Adaptability

After sufficient training and practice, even complicated tasks become routine.  I spend most of my days administering variations of an anesthetic milieu with appropriate adjustments for patient- and surgery-specific factors.  Every so often, though, a patient or case comes my way that requires me to truly become creative and adaptable.  I encountered one such patient a few months ago.

I was approaching the end of a long swing shift when I received a page from the holding room nurse.  "Dr. Sutton, multiple providers have tried and failed to start an IV on your next patient.  Could you please come try?"  As I started toward the holding room, I called the anesthesia tech and requested an ultrasound.

My patient was a young man in his mid-20s.  He had a history of IV drug abuse, which had played a role in him crashing his car earlier that day.  While none of his injuries were life-threatening, he had sustained painful bilateral lower extremity fractures that would require operative fixation.  He was lying in a hospital bed, the splints kicked free from both legs and soft restraints attached to his wrists and ankles.  A small group of nurses and residents was completing preoperative paperwork and clearing the evidence of several unsuccessful attempts at IV placement.  I approached the patient and introduced myself.  "Hi, I'm Dr. Sutton, the supervising anesthesiologist this evening."

The patient's response was less than polite.  "Oh great, now I guess you're here to stick me like a pincushion."

I remained polite but direct.  "I'll try to get an IV on you with one stick, but your history of IV drug use means your veins are in bad shape.  You can help me by telling me which is your best vein."

The patient nodded toward his shoulder.  "Right there.  Just put me to sleep right there."

I inspected the patient's shoulder, but his vein was obscured by a large tattoo.  "I can't see that vein.  I think our best bet is for me to use the ultrasound and put one in your arm."

"I don't need an IV, just skin pop me!" he exclaimed, scowling.

"Skin pop you?" I asked, raising an eyebrow.

His scowl deepened as he retorted, "Yeah, just get some heroin and skin pop me!"

I considered the patient as I responded, "OK, two things.  First, that's not how we do things here.  You get an IV because I need to be able to give you medications to keep you safe through surgery.  And second, this is a hospital!  We don't have heroin!"

Growing increasingly irritated, the patient looked at me as if I were crazy.  "Then take these things off me!" he demanded, indicating the soft restraints that held him.  "If you don't have anything for my pain, I'm gonna get up and walk out of this s**tty hospital!"

Exasperation got the better of me momentarily as I met the patient's challenge with one of my own.  "Dude, you've got two broken legs!  How in the world do you plan to walk out of here?!"  Taking a breath, I continued in a more conciliatory tone.  "Besides, I didn't say we don't have painkillers."

"Then what do you have if you don't have heroin?" the patient asked, still visibly frustrated.

"Fentanyl."

"Oh," he replied, his glare softening.  "OK, that'll probably work."

Yeah, I know, I thought.  Believe it or not, I'm actually a much better pharmacologist than you.  Without saying a word, I focused on placing a long 18-gauge IV in his arm under ultrasound guidance.  I was rewarded with dark venous blood, which I drew back into a syringe and passed to a nurse for laboratory evaluation.

Together with the rest of my anesthesia team, I completed the patient's preoperative evaluation, and we rolled down the long hallway connecting the holding room to the orthopedic trauma OR.  After applying the standard monitors and preparing for induction of anesthesia, I turned to my CRNA and SRNA.  "Kevin, Jill, you ready to induce?"  They nodded, and Kevin applied pressure to the patient's cricoid cartilage as I gently pushed medications through his IV.

The combination of intravenous propofol and succinylcholine should cause patients to rapidly lose consciousness, then twitch as their muscles contract and relax.  But this patient continued looking at us and breathing into the facemask.  Oh, crap, I thought, realizing his IV must have blown.  "Does your arm hurt?" I asked.

"No!  My legs hurt, and I want to leave!" the patient answered angrily.  He began shaking his head violently in an attempt to escape the oxygen mask Jill held to his face.  His arms and legs tugged at the restraints as he struggled to free himself.  "Get this off me and let me go!"

As the patient rapidly became irrational and combative, I was forced to take decisive action.  Up to this point, we'd been trying to decrease the patient's risk of regurgitating and aspirating the contents of his stomach, but as his behavior became increasingly dangerous our priority shifted to protecting ourselves and him from physical injury.  Without a working IV, I had to get creative.  "Kevin, how much ketamine have you got?"

"A hundred milligrams."

"Stick all of it in his deltoid.  Jill, switch to 7/3 nitrous/oxygen and crank the sevo!" I instructed.  The combination of intramuscular and inhalational agents would render the patient unconscious, but it would do so much more slowly than the intravenous propofol I had hoped to administer.

As the anesthetic agents took hold, the patient stopped struggling and descended into pharmacologic sleep.  I considered my options for IV access.  "Kevin, I don't want to drop a central line in him.  I'm afraid he'll rip it out and either exsanguinate or air embolize his brain."

"How about the EJ?" Kevin asked.

I nodded.  "Yeah, let's go with that."  Over the next few minutes, Kevin and I each attempted to place an IV in the young man's external jugular vein but met with failure.  Ten minutes later, we still had no IV and an unprotected airway.

Deciding I couldn't wait any longer to secure the patient's airway, I asked Kevin to prepare succinylcholine for IM administration.  "Be ready to give it, Kev, but I'm going to look first with a GlideScope without relaxation."  To my surprise, I was able to visualize the patient's vocal cords very easily, and I successfully intubated him on the first attempt.  The patient bucked on the endotracheal tube once it was in place, so I asked Kevin to give him intramuscular rocuronium, a muscle relaxant.  Then I turned to the SRNA and instructed, "Jill, please put him on pressure support ventilation.  Once the roc hits enough for him to stop triggering the vent, switch him over to volume control."  Next, I turned to the orthopedic team, which had been patiently waiting as we struggled with this challenging patient.  "Thanks for your patience," I said.  "I still need to get IV access, then you can get started.  You'll want to get an ICU bed because I'm planning to leave him intubated."

