Bugs and Drugs

I have spent the last few days doing largely orthopaedic "emergencies". While this is good mindless work, it has entailed administering multiple doses of Ancef.

When I first started out in medicine, the dose of Ancef was 500 mg. Now 1 g is the routine dose, 2 g is more common and 3 g no longer surprises me. Nobody seems to comment on this dose inflation.

While published data suggests that if Ancef is to work , it must be administered 2 hours early, normal practice is for it to be administered by the anaesthesiologist in the OR at the beginning of the case. This is a practical matter as most patients have their IV started in the OR; even patients however who have been in hospital for several days on IV fluids are sent to down to have their first dose of Ancef given "just in time". This means that Ancef is usually administered at an inopportune time at the beginning of the case, when you are trying to give other drugs watching the blood pressure on induction, moving and positioning the patient etc. It is hard to predict in which patients the surgeon wants Ancef, some of them just assume you will give it and get mad when you haven't correctly read their mind. Not infrequently the surgeon doesn't want Ancef until after he has taken cultures (you are supposed to figure this out too!) Quite frequently I find the little mini-bag in the chart in the middle of case well after the tourniquet is up or I find that the nurse has placed it in an inconspicuous spot on my table.

Other surgeons just ask, "Can the patient have some antibiotics?". While I am quite pleased that they think highly enough of my bacteriologic and pharmacological knowledge to chose what antibiotic they want, I usually ask, "Any particular antibiotic?"

Anyway you get the impression that I find giving Ancef to be distasteful.

Part of the whole issue for me is the cognitive dissonance of the whole issue. I don't remember much from medical school but I do remember something about microbiology and the action of antibiotics. I also took a course in population genetics as an undergraduate.

The bacteria that is giving or is going to give you an infection is actually a heterogeneous group of individuals. This means that every little cocci or bacilli has a different degree of susceptibility to antibiotics. The weaker ones may succumb to one dose, some may require 10 days or more. Now if a patient gets only one dose of antibiotic as quite a few of these patients do, this means that the weaker bacteria are killed off leaving a population of slightly more strong bacteria. This well known with tuberculosis where incomplete treatment of TB has lead to drug resistant strains. The same thing is of course happening to our garden variety bacteria as well.

Another thing, as I found out when I had to buy Ancef for a medical mission (who better to buy Ancef than an anaesthesiologist) Ancef cost $7.00 for 1 g. That is by the way for generic Ancef. So what $7, not even 2 lattes. Remember when Propofol came out? It cost $8 a bottle. Do you remember the hassle we had to go thru to get the bean counters in pharmacy to let us use it, the rationing, the special populations. In fairness to pharmacy they have cracked down on the use of some of the more expensive antibiotics.

Which brings me to a case I did on the weekend amongst all the ortho cases.

This case was debridment of an infected ankle in a patient with Methicillin Resistant Staph Aureus (MRSA). When one of those patient known to have MRSA comes to the OR, the whole OR springs to an even higher level of paranoia and irrationality. The patient comes down from the floor gowned, hatted and masked and is whisked an OR that has been stripped of all it's equipment except what is absolutely necessary. This means aside from the anaesthetic machine, all your equipment is also not in the room. You have to figure out what what you might need, and bring it into the room with you, otherwise you have to ask someone outside the door to pass in the syringes or drugs you need. Having usually no idea what the surgeon is doing or for how long, the case usually involves me repeated going back and forth between the head of the bed and the door to ask for stuff.

Afterwards, the room is closed for cleaning and the patient is parked in a far corner of the recovery room.

All this makes some sense. Nobody wants innocent bystanders in the hospital infected with MRSA, or VRE or even C Diff.

Except quite often a couple of days later, you will inevitably run into the same patient, sitting outside smoking, having walked from his room, into elevator (touching door handles and elevator buttons on the way) and thru the lobby in a cloud of MRSA. Nobody seems to care.

Now a significant number of these patients originally acquired their infection in a hospital. And where do you think these supercharged bacteria originated. Could it be the single doses of Ancef? Am I the only person who has made the connection.

On another tangent, we frequently see in the press estimates of numbers of patient who have died as a consequence of infection with one of these bad bugs like MRSA, VRE or C. Diff. All these are of course the consequence of promiscuous use of antibiotics. Now as a consequence of working at the CofE which among other things is a cesspool of nasty bacteria I probably carry all three of these bugs plus several other nasty ones. But I feel fine.

