A Saturday Trauma Shift
Under ‘Better To Be Lucky Than Smart’:
An 18 year old male attempting to
break the ‘car surfing’ distance record (I didn’t know they kept such records) at mile three was struck
in the eye by a bug (no goggles), lost his balance and fell off the car striking his head on the pavement (no helmet either).
Despite an occipital skull fracture and a subdural hematoma, he’s awake and alert and talking. He’s likely to
survive to attempt the record again.
Under ‘No Cure For Stupid’:
A thirty-year-old male, passenger in a car that spun out on the freeway and struck the guardrail. He was unhurt in
the crash, but when the police approached he got out of the car, jumped over the guardrail and fell fifteen feet to the bottom
of a ravine. He broke his heel and his femur (thighbone) and required a crane to extricate him from the ravine. It seems he
had a bag of illegal oxycontin in his pocket and didn’t want the cops to find it. It didn’t occur to him to simply
toss the bag out the window and retrieve it later. To add insult to injury, the cops say they wouldn’t have searched
him anyway since he wasn’t driving and was unhurt in the original accident.
‘No Good Deed Goes Unpunished’:
A twenty-year –old male was the designated driver for a buddy’s 21st birthday celebration. He
did his job, stayed sober and safely delivered all the partygoers home before heading for home himself. He fell asleep at
the wheel and drove the car into a dry canal, shattering his second lumbar vertebra. He has no sensation below mid-thigh and
can’t bend his legs. Fortunately, the neurosurgeons stabilized his spine and say he has a reasonable chance at a full
Under ‘Only in Arizona’:
An amateur cowboy was practicing his
roping skills for an upcoming rodeo. He dropped his loop around a practice post, cinched it up tight and went to wrap his
end around the pommel of his saddle. For some reason, the horse reared, the rope wound around his thumb as well as the pommel
and sheared his thumb off at the base. The rope then broke, the end whipped back under tension and caught him in the right
eye, rupturing the globe (eyeball). He fell from the horse breaking some ribs and the horse stepped on him breaking his femur.
Four major injuries from a single freak event.
Every shift is a new adventure.
and M (not the candy)
am going to present a case at the Morbidity and Mortality conference. M&M is a time-honored surgical tradition that, ideally,
is an open forum for surgeons to give and accept criticism, dissect their errors and try to understand why adverse events
happened. Surgery is not an exact craft. It’s not like working on an engine or a malfunctioning computer. Every case
is different and presents different opportunities to excel or to trip over your own feet.
cases that I’ll have to discuss aren’t important. Suffice it to say, there was room for improvement in my management.
That’s okay. As my friend, the late Troy Brinkerhoff used to say, ‘Every day’s a school day’. We learn
by doing, and sometimes by screwing up.
M&M is part of a larger process of peer review. I know
the ability of physicians to police themselves has been seriously questioned of late, but in the setting of a peer review
meeting, or M&M conference, surgeons tend to be their own harshest critics.
The process of reviewing
and discussing another surgeon’s complications can be gut wrenching. We all share a common set of experiences from our
training, and after a few years in practice, a common case log of operations performed and problems managed. A few key words
about a patient’s history or the appearance of an x-ray convey a host of potential difficulties and complications that
it would take several minutes to describe to the non-surgeon.
Sometimes that shared experience
leads to sage nods of understanding when a difficult case is presented. Yes, we understand. We’ve been there and but
for the grace of God it could be one of us dealing with this complication (And thank God it’s you and not me). Other
times it leads to forehead smacking what-the-hell-were-you-thinking condemnations.
The key to good
peer review is an atmosphere of mutual respect and a commitment to confidentiality. Case discussions under the umbrella of
peer review are protected from discovery. Nothing we say to or about one another can find its way into a malpractice suit.
That may seem a bit cold at first blush. We are talking about patients who have been harmed by a complication of our surgeries.
But if we are to be honest and fearless in our examination of these problems, we can’t be looking over our shoulders
for a subpoena if we admit to an error in judgment or a lapse in attention.
Does it always work
that way? Of course not. Honest criticism sometimes degenerates into acrimony. Competing groups use the peer review process
to bludgeon one another. But by and large, the system functions. Relations are patched up and the job of a department chairman
is to protect the integrity of the M&M conference. Especially when its his own dirty laundry that’s about to be
I did an urgent laparoscopic cholecystectomy today on a young woman who called the office with a sudden worsening
of her gallbladder symptoms. By the time we got her to the OR preop area, she was pale, diaphoretic (cold and sweaty) and
writhing in pain. Her gallbladder was sick but not infected and she had a stone stuck tight in her cystic duct, the tube that
drains the gallbladder. The stuck gallstone was probably what caused the sudden worsening of her symptoms.
I had originally seen her in the office
late in July, just before I went on vacation. She was having episodes of upper abdominal pain once or twice a week and had
gallstones diagnosed by ultrasound. She's an otherwise healthy thirty year old who had stones diagnosed on a pregnancy
ultrasound and symptoms that started four months after the recent birth of her third child--pretty typical history. She took
no prescription medications but did take a handful of herbal and vitamin supplements daily and told me she stayed away from
processed foods in favor of a 'natural' diet. That should have tipped me off, but it didn't
at the time.