With a look of surprise, the orthopedic resident replied, "You're leaving him tubed?  Why?"

I smiled wryly.  "Let me put it this way: do you want to deal with this guy awake all night long?"

Surprise disappeared from the resident's face as he nodded his understanding.  "Gotcha.  Good plan.  I'll call the trauma team and get him a bed in the unit."  The attending orthopedist indicated agreement with a thumbs up, and I turned my attention back to the patient.

"Kevin, I'm gonna do it," I lamented, shaking my head.

"Central line?" he queried.

"Yeah," I sighed.  "They'll just have to keep him in restraints until they're sure he won't auto-d/c it and bleed out."

Placing the central line proved as challenging as starting a peripheral IV in this patient.  After a couple attempts under ultrasound guidance, I placed a triple-lumen catheter in his internal jugular vein.  "OK," I said wearily but triumphantly, "you guys can start surgerizing."

I left the OR and made my way to the faculty lounge, where I sat at a computer.  My watch showed two hours had passed since I met the patient in the preop holding area.  I shook my head and mouthed, "Two hours..."  Then I logged into the computer and began entering notes to document all that had transpired.  No sooner had I signed the final note than my pager beeped.  I dialed the number shown and heard Kevin's voice on the other end of the line.

"Hey Matt," he said, "I know your shift ended a while ago.  Have you already signed out and left the building?"

"No," I replied, "I'm still here finishing my charting."

Kevin chuckled.  "You're gonna love this.  They're done."

My jaw hit the floor.  It hadn't even been twenty minutes since I walked out of the operating room!  "You serious?" I asked incredulously.  "You're not yanking my chain?"

"Totally serious," he laughed.  "They're done.  I'm taking our young friend to the unit."

I hung up the phone and shook my head again.  The faculty lounge was vacant except for me, the lights dimmed.  "Twenty minutes," I announced to the empty room.  "Two hours to get the anesthesia going, and surgery took twenty minutes."

After a moment, I smiled and stood to leave.  "Well," I continued to the otherwise silent room, "I guess I don't have much room to complain the next time they take an hour to close!"

The dance

I was a third-year medical student on my psychiatry rotation when a series of events began that would ultimately alter the course of my life.  It started with a middle-aged woman with schizophrenia who complained of severe low back pain.  Well, I thought, even paranoids can have enemies, and even schizophrenics can have legit back pain.  I acquired an MRI performed on the patient during a previous incarceration and placed a consult with the Acute Pain Service.

The resident who came to see my patient was a soft-spoken Filipino man.  He thoughtfully evaluated my patient, then wrote a note providing recommendations for management of her pain.  Afterward, he sat in the residents' workroom with me.

"What do you want to do with your life?" he asked.

I had my answer ready.  "I want to be a surgeon."

He smiled.  "I wanted to be a surgeon once, too.  Do yourself a favor, and do one elective in anesthesiology.  You may love it, in which case thank me later.  If you still become a surgeon, you'll be a better one because you'll know what happens on that side of your patient.  And if you do anything else, you'll still learn how to start IVs, mask ventilate, and intubate, and those are useful skills for any physician to have."

His advice made sense, and four months later I found myself on an elective anesthesiology rotation at the public hospital across town.  For the first two weeks, I enjoyed the specialty's combination of applied pharmacology and procedures.  But it was during my third week on service that the course of my life changed.

The event that changed my life began when my attending received a page from the OR control desk.  "Dr. Evans," said the head nurse, "General Surgery has posted an emergency ex lap on a patient in the ICU.  They think he's hemorrhaging.  They say we should treat it like a trauma.  Our trauma room is OR 12."

My attending started walking down the hall as he called an available senior resident.  "Steve?  A patient from the unit is bleeding out.  Set up room twelve for trauma."

Within minutes, Dr. Evans and I were running alongside an ICU bed getting information from the surgery team.  The patient was a 50-something male with a history of alcohol abuse who'd been admitted to the hospital with Mallory-Weiss tears.  He'd been stably ill in the ICU for a day but had acutely decompensated that morning.

We arrived in the OR where Steve was ready to receive the patient.  He'd enlisted the help of Megan, another senior resident, and activated the hospital's massive transfusion protocol.  The OR became a blur of action as we moved the patient to the OR table, attached monitors, and started high-flow oxygen.  The patient looked terrible: heart rate in the 160s, blood pressure of 50s/30s, and altered mentation, all consistent with hypovolemic shock.  Dr. Evans administered scopolamine and rocuronium through the patient's IV, I applied cricoid pressure, and Steve intubated the patient.  I noticed that nobody turned on any volatile anesthetic for maintenance anesthesia.  Megan leaned over and explained, "He's too shocky.  Gotta make him earn his gas."

The next hour was a blur.  The surgeons opened the patient's abdomen and found that he had nearly exsanguinated from his left gastric artery.  They stopped the bleeding, then searched through his abdomen for any additional sources of hemorrhage.  But I hardly noticed them, so enthralled was I with the anesthetic dance that unfolded before me.  For a dance it was, with the three anesthesiologists coordinating their efforts to thwart death as it sought to claim our patient.  There was no wasted movement.  There were no wasted words.  There was no duplicated effort.  Steve, Megan, and Dr. Evans danced around and with each other to administer drugs, transfuse blood, draw labs, evaluate and adjust, evaluate and adjust.  They put me to work as their go-fer, running between the OR and the lab, the pharmacy and the blood bank, retrieving the precious information and materials with which they would save a man's life.

