Thursday, July 26, 2007

An Open Letter to Surgeons

It seems in the Medical Blogosphere, every specialty is writing open letters to every other specialty. Maybe some anaesthesiologist has already written one. I haven't looked. Here is mine.

Dear Surgeons:

I actually like most of you guys. At least I like you a whole lot better than most internists. Maybe because we work so much together there are a few things that piss me off.

1. Punctuality. Maybe I am a bit anal about being on time. I frequently arrive at parties at the acutal time the invitation says. However when the case is booked to start at 0730, I try to show up at least 15 minutes early, the nurses show up at least 30 minutes early, all so we can have the patient ready for you. But you consistently show up at 0745. Now if we start 15 minutes late, we rarely ever make up the time which means that we leave 15 minutes late. That is assuming we get to do the last case which is often cancelled if we are running late which hits me in the pocketbook, not to notice having to witness an ugly scene between you and nursing.

When confronted on this, your excuse consistently is, "but it's only 15 minutes". Next time you fly somewhere show up 15 minutes late and see if you get to board the plane.

Maybe 15 minutes isn't much, however when I finish 15 minutes later than I should have, that might mean I don't get to eat supper with my family, I miss my children's soccer game completely or I miss the meeting I scheduled at the end of the day.

And by the way. I cannot start the case until we know you are in the hospital. That is because you could be operating at another hospital, in court, or have died in your sleep. I am aware of all three scenarios happening. Quite often the patient wants to talk to you, frequently the consent has not been signed.

And having started the day, try to arrive on time for each subsquent case. If you can't because you are dealing with something in emergency or on the floors, why not call and tell me. If I know I have an extra 15-30 minutes, I can actually do something with the time.

2. Residents. Those surgeons who don't work in teaching hospitals can skip ahead here. Most doctors my age were junior house staff on a surgical service years ago and we know how hard surgery residents used to work and how completely soul destroying and uneducational it was. The current group of surgery residents are quite right to refuse to put in that amount of work. However... most of that work still has to get done. That means if the residents won't do it, you had better find someone else to do it; the nurses, yourself I don't care. The standard of care on most surgical services is disgraceful. By the way, you might want to ask your colleagues at non-teaching hospitals how they manage to provide pretty good care without residents.

Further while it is important to train the residents, the middle of the night or late in the day when you are already behind are not good times to teach. When I am letting a resident do something I make sure they try to do it as efficiently as possible, I come in extra early and I help them as much as possible so that they can do the procedure or get the case started faster.

3. "I really don't want to do this case but the family is insisting on it" God man, how many years did you train so you could be intimidated by Mrs. Jones' high school dropout grandson. To put it another way, I have as much training as you and do you ever respect my opinion? And isn't it funny how these discussions only occur after hours, never during your elective slate? Grow some balls, sit down with the family tell them how operating on granny will at best slow her demise, may likely hasten demise but will not prevent her demise.

4. Yes we don't work after we've been on call. Sometimes now we don't even work the day before night call. This is not because of some weakness but because we have learned that it is dangerous to work without sufficient rest.

Like the alcoholic who thinks he is witty and sexually attrative when he is drinking, you believe you can provide competent care without much sleep. We have watched you for years. Trust us, you can't and you don't.

5. We do emergency cases in the order determined by whatever protocol the hospital has decided for prioritizing cases. Surgeons presumably had some input into the process. If you feel your case is more urgent than the one ahead of yours, don't whine to us. Call your "colleague" and ask him if you can go ahead.

6. Oh and while we are on call or even in the course of our elective lists, we may have to go the ER, the ICU or the ward to intubate somebody. We may also have to do a labour epidural. This may delay you. We do these because we are physicians.

7. Try telling the truth for a change. Instead of saying you have to do Mrs. Smith right away because she has perforated, why not say,"I know Mrs. Smith can wait but the family is driving me crazy." We may still not do your case when you want it, but won't you fell better about yourself. Be truthful about the patient's medical condition, and how long you are going to take.

8. I don't know about the medical training of people recently but anybody who trained in my era had pretty good grounding in history and physical examination skills. Put those skills to use. Not just in the areas related to where you are operating. Currently when I read a chart, I get my best information from the nurses notes which is kind of disgraceful. Also you might consider writing the odd progress note. Like, say every day. Just so we have some idea about what happened to Mrs. Smith in the 5 days since she was admitted and why she is having surgery today.

