Sunday, April 24, 2011

Finger pointing; a life of blame.

My fellow blogger the Anesoboist is becoming more cynical.

This reminds my of several incidents in my professional life. Surgery is of course an inexact science. People do not always get the outcomes that they were promised, many times they are left worse off than before. To cut and saw another human being requires a huge ego and a lot of self confidence. It is therefore difficult to accept that when what you promised the patient didn't turn out that it was simply bad karma or maybe even your fault.

Fortunately it is not possible to do most surgeries without an anesthesiologist so you have a living human being to blame.

It is of course possible to be blamed for a case you were not even involved in. When I was resident, I was sitting minding my own business in a general room. There was a general surgery case going on next door and at the end of the case they were one sponge short. The staff surgeon therefore un-scrubbed and dug into the garbage. After some time he found the missing sponge. It was in the same strata as the central line kit. It was therefore "obvious" that the anesthesiologist had surreptitiously removed a sponge from the sterile table for his central line without telling the nurses. After appropriately venting his spleen in his room, he had some spleen left over, so went into my room where he regaled at length the surgeon with his accusations. I wasn't paying much attention until one of the nurses came over to me and said, "he is really taking anesthesia's name in vain." As I have said I wasn't paying attention and replied,"You should hear what we say behind his back." That was the wrong thing to say apparently. He got right in my face and yelled, "Well it was bloody irresponsible" and stormed out of the room. I actually had to ask exactly what it was he was upset about. It was then that I learned it was possible to be blamed for something that went on in the next room.

The first night on call as a staff anaesthesiologist, there were actually no emergency cases booked at the end of the day so I was able to go home. Around 1830, I got a call from a gynaecologist. "I have a lady with a pelvic mass that I need to remove," said the gynie. "Unfortunately I have an evening office so I can't start until after 2000". "Fine," I said, " But if something else gets booked, it will have to go ahead of your case." Seconds later the phone rang and ortho had booked a case. I went in, the case of course took longer than it should have and because the hospital only had two nurses on evenings there was a long turnover and it was 2300 before we were ready to do the pelvic mass. I was sitting in the lounge waiting for the patient to come into the room when I heard the GP who had come in to assist, on the phone to his wife. "We are running late," he said, "anesthesia bumped our case." I should have confronted him and pointed out that we were starting late because the surgeon hadn't been available earlier but he was a nice guy who became our family doctor and delivered my number two son. I also found out why the gynie had an evening office. It was so he could golf in the afternoon.

About a year later, I found out from the recovery room nurses that Dr. P a surgeon long past his best-before date had been sniffing around recovery room asking about the open cholie we had done two days ago. Apparently the patient had aspiration pneumonia. The patient was obviously still in hospital so I went up to see her. Did I mention she was a lawyer? I was able to read in the chart that she indeed had pneumonia, as did her husband and that her blood culture had grown strep pneumonia. Sounds like a community acquired pneumonia to me, I thought. This hadn't stopped Dr. P's son, an intensivist from writing a consult stating she definitely had aspiration pneumonia. I spoke with the patient who was quite reasonable and accepted the fact that her pneumonia had very little to do with her surgery. I wrote a note in the chart which started, "while it is nice to learn about potential complications of anaesthesia, even by such a back-handed method...." A few days later Dr. P. approached me to sort of apologize. "She is a lawyer," he reminded me; translation it is better that you get sued than that I get sued.

Being blamed for turnovers comes with the game. Early on my career I was working with a plastic surgeon who had a morning list with another surgeon having the afternoon list. The surgeon had an emergency case he wanted to do at the end of his list. He was quite quick and could normally do this. Unfortunately his first case went 30 minutes over, the turnovers were glacial and he just ran out of time. I could see that as the morning went on he was getting more and more pissed. As it happened his wife was working in the room that day. "I wonder who he is going to blame for this," I wondered. I shouldn't have wondered. After dumping his last case in the RR, he pulled me into his office where I received one of the ten worst tongue lashings of my life for delaying his list.

One of my colleagues told me of an interesting story. He was approached many years ago to come to internal medicine grand rounds where they were presenting a case of Halothane hepatitis. He didn't review the chart of the patient they were presenting until the day of rounds. After the case had been presented, the question came to him, "Dr. H, do you think this patient had halothane hepatitis," "No," said my colleague. "Why," came the question. "Because she had a spinal," said Dr.H.


(I have always suspected most cases of "Halothane hepatitis" were actually hepatitis C,D,E,F or G which is hardly good grounds to abandon such a safe and inexpensive drug.)

We always joke about "anaesthetic bleeding". Sometimes this isn't a joke. A the CofE. I was doing a cystectomy. On opening it was found that the bladder tumour was invading the pelvic wall. A less excellent surgeon would have said,"she has had a good life" and closed. Not this surgeon and so I had about 6 hours of major blood-letting. Fortunately I knew the surgeon and had "come to play" with a 7 Fr. CVP, large bore peripheral and an art line. None the less she lost about one blood blood volume, developed a coagulopathy and ended up in ICU. I heard from an anaesthesiologist at another hospital where the surgeon also worked that he had been slagging me in the doctor's lounge. Apparently I had caused the coagulopathy by giving too much fluid.

The CofE was of course a culture of blame except you didn't just have to deal with surgery, internal medicine and ICU. Your anesthesia colleagues were always ready to enthusiastically join in, in true Lord of the Flies style should something go wrong.

I could go on. What really concerns me is the number of times I may have been blamed for a bad outcome where I never found out about it.

Part of this is of course our fault. We often see patients in a rushed fashion, we ask them a whole bunch of questions(some they have been asked already, some they haven't but should have been), we dress mostly like the rest of the OR staff, there is very little to distinguish me from one of the porters. We warn them about things like dental damage and other bad things that might happen to them. We never see patients post-op. It is pretty easy to blame somebody like that.

I have often thought it would be interesting to go up to a patient's room when something surgical goes wrong and actually tell the patient what happened. "Did you know that it was the surgical resident who 'accidentally' ruptured your spleen." "By the way how do you like your scar, the student intern closed" "Did you know that your surgeon didn't get any sleep last night?" "This happened to his last total hip by the way".


ZMD said...

"Because she had a spinal."


burnttoast said...

Cardiac patient bleeding to death after coming off bypass, you would think the surgeon would be busy enough trying to correct the problem, but no, he accused me of giving the patient 10,000 unit/ml heparin instead of 1000unit/ml. I had to ask the RN circulating the case to document with me that the sharps box on the anesthesia cart contained only 1000 unit/ml empty heparin vials.
Lots of others, but that was the worst.