As quickly as it had begun, the dance ended.  The surgeons had controlled the bleeding, closed the patient's abdomen, and applied clean white dressings to his wound.  We moved him back to his ICU bed, made up during the case with fresh linens by the attentive housekeeping staff, and began the long journey back to the ICU.  The patient was critically ill, but alive.  We gave report to his nurse, then gathered our equipment and returned to the OR suite.

The rest of my workday was unremarkable -- just bread-and-butter patients receiving bread-and-butter anesthetics for bread-and-butter surgeries.

As I left the hospital that evening, I pondered the events of the day.  That's when I had a sudden thought, so simple and profound that its arrival could herald nothing less than a life-altering shift.  They saved his life, I thought.  That whispered thought seemed to echo across my mind.  They did.  They saved his life.  A pause.  Then another thought.  I helped.  I did.  We did.  We saved his life.  My shiver had nothing to do with the cold.

In that moment, all the other clinical work I'd done shrank to insignificance in my mind.  I'd helped care for inpatients and outpatients, children and adults, women and men.  But all of that work had been chronic or subacute care.  This was different.  This altered the framework of my very thoughts.  Never before had I seen a life rescued as death was in the very act of claiming it.  Never had I seen a man tumble from the precipice, only to catch hold of a lifeline thrown by an angel of mercy.

Suddenly, I knew what I wanted to do with my life.

End-stage

“Dr. Sutton, have you taken a look at our next patient yet?”

I looked up from my computer to see my CA-2 resident standing in the workroom doorway.  “I was just pulling her chart, Joel.  How’s she look?”

“You’re not gonna like it, sir.”

It was 11 pm and our general surgery colleagues had posted an ex lap on a 55-year-old woman with free intraperitoneal air.  I opened her chart and started scanning her notes as Joel watched from the doorway.  One entry in her problem list stood out: alcoholic cirrhosis.  “How bad is it?” I asked.

“Horrible,” he said.  “Pull up her labs.”  He entered the room, followed by Kaitlin, the CA-3 resident on call.  Joel waited while the screen loaded, then pointed to a series of sequential BMPs.  “See that?  Right there, from one draw to the next.  Her chemistries looked stably marginal, then in the last two hours they just fell off.  Her kidneys just gave up.  And she’s on a non-rebreather upstairs with a gradually increasing oxygen requirement all day.  She’s in florid hepatorenal and hepatopulmonary syndromes.”

“You know I hate it when you’re right, Joel,” I teased.  Joel was an exceptional resident – one of the brightest and hardest-working people I’ve ever met.  I’d rarely found a reason to doubt his instincts or thought processes, and on this night I agreed with him completely.  Still, it’s my job to teach, so I swiveled my chair to face him and started to elicit his thoughts.

“What do you think we should do, Dr. Pierce?” I asked.

Without missing a beat, Joel told me his plan.  “I think we should ask the surgeons if they really think this is going to help.  Her perioperative mortality risk is off the chart.  She’s an optimal candidate for comfort care.”

“And if they say, ‘Damn the torpedoes’?” I asked.

“She’s already lined up,” he said, referring to the patient’s pre-existing arterial line and venous access sites.  “Induce with etomidate and a prayer.  Albumin for volume, get a gas and switch to product if indicated.”

“Extubate?” I asked.

He thought for a moment before answering.  “Maybe see how she does.”

I shook my head and pointed to her serial ABG results.  “She’s got progressive respiratory decompensation and they’re gonna do a big abdominal whack.  I think we’d get called to tube her at some point tonight regardless of whether she had surgery.  Let’s just plan to leave her intubated.”

“Makes sense to me,” Joel agreed.

I turned back to the computer and paged the attending surgeon, who returned my page almost immediately.

“Hi, Matt, you guys ready to bring our ex lap patient down?”

“Hey, Raji, I wanted to talk to you about that.  Her labs look like the beginning of the end.  Have you guys had a ‘goals of care’ discussion with her and her family yet?” I inquired.

“Yes, we did,” he answered.  “She’s got hepatic encephalopathy, but we discussed everything at length with her mother.  Her mom wants to go forward.”

I sighed.  “OK, they’re setting up room 6.  We’ll go see her and bring her down.”

Joel, Kaitlin, and I gathered the equipment we’d need to transport the patient to the OR, then went to the ICU to meet her.  We arrived to find a cachectic-appearing woman with clear increased work of breathing.  Despite the non-rebreather facemask, her oxygen saturation was 93%.  Her mother was at the bedside, an anxious woman who appeared to be in her mid-70s.  Two other women, who appeared to be the patient’s sisters, were also present.  A surgical resident was in the room writing orders, and two nurses were preparing the patient for transport.

As I took in the whole scene, I made introductions.  “Hi, ma’am, I’m Dr. Sutton and these are Drs. Berthold and Pierce.  We’re the anesthesiologists working tonight.  We understand the general surgeons think you could benefit from an operation.”

The patient nodded, but her mother answered for her.  “Yes, they think she has a hole in her intestines.”

I stepped to the bedside.  “We want to talk to you about your health and our plans for your anesthesia before we get going, OK?”

