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.
Showing posts with label big cases. Show all posts
Showing posts with label big cases. Show all posts
Tuesday, January 22, 2008
Sunday, January 13, 2008
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!
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!
Friday, January 4, 2008
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?
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?
Tuesday, December 4, 2007
the worst complication
Several months ago, I was on a rotation that dealt mainly with "foregut" surgery and hepatobiliary cases. On this service, that meant anything from the gastroesophageal junction to just below the ligament of Treitz, including the liver, common bile duct, pancreas, and duodenum. I got to see tons of gastric resections, whipples, ampullary tumors and pancreatic tail/body tumor resections. The operative (no pun intended) word here being *see*. These cases were often so big that the chiefs on the service were relegated to sucker/bovie monkey.
One of the operations we did was a vagotomy and antrectomy for gastric outlet obstruction - a surgery that is nearing it's end in the practicing world of surgery and being seen only in the text books. This is largely in part to the development and use of proton pump inhibitors, which have all but eliminated the worst complications of peptic ulcer disease. Sure, we'll occasionally see a perforation or hemorrhage from a gastric or duodenal ulcer, but gastric outlet obstruction? Most of my attendings haven't seen that in about 10 years and I, in my short amount of time in the OR have *never* seen one.
Our patient was skinny, but by no means cachetic. The EGD that was done said they could not pass the scope through the pylorus, but they could get a wire down... so liquids could pass. His nutrition is probably ok.
My attending and I proceeded with the antrectomy first. That was the easy part. We did a Roux-en-Y anastamosis instead of a Bilroth II. I'm not sure why we chose to do a roux, and I have yet to find a satisfactory answer, either from my attending at the time, any other attending, or the literature. He again reinforced his notion that we residents are relying too much on staplers and had me hand-sew the anstamoses, which was great.
Now for the vagotomy. We felt just above the gastroesophageal junction for the NG tube, which we had the anesthesia resident pull up for our anastamosis. He wasn't happy with how flimsy it felt in the esophagus, and asked him to replace it with a small bougie for easier palpation. The posterior vagus was the first and easiest to find. It was very large; almost as big as the sciatic nerve, and we were able to do the "plucking of the violin string" that I've read so much about. We sent a piece of it off to pathology to confirm nerve tissue because that's what the books tell us to do, but we were sure we had it.
The anterior vagus was quite a different story. My attending was dissecting through connective tissue, closer and closer to the esophagus. He would use the Angle of Truth (aka, right angle instrument) to lift up a few strands so I could use the electrocautery. I was getting uncomfortable at how close we were to the esophagus and I kept hearing other attendings in my head... "The esophagus has no serosa, so when there is a hole in it, it is very difficult to repair." More dissection... sh*t. There's the bougie. Ok, we'll fix that later. That happened about two more times with even more obscenities.
Then he called another senior surgeon who has experience with this operation into the room to help. (Which, by the way, gave me an immediate promotion to scrub tech assistant.) They got into the esophagus two more times. They found what they thought was a piece of nerve and then started to repair the esophagus as best they could by primary closure. We finished the case and took the patient to the ICU.
Five days later, we got an upper GI series, where the patient swallows water soluble contrast and we check for leaks or obstruction as seen on x-ray. No obstruction anymore, and reportedly no leaks per the attending radiologist. I checked the films myself, but saw an area that looked like a leak to me. I paged him anyway, unaware of the fact that my attending was about to do the same thing. He assured us both independently... no leak.
We gave him clears and that night he went into renal failure and respiratory distress. We got a CT scan and a *different* radiologist read the CT scan. He compared to the UGI we got two days prior.
"Who told you guys there was no leak?"
"The attending."
"Well... he was wrong. There's a BIG leak."
Oh. Crap. Back to the OR to suck out the cranberry juice and jello that was now free floating in his peritoneal cavity. We got an endoscope and checked the esophagus while other members of the team had the belly open. The esophagus was attached to the stomach by two tiny bridges of frail tissue... the rest had simply disintegrated, likely as a result of the holes that were made in the first place, his unrecognized malnutrition, and having food leak out through it and cause massive inflammation. The only saving grace here was that the damage was in the abdomen and the mediastinum was free from the bomb that was happening a few centimeters below. If he had mediastinitis on top of everything else, he would have likely died before we got to the operating room. Maybe it would have been better if he did...