The surgery went well, although the stone was wedged pretty tightly and I did an x-ray of the common bile duct, the
main tube that drains bile from the liver, just to make sure no other rocks had gotten away from us.
When I talked to her family after surgery,
her husband asked if the 'purge' had worked. I asked what he meant and he told me she had read about a gallbladder
purge that was supposed to get rid of stones 'naturally' and had tried it a couple of days before. The increased pain
and the stuck gallstone now made sense.
These purges are touted on various websites as a natural cure for gallstones. There are several popular ones, but
they all involve a fast of several days followed by a large dose of olive oil or similar fatty meal. The idea is to make the
gallbladder 'expel' the stones. These purges are at best a bad idea and at worst dangerous.
Why? First, a few words about the gallbladder
and what it does. The gallbladder stores bile. When we eat, especially a meal rich in fat, the stomach and intestine secrete
a hormone called cholecystokinin (CCK) which causes the gallbladder to contract and push a big slug of bile into the common
bile duct and through it into the intestine. Bile acts like detergent to break fat into smaller globs that the digestive enzymes
can work on. People have gallbladders because for most of human history, food supplies were unreliable. Especially for our
hunter-gatherer ancestors. They might eat a large meal one day and then little or nothing the next. An organ to store bile
during fasting and mobilize it in response to a meal prevented crippling diarrhea from poorly digested fat.
When we eat every
day, which most people in this country do, and especially when the quantity and quality of our food doesn't vary much,
the gallbladder can languish. It has nothing to do. That may be why some gallbladders form stones. We don't really know.
But we do know that healthy gallbladders don't allow stones to form in the first place. So if you have gallstones, your
gallbladder isn't working very well.
Purges try to take the normal physiology of the gallbladder and use it to pass the stones out into the bile duct
and thence into the intestine. Sounds nice, but in practice, only small stones can pass this way. And, because the bile duct
is a low pressure/low flow system, even then they often get stuck. A larger stone will just wedge itself into the duct and
jam up there, causing unrelenting pain and setting up the potential for an infection or even a ruptured gallbladder.
I see five or six
patients a year who come to my office or to the ER acutely ill after one of these purge attempts. Often they were referred
to a website by a helpful friend, or worse, had the purge prescribed by one of those charlatans who call themselves 'Naturopathic
Physicians'. Just because it's natural, doesn't make it safe. (Hemlock is a natural substance but it wasn't
very good for Socrates.) You may know a friend or a friend of a friend of a friend's second cousin who 'cured'
gallstones this way, but that doesn't make it a good idea.
On the other hand, it doesn't hurt my business to have a patient who
is convinced in such a graphic way that they need an operation. Olive oil cocktail, anyone?
Win One, Lose One
Sometimes the magic works and sometimes it doesn't. Last night was like that. About midnight a young woman came
in with a stab wound to the groin. Paramedics said it was a five or six inch blade that entered her groin in the crease between
the upper thigh and the abdomen. There was a lot of blood at the scene and her blood pressure was low--50 over nothing. There
was about a pound of gauze covering the entry wound and it was saturated.
The groin is a busy place. Both the femoral artery and
the femoral vein, the main vessels into and out of the leg run through the area where she'd been stabbed. The distinct
crease in the groin is created by the inguinal ligament. This is a tough band of tissue about an inch thick that provides
the point of attachment for all the abdominal muscles. Put a hook through it and you can lift the whole body off the ground.
The vessels run under it and that makes them hard to get at.
The first rule of arterial injuries is proximal and distal control. Get
the vessel above and below the injury and put your clamps on there. Trying to get control of a bleeding vessel at the site
of injury is usually a losing proposition. Especially when the blood is flowing as fast as your kitchen faucet. But getting
proximal control in the groin can be a challenge. Sometimes you have to get at the artery and vein from inside the abdomen.
This time, I got
lucky. The injury was just below the inguinal ligament. Not enough to get good control, but enough so that by cutting the
ligament, I could get at the artery and vein from the leg side and not have to open the abdomen. Lucky for her, too, because
as fast as we could pump blood in, it was gushing out of the wound. Once I got a vascular loop on the vessels (a soft rubber
tie that closes off the vessel without damaging it), we could catch up on the blood loss and call the vascular surgeon to
do the definitive repair.
The other vascular injury patient wasn't so lucky, but that was his intent in the first place. I am always ambivalent
about gunshot wounds to the head, especially when they are self inflicted. Outcomes are rarely good. Most through and through
wounds aren't survivable. Death, or at least brain death, is the norm. Even those people who survive almost never regain
a quality of life near to what it was before the wound.
This was a thirty year old man who shot himself with a nine millimeter
pistol. Entry wound in the right temple, exit wound behind the left ear with brain matter herniating through the wound. He
was hypotensive with a blood pressure of 70/40. Paramedics said he was breathing spontaneously on scene and had some purposeful
movement, so we were committed to treating him as a salvageable patient.
We pumped in volume, dressed the wounds with a turban-like
pressure dressing and I called the neurosurgeon. He was pretty pessimistic about the patient's chances. Through and through
wound in a bad zone of the brain, but even then, there was donor potential to think about. It sounds cold, but Donor Network
is one of our first calls in cases like this. I shipped the patient off to CT scan to assess the amount of brain injury. At
that point his pressure was up to 110/70 and he was breathing on his own. His pupils were fixed and dilated and he didn't
respond to pain. He was probably dead and his heart and lungs just didn't know it yet.