For the next couple minutes, my residents and I gathered information and learned little that we didn’t already know.  Her cirrhosis had decompensated to the point of impairing her pulmonary and renal function.  Otherwise, the patient and her family denied any significant medical issues.  Kaitlin and I stood back while Joel explained the anesthesia plan.  He told the patient she’d be intubated and remain unconscious throughout the operation.  Then he said that we intended to leave her intubated postoperatively.  The patient and her family went quiet as they digested this new piece of information.  After a moment, her mother spoke.

“How long will Patty have the breathing tube?” she asked.

Joel took a breath.  “We’re not sure,” he replied.

I stepped forward to take the lead.  “Ma’am, we sincerely hope she can wean off the ventilator over a period of hours and have the breathing tube removed.  But you’ve seen how her breathing has worsened throughout the day.  As sick as she is, there’s a chance that she might not be able to come off the ventilator at all.”

Again, the room went quiet for several moments.  “So she might have a breathing tube for the rest of her life?” the mother asked.  “For years and years?”

I looked around the room.  The nurses had stopped what they were doing and the anesthesia and surgery residents were still.  One of the patient’s sisters had tears in her eyes.  And in the mother’s eyes was a look of expectation and confusion.  She doesn’t understand, I realized.  She doesn’t know her baby is dying.  A pause.  Then, another thought: We’re having the wrong conversation.

I looked around the room.  When I spoke, my voice was steady but gentle.  “May I please have a few moments alone with Ms. Foster and her mother?”

The others in the room looked at one another before moving toward the door.  As the last of them left the room, I quietly sat facing the patient.  My words were addressed to the patient but directed toward her mother.

“Ms. Foster,” I began, “I need to be very frank with you.”  Both women eyed me anxiously.  I took a deep breath before continuing.  “I don’t think you’ll be able to wean from the ventilator, and I don’t think you’ll need long-term mechanical ventilation.  You’re dying, ma’am.”

Silence.  The faces of the patient and her mother registered unrestrained shock.  I had dropped a bomb, its impact just beginning to be felt.

The mother mouthed something before finding her voice.  Her next words were shaky as she grasped for hope.  “She can still get better, can’t she?”

My heart ached for this mother.  She'd clung to the hope that her daughter would recover, would live for years yet, and I had just torn that hope from her hands.  “I’d love it if I’m wrong,” I said, “but I don’t think so.  Everything that’s going on right now – this is the end of end-stage liver disease.”

Shock and silence before a feeble protest.  “But she saw her doctor six months ago, and he said she had plenty of time to turn things around.”

I shook my head gently.  “I can't say what she looked like then,” I answered.  “I can only base my opinion on how she looks now.”

“How long do you think, Doctor?  Months?”

Again I shook my head, and pulled out the last remaining foundation on which this mother had built her hope.  “Days.”

The mother's face was a picture of devastation.  Silently, I allowed her a moment to process my words.  Eventually, though, I had to go on.  “Ma’am, I’m sorry to have to give you that news.  The truth is, I don’t think your daughter will live much longer with or without surgery.  And we don’t have to do the surgery if you don’t want to.  We can initiate comfort care.”

“The surgeons said she would die without the surgery,” the mother said softly.

Just as softly, I answered, “She’s dying either way.”  I watched as the mother continued to survey the devastation of her world.  “Ma’am, your daughter’s liver has failed.  Her blood ammonia levels are very high.  That has the effect of impairing her judgment.  She’s not mentally capable of making an informed decision or consenting to an operation.  She has no other power of attorney.  You’re the one who has to make the decision.”  More silence.  Then, the final bomb: “Ma’am, I believe if we take her to the OR tonight, you will be called upon to decide – some time in the next week – to pull the plug and let her go.”

The mother stared at the floor in disbelief.  After several moments, I stood.  My face and voice conveyed my sympathy.  As a parent, my greatest fear is that I might have to bury one of my own children.  “I’m sorry.  I’ll leave you alone to think about things without outside pressure.  Take all the time you need.”  I stepped out of the room and closed the door.

My residents approached me and I told them what had transpired.  Then we stood in silence for the next five minutes as the heartbroken mother decided what to do.  Finally, the door opened.

“Please do the surgery, and do the best you can for her.”

I nodded.  “We’ll give her our very best, ma’am.”

Patty Foster survived surgery that night.  Six days later, with her mother and sisters at her side, she was compassionately extubated and allowed to leave this world.

Years ago, I was an eager young premed student.  I volunteered and was chosen to shoulder the mantle of a physician.  For years I trained, learning the art and science of my profession.  I've blessed thousands of lives, ushering people through the perioperative period.  Not a day goes by that I don't thank God for His goodness in making me a tool in His hand.  But with that gratitude often goes a plea: God grant that I not outlive my children.

Clinical detachment

I had just laid down when my pager went off.

“Hey man, we have an ex lap going into OR 18,” said my junior resident.

I looked at my watch.  The time was 2:45 AM.  I was still trying to shake the cobwebs from my head when my junior added, “ACLS in progress.”

That got my attention.  “Room 18?” I confirmed.  “I’ll be right down.”

I hurried to the OR and grabbed a mask, looking through the window as I did.  Despite the flurry of activity surrounding the patient, I could see that the left side of his chest was cut wide open.  I could see his heart beating through the incision.

People were already engaged in resuscitation as I entered the OR.  I quickly surveyed the scene – patient status, monitors, lines, etc. – as I stepped to the head of the bed.

“What’s the story?” I asked my attending.

“This guy fell forty feet from a train,” he replied.  “Get an a-line started.”