9. If you have a problem with the way I work or the way a particulary case went down, talk to me first. In private, not yelling in front of the nurses. Before you write a letter or talk to my chief. Definitely befor you talk to the family. Aside from being courtesty, I may just be able to explain why I do something or what happened in that case. And please no sneaky progress notes that I will never read but that are in the chart forever.

10. No amount of lab work is a substitute for a legible history and physical documented on the chart. The more lab work you order, the more likely something is going to be abnormal which will lead to more testing and possibly the cancellation of your case. Also when you really need something stat like a PT INR, the lab can't do it promptly because it's queued up behind all the routine "baseline" PT INRs you and your colleagues ordered. There are specific guidelines for pre-operative lab work. Look them up and use them. Don't forget, some tests have a shelf life. Electrolytes done on admission don't mean much 2 days later in a patient who has been vomitting or hasn't peed.

11. Your responsibility for the patient doesn't end when you book the patient. Many patients need ongoing monitoring and rescuscitation in the few hours before they are booked and when they get to the OR. Don't tell me after the blood pressure crashes on induction "Oh he might be a little dry". That should have been taken care of before he got to the OR.

12. Yes we do get paid by the hour. Years ago somebody decided that was the best way to pay anaesthesia. It turns out they anticipated laparoscopic surgery. The downside of this is of course of income is limited by how many hours of work you and the hospital will provide us. Essentially we work when you want to work. That's the cross we have to bear. We do not however slow down cases to increase our income or to fill up an underbooked day. I must say, I am bemused and occasionally disgusted by how much time some of my colleagues take to get a case underway, but I actually have life and when I see the chance to finish early, I go for it.

13. No matter what your overhead really is (and it is much less than you always say it is), you make several times more money than the nurses. Please don't whine about how overpaid or lazy they are. Also please don't flaunt your lifestyle in front of the nurses or me. I know you work hard and have a lot of training. So do I. Also if you drive a Porsche, why the hell are you aways late in the morning?

14. I'm all for new technology but nights and weekends aren't the best time to try out the new orthopaedic hardware. Instead of franticly calling the rep and yelling at the nurses, do things the way it has been safely and effectively done for years or postpone the case. Also watching the rep walk you thru a case doesn't engender a lot of confidence in your abilities or judgement.

15. When I am on call, I have to miss things. Please don't use family or personal business to try and get your case done at a time of your chosing. Call up one of your colleagues and get him to do the case for you. I realise some of you are on call more often than me (some of you are also on call less).

16. When you "outsource" your easy cases to the private surgical suite or the community hospital please don't come and boast about how efficient it it there (especially when you show up at 0745 to start your 0730) case. It takes a lot longer to set up a radical neck than it does to set up a myringotomy. Secondly don't be surprised if we are a little surly when you bring your complications back to our hospital. Thirdly it is really good that you help mop the floors in your private suite. Why don't you ask the cleaning staff here if they want some help.

17. Before whining "it's on my card" make sure it actually is on your card. Also if a piece of equipment is so important why don't you, during the changeover that you complain about, make sure it is actually on the tray. We have nurses and techs who are supposed to provide equipment for us like laryngoscopes but we still actually check before the case that we have one that works.

Wow I didn't realize I had some much spleen (the metaphorical kind, not the organ that is bleeding under your retractor) to vent. I really like you guys and I know not all of you do any or all of the above transgressions. It's the 90% of you that give the other 10% a bad name.

See you tommorow (at or before 0730).

Bleeding Heart.

I got sued part 2

Actually maybe things didn't go that well. As the case wore on, she required more oxygen to keep her saturation up. In retrospect, the rotten food I should have sucked up was probably getting past my et cuff.

So I decided to keep her intubated, get a chest X-ray and call ICU.

I took her out to recovery and put her on a ventillator there and called ICU who sent their fellow over right away. As it turned out her oxygenation got worse in the next few minutes and her CXR was gross.

To make a long story short, she spent several months in the ICU, a few more in hospital but was actually discharged with no new deficits. Not that spending a few months in ICU is necesartily a good thing.

