Frustration

Being a doctor means I get to meet a lot of people and do a lot of cool stuff.  I've done a preop evaluation on one of the original Tuskegee Airmen.  And I've done the anesthesia for a total knee replacement on one of the test pilots of the SR-71 Blackbird (the one who flew it cross-country when President Johnson wanted to see it, actually).  I've taken care of a 99-year-old man (I'll blog about that one some other time) and I've taken care of a 7-day-old infant who was born nearly four months premature.  I've eased the pain of childbirth and I've eased pain at life's end.  Most of my patients are great, and I love taking care of them.

Sometimes, though, I run into patients who are so obnoxious, crass, rude, or otherwise unpleasant that I can't wait to push an induction dose of propofol just so they'll shut up.  (Not often, but sometimes.)  And sometimes it's not the patients, but the patients' families or friends who try my patience.

I recall one such family member whom I met about two or three months into my CA-1 year (first year of clinical anesthesiology training after completing internship).  She was the mother of a 10-year-old boy who had broken his radius and ulna, requiring operative repair.  My attending and I went to the preop holding area to meet them.

"Hi, I'm Dr. Sutton," I said, shaking the patient's hand.  "How'd you get hurt?"

"Skateboarding," came the reply.  Boys will be boys.

I ran through the rest of the preop questions with the patient and his mother.  Pretty predictable answers: completely healthy kid, no prior surgeries, not taking any medications, allergic only to shellfish.  His mom signed the consent form, but then said she had a couple more questions.  My attending asked me to stay behind and answer them; meanwhile, he was going to take the kid to the OR and start getting our monitors on.

As the patient and my attending left the holding area, the mom turned to me.  "Is Cardiology standing by in the OR in case he arrests?" she asked without preamble, appearing very anxious.

This caught me by surprise.  Why was she concerned about cardiac arrest?  I had just done a preop eval and she had told me her son had no history of heart problems.

"No," I said, "Cardiology doesn't handle things in the OR.  Why are you concerned he might arrest?"

"Well, people can arrest during anesthesia!"

"It is a risk, but in a normal patient with a healthy heart it's an extremely remote risk.  And you said your son has no history of heart problems or known birth defects, right?"

"But he's just a kid!" she persisted.

"Ma'am," I told her, "he was at higher risk for being in a car accident on the way to the hospital today than he is for an anesthesia-based complication."

She looked a bit sheepish but persisted: "But you need to be ready for emergencies!"

By this time, I was a bit frustrated but still composed.  "We are ready for emergencies, ma'am, but that doesn't include making a Cardiology team waste their day sitting around waiting for complications that are exceedingly rare.  My attending and I are acute care physicians.  We are perfectly capable of running codes by ourselves, and in an emergency situation in the OR there isn't anything Cardiology could add to our management.  In the OR, we are the cardiologists and the pediatricians!  It's what we're trained for."

She looked skeptical.  "But you're not a cardiologist.  You're an anesthesiologist."

"That's true, ma'am," I replied, "but I practice acute care much more regularly than cardiologists.  Part of anesthesiology is managing crises when they arise.  As I said, there is nothing a cardiologist could add to my management of an intraop crisis."

She still seemed very nervous, but appeared ready to concede the point.  She then reached into her purse, saying, "Well, OK, but let me give you his EpiPen, just in case."

I stopped her.  "Ma'am, I have epinephrine in the OR.  I'm all but certain we won't need to use it, but we can give it IV if we do."  What do you expect me to do, I didn't ask, jab it in his thigh and wait for five minutes?

"But what if he has an allergic reaction?"

"Again, ma'am, I can give concentrated epinephrine IV in the OR.  It will work faster and more effectively than intramuscular injection."

I was very frustrated at this point, needing to get into the OR to get the case started lest the orthopedist yell at me for delaying his case.  The patient's mom wasn't ready to let me go yet, though.

"Well, will you make a list of all the medicines you give him in the OR?  I'll need to review it afterward."

That kind of statement does not make doctors particularly happy.  It practically screams "lawsuit-happy."  However, it's the right of every patient to request a copy of his/her medical records.  I assured this extremely anxious (and I suspect rather litigious) mother that we record all intraop medications and vital signs for every procedure and would be happy to provide her with a copy of the record after completion of the case.

Finally, she was satisfied.  "I know I must seem crazy to you," she said.  "You'll understand when you have your own kids."  I was a bit put-off by her presumptuousness.  I do have kids, I thought, and you're right, you do seem crazy to me.  I reached my hand out and she shook it.  "It's just, I watch a lot of medical shows, so I worry a bit."