We completely disrupted the esophago-gastric connection, with the inention to go back in 6-9 months to reconnect him. He spent months in the ICU and had multiple CT-guided drainage procedures. Fevers, bacteremia, fungemia, delerium, and pneumonia visited him during his course.
Then I rotated off service. I would occasionally see the chief who replaced me at conferences and I would ask how he was doing. "Oh, you know. Hanging in there," was usually the answer. Until last week, when I was told he was going to die.
And he did.
I'm not sure if I have a point, really. I'm just retelling a story that I was a part of. I feel horrible. He came to us a "walkie-talkie" as I like to call them, and we discharged him to God. And what about his family? They were constantly overwhelmed by the whole thing. His surgery went from, "Oh, yeah, we can fix that. He'll stay in the hospital for about a week, and then he'll be able to eat" to "I'm sorry, but your dad is very sick and may not live through the night."
There is obviously nothing we can do now for this patient. But it is my responsibility, nay, my moral obligation to learn what could have been done differently. I have a few things: 1) always check an albumin and maybe even prealbumin before a major, but elective case. If it is inadequate, arrange for supplemental nutrition. 2) If I ever get into the esophagus at the GE junction, I will protect my repair with a Nissen fundoplication (wrapping extra stomach around the repair for reinforcement). 3) If I'm in over my head in the OR, at any point in my career, call for help. It didn't really work this time, but at least he had someone else experienced in the room.
One of the operations we did was a vagotomy and antrectomy for gastric outlet obstruction - a surgery that is nearing it's end in the practicing world of surgery and being seen only in the text books. This is largely in part to the development and use of proton pump inhibitors, which have all but eliminated the worst complications of peptic ulcer disease. Sure, we'll occasionally see a perforation or hemorrhage from a gastric or duodenal ulcer, but gastric outlet obstruction? Most of my attendings haven't seen that in about 10 years and I, in my short amount of time in the OR have *never* seen one.
Our patient was skinny, but by no means cachetic. The EGD that was done said they could not pass the scope through the pylorus, but they could get a wire down... so liquids could pass. His nutrition is probably ok.
My attending and I proceeded with the antrectomy first. That was the easy part. We did a Roux-en-Y anastamosis instead of a Bilroth II. I'm not sure why we chose to do a roux, and I have yet to find a satisfactory answer, either from my attending at the time, any other attending, or the literature. He again reinforced his notion that we residents are relying too much on staplers and had me hand-sew the anstamoses, which was great.
Now for the vagotomy. We felt just above the gastroesophageal junction for the NG tube, which we had the anesthesia resident pull up for our anastamosis. He wasn't happy with how flimsy it felt in the esophagus, and asked him to replace it with a small bougie for easier palpation. The posterior vagus was the first and easiest to find. It was very large; almost as big as the sciatic nerve, and we were able to do the "plucking of the violin string" that I've read so much about. We sent a piece of it off to pathology to confirm nerve tissue because that's what the books tell us to do, but we were sure we had it.
The anterior vagus was quite a different story. My attending was dissecting through connective tissue, closer and closer to the esophagus. He would use the Angle of Truth (aka, right angle instrument) to lift up a few strands so I could use the electrocautery. I was getting uncomfortable at how close we were to the esophagus and I kept hearing other attendings in my head... "The esophagus has no serosa, so when there is a hole in it, it is very difficult to repair." More dissection... sh*t. There's the bougie. Ok, we'll fix that later. That happened about two more times with even more obscenities.
Then he called another senior surgeon who has experience with this operation into the room to help. (Which, by the way, gave me an immediate promotion to scrub tech assistant.) They got into the esophagus two more times. They found what they thought was a piece of nerve and then started to repair the esophagus as best they could by primary closure. We finished the case and took the patient to the ICU.
Five days later, we got an upper GI series, where the patient swallows water soluble contrast and we check for leaks or obstruction as seen on x-ray. No obstruction anymore, and reportedly no leaks per the attending radiologist. I checked the films myself, but saw an area that looked like a leak to me. I paged him anyway, unaware of the fact that my attending was about to do the same thing. He assured us both independently... no leak.
We gave him clears and that night he went into renal failure and respiratory distress. We got a CT scan and a *different* radiologist read the CT scan. He compared to the UGI we got two days prior.
"Who told you guys there was no leak?"
"The attending."
"Well... he was wrong. There's a BIG leak."