I grabbed an a-line start kit and an ultrasound as I stepped around to the patient’s arm, anticipating difficulty finding a good radial pulse.  “He fell off a train? Strange place to be at two in the morning.”  I felt for a pulse, got nothing, and fired up the ultrasound.  In place of a pulsatile artery, I saw a shallow round vessel that was slightly less compressible than its neighbors.  After two attempts at cannulation, I was rewarded with sluggishly pulsing arterial blood.

By the time I secured the arterial line, the surgeons had already opened the abdomen and unleashed a torrent of blood.  I stepped to the head of the bed and began directing the patient’s resuscitation together with my attending.  The first ABG was not reassuring.  pH 6.75, PaCO2 over 70, base deficit approaching 30, iCa around 0.7...things were looking less than stellar for this patient.

Over the next several minutes, we continued resuscitating the patient with blood products, vasopressors, calcium, and other drugs, attempting to keep up with the rapid blood loss that continued on the other side of the drape.  I asked my attending what else had transpired prior to our operative management, and he told me that the patient had arrived in the ED with cardiac activity but without a palpable pulse.  He quickly proceeded to complete cardiac arrest, at which point a code was called.  The ED attending was ready to pronounce the patient, but the chief surgical resident on call performed an emergency thoracotomy, applied an aortic crossclamp, performed manual cardiac massage, and injected two doses of intracardiac epinephrine, at which point the patient recovered a perfusing rhythm and was rushed to the OR for surgical management.

“What do you see in there, John?” I asked the surgery resident.

“He’s got a huge liver laceration,” he answered.

“Is he making any clot for you?” I asked.

“Not really.”

So we continued with our management, administering packed red blood cells for oxygen-carrying capacity and plasma, platelets, and cryoprecipitate to promote clotting.  But the bleeding was too fast, and we seemed to be falling behind.

“Give him factor VII, 90 mcg per kilogram,” ordered the attending trauma surgeon.

Factor VII is a recombinant clotting factor.  It is reserved for cases of severe coagulopathy in which other attempts to control bleeding have failed.  This is for two reasons: it can promote dangerous amounts of clotting in many patients, and it costs about $1 per microgram.  The requested dose of 9 mg was therefore something to be given only when necessary.  We called the pharmacy and placed the order.

After a few minutes, the factor VII arrived and was given.  Still the patient continued to bleed.  Still the surgeons attempted to control the hemorrhage.  Still we persisted in our resuscitative attempts.  The trauma surgeon ordered 10 mg more factor VII, and this was given.

And then the trauma pager sounded.

“Major trauma alert,” read my junior as he took the pager from his hip.  “Gunshot wound to chest.”

“I know about that patient; he’s stable,” said the trauma surgeon, “but I should still go eyeball him.”  With that, he scrubbed out and left the OR.

For the next ten minutes, we continued our resuscitative efforts as the surgery resident packed the patient’s abdomen in an effort to tamponade the bleeding.  But when the attending surgeon returned, we still seemed not to have made much headway.  And in addition, the patient’s pulmonary status was worsening, probably from all the blood products he’d received.

“How’s it going, John?” the attending surgeon asked as he re-gowned.

“Um...not excellent, sir,” the surgical resident responded.  “He’s still bleeding pretty bad.”

“He’s not looking great up here, either,” I told him.  “We’ve got increasing airway pressures and decreasing sats.  I haven’t been able to suction anything out of his tube, either.”

Our resuscitative efforts continued in earnest as the attending surgeon and attending anesthesiologist conferred.  Ultimately, they decided that the best course of action would be to pack the patient’s abdomen and take him to the ICU for continued resuscitation and respiratory optimization on an ICU ventilator.

My attending and junior transported the patient to the ICU while I stayed behind in the OR to reconcile the chart and ensure that all blood products and controlled substances were documented appropriately.  It took me over an hour, and I eventually determined that the patient had received over 80 units of blood products in our attempt to save his life.

Unfortunately, there is no happy ending to this story.  The patient required more epinephrine upon arrival in the ICU and another code was called within minutes.  Within forty-five minutes of leaving the OR, it was all over.

The next day, I went to church.  I spent some time talking to a friend and told him about my patient.  By the time I finished, he was shaking his head.

“I don’t know how you guys do it.”

“Do what?”

“How you handle taking care of these sick patients without losing it?  I couldn’t handle it.”

I had to think about his question a bit before I could answer.  While I’ve been involved in the care of several patients who have died, none has affected me quite as much as the first one did.  After this most recent patient death, I had finished my charting, driven home, and gone to bed.  Was that callous?  Had I become insensitive to the sanctity of life, able to attend its passing with as little emotion as I would feel watching the “death” of character played by a television actor?  The patient who had just died was someone’s friend.  He was someone’s son.  Maybe he was someone’s brother.  Maybe their husband.  Maybe their father.

So how did I deal with my proximity to such tragedy?  I maintained clinical distance from the situation, viewing the patient as a case rather than as a man.  And even as I realized this with a wave of guilt, I knew that’s how it had to be. 

Maintaining clinical detachment from tragedy in the hospital is how I maintain the composure and professional objectivity to make decisions under pressure.  It’s how I keep my nerve when I know a poor decision could result in considerable harm or death to another person.  It’s how I reset after a difficult or complicated case so my next patient can receive my full attention and best care.  It’s how I fall asleep mere hours after watching the life leave another human body.  I can’t speak for my colleagues, but emotional detachment from tragic circumstances is the coping mechanism that helps me face serious illness and say, “I can handle this.”

