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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.

Under ‘No Good Deed Goes Unpunished’:

A twenty-year –old male was the designated driver for a buddy’s 21^st 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 recovery.

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.

M and M (not the candy)

Tomorrow I 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.

The exact 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 aired.

Gallbladder Blues

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.

Traffic Cop

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.

Recently 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 abdomen.

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.

The 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 the office.

I 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 elective situation.

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.

The 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?