No doubt many elderly patients or younger patients with significant medical conditions succumb to these bugs. This is however rarely the sole cause of their demise, it was just the final straw that pushed them over the edge. In most cases we are talking of maybe a few weeks taken off their lives. (A nephrologist where I trained always said, nobody dies of renal failure; he was quite right, if you keep dialyzing them you can keep their numbers correct every 2 days until they die of complications of renal failure or of dialysis or even from VRE, MRSA or C. Diff. A fine distinction)

Now occasionally healthy people do succumb to nasty infections like "flesh eating disease" or meningococemia. These are however bugs that are largely sensitive to antibiotics if you can get them in soon enough and in the correct doses.

Privacy

Yesterday and today I am on call which means covering the case room. Now a universal feature of caserooms since I was a medical student in the last millenium was "The Board".

"The Board" was a then a blackboard, now a whiteboard with every labouring patient's last name, status including dilatation, station, NPO status, epidual and whether they were being induced.

In the interest of privacy now, the patient's last names have been replaced with only the first 3 letters of their name. This caused a problem for me right away when I arrived in the morning. The first three letters of the only patient with an epidural made up a name that is not common. So in I went saying "high Ms. , I'm Dr. BH" and then went out to the desk to find her chart. After I couldn't find her chart I asked, "who has Ms <3 letter word name>'s chart" and after getting blank looks, "who has room 5's chart". One of the nurses handed me a chart with a six letter last name and when I said no I want <3 letter word>'s chart; they looked at my like I was stupid and told me that they were only putting the first 3 letters of the patient's name on "The Board". I never asked how they proposed to deal with patients whose last name only had 2 or 3 letters something increasingly common now (or two patients with similar three letters).

Most medical and surgical wards used to have boards with everybody's names on and what bed they were in. Alternatively the name was on the door so you could at last walk around looking for the patient you had to see. Unfortunately boards have gone by the way and in several hospitals now there are no names on the door either. This forces you to look for the chart (which if it is in the rack is filed by room number) or ask the ward clerk or a nurse.

At the same time we are very concerned about proper identification of patients to prevent the wrong treatment being done to them. Now I think everybody has had the experience of going in to see the wrong patient and realising half way through talking to them that you really should be talking to someone else. When one wants to estabilish a therapeutic relationship with a patient, the least auspicious way to meet them for the first time, has to be to enter the room and go straight for their arm band to see who they are. Yet with names not on the door, or the patients bed, in patients who are deaf, demented or half asleep, that is now the only way of ensuring you are actually talking to the right patient.

At the same time most units allow patient and their visitors to use the phones at the desk. Of course what are usually sprawled all over the desk for everybody to see. Charts of course, so the patient or their visitors can read whatever is in their visual range. (Maybe that's why nobody writes progress notes anymore).

Very few names are unique anyway. If I see a name on a door that is the same as someone I know, I just assume it is someone with the same name. Occasionally much to my surprise it is someone I know. I once ran into the contractor who built my house while on Pain Rounds. The name didn't ring a bell and people surprisingly don't look the same with an ng tube. I was talking to him when he interrupted me and said, "I built your house". I didn't tell him it was a good thing for him that I didn't give him his anaesthetic.

A number of years ago we had a victim of a gang related assault in our trauma unit. The staff were somewhat concerned that someone was going to come in to finish him off so as this was still when there were names on the door, instead of putting his name on the door, they put his hospital number.

Great...

I'm a gang member assigned to finish him off and I learn what ward he is on. So I sneak around the ward and there are 19 rooms with a name on, and one with a number on. I wonder which room I should chose.

I grew up in (what was by today's standards) a small house with three brothers (and two parents). My mother always said, "If you don't have anything to hide, you don't need privacy".

So please put my name on the door.

Information I really shouldn't be posting on my blog (but that is too juicy not to)

When I worked at the CoE there was a surgeon whose ego was the inverse of his height. Now he was not a modest guy so you can guess he was quite short. He compensated for this by wearing ridiculous cowboy boots with heel lifts and I know everybody (even some short people) made jokes about his height mostly behind his back. Now I am reasonably tall but I have come to realise that outside the NBA, NFL and CFL this is largely a world suited for short people so I couldn't really see what the "big deal" was.

Despite this surgeon's lack of physical attributes he had quite a successful life. (The operative word is had as I will explain below).

He became a successful surgeon, helped pioneer a few new procedures, was well respected in the community (if not by his colleagues), and was a successful political fund raiser for the ruling party. He was incredibly wealthy, had a huge house, and drove what he described as (after one of the nurses' daughters rear-ended him) the most expensive car in the province.

All was not rosy in his life. About 10 years ago he ran away from a long marriage to a woman who had put him through medical school, bore his children, etc to marry a sales rep. This didn't seem to affect his standing in the community, in fact even before he remarried he was in the social pages accompanied by his new wife-to-be. At his second wedding, his adult children from the first wedding picketed the ceremony and he had them arrested.