A few minutes later, I got a call from
the CT scanner. The patient had dropped his pressure and there was massive bleeding soaking through our dressing. The scan
was done, so we hustled him back to the trauma bay. I took down the dressing and found blood gushing from the exit wound behind
the left ear.
First rule of bleeding control: stick your finger in the hole. I did and knew immediately that the ball game was
over. I could feel the jet of bleeding from the internal carotid artery hitting my fingertip. Unlike the artery in the groin,
the internal carotid at that point is encased in a boney canal. There's no way to get at it. Imagine a fire hose encased
in concrete. Imagine trying to get at the hose by chipping away the concrete without making more holes in the hose. It can't
be done. I could plug the hole with my finger inside his skull, but that just diverted the flow to other branches in the face
and nose and all the blood started leaking from there.
I called the neurosurgeon who was looking at the scan from a remote monitor.
He could see that the bullet had blown away the carotid canal in the skull and had taken out most of the frontal part of the
brain as well. We decided that further efforts were a waste of time and blood products. I'd never be able to get him stable
enough for transplant harvest. We stopped pumping in blood and the end came within a few minutes.
Why hadn't the bleeding been immediately
obvious when he came in? I think his pressure was low enough that a clot formed in the injured carotid. Sometimes it's
better if an artery is completely divided rather than slice halfway in two. A completely divided artery will contract and
narrow the hole, maybe enough to allow a clot to form. The partially cut artery can't close the hole and it keeps bleeding.
I think when we resuscitated this patient and pushed his pressure up to 110, it blew the clot out of the end of the artery
and he started bleeding again.
Object lesson--not all bleeding can be controlled, but all bleeding stops eventually.
Sometimes, my job involves playing
traffic cop, or referee when two different specialists have competing interests in the same trauma patient. As the trauma
surgeon, I have ultimate responsibility for decisions on care, even when it isn't care that I personally am delivering.
we got a man in from a motorcycle accident with a complex pelvic fracture. He had what's called an open book fracture.
It's a disruption of the pubic symphysis, the joint in the front of the pubic bone, as well as a disruption of the sacroiliac
joint in the rear. Think of it as the splits taken to the extreme. This disrupts the plexus of blood vessels around the pelvic
ring and often causes massive bleeding. It can also tear the bladder or rectum and spill their contents into the pelvis or
The treatment for the bleeding is to reduce the fractures-pull the separated bones back together again. We can use
a metal frame and screws placed into the bone through small incisions, or a simple binder around the hips. The bleeding isn't
the kind you can fix with ties or sutures. It's rapid bleeding in a tight dark box with no easy ends to tie or tissue
to sew. Fortunately, if you close the box, by pulling the bones together, you may create enough pressure to slow or stop the
blood loss. The last thing you want to do is open that box by making an incision in the abdomen or pelvis. It's like taking
the top off of a shaken up bottle of soda.
So my orthopedic colleague wants to place a binder on this gentleman and
monitor him in the ICU, aggressively replacing blood and components until the bleeding is controlled. Then he can operate
to fix the fractures.
But in this man we also had a ruptured bladder. Worse, the rupture was into the peritoneum, the abdominal cavity,
and was bathing the intestine in urine. The treatment needed is an operation to repair the tear. But that involves opening
that bloody box and releasing the pressure.
Now I have a Urologist and an Orthopedic Surgeon glaring at me, a charge
nurse who wants to know if she should call the OR or the ICU and a patient whose blood pressure is starting the slow slide
that means we're falling behind on his volume replacement. DO we delay surgery and risk infection, sepsis, and possible
death? Do we go to the operating room and repair the bladder and risk releasing the pressure keeping the bleeding down to
a manageable rate? My decision, my job.
After some consideration, I decided that the risk of infection from a bladder
rupture outweighed the bleeding risk. Urine itself is sterile, but it is a chemical irritant to the bowel and is a pretty
effective anticoagulant. Enough urine in the pelvis and the blood won't clot anyway.
We started some bigger IV line,
ones that we could pump blood through as fast as it would run through the tubing. I helped the urologist. The bleeding was
alarming. the suction ran continuously making a sound like water running down a drain. The anesthesiologist did a great job.
She pumped in ten units of packed red blood cells, ten units of plasma, two platelet packs and two rounds of concentrated
clotting factors (called cryoprecipitate). That's on top of almost five liters of saline. We fixed the bladder and the
orthopedic guys placed an external fixator-a frame to pull the pelvis together. We made a stop in the angiography suite after
surgery where the radiologist embolized some big bleeders. By placing a catheter in the bleeding vessel, they can inject small
plugs that block the bleeding vessels and help control the bleeding as well. By the time we made it to the ICU, the patient
was stable, the bladder was fixed and the pelvis was reasonably stable. He's facing a lot more surgery, but should recover.
point of this story is that this was a team effort. A lot of different people had to do things as a team to get the result
we did. I couldn't do it myself. I don't have the training to fix the bones, and although I could fix the bladder,
the repair wouldn't be as good as the urologist's. He does that work every day. My primary role
here, and in a lot of other, less intense traumas is to prioritize the interventions and make sure that the competing interests
don't sabotage each other.