I had a somewhat unpleasant meeting with my chief, (who you may recall was the individual who was able to see the patient in a relaxed un-hurried fashion in the preassessment clinic and failed to document the patient's achalasia) and called the Canadian Medical Protective Association.

Several months later the patient's father called me up and asked to meet with me regarding what had happened to his daughter. I called up the local lawyer on my case who advised me to only meet with a lawyer present. I phoned the father back and told him, this. His response was, "Is this how you doctors handle things?" I often think if I had just met with him I might have avoided legal action (or least shifted blame onto the surgeon and my chief). A few weeks later he called me up and asked if he could photocopy the chart. As patient charts are legally the property of the patient, I told him to go ahead. Unfortunately the hospital refused to let him photocopy the chart which lead to me receiving a letter from his lawyer. Strike two.

Time passed. In my province at that time you had only one year to file a lawsuit. As eleven months rolled by, I began to feel good about myself again. At eleven months and two weeks I got served! Along with the surgeon, and the hospital. Curiously my chief managed to escape.

About 2 years later I had what is called an examination for discovery. This is a process in civil suits where you sit down and the other lawyer questions you. Your lawyer is present, but does not ask questions; he may interupt to clarify and he may by hand or eye signals caution you on answering a question. The plaintiff is usually present, although there is no requirment that she be there.

This of course involves taking a day off work although in anaesthesia one can do this by working around the call schedule. The other side of course cancelled the first session on short notice and we had to reschedule.

Now as I have said, there were mitigating factors; the bottom line is that I screwed up. I could have and should have dug deeper asked more questions of the surgeon and patient. I should have got the chart back from the surgery resident. I should have cancelled the case after the induction. I should have checked for a suction. Blah, blah, blah. I should have done all these not so I wouldn't get sued, but rather to prevent a patient would was told she was coming for a simple short stay surgery that would solve her problems forever from spending months in the ICU, a fate I would wish on no-one (even my chief).

The other lawyer of course missed all this in his two hour interogation. The examination ended with the curious question, "Did you give her chlorine" to which I answered no.

Now there were a few other problems. As I mentioned the patient was deaf-mute. She also had a variety of pre-existing neurological problems which of course nobody bother documenting pre-operatively. Also in the ICU as they began to wean her off her sedatives, she developed twitching, which the neurologist said was due to "anoxic brain damage". Although the patient required high concentrations of oxygen and other ventillatory support she was never even hypoxic, let alone anoxic.

Eventually the case was settled out of court for a low six figure amount.

The only consolation when something bad happens to one of your patients, is that you learn something that will help future patients, and the institution may make changes that may prevent future events. I have done achalasia patients since uneventfully and I now know what a "Heller's Myotomy" is. I can even google it now:

Years later I was talking to the scrub nurse in that case and I learned why I had a student nurse helping me. At that time, in the Centre of Excellent, each service had its own head nurse in the OR. Some of the head nurses actually helped out. The head nurse in this case usually didn't. On that particular day because they were behind and were busy setting up for this laparoscopic procedure, they asked the head nurse if she could help me get the case started. Her response was to send the student nurse in to "help" me. I gather that when her bosses in the OR asked her why she didn't help me, she said it was because she didn't like me. At that time I had worked at the CofE for 3 months and had never worked in her room so I must have managed to piss her off in the first couple of hours that day. She retired a couple of months later. This says something about the institutional culture at the Centre of Excellence. Normally when you give an excuse like "I didn't help him because I don't like him", the usual response would be "I don't care whether or not you like him...your job is to help him". As it was one of the items discussed with my chief at the unpleasant meeting I mentioned above was the fact that according to my chief after 3 months all the nurses hated me. Well I certainly wasn't too impressed with the nurses around that time.

Monday, July 16, 2007

I Got Sued Part 1

A few weeks ago while channel surfing I came across the movie "The Verdict" with Paul Newman. I first saw this movie in 1984.

The movie is about a lawsuit against an anaesthesiologist.

The "facts" in the movie are that the plaintiff came into hospital to have her baby and was "given the wrong anaesthetic". Essentially the patient had eaten just before she came into hospital to have a baby and was given a general anaesthetic with a mask during which she vomitted, aspirated, had a cardiac arrest was rescuscitated but was left in what we call a vegitative state.

