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...

i may be glowing, but not from radiation

After the events of the last few months, I started asking around about x-rays and radiation and all that. Turns out that the lead we wear blocks almost all of the x-rays. And there is lead covering the source on the C-arm at this hospital, which blocks about 90% of the radiation at the source.

Our x-ray tech said that our attendings, who are usually closer to the source, are well below the recommended dosage on their dosimeter. And that is worn on the *outside* of the lead apron.

So, I have concluded that my eggs are safe. I'd hate to fry them before they had a chance to be put to use!

The glowing must be from my most recent facial. ;-)

am i glowing?

I'm still on vascular. Been sprayed a few more times. If it's not blood, it's contrast that we use for the endovascular stuff. Which, by the way, there is a lot of. Five or ten years ago, a chief resident's experience on vascular surgery meant a lot of complicated "re-plumbing" jobs: extra-anatomic bypasses like axillary-axillary-femoral-femoral bypasses, in situ bypasses like femoral-popliteal bypasses or femoral-anterior tibial bypasses, elective open AAA repairs, and access for hemodialysis.

The access hasn't changed much; there are still just as many people getting into renal failure from hypertension or diabetes than there ever were. Maybe even more. But most of those big bypasses have fallen out of favor now that we have endovascular techniques. When I explain it to people, I tell them that we are trying to fix their pipes from the inside instead of laying new pipes. Roto-rootering and stenting whenever possible. No big incisions for these guys to heal, which often never healed anyway and ultimately ended up in amputation.

That means we have to use contrast and x-ray to see our work and to tell us which vessels to fix. Which means that I'm getting exposed to tons of radiation. I didn't realize just how much until last week when we tried to fix a leaking AAA with endovascular techniques. Yes, I know it's an emergency and an argument can be made that we should have just done an open rapair to begin with, but this guy was hemodynamically stable when we started and my attending thought this would be the best thing for him... provided it worked. (It didn't, by the way. He started to crash, we opened, repaired it, and he died in recovery.)

The drive in total for that one case was over 90 minutes of x-ray exposure. That's more than the recommended exposure in one month, someone told me. Not to mention the fact that the hospital does not provide leaded glasses to protect our lenses from developing cataracts, which is a known long-term consequence of x-ray exposure. How is that even allowed?

I have another combined open/endovascular case tomorrow. With an attending who says that for endovascular work, "Time should stand still." Easy for him to say, he's old and he's already had his kids. Not to mention the fact that he's an older attending and is himself still trying to master the various endovascular techniques that are available and does most of the case himself. Not to toot my own horn (and if you knew this attending, you'd know I'm *not*), but *I'm* much faster at endovascular procedures than he is.

i must have a target on my head

Now that I'm on the vascular service, we're doing lots of endovascular procedures, which is where we gain access to the arterial system at a location remote from the site of disease and use various wires, stents, and balloons to treat arterial (or sometimes venous) disease elsewhere. At the end of the case, there is a hole of varying sizes in the artery where our access was. There are all kinds of devices that have been developed to close this hole with a stitch or clip or whatever. Like all devices, sometimes they fail. When that occurs, we resort to the old fashioned way... hold pressure for a very long time.

A known complication of endovascular procedures is formation of a pseudoaneurysm which is when there is a leak in the artery and an inflammatory capsule forms around the flowing blood. The risk of this happening is increased if the patient requires systemic anticoagulation (for a heart valve, for example) or if there is a hematoma.

We were recently doing a groin exploration for just such a complication. We were carefully dissecting around the pseudoaneurysm, keeping in mind that the only thing separating us from a blood volcano was a thin wall of inflammatory tissue. Our dissection was almost complete... POP!

Right. You guessed it. All over me. It's was quite funny, actually. Not as bad as the last time, but messy enough to require me to wash my face and neck and change my shirt. My attending generously held pressure over the common femoral while I cleaned up so I wouldn't miss anything. With the exception of the anesthesiologist and my attending, the rest of the operating room staff was the same as the first blood bath. After that first one, which is already legendary around here, I vowed that I would handle the situation differently. And I did.

The rest of the case was uneventful. Cleaned out the capsule, gained control of the artery with a fogerty, repaired the hole with a few 5-0 prolenes in a figure-of-eight fashion, closed. The patient is great and going home today.

These two instances by two different attendings leaves me wondering, is this just how vascular is? If not, I may set a record for being sprayed with blood in the residency. I have three more months, so I'm sure I'll find out.