And yet, in my quieter, more reflective moments I often feel the humanity of my work rush back to the forefront of my consciousness.  I find myself regretting my inability to cure all ills, and I pray that God will right the wrongs that defy the limits of human ability and of mortal comprehension.  It’s during such times that I remember the faces and the voices of those who have slipped beyond the veil of this life and into the next.  I pray that they have peace, and that their loved ones may find comfort even as they grieve.  I think of my own father and give thanks for the outstanding medical care that eased his pain at the end of his mortal journey, and I pray that I may have the wisdom, knowledge, and sound judgment to provide such excellent care even when faced with disease that exceeds my ability to heal.

During these reflective moments, the patients cease to be cases; they again become human beings, men and women whose time on Earth came to an end.  Inevitably, I reflect on the tenuousness of life and of the common threads that tie all of us together, the events and needs that we all experience.  Then I realize that each patient who dies is not just a patient; it is my brother.

And with that realization, I have wept for those I was unable to heal.

Do I look stupid to you?

Spontaneous rupture of membranes (aka SROM, aka water breaking) is a great reason for doctors to actively intervene in a pregnant patient’s care.  If the pregnancy is at term, it’s a good time to induce or augment labor in order to facilitate childbirth.  If it’s preterm, it’s a good time to attempt to stop or prevent labor, at least temporarily, to help prepare the mother and baby for delivery.  If, on the other hand, the water has not broken but the mother tells us it has (either because she really thinks her water broke or because she’s just tired of being pregnant), it’s important that we not promote labor and delivery, largely for the benefit of the child.  Either way, if a woman tells us her water has broken, it’s important for us to determine whether or not that’s really the case.

There are, of course, ways for the OBs to tell if a patient’s SROM is legit.  Typically, they perform three tests: speculum exam, ferning test, and nitrazine test.  The speculum exam involves using a speculum (what else?) to look for pooling of amniotic fluid the patient’s cervical vault.  The ferning test is done by putting a sample of the presumptive amniotic fluid on a microscope slide and looking for a characteristic crystallization pattern.  And the nitrazine test is done by exposing a sample of presumptive amniotic fluid to nitrazine and watching for a distinctive, characteristic color change.  If more than one of these tests are positive, it’s more likely that the patient did indeed experience SROM.

Despite modern medicine, however, some TOBPs think they can fake out their OBs.  "Hmm," they think, "I'll bet if I sit on a gurney and get the Chux pad under my butt wet, the doctors will think my water broke."  And what's the easiest way for them to get that pad wet?  Why, urinating on it, of course!

Which brings us to the patient.  She was a young woman, maybe 25 years old, who presented to the L&D deck one night while I was covering the night OB anesthesia service.  She arrived with a large water bottle in hand (really a 32 oz. mug full of water), which she was quite attached to.  She was complaining of regular, severe contractions, despite appearing to be quite comfortable.  The L&D nurses set her up in a triage room and took her vital signs, then she was seen by an OB resident.

The OB resident emerged from the patient's room several minutes later, shaking her head.  "That patient is gross," she said.

"What happened?" I asked.

"I was getting ready to do a spec exam, and I had my back turned to her, and she peed all over the Chux!" was the disgusted reply.

"Wait, what?!"

"She peed!  I had my back turned, and I was putting on gloves, and she got all excited and said, 'What was that?!  What was that?!  My water just broke!"

"OK..." I prompted.

"The Chux pad under her was wet, and her urine was really dilute from all the water she's drinking, but I could smell it and there wasn't much fluid in her vagina.  She peed on the Chux to try to make me think she SROMed."

"Wow..." I muttered, shaking my head.

"Anyway, I got what sample I could, and now I have to check nitrazine and ferning.  See you."

With that, the resident left and I returned to my reading.  I had all but forgotten about the incident when the OB resident returned and tapped my shoulder.

"OK, Matt, get this: you know how sperm makes the nitrazine test have a false positive?" she asked.

"You're asking me to cast my mind back to the dark days of med school, but yeah," I answered.

"Her nitrazine turned blue, but I could see swimmers on the slide.  So I went back in and asked her when the last time was that she had sex."

"OK..."

"And her husband said, 'Oh, it's been more than a week,' but she got really quiet and wouldn't look at me."

I looked over at the resident.  "You don't think..."

"Yes, I do think.  This lady is some piece of work.  I think I'm not the only one she's lying to this evening."

I shook my head in disbelief.  "I guess I'd rather be in your shoes than her husband's.  You think he'll put two and two together, and figure out why you asked when they had sex?"

"Maybe," she answered.

And there you have it.  Sometimes, the answers you get are a bit more than you bargained for.  And as irritating as it is when patients think their doctors are gullible fools, there are certainly worse things.

Ascending aortic dissection

No matter how much you know about medicine and anesthesiology, you’re going to come face-to-face with cases that challenge you.  Whether it’s the patient’s disease process, their overall health status, or considerations stemming from the surgical procedure itself, some cases are going to present a challenge.  And when those factors all combine with patient beliefs that prevent you from using some of your most important tools, you just set up for the case and know that you’re screwed six ways to Sunday.

My patient was a 33-year-old black woman with Marfan syndrome.  She had suffered an ascending aortic aneurysm with subsequent dissection.  Her chart showed that she had presented to an emergency room two months prior for chest pain, but a full workup had been unrevealing.  At the time of her dissection, she had become neurologically compromised, and on the day of her surgery she was in the ICU intubated but requiring no sedation.  She had also become hemodynamically unstable and her kidneys had failed; she was on CRRT.  She had anasarca with her tongue so swollen that it protruded several centimeters from her mouth; it was obvious that if we dislodged her endotracheal tube she would asphyxiate as we were unlikely to be able to replace it.  Similarly, we could see that placement of her lines was going to be very complicated.