Oh. Crap. Back to the OR to suck out the cranberry juice and jello that was now free floating in his peritoneal cavity. We got an endoscope and checked the esophagus while other members of the team had the belly open. The esophagus was attached to the stomach by two tiny bridges of frail tissue... the rest had simply disintegrated, likely as a result of the holes that were made in the first place, his unrecognized malnutrition, and having food leak out through it and cause massive inflammation. The only saving grace here was that the damage was in the abdomen and the mediastinum was free from the bomb that was happening a few centimeters below. If he had mediastinitis on top of everything else, he would have likely died before we got to the operating room. Maybe it would have been better if he did...
We completely disrupted the esophago-gastric connection, with the inention to go back in 6-9 months to reconnect him. He spent months in the ICU and had multiple CT-guided drainage procedures. Fevers, bacteremia, fungemia, delerium, and pneumonia visited him during his course.
Then I rotated off service. I would occasionally see the chief who replaced me at conferences and I would ask how he was doing. "Oh, you know. Hanging in there," was usually the answer. Until last week, when I was told he was going to die.
And he did.
I'm not sure if I have a point, really. I'm just retelling a story that I was a part of. I feel horrible. He came to us a "walkie-talkie" as I like to call them, and we discharged him to God. And what about his family? They were constantly overwhelmed by the whole thing. His surgery went from, "Oh, yeah, we can fix that. He'll stay in the hospital for about a week, and then he'll be able to eat" to "I'm sorry, but your dad is very sick and may not live through the night."
There is obviously nothing we can do now for this patient. But it is my responsibility, nay, my moral obligation to learn what could have been done differently. I have a few things: 1) always check an albumin and maybe even prealbumin before a major, but elective case. If it is inadequate, arrange for supplemental nutrition. 2) If I ever get into the esophagus at the GE junction, I will protect my repair with a Nissen fundoplication (wrapping extra stomach around the repair for reinforcement). 3) If I'm in over my head in the OR, at any point in my career, call for help. It didn't really work this time, but at least he had someone else experienced in the room.
Friday, November 9, 2007
blood. bath.
The other day we were scheduled to do a carotid endarterectomy, which is essentially where we remove the plaque caused by decades of eating Big Macs from the carotid artery. To review a little anatomy, there are two of them; one on each side. Cances are if you've got a messed up carotid on one side, the other side is also abnormal. Sometimes the lesion on the opposite side is not hemodynamically significant, meaning that that single vessel is sufficient to supply blood to the whole brain by itself. But if the plaque is causing stenosis over a certain percentage, the chance of stroke is much higher, or you've already had a stroke. So to prevent a stroke, we scrape out the junk.
During such a surgery, in order to preserve blood flow to the brain, you have to put in a temporary shunt. That's a fancy name for a piece of plastic tubing that diverts blood around where you need to work but gets plugged into the pipeline on the other side. Since these things are temporary, and too much clamping on an artery can cause damage in and of itself, sometimes they fall out. Which is usually ok, because the surgeon is an experienced, skilled vascular surgeon and he can handle the situation. But as this surgeon reminded the anesthesia resident, during this very case, "They don't call me Bloody Smith for nothing."
There we are, with our little plaque spatula (yes, it looks like a mini spatula with rounded edges), scraping away long-forgotten Big Macs, when our surgical field slowly fills with blood.
"Hmm... where do you think that is coming from."
"I'm not sure, you might want to check the shunt," I suggest diplomatically.
"Ok. Let me see about this clamp first."
Have you ever seen those cartoons where a firehose is attached to a firehydrant, the water gets turned on full blast, and the hose flies all over the place? That's precisely what happened, except it wasn't water coming out of the little tube. It was blood. Full blast.
Onto my neck. And my shirt.
I can feel the warmth running under my shirt.
Onto my bra.
Then dripping on my stomach.
I don't remember doing this, but people who were there said I took a step back, looked down at my gown in disbelief. I informed the surgeon that I had to leave. I had to go home and take a shower.
"But I need some help."
"I'll get you some help. But there is blood on my bra, and I've got to go home to shower and change. I'm sorry Dr. Smith, but I cannot spend the rest of the day in bloody underwear and I'm not about to go without, either."
"Do whatever you need to do, but I bring a gym bag and a change of clothes to work."
I left the OR, not knowing how to address the fact that he basically suggested that I bring all my toiletries, make-up, and spare underwear to work everyday in case he douses with me with blood. I walked through the hallways, in my blood splattered boots, looking for my junior resident to scrub in an help finish the case. People got out of my way as I passed them and uttered things like "Oh my God" and "Look at her shirt."