How Surgeons Think, Part 2
A long time patient of mine was admitted by the Hospitalists
five days ago with a bowel obstruction. He has known metastatic colon cancer and has trouble with intermittent obstructions
for some time, probably due to tumor. I admitted him for the same problem just after Thanksgiving and he got better as 80%
of obstructions do. We talked then about surgery. The bottom line in this situation is that when the obstruction doesn't
resolve or when it becomes a recurring issue, surgery is an option. With tumor you never know. You may or may not be able
to fix the blockage. If the tumor is too extensive you may do an operation for no gain. I told him I would discuss it with
him again if the symptoms became unbearable and he wanted to try an operation.
He went home but didn't fully recover. Every few
days he'd have obstruction symptoms again. He'd stop eating for a day, get better and start back on a diet only to
have trouble again several days later.
This admission, the Internists plugged him into IV nutrition, and resolved his pain and nausea. They then dithered
for five days, trying again and again to advance his diet before deciding to send him home on home IV therapy. For some reason,
the Hospitalist on call New Year's day decided to call me to see him before discharge so I could arrange to see him in
sat down with him and layed out the options. He clearly wasn't getting better with waiting. His choices were to have surgery
in hopes of relieving his blockage or do nothing and enter hospice. The options are easy to present, the choice is very hard.
But up until our conversation, none of the doctors caring for him had laid the choices out clearly for him. He chose to risk
the operation. I canceled his discharge and he's scheduled for Monday.
The difference in approach to this patient was very
clear. From the admisssion five days earlier it was clear to me that he was going nowhere. No amount of time or medication
would resolve the problem. A clear presentation of options was needed so that a very hard choice could be made. But someone
needed to articulate tose options for the patient. None of the internists could or would do that.
A Surgeons Day
It was a quintessential General Surgery
day. An elective line up that started with a complex abdominal hernia repair, followed by a thyroid lobectomy, a laparoscopic
cholecystectomy (removing a gallbladder with the laparoscope) and finishing with a robotic laparoscopic Nissen fundoplication
(fixing a hiatal hernia and wrapping the esophagus to prevent acid reflux). Halfway through the second procedure, an internist
friend of mine called me. Bad sign--he never calls personally unless it's a disaster.
"Are you busy?" he asks. Another
bad sign. He's not given to small talk and that kind of lead-in means he needs a favor.
"What's up?" I ask. He
jumps right in. He has a patient in the ER with abdominal pain and a CT scan showing a perforated colon. Probably diverticulitis,
but there's a lot of spillage and free air in the abdomen. Free air means that air from the intestine is leaking into
the abdominal cavity and showing up in places where air doesn't belong. The implication of free air is that the leak is
large and the body can't wall it off. Peritonitis usually follows. So far, a pretty standard presentation for a perforated
diverticulum of the colon, serious but not disastrous.
"What's the rest of the story?" I ask. After an apology for
dumping this on me, he fills in the details. The patient has emphysema. She has poor oxygen saturations on a good day and
now is hypoxic, blue, hypotensive and getting emergently intubated as we speak. She is on high dose steroids for her lungs
and her rheumatoid arthritis. She has had two strokes and a blood clot in her lung and is on Coumadin, a powerful blood thinner.
Her INR, a measure of her prolonged clotting time due to the drug, is 4.5 (normal clotting is 1).
Surgeons hate Coumadin. It's hard
to control and not easily reversed in an emergency. We also hate steroids. They inhibit the immune system so patients are
more susceptible to infection. They delay wound healing so patients on high doses are at risk for wound breakdown. This lady
is a train wreck. She would not be a candidate for an elective procedure under any circumstances, but this is no longer an
I finish the thyroid operation, which fortunately was not a cancer, speak to the family, and then hustle over to
the ER. Mrs. G. is now intubated and has a couple of large bore IV lines in. My internist friend has started antibiotics,
gotten some blood typed and crossed (with her coagulation profile, we're going to need it), and started pressors (drugs
like epinephrine that raise the blood pressure) because she's now in septic shock. Dr. K. is one of the good ones; an
internist who follows his own patients when they are admitted and who is comfortable with seriously ill people. The only thing
I add is a dose of recombinant Factor VII.
Factor VII is a clotting factor in the coagulation cascade. It used to be precipitated from donor blood and is used
for hemophilia. It's now manufactured by recombinant DNA technology and is free of human pathogens. It's also beastly
expensive and dispensed by the microgram. An off-label use is in the severely bleeding patient and as a temporary reversing
agent in patients on Coumadin. It buys you a couple of hours before it metabolizes away and the blood stops clotting again.
We use it as a bridge in situations like this where anticoagulated patients need an immediate operation. There are other agents
that can be used, but they are all either expensive or take a long time to work.
I bump myself (delay my other cases and use the room
and anesthesiologist for this case) and we rush off to the OR. The operation is pretty straight forward. I take out the perforated
segment of colon, oversew the downstream end as a blind rectal pouch and bring out the upstream end as a colostomy. We close
the abdomen with some retention sutures, extra heavy sutures, through the big abdominal muscles. Two hours, five units of
packed red cells and four units of plasma later, we transfer the patient to the intensive care unit.
