sunday, bloody sunday

I was supposed to have the whole weekend off. Quite a rarity for a surgical resident, acutally. So imagine the dread that I woke up with when my pager went off on Sunday at 0115. The resident responsible for the page regretted to tell me that the vascular attending had accepted the transfer of a patient with a ruptured AAA and that the other on-call people were far to busy with traumas to scrub the case. I'd have to come in and the patient was on his way.

Maybe it was being just woken up with really bad news. Maybe it was knowing that I was going to spend Sunday studying for my in-service training exam that is coming up with week, and now I probably won't. Maybe it was knowing the futility of the proposed surgery and there is a 50% mortality associated with it and there is likely an even higher mortality with the on-call attending. Maybe because I was going to have to scrub with the attending who bathed me in blood a few months ago. But for whatever reason, in a very uncharacteristically surgeon move, I started to cry.

I pulled myself together, got my contacts in, and drove to the hospital. When I arrived, they were checking him at the front desk of the OR. He was begging for another pillow.

We opened the abdomen and didn't find an intraperitoneal rupture; rather there was a quite extenisve retroperitoneal hematoma. In addition to the infrarenal AAA, he had aneurysmal extension into the right common iliac and a separate common femoral aneurysm. Just to add something interesting to the mix, his INR was 3 (normal is 1) because he was on coumadin for his chronic atrial fibrillation.

Just when we were gaining control of the neck of the aneurysm, my attending and I had a very interesting exchange:

"You know, I should have probably never accepted this transfer."

"Why, because of his INR?"

"Yeah. That and the fact that he was turned down by seventeen other surgeons before they called me." Seventeen may have been a bit of an hyperbole, but you get the point. I certainly did.

"Well, then why did you accept him?" A little insolent for me, but it was 3:30am, after all.

...

"Just before I received the call about this patient, I had won a $600 hand of poker." The only way I took that unfinished thought was that he'd just had a bit of luck and thought it would continue.

I'm sure you can predict how things went from here. We had some hairy moments of hemodynamic instability in the operating room. 16L of blood loss; 4.2 of which we returned. Dozens of blood and blood products. A tube graft was sewn in; we never even laid eyes on the right iliac. Due to the massive and ongoing fluid resuscitation, his bowel was too edematous to close the abdomen, so we had to place an abdominal wound vac on.

I told my attending we weren't dry when we placed the wound vac. (Meaning that there was something still actively bleeding.) He insisted that he was diffusely oozing from all exposed surfaces from his hypothermia and coagulopathy.

In the recovery room, the wound vac put out another 6L. The family didn't want us to go back to the operating room to find the source of the bleeding. We stopped transfusing and he died there.

I am not cut out for vascular surgery. I admit it.

a new cardio work out

I couldn't make it to the gym yesterday. It always seems that the days we need those endorphins the most are the days we can't get there.

Would killing my intern be considered a cardiovascular workout? I guess it would depend on the method. Shooting? No. Stabbing? Maybe. Multiple stabbings? Possibly. Strangle with bare hands followed by kicking/jumping? Definitely!

Oh, and I'm not just being an evil chief here. He completely deserves it. He's like a negative resident. It would be easier if he weren't even here and we had to split his work up among the rest of the team. He coutns as negative because he has to be checked up on, which takes longer than actually just doing it yourself. :-P

how much do i need to take?

Accesses for hemodialysis fail; every single one. They all eventually need to be revised or abandonded in favor of creating a new one. The issue then becomes how do dialyze them in the mean time.

A patient currently on my service is having access issues. We tried to de-clot his graft with this slick endovascular device that is like a squishable egg beater. When we were done, we didn't think it was going to work and that he'd need to be revised in the operating room the following day. But he still needed to get dialysis. So I had to place a quinton (a non-tunneled central venous catheter).

Before having to place the quinton, I was his room with my attending so we could let him know what the plan was. From the start he was belligerent and not listening. He was yelling at his wife. Then my attending told him to not yell at his wife like that. He proclaimed that we weren't helping him and he was going to leave. He stated that we never explained anything to him and he had no idea what was going on. He just kept going on and on...

I'm sure having renal failure and getting dialysis is a very frustrating life. I can't even imagine how much so.

A few hours later, I was back at his bedside, ready to place the quinton. He kept touching the sterile field and his groin so we had to keep re-prepping. I kept trying to explain what I was doing, since he was awake and all. But every time I opened my mouth, he would just start yelling, stating that he doesn't understand what we're doing. Keep in mind, it's been explained about 10 times at this point.

"Sir. Do you want me to explain what I am doing right now, or not?"

"I don't know what's going on or WHAT you guys are doing."

"Ok. I'm going to take that as a no."

I placed the quinton without any problems. Accessed the vein with one stick, so he couldn't even complain about that. I warned him when I had to stitch it in. And, yes, I used lidocaine. I told him when I was done and he literally sat up and started yelling "PRAISE GOD!" and waving his hands around my face.