The surgical plan was, of course, for median sternotomy, cardiopulmonary bypass, and repair of her dissected aneurysm.  Bypass causes notable dilution of the patient's blood, and transfusion of red blood cells and other blood products is very common in such cases.  This patient, starting with her hemoglobin a very anemic 7.3 gm/dL, would certainly require transfusion.

Except that she was a Jehovah's Witness.

It's not much fun to walk into a case knowing that your patient will die if she doesn't have surgery, but that she'll probably die because of the surgery.  The only solace you can take is from the knowledge that no matter what you do, it's going to be very difficult for you to make her any worse.  Some consolation.

The procedure and anesthetic management had been discussed at length with the patient's family, and their wishes had been made extremely clear.  We documented everything imaginable, partly so we could honor the patient's and the family's wishes and partly so we would know what fluids we would be able to administer.  The patient could receive no red blood cells, platelets, or plasma, but she could receive albumin, recombinant factor VII, and Cell Saver.

My attending and I made the best of it and prepared for the procedure.  He handled transport since my mobility is still limited by my tibial fracture.  The anesthesia techs helped with positioning and monitoring the patient, and I scrubbed and gowned for the placement of lines.

This patient already had a triple-lumen central line in her left IJ and it was simple to swap it over a wire for one of the double-lumen lines preferred at this particular hospital.  Placement of a MAC in her right IJ was a bit more complicated due to her extreme edema.  With virtually no neck mobility and great difficulty in retracting her edematous folds of skin, a two-handed procedure became a four-handed one as my attending and I each retracted skin in opposite directions, he handled the ultrasound, and I drove the needle.  We ultimately prevailed, though, and the case was soon underway.

Transesophageal echocardiography is a very useful tool in assessing the anatomy and function of the heart and the great vessels.  This young lady's TEE was wretched.  It showed a functional heart pumping blood into a badly traumatized aorta, a massive communication evident whereby blood could move from the true lumen to the pseudolumen.  The pseudolumen had grown in size until it dwarfed the true lumen; I thought it miraculous that the patient still had peripheral pulses.  The surgeons and my attending, for whom cardiac surgery and cardiac anesthesia are daily aspects of life, seemed impressed by the extent of her dissection.

For several hours, the surgeons worked, opening the young woman's chest and repairing her aorta.  All along, there were indications of how sick this young woman truly was.  Her BIS was constantly low, starting in the mid-20s when we rolled into the room and actually going to 00 with a flat EEG on 0.3 MAC of isoflurane, indicating the probable extent of her neurological devastation.  We drew no unnecessary lab work, regarding every milliliter of her blood as a precious commodity that should not be wasted.  An ABG drawn shortly after initiation of bypass showed that she was severely anemic, with a hemoglobin concentration of about 6 gm/dL.  Instead of waiting until the end of the case to administer Cell Saver blood, we asked the perfusionist to start making whole and half units as soon as he was able.

And still the surgeons worked.  They were ultimately successful in repairing her aorta, and we all breathed sighs of relief as the patient tolerated the weaning of cardiopulmonary bypass with only two vasoactive infusions.  The sternotomy was closed and the attending surgeon scrubbed out to dictate the case as his assistant continued with skin closure.

But as he closed, the patient began to deteriorate.  Her pressures worsened, her heart rate accelerated, and her BIS, already tenuous, dropped.  Fearing what we would see, my attending and I looked at the TEE and found the diagnosis: cardiac tamponade.  The patient was bleeding into her pericardial sac, and the blood looked like it was already clotting.

We showed the junior surgeon what we had seen and he immediately began cutting the sutures holding the patient's chest closed.  The attending surgeon hastily scrubbed back into the case and within a minute the patient's sternotomy had been reopened.  My attending and I watched the surgeons scoop clotted blood from the patient's pericardium, knowing that every red blood cell lost to that clot was a cell she needed desperately.

 As the surgeons closed the patient's chest again, we very cautiously administered albumin to maintain a reasonable blood volume without hemodiluting the patient too much.  By the end of the case, the patient's total fluid input was just one liter of albumin and 300 ml of lactated Ringers.  And still her final hemoglobin was just 4.4 gm/dL.  My attending and I traded dire prophecies with one another after we dropped our patient off in the ICU.  Neither of us thought she would live out the night.

Nearly a week later, she remains alive.  But all is not well.  Her neurological exam remains remarkably poor, and each day further dims the hope that she will experience any sort of meaningful recovery.

To me, that is one of the most difficult parts of medicine: knowing you've done your best, knowing you've done as well as anyone anywhere could do, and still feeling that you've been beaten.  All you can do is say a prayer for your patient and hope that you can help the next one.

Ortho to the rescue!

So, I've given Ortho some grief on my blog, and I think it's time to give them their due.  That's largely because of my innate sense of fair play, and also because they recently saved me from serious injury.

I've never been much of a runner, but I decided to take it up in earnest about six weeks ago.  My decision was made partly to trim a little from my waistline, partly for cardiovascular fitness, partly for bragging rights ("my 5k time is better than yours"), and partly because I was on an out-of-town rotation and staying in an apartment complex with an air-conditioned workout center with treadmills.  I started fairly slow -- just 1.5 miles on each of my first few runs, building up over the course of a couple weeks to a bit past 2 miles.  Nothing out of the ordinary -- not even that long of a run.