It wasn't a long walk, but it was long enough for me to recall all the stories I had heard from other residents about Bloody Smith in which they or their chief got some inexplicably large volume of patient's blood on them. When I arrived at our workroom, I asked my junior to scrub. I can't remember exactly what I said, all I know is that my voice was trembling with fury. And I said please. We walked back up to the OR, where everything was going fine again. I took off my boots, washed my hands and arms, and told them I'd be back.
I didn't even want to stop and look in a mirror. I just wanted to go home. I grabbed my keys and headed out to the elevators. I saw a nurse from the surgical floor. He looked at my shirt.
"How ya doin'?"
"Awesome."
"I can see that."
I got off the elevator when another elevator arrived to the first floor at the same time. A woman looked at me and asked if I was ok. I said it wasn't mine.
Then I sat in traffic for 30 mintues because the city officials thought it would be good to take a three lane road down to one. The very road that leads to the freeway that would get me home.
I surveyed the damage when I got home. Blood all over my shirt. My bra. A little on my stomach. And my neck. At the level of my carotid. It's a good thing I didn't get pulled over for speeding on the way home; they might have dragged me in as a suspect for murder or something the way I looked. And I'm positive there was a murderous expression in my eyes.
It's not that I have never had blood on me or my clothes. There have been plenty of traumas where I didn't even have time to put a gown on and had to crack someone's chest with cheap-o unsterile gloves. This was different. One because it was on my BRA. That really grossed me out. And two, because this kind of stuff only happens with this one attending. And it's usually completely unnecessary.
P.S. The patient is fine. He got two units of blood in the operating room and was discharged today. He just had to stay to watch the end of Oprah.
During such a surgery, in order to preserve blood flow to the brain, you have to put in a temporary shunt. That's a fancy name for a piece of plastic tubing that diverts blood around where you need to work but gets plugged into the pipeline on the other side. Since these things are temporary, and too much clamping on an artery can cause damage in and of itself, sometimes they fall out. Which is usually ok, because the surgeon is an experienced, skilled vascular surgeon and he can handle the situation. But as this surgeon reminded the anesthesia resident, during this very case, "They don't call me Bloody Smith for nothing."
There we are, with our little plaque spatula (yes, it looks like a mini spatula with rounded edges), scraping away long-forgotten Big Macs, when our surgical field slowly fills with blood.
"Hmm... where do you think that is coming from."
"I'm not sure, you might want to check the shunt," I suggest diplomatically.
"Ok. Let me see about this clamp first."
Have you ever seen those cartoons where a firehose is attached to a firehydrant, the water gets turned on full blast, and the hose flies all over the place? That's precisely what happened, except it wasn't water coming out of the little tube. It was blood. Full blast.
Onto my neck. And my shirt.
I can feel the warmth running under my shirt.
Onto my bra.
Then dripping on my stomach.
I don't remember doing this, but people who were there said I took a step back, looked down at my gown in disbelief. I informed the surgeon that I had to leave. I had to go home and take a shower.
"But I need some help."
"I'll get you some help. But there is blood on my bra, and I've got to go home to shower and change. I'm sorry Dr. Smith, but I cannot spend the rest of the day in bloody underwear and I'm not about to go without, either."
"Do whatever you need to do, but I bring a gym bag and a change of clothes to work."
I left the OR, not knowing how to address the fact that he basically suggested that I bring all my toiletries, make-up, and spare underwear to work everyday in case he douses with me with blood. I walked through the hallways, in my blood splattered boots, looking for my junior resident to scrub in an help finish the case. People got out of my way as I passed them and uttered things like "Oh my God" and "Look at her shirt."
It wasn't a long walk, but it was long enough for me to recall all the stories I had heard from other residents about Bloody Smith in which they or their chief got some inexplicably large volume of patient's blood on them. When I arrived at our workroom, I asked my junior to scrub. I can't remember exactly what I said, all I know is that my voice was trembling with fury. And I said please. We walked back up to the OR, where everything was going fine again. I took off my boots, washed my hands and arms, and told them I'd be back.
I didn't even want to stop and look in a mirror. I just wanted to go home. I grabbed my keys and headed out to the elevators. I saw a nurse from the surgical floor. He looked at my shirt.
"How ya doin'?"
"Awesome."
"I can see that."