"Here! Let me praise you some more! You need lots of praise, don't you?"

"No, sir, I don't need any praise. I'm just trying to take care of you. I don't need any thanks for it."

"You're not trying to take care of me. I don't know *what* the hell you're doing. And you can leave now."

"Ok. Well, please try to remember to not eat or drink anything after midnight so you can have your surgery tomorrow. The dialysis nurse will be here soon. Can I get you anything?"

...

"Can I have some ginger ale? please."

So I bring him his ginger ale.

I can usually take patient abuse pretty well. I know they're sick and I'm a safe target and all that. But he got under my skin. Don't know why. Should I have set better boundaries? Told him to be quiet? I know I could have handled things better.

hi everybody!

I'm on trauma call today; I'm about 14 hours in and I've had six already. All moderate blunt traumas. (Meaning not really sick, but needs the activation of the trauma team. Trauma team = surgery trauma service, senior ER resident, x-ray techs. Blunt injury is like a motor vehicle or motorcycle collision. Penetrating is like a stab wound or gunshot wound.)

EMS brings the patient into the trauma bay and they've got en route vitals and the story of what happened, as well as the condition at the scene. When they arrive, there are at least 10 people in the room and it can get pretty noisy. But we all need to shut-up and listen to the whole story, which can be difficult at times. Sometimes the medic is in training or the firefighter isn't used to giving an oral narrative of what happened and sort of stand there waiting for an invitation to speak. So I say something to let them know we're ready for them.

Tonight when they arrived, I exclaimed, "Hi, everybody!"

The ER attending was standing right next to me and immediately answered, "Hi, Dr. Nick!"

done deal

Two posts back, I wrote about a gentleman who needs an amputation. After many more meetings and disscussions about the necessity of it all, he and his daughter agreed. We did something pretty clever about the wound on the other leg, though. It needed a skin graft in order to heal.

Skin grafting is very cool. If you envision the skin as having say... seven layers or so, we take off the top 3-4, depending on how thick we want it to be. Then we take this motorized tool that resembles a cheese slicer and shave off the top part of the skin. Then we usually end up meshing it, so it can expand to fill the wound without taking too much skin from the donor site. The little holes that make up the mesh get filled in by new skin cells, but the healed result will always have a faint mesh pattern. So now the patient has to heal the harvest site in addition to the original wound. The pain is often worst at the harvest site; imagine a *huge* rug burn.

Here's where our neat thing comes in. We did the amputation, but didn't pass the leg off of the field right away. Then I prepped the wound to receive the skin graft while my attending grabbed the leg and harvested the skin from *that*. No donor site to heal!

grandpa

Every academic program has at least one. An old surgeon, usually a former Chair of the department, who at one time was a legend. Perhaps even one of the greats of surgery. And if they weren't great, they knew the greats.

We have one of those. He goes to every M&M conference and adds his two cents to an interesting discussion, usually with data and practice patterns that were cutting edge thirty years ago. We all listen politely, giving him the respect and deferrence someone of his years and experience deserve.

When I was an intern, he still operated. At the time, he would only operate with the chief resident because, more often than not, he was not capable of doing the operation himself due to his tremor. But he had enough experience that he would be able to walk a chief through it. He doesn't operate anymore.

There is a clinic that he staffs for the residents once a week. (Don't ask me what he does the rest of the week, but he still comes to work.) I wish we could just divide up those patients amongst the rest of the attendings in the division. I'm sure his bedside manner was acceptable when he was younger, but you just can't talk that way anymore. Allow me to provide some examples:

Number 1: "You're much too fat. Just look at these rolls. [Grabs rolls of fat on the abdomen and shakes them.]" Then he turns aside to whatever resident or medical student is in the room and says, "We could put her in a cage for two weeks, not feed her, and she'd be fine."

Number 2: "You're too fat. What do you eat? Tacos and beans all day?"
"I'm not Mexican. I'm Bolivian."
"What do you eat then?"

I could go on, but the other examples are just as bad and all in a similar vein. As much as we respect him for the phsycian and surgeon he was, someone needs to sit down, talk to grandpa, and take away his keys. He can't drive anymore.

what do you say? part II

Another patient on my service is also in that proverbial place between the rock and the hard place. He's young as far as our patients go -- only 51. But he has the body and face of a septuagenarian. Through a constellation of events, some self-induced, some self-neglect, some medical neglect, he is facing an above knee amputation.

He was trasnferred to our facility for a "higher level of care," which sounds like the transferring facility has reached the limits of what they can do, either with expertise or equipment. More often than not, however, this term just means that they don't want to be bothered with the difficult work up, or they have done a "wallet biopsy," determined that the patient doesn't have insurance and don't want to do something for which they will not be compesated. But I digress.