I smiled pleasantly, but I couldn't resist giving one bit of unsolicited advice.  "Ma'am, you may want to reconsider watching those shows, for your own peace of mind."  And your kid's, I didn't add.

And to think, when I was a teenager I used to think my mom was neurotic.

TOBP

Forty weeks is a long time to be pregnant.  Granted, 40 weeks is “term,” although the phrase “term pregnancy” actually refers to any gestation between 37 and 42 weeks.  (Yes, ladies, that means if you delivered anywhere between 37 or 41 6/7 weeks, you were not “early” or “late.”  You were “at term.”)  Many women understandably become anxious for their pregnancy to end, and quite a few of them present to the L&D floor thinking they may be in labor.  “Active labor” has some very specific definitions, however, and the obstetricians (OBs) generally won’t admit a woman to the hospital for delivery unless she’s in active labor or has had some other reason for admission.  The OBs end up doing a lot of labor checks on women who aren’t actually in labor but are, as the OBs like to say, “TOBP” (tired of being pregnant).  Most TOBPs will grumble and go home when told they’re not in active labor.  Some of them try to trick the OBs into admitting them, though, as if the OBs haven’t seen all these tricks before.

One thing TOBPs commonly do to get themselves admitted is to mess with the tocometer, the device that monitors uterine contractions.  The tocometer is placed on the abdomen and works by sensing how easily the skin can be indented; this decreases during uterine contraction.  A normal uterine contraction should produce a tocometer strip that looks like this:

TOBPs have figured out that the OBs are looking for contractions as one of their criteria for diagnosis of “active labor.”  Some of the more clever ones (well, they think they’re being clever) try to fake it by pressing the tocometer into their belly when nobody’s looking.  Problem is, it’s nearly impossible to simulate the gradual uterine tension changes that result from a real contraction, and the tocometer strip generally turns out looking something like this:

Doctors and nurses aren’t fools, though, and we know what’s up when we see that sort of tracing.  The nurses watch the toco strips from the nurses’ station, and they’ll often go check on the patient during one such “contraction” so they can catch them in the act.  The nurses typically say something benign like “You need to keep a bit more still, sweetie, or our monitors won’t work right.”  But the patients know what they’re really saying: You got busted.  We’re not as dumb as you seem to think we are.

The OBs will also watch the tracings from their work room and chuckle when they see those tracings.  They call that pattern a “Bart Simpson” for reasons that should be fairly obvious.  When they approach the patient, though, they tend to be a little more direct: “You need to stop pressing that thing onto your belly.  It messes up the readings.”

Some patients will get embarrassed at having been caught, but some try to argue about it.  They deny what we all knew they were doing and insist that their “contractions” are real.  The OBs tend to stand their ground, though, and let the ladies know that a real contraction looks different from a simulated one.  Those ladies get sent home, just like all the others who aren’t in active labor.

We laugh about that kind of stuff together, of course.  We’re human and we like sharing funny stories with each other just as much as the next guy.  We try not to let things like that make us too cynical.  But we still want to ask a lot of folks, “Do we really look stupid to you?”  Instead, we just shake our heads and move on.  (And then we post it on our blogs.)

"For with what judgment ye judge..."

Doctors are just as imperfect as everyone else, but those of us who volunteered for the healer’s role can’t afford to make many mistakes.  Our mistakes can cause a patient to stay in the hospital longer.  Or they can lead to unnecessary surgery or other treatment.  They can cost someone their arm, or their leg, or their eyesight.  Ultimately, our mistakes can cost someone else their life.  So we tend to focus on self-evaluation, on debriefing ourselves, and on discussing complex or tragic cases with one another so we can all learn.  We are taught to constantly ask ourselves what we did right and what we did wrong, to look for areas for improvement.  We have little patience for ourselves when we make errors in judgment, especially if they were errors that we feel we should have avoided.  Because of this self-evaluation (which can often become self-recrimination, self-punishment, or, as I say, emotional masochism), we are often able to learn from our mistakes and avoid future pitfalls.  Because of our tendency to talk amongst ourselves about the difficult cases, we can learn from the mistakes or the challenges of our colleagues.  As a wise man once told me, wise people learn from experience, but super-wise people learn from others’ experience.