The movie doesn't say what type of operation she had.

Assuming she had a caesarian section, there was no right or wrong anaesthetic in 1983 or now. The standard of care for a caesarian section under general since the 1960s would have been to intubate the patient. A mask anaesthetic would have definitely been the wrong anaesthetic. Pregnant patients are assumed to have a full stomach regardless of how long they have fasted and stomachs empty much more slowly in pregancy.

Now up until the 1960s or later, it was fashionable to give women heavy sedation approaching or exceeding general anaesthetic for labour and this is what may have happened. Judging from the clothing and hairstyles however, the movie is set in the early 80s/late 70s.

I am constantly amazed that producers are prepared to spend millions on a film without asking a specialist in the field, "Is this a plausible scenario?"

This however is not about reality in the film industry, it is about my brush with the medico-legal system.

Actually it was 14 years ago and I believe it was settled at least 10 years ago. I was reading Dr. Sid Schwab's blog and he talked about how he got sued years ago so I thought I should relate my experience.

Firstly I fully admit that while there were extenuating circumstances which I will detail, there were actions that had I followed them, the whole mess would not have happened. The bottom line is I have always accepted full responsibility for what happened.

It happened a few months after I joined the staff at the centre of excellence. I have been in practice for just over 2 years at the time. Statistically anaesthetists are at their most dangerous in their first 3 years of practice. (Some people think that more experienced anaesthetists are just better covering up their mistakes.)

Anyway as I have mentioned in a previous post, I had already by then realized that I did not fit in at the centre of excellence and that I would probably never fit in.

When I was a resident and in my first years of practice, when a patient needed to stay in hospital after their surgery, they were admitted the night before and they were seen the night before by the anaesthetist assigned to the room. This meant up to an extra hour of (unpaid) work after your list had finished not to mention the Sunday night visits. This was we all belived the cross anaesthetists had to bear. Now it was around that time, the hospitals in the name of saving money decided that patients could be admitted on the day of surgery. This meant that they were seen in advance of their surgery at a Pre-operative Assessment Clinic (PAC) by one anaesthetist who was assigned there that day. That lucky person would see all the patients, review the lab work and fill out the anaesthetic form. Hopefully if there was a potential problem, that would be relayed to whoever was supposed to do the case. At that time a copy of the anaesthetic form would be faxed to the office the day before so you had some idea of what you were doing.

Anyway, the day before I looked at the slate and saw that one of my cases was a "Laparoscopic Heller's Myotomy". Even with a medical degree, five years of medical training and over two years clinical practice, I had no idea what that was. Nor did anybody in the office. I suppose I could have gotten a surgical textbook and looked it up (I did several months later and even some surgical texts didn't use that term). Or I could have phoned the surgeon's office and talked to him. But I didn't. I figured I could talk to the patient the next day, read the chart and I would be able to figure out what I could or couldn't do. (Nowadays I would just Google Heller's Myotomy but back then Al Gore had only just invented the internet).

Complicating matters was that the surgeon was probably the most clumsy incompetent surgeon at the CofE. There are many clumsy and incompetent surgeons and many of them know their limitations and stick to hernias, lumps and bumps. Then there are those who don't know their limitations. This surgeon, widely known for his incidental splectomies was one of the later group. Worse still, he had jumped onto the laparoscopic bandwagon well in advance of many of his colleagues.

Anyway on arrival in the room, I asked the nurses if they had any idea what our second case was. They too had no idea. So we asked the surgeon when he came in. He mumbled something like, "just like a laparoscopic cholie, no problem". Our first case was a breast biopsy which unfortunately needed a frozen section which took much longer than planned, so we were already running late. All this time I was thinking no problem, I'll talk to the patient and read the chart and I can do this next case.

On dumping my first patient in the recovery room, I went out to the receiving area but my second patient wasn't there yet. Quite often I will see the patient in the operating room but I distinctly remember telling the nurse in receiving, " call me when the patient gets there". Then I went to have coffee.

The next call I got was from the room telling me that the patient was in the room. No problem, I can read the chart and talk to the patient there. Except.....