I'm now two hours behind schedule
and have the hardest part of my day coming up. The laparoscopic cholecystectomy is easy and the patient is a young healthy
woman. She does well and will go home from the recovery room.
The robotic case is much different. Robotic surgery is a misnomer. Remote
teleoperation surgery is more accurate. The robot does nothing on its own. It is a tool, an extension of my hands. I sit at
a console, several feet away from the patient and operate the arms and manipulators of the robot with fingertip controls.
My head is in a hood with binocular eyepieces that give me three dimensional vision through the robot's two cameras. It's
just like having my head inside the patient, up close to the area where I'm operating. The drawback is the complete lack
of any tactile sensation. Even with the regular laparoscopic instruments, I can still 'feel' what's going on.
Not the same as with my fingers but like the feel you get using chopsticks to eat. You can tell the texture of the food, it's
size and resistance to tearing. Regular laparoscopic surgery is similar. I can tell if tissue is hard or soft, weak or sturdy
by the feedback sensation through the instrument. Not so with the robot. It's all visual.
Robotic cases are stressful. Even after
fifty or so, I still feel stressed while operating. I don't schedule more than one a day and would prefer not to have
other hard cases on the same day. This day, I've already been stressed and am not looking forward to the robot. Fortunately,
my patient is a healthy man and is reasonably thin. The case starts well and by fifty minutes in, we have the robot docked,
the instruments in and I move to the console to start work.
That's when the pages from the ICU start. Mrs. G. is still bleeding,
soaking through her dressing and leaking from the edges of her colostomy. Her INR is 3; better than before but still too high.
I order more plasma and some vitamin K. Fresh Frozen Plasma (FFP) is full of clotting factors and helps reverse the Coumadin.
So does Vitamin K. (Coumadin blocks vit K in the manufacture of the clotting factors by the liver).
Throughout the robotic operation, I
field calls from the ICU. My mind has to be able to split attention between the operation at hand and the resuscitation of
my critical patient in the ICU. I also maintain a low level of situational awareness for the room around me--what my assistant
nurse is doing, how the monitors of the patients pulse and BP read, whether the anesthesiologist is relaxed or busy--all these
things are there in the background.
The robot surgery goes well. We finish in a little under three hours--about par for that type of surgery. I'm
convinced it would have gone faster without the interruptions from the ICU, but don't worry much about it. It's a
decent time and I feel like I still know what's going on with Mrs. G. I write post op orders and talk to the family before
returning to the ICU.
Mrs. G has stabilized somewhat. She's off the pressors and the oozing seems to have slowed down. Her saturations
are terrible, but survivable and probably as good as she ever gets. More importantly, her base deficit (a measure of acid
in the blood) is less than -3, which means she's delivering oxygen to her tissues adequately. The shock seems to be clearing
and her INR is down to 1.5. Now we only have her lungs and kidneys to worry about. But at least I can go home. It's nine
P.M. and I've been in the hospital since six in the morning.
It's not that this day was so special. Quite the contrary. Many days
are less busy, some more so. The day was not unusual for me or for many of my colleagues, which is why we are becoming dinosaurs.
Few choose to go into surgery these days, fewer into General Surgery. That broad range of skills and orientation is slipping
away, replaced by specialists who concentrate on single organ systems or disciplines. I don't know if this is a good or
bad thing. Specialists can concentrate on the latest knowledge and techniques but sometimes miss the bigger picture. I still
think the ability to shift gears rapidly between a routine schedule and an emergency and then back again still has value,
though. I just don't see very many successors in the current training programs.
How Surgeons Think
I was on trauma call recently and an unfortunate young
man was brought in after being run over by a car. He was riding his bicycle home from a local pub, (blood alcohol .2) when
he lost his balance and fell. He landed in the traffic lane rather than the bike lane or sidewalk and was run over by a car.
The wheels went over his pelvis and abdomen. He arrived at the trauma unit in serious trouble with a nasty pelvic fracture,
a dislocated hip, multiple broken ribs, a punctured lung and a distended abdomen. He was in shock and having trouble breathing
and in severe pain. We quickly determined that the problem with his breathing was the hole in the lung and the resulting pneumothorax
(Air in the chest cavity that compresses the lung and restricts breathing) Easy fix with a chest tube, a tube passed between
the ribs into the space between the chest wall and the lung to suck the air out and reinflate the lung. Sixty seconds after
placing the tube he was breathing better.
His blood pressure was still low but it responded transiently to a shot of IV fluid. Better to replace lost blood
with blood, so we gave him two units of O negative. Wonderful stuff, blood. O neg is often called 'universal donor'
blood because it lacks the major antigens that cause most transfusion reactions. You can give it with reasonable safety to
any blood type without waiting for a cross match. The blood boosted his pressure to a safe range and bought us time.
A quick exam and
a plain x-ray of the pelvis showed a complex pelvic fracture and a dislocated hip. You can lose a lot of blood into a fracture
like that. It could account for his shock. But his abdomen was tender and distended and he was still having episodes of low
blood pressure. He just looked like he had blood in his belly. I thought about going to CT scan, but another dip in the pressure
decided the issue. We were going to the operating room.