Notwithstanding our best efforts to evaluate ourselves, physicians still struggle with burnout and cynicism.  Right from the beginning of medical school, my professors warned me and my classmates about the dangers of becoming tired and jaded.  When interacting with other people, you often see what you expect to see, even if it’s only a shadowy reflection of who the other person truly is.  When you base your personal judgments on such a warped, one-dimensional view of another person, you fail to appreciate the complexity and humanity of your fellow man; and when a doctor allows such flawed perceptions to affect medical decision-making, the results can be disastrous.

Even as I reflect on the words I’ve just written, I can’t help being a bit frustrated.  If only it were that easy to avoid burnout!  But many stereotypes exist because they’re true.  And far too often, people present to the hospital as victims of their own poor choices.  They become living clichés, and therein lies the crux of the problem: we become jaded because of our experiences, not in spite of them.

Every so often, though, we see a glimmer of light.  It’s usually small, but it can be just enough to remind us of the humanity and significance of what we do.  I saw one such glimmer during my third year of medical school.

I did my pediatric rotation that year right around Christmas.  The attendings were great and the hospital was top-notch, one of the five best pediatric hospitals in America.  But the intern to whom I was assigned was awful.  She was very passive-aggressive and, worse, she was dishonest.  She was the type of resident who would give a student very positive feedback face-to-face, then log into the computer evaluation system and destroy them.  (I know.  It’s what she did to me.)  She showed no interest in teaching, but she treated students like they were stupid for not knowing things.  The four weeks I spent with her were truly horrible.

It was during that painful rotation that I broke away from my regular team to spend a week working in the newborn nursery.  The hospital was in a major American city with significant socioeconomic problems, and many of the patients came from poor, run-down neighborhoods.  Drug abuse was an issue, as was venereal disease.  Many of the mothers were very young, had several children in tow, and had only a vague idea who had fathered each.  It was a perfect place to become jaded.

Toward the end of my week there, I went to interview a new mother prior to her discharge home.  Did she feel safe at home?  Yes.  Did she have someone to help take care of her other child?  Yes.  Was she returning to work?  No.  Did she plan to breastfeed her baby?  No, she had HIV.  I catalogued all this information to share with my resident (not with the intern from hell).  Without thinking about it, I also filed the patient into a mental file cabinet labeled “Social Problems, Probable Drug Abuse.”  I then reported to the resident, though I kept my personal judgments about this patient to myself.  It’s good that I did.

My resident went to the patient’s room to do his own interview and exam before we discharged this young lady from the hospital.  I followed.  The resident seemed in very good spirits.  He knocked on the patient’s door and we entered.

“You’re ready to go home!”  It wasn’t a question.

“Yeah, I’m ready to get out of here,” she replied.

“And just look at your baby,” the resident continued.  “He’s a living miracle.”

The new mother just beamed.

The resident turned to me and said words that caught me completely off guard.  “I know Ms. Jones here from my continuity clinic.  She and her husband were born with HIV.  But thanks to modern antiretroviral drugs, they’re both healthy.  Now they’ve got an HIV-negative two-year-old girl and a beautiful new baby boy.  This whole family is a miracle.”

As we walked back toward the work room, I felt about as small as I’ve ever felt.  I had dismissed an entire family as a social disaster, and I could not have been more wrong in my appraisal.  Where had I gone so wrong in my judgment?  How had I allowed myself to write them off so easily?  And perhaps most importantly, how could I keep it from happening again?  Those are questions that I pondered for the rest of the day.  And I still ponder those questions years later.

I firmly believe the old adage that there’s nothing new under the sun.  Many patients are living clichés.  But I’ve learned how important it is to avoid mindlessly putting people into little boxes.  Behind every complaint, behind every cliché, behind every stereotype is a living, breathing person.  And when our prejudices lead us to distill a person down to a stereotype, we can miss that little glimmer of light that reminds us why we do the work we do.

The happiest seizure on earth

A doctor never knows when his skills may be needed.  For example, one of my attendings in med school once delivered a baby in a Disney World restroom.  I recently had my own chance to be a first responder.

I took my family to Disney World about three months ago.  I hadn't had any time off from work since early fall, so I was looking forward to a fun, much-needed vacation.  The trip started off uneventfully and we were enjoying Hollywood Studios on our third day when the vacation suddenly got more interesting.

We were vacationing with several family members, so we spent some of our time separate and some together.  By mid-afternoon, we had reconvened to go on Star Tours before having dinner.  We breezed through the line, enjoyed the ride, and navigated the exit that (naturally) let us out in the gift shop.  We were just leaving the gift shop when I saw my soon-to-be patient.  He was overweight, in his mid-40s, and apparently alone.  He was standing next to a garbage can about ten feet from me and making an odd grimace.  Just as I noticed him, he made some grasping motions at the garbage can, then collapsed on the ground and began to seize.