My mistake was to run too frequently from the beginning.  My previous attempts to become a runner involved a MWF jogging schedule, adjusted as necessary based on my work schedule, but never with more than three runs per week.  While I was out of town, however, I had lots of free time and none of my normal distractions (family, video games, my movie collection, etc.) so I adopted a M-F running schedule with rest on Saturday and Sunday.

About two weeks into this schedule, I began to develop some left knee pain, particularly at the beginning of my run and after it was finished.  I foolishly rationalized that it was simply muscular soreness that would resolve with time in my new routine, so I continued my aggressive running schedule and used Motrin 800 mg tid to control my discomfort.  To an extent, it worked, and I was able to keep pushing myself more than I should have done.

My away rotation was four weeks long, and by the time it was over I realized something more than simple muscular soreness was at work.  I backed off to two runs per week, but those had become very painful, especially for the first half mile.  After each run, my wife was treated to my best Vanilla Ice impression as I collapsed into a chair ("Ice, ice, baby!").  My knee pain had quickly progressed from something associated with my runs to constant discomfort, hurting me even on my run-less days.  I was loathe to stop running, since I had come to enjoy it apart from my knee pain, but something was clearly wrong with my knee and I knew I needed to back off or risk serious injury.

At this point, I had a quandary: should I use my own medical knowledge to manage my injury conservatively, or should I involve an orthopedist?  It's not always easy for doctors to get time away from their clinical responsibilities, especially if they're residents.  Fortunately, one of the perks of medicine is the ability to informally ask for medical advice from colleagues in many specialties, and I approached an orthopedist in the OR two weeks ago to ask his recommendation.  He replied that he'd be happy to examine my knee in between cases, and when he did he became a bit concerned.

"You have a clear medial collateral ligament strain," he told me, "but you've also got pain too anterior to be explained by that.  I'm worried you may have a small medial meniscal tear."

The orthopedist (I'll call him Dr. Thompson) ordered x-rays and an MRI to further evaluate my injury, asking that I call him when the scans were done so he could check them.  I was able to get the x-rays done the same day, but MRIs must be scheduled and it took a week before I was able to have that study completed.

On the appointed day, I went downstairs for my MRI scan.  It was completed in about 30 minutes, and afterward the technician returned me to the waiting room while the radiologist checked the images to confirm their adequacy before I left the MRI clinic.  Five minutes later, the technician came back and informed me that the radiologist was on the phone and wanted to speak to me.

"Hi, this is Dr. Wong," he said.

"Hi, I'm Matt, one of the anesthesia residents," I replied.

"Matt, I'm looking at your MRI right now and you have a grade 4 stress fracture of your medial tibial plateau.  I want to get you on crutches.  This fracture looks pretty impressive."

I had a sinking feeling, knowing how crutches would complicate my job, which includes pushing patients around the OR suite and spending a lot of time on my feet.  But two things the radiologist said caught my attention.  First, he said the fracture was grade 4.  I was unfamiliar with the criteria for grading stress fractures by MRI, but lots of things in medicine are graded on a scale of 0 to 4 with 4 being the worst.  Second, he said the fracture looked "impressive."  That's generally doctor-speak for, "damn, that looks bad!"

Just to be sure, though, I asked him what a grade 4 fracture was.  He said it meant you could actually see a fracture line on the MRI instead of just bone marrow inflammation and edema.

So off to the radiologist I went.  He showed me my MRI (the picture at the top of this post is a screen capture from my MRI, and all the white crap in my tibial plateau is edema and angry inflammatory cells that shouldn't be there) and wrote me a prescription for crutches, which I could pick up from Physical Therapy.

A few minutes after I picked up my crutches, my cell phone rang.  It was Dr. Thompson, who had already looked up my MRI.  He had taken the time to look up my home number from the hospital computer system, then had my wife give him my cell so he could touch base with me.

"Matt, this stress fracture isn't pretty," he said.  "You need crutches."

"Just picked them up, sir.  Dr. Wong from radiology said the fracture looked ugly."

"Yeah, it's impressive.  In addition to crutches, I want you in a full-length knee brace.  It should be unlocked because I want you to be able to move your knee, but you need to wear the brace at all times.  And you can toe-touch, but no weight-bearing at all on that leg."

That gave me another indication of just how much damage I had done to my knee.  Total non-weight-bearing?  For an active resident who has to walk around the OR suite and the hospital all day long?  That's serious business.

I asked about the other MRI findings and Dr. Thompson told me that the MRI confirmed the MCL strain he'd diagnosed, but my meniscus looked good.  He told me where to go for the brace and said he'd follow up with me on his next operating day.

And that's pretty much where we are now.  I'm hobbling around on crutches because I broke my leg by advancing my running schedule too aggressively.  But for now, I seem to have avoided more serious injury (like the fracture extending all the way through my tibial epiphysis).  I know the extent of my injury and I now know exactly why my knee was hurting me so much, which knowledge is empowering since it allows me to undertake the appropriate management to promote healing.  And it's all because a good, attentive orthopedist was willing to increase his own workload by examining me between his cases, then take an active role in my follow-up and intervention.  And a good radiologist was willing to stick his neck out, too, instead of just dictating his findings and closing the MRI.

So here's a big "thank you" to Drs. Thompson and Wong (whose names have been changed, as always) for their excellent work in diagnosing and treating my fracture.  I'm deeply grateful for their willingness to go beyond the call of duty to follow up with me and ensure that I received the information and equipment required to prevent further injury.

And I learned a lesson from all this: when you decide to take up running, it is important, as with so many things in life, to pace yourself.