At surgery, I found very little free blood in the abdomen. But under the
colon on the left side, where the left kidney lived there was a tell-tale stain of bright red. The bleeding was in the space
behind the intestine called the retroperitoneum. Dangerous stuff lives back there: the kidneys, the pancreas and the great
vessels--the aorta and the vena cava, the largest blood vessels in the body. Bleeding back there can make a noise when it
cuts loose. (Literally, turn on a faucet and listen to the sound it makes splashing into the sink. Bleeding from one of those
vessels can sound like that). Surgeons say a brief prayer before entering that area.
I opened the area where the blood was, taking care
to stay close to the big vessels so that I could get control of them if I needed to. The bleeding was coming from the artery
and vein that supplied the left kidney. A vascular clamp on the root of the renal artery slowed things down and bought time
to dissect out the artery and vein and assess the kidney. Unfortunately, the artery had been torn off of the hilum of the
kidney, the place where the vessels and the ureter enter the substance of the organ. (Imagine a kidney bean; the hilum is
the dent in the side of the bean) That's not a repairable injury. I might be able to jump a graft from the aorta, but
there wasn't enough vessel on the kidney side to sew to and the substance of the kidney around the hilum had been crushed
to hamburger. No other choice really. The kidney had to come out.
That's a hard decision to make on the fly. This was a healthy young
guy with no medical problems. He had an intact right kidney and clear urine in the catheter we placed before surgery. I had
the anesthesiologist give a little blue dye in the IV and within seconds the urine turned green so I knew the right kidney
worked (A one shot IVP or a CT would have been better but we didn't have time and I was concerned about giving contrast)
He'd survive just fine with one kidney, but taking the left one out still felt like a failure. I went
ahead anyway. The rest of the procedure was routine and after closing the abdomen, we went to CT and got good pictures of
the head, neck and pelvis. The right kidney is working fine. He's still sick, his lung is damaged and he has a lot of
toxic byproducts from the crush injury to his muscles in his system causing problems for his heart and kidney.
I am still second
guessing the decision. It's an occupational hazard. I still believe it was the right thing to do. The interesting thing
is the reaction of the various specialists who are involved. My fellow trauma surgeons listen to the description
of the injury and nod and say "Good call". The intensivist (a pulmonologist, or lung specialist, by training) asks
if I called in a vascular surgeon or urologist to help make the decision. I didn't. Aside from it being O-Dark-Thirty
in the morning, the answers would have been the same. Why spread the pain around? The answer, of course, is spreading the
responsibility. Internists are accustomed to medicine by consensus. Get multiple opinions and decide on a course of action
that all agree upon. Surgeons tend to take individual responsibility for action. I may ask for input if I'm uncertain,
but in the end, I'm ultimately responsible for the outcome.
As Dr. Blalock, the father of pediatric cardiac surgery, said back in the
1940's "The mark of the surgeon is the ability to make irrevocable decisions on the basis of incomplete information."
AN O.R. TALE
She was 94 years
old and had been labeled demented. She was admitted through the Emergency Room because she had stopped responding to the caregivers
at the assisted living center. The ER doc checked her out and found that she was again extremely hypercalcemic--her blood
calcium was too high. Normal range is 8 to 10 mg/dl. Hers was 13. This wasn't her first trip for this problem. In the
past two months she had been admitted three times with calcium's over 12. The Hospitalists would tune her up with saline
and diuretics, treat her with Sensipar, a drug that lowers calcium, and send her out, only to have the cycle repeat. Either
she wasn't taking her meds, or they weren't working to keep her stable. After all, she's demented; she may not
be able to take her meds properly.
This time, the Hospitalist who admitted her was a friend of mine. She's an Internist who is old enough to remember
the days before DRG's and 'best practice guidelines'. Those guidelines say that for patients over 80, the best
management for hypercalcemia is medication. Rather than simply follow the guideline. she worked the patient for hyperparathyroidism.
parathyroid glands control calcium in the body. Most people have four glands, two on each side of the neck. Once in a while,
one of those glands will stop responding to the feedback mechanisms that control the production of parathyroid hormone (PTH).
It then becomes an adenoma, a benign tumor that keeps churning out PTH, no matter what the calcium--a condition called hyperparathyroidism.
The old lady's
PTH was 380, over ten times normal. And her parathyroid scan, a nuclear medicine study, showed a probable adenoma on the right
side. So my friend the internist called me. My first response was 'You've got to be kidding'. Did she really expect
me to operate on the woman? When I first saw the patient, she could barely put two words together and those didn't make
sense. She was so thin and frail a strong wind would blow her away. And yet, my friend insisted that her mind seemed clearer
when her calcium was below 10 and her family was in favor of either surgery or completely withdrawing care and letting her
go. So I reluctantly agreed.
We went to surgery . I did a focused operation on the right and removed one of the biggest parathyroid adenomas I
have ever seen. Her PTH went from 380 preop to 36 in the recovery room and ultimately fell to 16. Her six hour postop calcium
was 10.5 and she did surprisingly well with the anesthesia. I felt pretty good about it.
When I went into her
room the next morning, I thought I was in the wrong place. In bed was a bright animated elderly woman happily eating oatmeal.
Her first statement to me was 'When can I go home? I have things to do.' She was a totally different woman. One of
the effects of hypercalcemia is mental depression that can simulate dementia. It's called metabolic encephalopathy and
had been the problem all along. Not only did we fix her high calcium, we fixed her brain, too.