If you've ever seen a genuine tonic-clonic (AKA grand mal) seizure, you realize how frightening they can be.  The man fell down hard and the back of his head visibly rebounded on the asphalt.  His entire body began to convulse violently.  My first thought was, "This man needs a doctor!"  I'd been caught off guard, and it took a couple seconds for me to realize, "Wait, I'm a doctor!"

I pulled out my "Dad voice" (the same voice I use to let my kids know that the goofing off needs to stop and they need to start listening) and announced, "Out of the way, I'm a doctor!"  The crowd that had already started forming parted and I was at the patient's side almost immediately.  My stepfather quickly started doing crowd control; he was joined within seconds by Disney employees who formed a circle to keep the gawkers back.  I was joined at the patient's side by my mother, who is a cardiac nurse with twenty years of experience, as well as a man whom I don't know; I'll call him Mr. Smith.  My mom checked the patient's pulse while I verified the patency of his airway.  Good pulse, good respirations, so we knew at least that we didn't need to start BLS (or CPR, for you laypeople).

In the hospital, I have ready access to benzodiazepines, which are first-line therapy to break a seizure.  I also have access to and technical proficiency with airway adjuncts and monitoring devices.  None of that was available in front of Star Tours.  The only thing we could do was ride out the seizure.  I stuck my foot under the patient's head so he wouldn't crack his skull on the ground; my mom and Mr. Smith tried, as best they could, to keep the patient from migrating across the pathway.  Someone said, "here give him some water!" but my stepfather wisely kept them back.  The last thing this patient needed was to have something poured in his mouth when he was unable to protect his airway.

The seizure lasted for probably about thirty seconds, although it felt much longer at the time.  Finally, though, the patient stopped jerking and was still.  We rechecked his pulse and breathing, both of which were fine.  Someone passed me a cell phone and said 9-1-1 was on the line; I gave them what info I could and handed the phone back.

Over the next couple of minutes, the patient began to stir.  Many people don't realize that lots of seizures are followed by a period of confusion; we call it a post-ictal state.  The absence of a post-ictal state can be one clue (of many) that a person may have faked a seizure.  Other clues include: collapsing but managing to miss every obstacle on the way down, protecting the head and face while falling, and maintaining bladder control.  We were sold on this patient's seizure being real: he had a huge goose egg on the back of his head and the front of his jeans was wet.  We also found he was very post-ictal.  What that means in practical terms is that he was big and he was very confused.  He started to thrash about in a dazed, mostly-asleep state.  He wouldn't answer questions or follow commands; he gave no indication that he even understood us or was aware that we were there.  It took me, my mom, Mr. Smith, and a couple other people to restrain the patient so he wouldn't come to any further harm.  This continued for a couple minutes before the patient regained his senses enough to settle down.

As our patient awoke, we found him to be a pleasant man who had been enjoying a pleasant vacation that was about to end rather unpleasantly.  He was from Nevada and was at Disney World with his family.  He didn't have a cell phone and he didn't have his wife's number memorized, but the Disney employees assured him they'd figure out how to contact his family.  (It was about this time that I noticed many of the bystanders were filming this whole thing on their phones or camcorders.  Note to self: kill these people.)

The EMTs arrived more quickly than I had thought they could, and they smoothly and professionally packaged the patient up for transport to a local ED where he would undergo further evaluation.  I told them what I could about the patient and helped move him onto their transport gurney.  That was the last I saw of the patient.

Medical education is a long process during which progress comes by baby steps more often than by great leaps and bounds.  Just a few years ago, I would have felt completely overwhelmed if that situation had been presented to me.  Now, with one year left before I become an attending anesthesiologist, I felt comfortable managing that patient's acute care.  Sure, I felt rather helpless since I didn't have the equipment or drugs to handle things more definitively if necessary; but at no point did I panic or feel that I was in over my head.  In fact, I felt confident and more-or-less in my element as I evaluated and cared for my fellow vacationer.  After the EMTs took him, I resumed my afternoon with my family; I didn't even feel drained like you do after an adrenaline rush.  More than anything else, I felt comfortable and prepared for that situation.

So in closing, I'd like to extend my gratitude to every professor and attending who's taken the time to teach and guide me.  Your hard work and patience have made an incalculable difference.  Thank you for all you've done.