We accepted this transfer because he had a huge saddle embolus from new-onset atrial fibrillation. The thrombus was occluding his common iliac arteries that eventually give blood supply to the legs, which meant that he was not receiving much blood supply to his legs. Superimpose this condition on pre-existing peripheral vascular disease caused by years of smoking and hypertension, and he has experienced necrosis of most of the toes on one of his feet. And this was all before we got him.

When he arrived, we were able to remove the clot from his arteries and restore the inflow, but much of the damage had already been done. In addition to the necrotic toes, he has a wound on his heel that extends to the bone and Achilles tendon as well as a large wound with exposed tendons on the lateral aspect of his leg. We could try to re-vascularize his leg and try to restore some blood supply to try to heal his leg wound, but he has a large vegetation on his mitral valve causing a large degree of mitral regurgitation and congestive heart failure. Simply put, he simply would not survive the major surgery needed to restore blood flow to his feet.

And this is how I received him when I arrived on the service. He was slowly getting his mind around the fact that he was going to lose his toes. Everyone but the patient and his family knew that the heel wound would not close and he would lose that, too. But so far, everyone was dancing around the idea of a bigger amputation and not talking to him or his family about it. That's easier, isn't it? I took down the dressings on the leg in question and knew immediately that a standard below knee amputation would not even be enough. The leg wound is on the posterior flap that we would create to close the stump with. He needs an above knee.

I tried as best I could to bring up the idea to him gently. I used words like "you should start thinking about the possiblity that we are going to need to amputate your leg" and other things to that effect, but no matter what or how I said it, he bawled and his daughter was hostile. Not that I'm offended in any way, but we don't have a magic scalpel.

Exactly how do you tell a relatively young man that one of his legs needs to be removed? And that after he recovers from that, he'll need open heart surgery? And after that, he may need major revascularization procedures?

what do you say? part I

Medical school can teach you a lot of things. Most of what they teach, they do very well: pharmacology, anatomy, physiology, pathology... One thing they don't spend much time on is how to deliver bad news. If they do have a one hour lecture devoted to it, consider yourself lucky. But something like that can't be taught in one hour. For some, even a lifetime isn't enough.

Learning how to deliver bad news seems to be part of the job description of a physician. We can't cure everything that crosses our paths. People don't get better, become debilitated, die. We should be able to do this very well.

For us, the new year has brought us to new rotations. I'm still on vascular surgery, but I'm at a different hospital. I've inherited some very sick patients who have run out of options.

One woman is in her 80's. She is on dialysis, which requries the ability to remove blood at a high rate, run it through a filtration machine, and return it to the body at the same rate. This is usually performed through what is called "access." Access can take the form of a fistula or graft in the arm, which is where we surgically make a connection between a large artery and a large vein in the arm. Or it can be via a large bore catheter with two ports sitting in one of the large veins in the neck.

Eventually, fistulas will become clotted and stop working. We can try to save the one they have through various means, but sometimes they need a new one. So you march up the arm towards the axilla making more connections between artery and vein in an attempt to keep them on dialysis.

Once all those spots on both arms are used up, you can try to do something in the groin. But these can become infected and don't usually last that long. Then all you're left with is the catheter version of access, which carries with it risk of infection or clotting of the vein in which it sits.

What happens when you run out of places for the catheter and something else hasn't killed you first? You die of renal failure. It's not a horrible death, really. The toxins in your blood make you sleepy so you just get to the point that you go to sleep and don't wake up.

Back to my patient. She's in her 80s and she's used up all the spots on her arms. All of her large veins are clotted. She is currently receiving dialysis through a catheter that is placed through a lumbar vein that goes directly into the inferior vena cava. That's the last spot. And even that is more than most people get.

Let's complicate things a bit more. We've been keeping her anticoagulated (blood thinned) on coumadin to help prolong the day when she will clot off that catheter. But for some reason (that happend before I got on the service) the blood was thinned too much (INR = 12) and she had an upper GI bleed. We the surgeons and the medicine doctors have weighed the risks; continuing anticoagulation to prolong the inevitable is not worth risking another potentially fatal GI bleed. Which would mean that we need to talk about the time when the catheter clots and we need to set up hospice care for her.

Add this to some very dysfunctional family dynamics involving debates over religion and a language barrier, and I'm a loss. Today we had a family meeting with a skilled palliative care specialist who is helping us from a hospitalist standpoint. He was able to cut through the communication issues with the family and get them to agree that the patient will indeed make her own decision about stopping anticoagulation or not. They will only become involved when she is unable to make decisions for herself. That conclusion alone is a huge help; before this meeting the daughter told me that she was "not authorizing" me talking to her mother via an interpreter about these issues.

Now that I have permission, I just have to do it. I've had these discussions before. I'm sure I could do them better. I hope I can show compassion but give her the facts she needs all at the same time.

Part 2 will include another difficult conversation I had today...