Because patients don't come in the night before, the surgery residents also don't get a chance to read the chart and the surgery resident had taken the chart somewhere to read it. And...

The patient was deaf-mute and no family member had accompanied her.

No problem. One of my colleagues must have been able to talk to the relatives, read the chart in the PAC. So I got the anaesthetic record (which hadn't been faxed over the day before). She had been seen by the chairman of the department, an eminent academic anaesthetist. To be honest there wasn't much on the chart just a couple of meds, no allegies and a note that the patient was deaf-mute. Nothing to get the spidey senses tingling. Now I have learned since and probably knew then that the more eminent an academic anaesthetist is, the less competent they are. But I figured, okay we're dealing with something like a laparoscopic cholie in deaf-mute but otherwise health person.

So we set up to induce anaesthesia. I had a student with me that day, somebody I had worked with for a couple of days. This was a smaller room and we had the two monitor towers on each side of the bed so there was only room for one person at the head of the bed. Since my student was going to intubate,that was him. When we start anaesthesia, there is supposed to be a nurse whose only responsibility for those few minutes is to help us. There was a female nurse-looking person standing at the side of the bed where the nurse usually stands.

So I inject the drugs and after waiting a few seconds, my student goes to intubate. First thing he says is "I think we need suction". So I ask him to get away from the head of the bed because there is not room for two of us because of the monitors and I take a look and her entire mouth is full of some gross whitish material. That was when I discovered that my lovely assistant was a student nurse who had never helped start a case and that she had not got a suction ready. (The nurses get the suction ready for each case, but I admit it is my responsibility to check for its presence).

At this point, the surgery resident wandered into the room with the chart, looked into her brimming oro-pharynx and said, "Isn't achalasia gross?"


Achalasia is a condition where the muscles in the esophagus that are supposed to propel food down towards your stomach don't work. This results in solid food accumulating in your esophagus where it basically decomposes leaving you with a massively dilated esophagous full of rotten food. This patient I learned later had a particularily bad case to the point where she had to sleep sitting up or else all this rotten food would go down her lungs.

Usually patients like this are admitted to hospital several days in advance and all the rotten food is sucked out and they kept on a liquid diet.

Now when you screw up like this, no matter how extenuating the circumstances are, when you should be thinking, "how can I help this poor person?", your first thoughts are, "boy am I in shit!"

So I pushed the student aside waiting for the real nurse to set up a suction, sucked out the oro-pharnynx and intubated. Fortunately the patient's oxygen saturation remained okay and she was not broncho-spastic. I called for a broncho-scope and looked down into her lungs. There was a little bit of "staining" in the parts of the lung I could get to with the bronchoscope which I tried to suction out as best I could.

At that point I should have cancelled the case. The patient had aspirated she was stable but she could get worse during the case and once we started, it might be difficult to stop. I didn't do that though. I felt so bad that my telepathic powers had failed to pick up what the patient had and what the surgeon planned to do that I felt I had to make things up by continuing on with the case. This is very irrational but that is how you think when things like this happen.

At the very least, I should have suctioned out the 2 or so litres of rotten food in her esophagous to keep it out of her lungs. (An endotracheal tube is only partial protectiona against aspiration.)

After that, the case went pretty good.

Bad haircuts

Having lived through the 60s, 70s and 80s I have seen more than my share of bad haircuts. There is one hairstyle that has become popular that is wearing thin (literally).

The shaved head.

Now I know that many balding men are now shaving their heads instead of a comb-over and yes we appreciate that. However it is possible to be balding and still look distinguished without combing over or shaving the entire thing off.

The problem is that what was once a novelty has now become almost boring. While some men look like Bruce Willis with their heads shaved, the unfortunate thing is that most of them look like Dr. Evil.

Oh and by the way nothing looks worse like somebody with a shaved head who had a laceration sutured in the past. I sutured up looks of scalp lacerations during my years as a family doc. Scalp lacerations are always chalenging because they bleed a lot and the hair gets in the way. Fortunately we all thought, no one will ever see the scar we leave. However due to the whim of the fashion gods, all these hideous scars that we thought no one would ever see, are now coming into view.

Please stop, grow your hair back. We promise not to make any more bald jokes.