Happy ending, right? So I go out and
get her chart, feeling on top of the world. I open the chart and find the dreaded Green Sheet. A missive from the Medicare
case manager. 'Dear Doctor, Best practice guidelines recommend medical management of hyperparthyroidism in patients over
80 years of age. Surgery is not approved treatment for patients in this age range. You must have prior authorization for surgery
or payment will be denied.' So my friend and I save this woman from spending her remaining days drooling in a corner and
Medicare is going to shake its bureaucratic finger at us and refuse to pay for her care? I hate to be pessimistic
(well, a little. Surgeons are natural pessimists), but I see this as a preview of where the regulation of healthcare is headed.
Follow the guidelines. Forget your experience, your training, your gut. Just follow the book. It was that gut instinct that
made my friend the internist work our patient up and then push me to operate on her. How long will we be able to keep that
kind of intuitive thinking in medicine?
Should We Insure Everyone
Guarantee Healthcare to Everyone?
In the current media blitz about healthcare reform, the idea that everyone should be provided with some sort of healthcare
coverage is accepted as axiom. The only question considered valid is how to expand coverage to one and all. "NO ONE SHOULD
DIE FOR LACK OF HEALTHCARE!" is the rallying cry.
But is this the proper business of a government such as ours? Is it proper
for a limited government to intrude in people's lives in such a fundamental way? Is it even permitted under our constitution?
That last statement echoes some of the arguments of the more radical Right, but is still a legitimate question whose answer
has implications beyond just healthcare.
So, first: Is healthcare a basic right? If so, why? Under what definition of 'rights'? And if we accept this
as a right, what about food, shelter, clothing? Aren't they basic rights as well? Where is the 'crisis' in government
provided food or fashion accessories? If we are to talk about rights to healthcare, we are accepting that some level of care
must be provided without any obligation on the part of the recipient. After all, a right is not something you have to buy.
It's yours already. You don't pay for your rights to worship in the church of your choice, or speak your mind in open
debate or vote in a public election. So why should you pay for healthcare?
Historically, rights were defined in very broad terms
and, in the American tradition, were endowed by the mere fact of being human, by our 'Creator'. They were 'inalienable'
and one needed to be constantly on guard that a despotic government did not usurp or infringe on those rights. Our Declaration
of Independence and Constitution speak eloquently about various rights and responsibilities. The main thrust of both documents
is to guarantee individual freedom and LIMIT the ability of government to infringe on that freedom. That's why the Bill
of Rights is mostly written in the negative--'Congress shall make no laws...' 'Rights shall not be infringed...'
and so on. Nothing in there about the government being obligated to provide any rights to the citizens, only prohibitions
on taking rights away. So where does this supposed right to healthcare come from? Yes, we can't be deprived of life or
liberty without due process, (hence the obligation on the government to provide CRIMINAL defense), but no mention is made
of illness or economic adversity. There is no constitutional right to care; only, perhaps, a right not to be arbitrarily denied
care based on race, religion, creed etc.
Much is said of a 'moral obligation' to provide healthcare. But how does a government incur a 'moral'
obligation? And how can it impose that obligation on a segment of its citizens? Moral obligations are questions of individual,
not collective, responsibility. A devout Muslim is morally obligated to pray five times a day. Not being Muslim, I chose to
pray when it suits me. A Jew is morally obligated to avoid eating pork. Not being Jewish, I like bacon with my eggs. I feel
a moral obligation to treat patients in my office regardless of their ability to pay. I cannot impose that obligation on my
peers or the labs, hospitals and pharmacies that I use. No government has the right (see above) to impose a moral obligation
upon me to provide a service to another person if I choose not to provide it. This is not the same as laws that impose obligations
on us to behave in certain ways. Those are prohibitions on destructive behavior that infringes on the rights of others. A
government can COMPEL me to do certain things against my will, but that not the same moral obligation. If I choose to disobey,
I can be deprived of my fortune, my liberty or my life, even if I believe I am morally in the right. (Which is why I pay my
income taxes despite my belief that they are inherently immoral). If individuals believe in a moral obligation to provide
healthcare to those without it, let them band together with like minded fellows and do what they can to provide it. Don't
use the instruments of government to compel me to do their work for them.
So, in my opinion. there is no legal or moral OBLIGATION
for the government to provide medical care to individual citizens, any more than there is an obligation to provide everyone
with food or clothes or a house or a car. We may, as a Republic, decide that it is desirable to provide these things for our
citizens, but that is not the same as an obligation. That is a question of economics and politics, not morality.
Despite media hand
wringing and political hyperbole, people are not dying in the streets for lack of universal healthcare. Any full service Emergency
Room in this country is obligated by law and usually by hospital charter to provide lifesaving care regardless of ability
to pay. It doesn't mean you won't get a bill afterward, but you won't be denied care for a life-threatening condition.
No one is bleeding out on a street corner because the ER wouldn't take care of them. The real tragedies are more subtle.
People who are faced with a sudden crisis, such as a diagnosis of cancer, who have no insurance to pay for treatment that
could save their life. Or who feel they must compromise their care in the interest of keeping a job or a family obligation.