I got off the elevator when another elevator arrived to the first floor at the same time. A woman looked at me and asked if I was ok. I said it wasn't mine.
Then I sat in traffic for 30 mintues because the city officials thought it would be good to take a three lane road down to one. The very road that leads to the freeway that would get me home.
I surveyed the damage when I got home. Blood all over my shirt. My bra. A little on my stomach. And my neck. At the level of my carotid. It's a good thing I didn't get pulled over for speeding on the way home; they might have dragged me in as a suspect for murder or something the way I looked. And I'm positive there was a murderous expression in my eyes.
It's not that I have never had blood on me or my clothes. There have been plenty of traumas where I didn't even have time to put a gown on and had to crack someone's chest with cheap-o unsterile gloves. This was different. One because it was on my BRA. That really grossed me out. And two, because this kind of stuff only happens with this one attending. And it's usually completely unnecessary.
P.S. The patient is fine. He got two units of blood in the operating room and was discharged today. He just had to stay to watch the end of Oprah.
Wednesday, November 7, 2007
better to be lucky than good
We were going to do a CEA carotid endarterectomy the other day. This guy's whole story started when he told his PCP about some foot numbness and tingling. For some reason, the PCP thought a total body CT scan would help. It didn't deliniate the source of the numbness, but it did find a mass in the right kidney.
A urology consultation was promplty obtained. When the urologist heard about his neurologic symptoms, which now included intermittent bilateral lower extremity paralysis and aphasia upon wakening, he very appropriately ordered an ultrasound study of the carotids, thinking that he was having transient ischemic attacks. This demonstrated bilateral carotid disease with the right side having greater than 75% stenosis. With or without symptoms, a 75% stenotic lesion is enough to prompt an endarterectomy.
The only problem was that his symptoms really didn't match what was going on. To have one stenotic area cause symptoms in both extremities doesn't make sense. And to have a aphasia, usually the lesion has to be on the left side, not the right.
Fortunatley, the attending who originally decided this guy needed a CEA couldn't do the case and he found a different surgeon. I'm so glad, because I kept telling the other attending, "I'm not sure we can attribute his neurologic defecits to his carotid disease." Which for a resident speaking to an attending is actually saying, "Hey! Red flag here! I don't think we should do this! We need further work up!" All of my protestations were very quickly dismissed.
This new surgeon (who is infintely better than the orignal attending) recognized the problem right away. He pulled me aside in the preop area and told me what I already knew: his symptoms didn't match his carotid disease. He wanted to postpone the surgery and get an MRI because he has a known renal mass, which is presumably malignant and he was worried about metastatic disease in the brain causing these problems.
So we got a stat MRI. It didn't show mets. It showed an acute on chronic subdural hematoma. Turns out the patient was riding his bike a few months ago and he fell. Shortly after that all his neurologic symptoms began.
If we had actually gone through with the CEA, he would have received heparin during the surgery as anticoagulation. It's routine. But for him, it would have caused him to bleed more in his brain. He could have herniated right there on the table and died.
When the second, better attending was told about all this, he simply said, "Well, I guess it's better to be lucky than to be good." But his skills as a clinician were evident. No luck there. Perhaps he meant the patient.
A urology consultation was promplty obtained. When the urologist heard about his neurologic symptoms, which now included intermittent bilateral lower extremity paralysis and aphasia upon wakening, he very appropriately ordered an ultrasound study of the carotids, thinking that he was having transient ischemic attacks. This demonstrated bilateral carotid disease with the right side having greater than 75% stenosis. With or without symptoms, a 75% stenotic lesion is enough to prompt an endarterectomy.
The only problem was that his symptoms really didn't match what was going on. To have one stenotic area cause symptoms in both extremities doesn't make sense. And to have a aphasia, usually the lesion has to be on the left side, not the right.
Fortunatley, the attending who originally decided this guy needed a CEA couldn't do the case and he found a different surgeon. I'm so glad, because I kept telling the other attending, "I'm not sure we can attribute his neurologic defecits to his carotid disease." Which for a resident speaking to an attending is actually saying, "Hey! Red flag here! I don't think we should do this! We need further work up!" All of my protestations were very quickly dismissed.
This new surgeon (who is infintely better than the orignal attending) recognized the problem right away. He pulled me aside in the preop area and told me what I already knew: his symptoms didn't match his carotid disease. He wanted to postpone the surgery and get an MRI because he has a known renal mass, which is presumably malignant and he was worried about metastatic disease in the brain causing these problems.