Now about 3 years ago I heard that he was going to take the whole summer off to have surgery. He was at that time of the age where people get prostate or colon cancer or require joint replacements so I didn't think much of it. That was around the time I left the CofE.

We were talking one day about him in the OR at my new place and somebody said that the reason he had taken the summer off was to have his legs lengthened in New York. The procedure had not been done. Just the fact that he had even considered such a procedure caused much amusement, although this would not have been out of character for him.

A couple a weeks ago someone came out and told everybody that he had actually gone ahead with the leg lengthening in the US. This is by the way called the Ilazarov procedure and is usually used for leg length discrepancy or occasionally for children of short stature. While this procedure is done on adults (particularily in adults who can afford it), there is generally a cut off at age 50 simply because you stop healing well, forming bone and rehabing well at that age. Being 50 myself, that is a little depressing. Apparently in the US, being able to afford a procedure can take years off your life (in both senses unfortunatley).

To make a long story short, he did terribly. His recovery was complicated by pulmonary emboli requiring an ICU stay, he has an infection, non-union and 60 year old nerves not liking being stretched, has developed causalgia which to my (and his?)relief is being treated by one of my colleagues and not by me.

Personally I blame myself. I should have never made all those short jokes.

But seriously....after the snickering about the shear audaciousness of a mature successful man undergoing mutilating surgery for a slight increase in his height, I really had to feel genuinely sorry for him. Not sorry for the predictable complications but sorry that he felt that his life was not perfect enough that he had to improve himself.

Another issue that came up is the issue of confidentiality. Yesterday in the surgery lounge this was the topic of conversation all day with people hearing the story and getting on the phone to someone they knew with, "did you hear about...".

Technically as a hospital patient, his condition should only have been known to his caregivers. While perhaps because of his actions over the years he has done more than most people to make his personal life less private, in his time of personal crisis, even if this came from a totally irrational decision on his part, he is entitled to privacy.

Still we all love gossip and this is a juicy story.

Death on the table

We recently had a death in the OR. Actually the patient died in the ICU afterwards but it was essentially a "table-death". This was a laparoscopic gall bladder in an octagenarian. She had an uneventful OR and then arrested in the recovery room. I didn't do the case but responded to the alarm, stayed for while until I figured there was enough help, so went on my way. Anyway she had a complex but no pulse which lead me to think she might be bleeding. After some rescuscitation they took her back to the OR where there was bleeding in the retroperioneum around the pancreas that nobody had noticed. She as I mentioned later died in the ICU.

This reminded me of a few things.

The first thing that came to mind was something that happened to a staff anaesthetist where I trained. This individual was not a very good anaesthetist. He however felt that he was the best anaesthetist around. This is a bad combination. He wasn't really fun to work with as a resident. (Aside from being a pompous twit, he had a nasty habit of poking you in the shoulder to make his point; nowadays laying hands on a resident would land you in the Dean' office.)The event in question however happened about 2 years after I finished. By that time I gather there had been a few other episodes.

He was doing a laparoscopic cholie around the time that surgeons started doing laparoscopic cholies and those of us who worked in that era remember what a dark time that was(3 hours of farting around followed by an open cholie). I gather during the case, the blood pressure continued to fall and fall. He asked the surgeon if there were any problems and of course the surgeon said no so on they went until the patient died.

My former "mentor" was told soon after that it was time he retired. This was before the autopsy showed a belly full of blood which the surgeon had failed to notice. Unfortunately my mentor had to keep retired while the surgeon is to my knowledge still working and hopefully learned something that day.

I have unfortunately over the years had a few deaths in the OR and few people that expired shortly after. Most of these have been predictable, ruptured aneurysms of both types, traumas and of course the ICU cases sent to the OR to be euthanized (this patient is going down the tubes and we can't think of anything to do so lets operate on him). Self flagellation comes naturally to anaesthesia and we always wonder if there was anything we could have done differently and looking back over the years, I don't think there was except maybe I could have run away.

The wierdest thing about a table death is that you usually have to start another case right after. Either you are on call or this case bumped into your elective list or it was in the middle of your elective list. So after an hour or so to clean up the mess and do the paper work, back in the saddle. Strange.

Several years ago, we had a province wide committee on peri-operative deaths and it was an interesting exercise. Essentially if a patient died within two weeks of surgery you had to come down to medical records, review the chart and fill out a form. Many of these were of course patients you knew died or you thought were going to die but you got the odd patient who just happened to die a few days post-op for no apparent reason. As I say it was interesting (and easier than reading the obits and looking for names you recognize.) This initiative stopped during our time of health care reform and downsizing in the mid 1990s when the province and hospital admins got worried that death might be attributed to their restructuring efforts.