developed after his surgery. I had not done any of the surgery and I had never seen him before, but I was called because the patient’s actual surgeons did not go to LTAC’s.
“Dr. P wants you to see Mitch because his drain broke,” the nurse reported.
I did my best to extract as much information as I could from the nurse. Mitch was stable, the drain hadn’t been collecting much fluid and it sounded like a closed suction drain’s tubing had broken off near where it attached to the suction bulb.
“Sounds like you can just cut the tube a little shorter and reconnect it to the bulb,” I deduced.
“It’s broke, I can’t do that.”
“OK, I’ll see him tomorrow.”
“But doctor. The tube isn’t draining into anything; it’s open to air.”
This was not much of a problem to me, the tube would behave like a different type of drain, called a Penrose, but I could tell the nurse was very worried.
“Just wrap it with some sterile gauze and tape it and he should be fine,” I suggested.
I went to see Mitch and found just what I expected. He had an intraperitoneal closed suction drain with plenty of tubing outside his abdomen.
“Where’s the bulb?” I asked the nurse, who was not the same nurse I had spoken with yesterday.
“I told them to save it, but they didn’t listen,” Mitch said. “They threw it away yesterday.”
The nurse was able to scrounge up another bulb, the tube was cut a little shorter and the crisis was averted, but only after I made a special trip to the LTAC to take care of a problem that should not have been a problem.
Then there are the techniques I have observed in other surgeons. I hear stories of surgeons taking two or three hours to do very simple procedures and I wonder what they are doing for so long a time. Sometimes I will ask that very question of the OR staff. The answers are scary:

“He wasn’t sure about the anatomy. He asked me my opinion, but I couldn’t help him,” reported by a surgical technician.
“He made a hole in the bladder and we had to wait for the Urologist.” I know things like this can happen, but not on a cholecystectomy.
“She just dissects very slowly, like she’s not sure what’s what.”

It’s always best to be as sure as you can be during surgery, and never cut anything unless you know what it is, but there is also some truth to the saying that “a good fast operation is always better than a bad slow operation.”
On occasion I assist younger surgeons in the OR. Most are careful and meticulous as they should be, but I have also helped some who can best be described as cavalier and sometimes dangerous.
I was assisting another surgeon on a colon resection for diverticulitis, an inflammatory condition of the colon. The segment of colon which was diseased was adherent to structures posterior to it. These structures are the ureter, iliac artery and iliac vein. Rather than carefully dissect the colon away, this surgeon took a pair of scissors and just cut away blindly, injuring the iliac vein in the process. I had to fix the vein as this surgeon did not do any vascular surgery. The patient lost about a liter of blood, because of this surgeon’s carelessness and inattention to the most basic rules of proper operative technique.

Incidents such as these make me wonder and worry a bit. If a nurse is not familiar with a particular drain, that’s OK. But, it would have been prudent to ask her head nurse what to do, rather than call in a consultant to address what was really a very simple nursing problem. I worry about the judgment, training and basic knowledge of personnel who are in positions where decision making and responsibility are of central importance. I see more and more incidents like these and I worry what will happen as I get older and face the infirmities that always come with age.