So we got a stat MRI. It didn't show mets. It showed an acute on chronic subdural hematoma. Turns out the patient was riding his bike a few months ago and he fell. Shortly after that all his neurologic symptoms began.
If we had actually gone through with the CEA, he would have received heparin during the surgery as anticoagulation. It's routine. But for him, it would have caused him to bleed more in his brain. He could have herniated right there on the table and died.
When the second, better attending was told about all this, he simply said, "Well, I guess it's better to be lucky than to be good." But his skills as a clinician were evident. No luck there. Perhaps he meant the patient.
Tuesday, October 30, 2007
it was all going well until...
Today was a very busy day in the OR. Both of my attendings were operating. We asked for help from some other attendings on one of the cases from another attending, but he couldn't come at the last minute because of an emergency. One of the cases was supposed to be a Whipple and the other was a partial/subtotal gastrectomy. Both are fabulous Chief level cases and, as much as I would have liked to do both, I haven't yet developed the ability to be in two places at once (much to the chagrin of my attendings). I've already participated in about 6 Whipples, which is about five more than most Chiefs at other surgical programs get, so I chose the gastrectomy. Besides, there is a much higher chance that I'll do a gastrectomy when I'm done with training than a whipple.
First thing was first; find where the stupid thing is in the stomach. One might think we should have known before we got into the operating room, but because of insurance reasons, the gastroeneterologist and the CT scans were done at outside facilities. Reports from both the EGD and the CT scan were woefully inadequate and didn't give us enough information.
So we did the EGD and found that the lesion was in the worst possible part -- on the lesser curvature about 1cm from the GE (gastroesophageal) junction. The board answer for an adenocarcinoma in the cardia is to do an Ivor-Lewis esophagectomy. But what does one do for a benign lesion? We decided to do a proximal gastrectomy. Risky, I know because of the retained antrum, but this guy really didn't want a total gastrectomy and he's so old I'm not sure that he would have tolerated it very well.
The dissection was difficult because he was so fat, but it went well. We did our resection, anastomosis, vagotomy, pyloroplasty and it all went well. At the appropriate time, we asked the anesthesiology resident to place an NGT tube (N=naso) so we could safely navigate it past our fresh anastomosis.
We finish the case, I carefully apply the dressings and take the dressings down. Just in time to see the anesthesia resident pulling out the OGT (O=oral).
"What the hell are you doing?" I asked.
"Oh you want this to stay? But it's an OGT."
"Yeah. That's why we asked for an NGT."
"F--K," comes flying across the room from my attending. "You've got to be f--king kidding me."
We got the EGD tower and scope back in there. Our anastomosis was intact. We had to blindly place an NGT and check an x-ray in the recovery room. It looked ok. But only time will tell. If he goes into a-fib or becomes febrile tonight, we'll know it really wasn't ok.
First thing was first; find where the stupid thing is in the stomach. One might think we should have known before we got into the operating room, but because of insurance reasons, the gastroeneterologist and the CT scans were done at outside facilities. Reports from both the EGD and the CT scan were woefully inadequate and didn't give us enough information.
So we did the EGD and found that the lesion was in the worst possible part -- on the lesser curvature about 1cm from the GE (gastroesophageal) junction. The board answer for an adenocarcinoma in the cardia is to do an Ivor-Lewis esophagectomy. But what does one do for a benign lesion? We decided to do a proximal gastrectomy. Risky, I know because of the retained antrum, but this guy really didn't want a total gastrectomy and he's so old I'm not sure that he would have tolerated it very well.
The dissection was difficult because he was so fat, but it went well. We did our resection, anastomosis, vagotomy, pyloroplasty and it all went well. At the appropriate time, we asked the anesthesiology resident to place an NGT tube (N=naso) so we could safely navigate it past our fresh anastomosis.
We finish the case, I carefully apply the dressings and take the dressings down. Just in time to see the anesthesia resident pulling out the OGT (O=oral).
"What the hell are you doing?" I asked.
"Oh you want this to stay? But it's an OGT."
"Yeah. That's why we asked for an NGT."
"F--K," comes flying across the room from my attending. "You've got to be f--king kidding me."
We got the EGD tower and scope back in there. Our anastomosis was intact. We had to blindly place an NGT and check an x-ray in the recovery room. It looked ok. But only time will tell. If he goes into a-fib or becomes febrile tonight, we'll know it really wasn't ok.
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