It would be nice to have a system that doesn't force those choices. But are these situations any more tragic than the
family whose home and possessions are destroyed by a fire or a tornado? Where is the hue and cry for universal homeowners
insurance? What about the small tragedies--the man who loses a job because his employer went out of business or the car that
breaks down preventing a single mother from going to a job interview. Do we insulate people from all of the misfortunes of
life because they have a 'right' to not suffer from misfortune? No. This country has a tradition, possibly a myth
but a common myth that binds us together, of self-sufficiency and personal responsibility. It's why the current system
of care evolved the way that it did in the first place.
Economics is the reality check in all the healthcare buzz. Plain and simple,
no matter how you crunch the numbers, there just isn't enough money in the system to pay for the current level of care
for all citizens. Period, end of story. Either you come up with more money or you reduce the level of care. There are no other
choices. There is not the level of 'fraud' in Medicare that will save the billions the administration claims. Preventive
medicine won't do it , nor will the magic of the electronic medical record. One way or another, the money paid out will
have to decrease. You can cut payments to doctors. We're an easy target, but a limited one. Make the practice of medicine
too restrictive or poorly paid and no one will do it. You can cut services. Not politically palatable,
but for a while you can get away with blaming it on greedy doctors and hospitals who won't provide the same level of service
for less money. Or you can have long waiting lists for specialty care and hope people die or get discouraged before their
turn comes. No matter what, though, you ultimately get the care you pay for.
Most of these points are not new. Nor are they necessarily
practical. I don't claim to be an expert on practical healthcare policy. I have opinions that are shaped by my experience
and political philosophy. What I do in my own practice is my decision and my business, not the business of some government
bureaucrat. For what it's worth, I take all insurance plans, even the ones that pay poorly. I don't turn people away
if they have no insurance. I don't usually provide free care, but I do have my office manager try to work out a payment
scheme that will be acceptable to the patient. For cancer surgery, I do what has to be done a worry about payment later. I
believe in personal responsibility and expect even my indigent patients to pay something toward their care. I have little
patience with people who feel entitled to my services simply because they feel they need them.
I encourage anyone reading this screed
to scroll down to my piece on the economics of private practice. Unfortunately, I believe that the solo private practice of
surgery is all but dead. I am an anachronism, a living dinosaur in the medical world. My only remaining goal in my practice
is to hang on for a few more years until my youngest son is out of school and my long term employees are able to collect on
their pensions. Then I will join the ranks of those clamoring for the services of those that follow behind me. Heaven help
ECONOMICS OF PRIVATE PRACTICE
I am a surgeon in private practice. I will say right up front that I make a good living. I have been at this for
better than 25 years and it has taken me a long time to build the kind of practice that can sustain itself through referrals
from my primary care colleagues. My practice is a business. I have expenses and fixed costs just like the plumber or the guy
who runs the tire store.
I am paid primarily by insurance companies or by the government through Medicare or AHCCCS (Arizona's
form of Medicaid for the indigent). Patients rarely pay more out of pocket than a token copay - anywhere
from ten to ninety dollars depending on their health plan. Most of the insurance companies peg their payments to Medicare,
even for non-Medicare patients. Rates for each service are expressed as a percentage of Medicare,
ranging from 95% to 140%. Since 1989, Medicare payments to surgeons like me have fallen by 20%. I make less per procedure
today than I did in 1989, in static dollars, not inflation adjusted. I make up for it by increasing volume. I'm working
more for less pay than ever before.
Surgeons are paid under something called 'global fees'. I get one payment for seeing the patient in the office,
determining what operation, if any, he needs, doing the surgery and 90 days of follow-up after surgery. Whether I see him
once or a dozen times the pay is the same. If he spends one day or twenty in the hospital after surgery, the pay is the same.
there is no adjustment for the patients preoperative health. The healthy 30 year old woman with a bad gallbladder is the same
as the 58 year old man with high blood pressure, diabetes and heart disease as far as the insurers are concerned. (Or Medicare
for that matter.)
Payment is mailed directly to me most of the time. The average turn around for a 'clean' claim is 45 days.
It may be as long as 90 days. There are no late fees or extra charges if the payment is delayed.
For self-pay patients, I charge 140%
of Medicare and discount the fee for prompt payment. I do not charge interest and do not send patients to collections if they
show good faith by keeping in touch and making even token payments. (I once had a man pay his entire bill in quarters over
a period of five years; one roll of quarters every two weeks.)
I have a number of fixed expenses: 1)Office rent, expendable supplies,
phones, copiers, computers, internet etc costs about $6000 per month or $72k per year. 2) I pay $76,000 per year in malpractice
insurance. I have never been sued. 3) I have two full time and one part time employees. Their salaries and benefits come to
almost $100k per year. 4) Additional but necessary expenses- answering service, transcription service, cell phones, yellow
page adds, my own health insurance add up to $65k.
Before I take any money home, I have to make over $300k. That's a lot of operations. And in addition, any retirement
funding comes from my own pay. I don't have an employer making payments into a pension or a 401k plan. Ditto, disability
insurance, health insurance etc.
So when politicians talk about how much doctors are paid, think for a minute about the last time you called a plumber
in the middle of the night. Last time I did that it cost $125 just to get him out of bed. I get $95 to go into the Emergency
Room at 2 AM to evaluate an elderly woman with acute abdominal pain and a list of other medical problems as long as your arm.