Give the surgeon a break

Well, I have had some interesting cases this past week, and thought I would share them with you all.
I have been on the Neurosurgery service this past week. This means that I deal a bit more with the sad cases. I guess it is something like oncology or neurology where there are devastating conditions, many times the prognosis is bleak, and people don't do so well. This all makes for patients who don't give you much backtalk, families who are upset, and attending neurosurgeons who are impatient, have a good sense of humur, and fly off the handle at the most "trivial" details. I say "trivial" because to me it doesn't seem all that important whether or not the patient has this or that done or medication taken. After working on their service for the past week I realize they deal with such intense situations and stressful situations that they need a place to vent or they will go nuts. Better they vent when not in the middle of someone's brain or spinal cord surgery, in my opinion.
One interesting thing I have learned about surgery and surgeons in particular is that they get a bad rap for being mean, harsh, unkind, insensitive, etc... I realize this is true very often, but hardly ever unprovoked, and hardly ever is it personal. In surgery, each patient can potentially die at any time. You live each moment of each day doing all you can to try to anticipate problems, complications, errors, and mistakes so the patient has the best chance of making it out of the hospital at least as well as they came in as. Against you there is a tremendous amount of opposition. First, you have the patient himself. Now, patients vary with the way they come in. The trauma patients are nearly always intoxicated out of their minds, foul smelling as if they are all having a competition to see who can make the most of us pass out or at least wrinkle our noses the most, and in great humor as we attempt to care for them by jabbing their arms with needles, poking and proding the extend of all injuries, and inserting large tubes in small orifices under the guise of "this is necessary for your care." Now, this is all true, the necessary part of course, but usually these patients work so hard as law abiding citizens during normal business hours, that they need to blow off steam and go to church around 2:30 am, which is when they are innocently walking home minding their business or driving to church when some idiot is driving through a green light.
Oh, sarcasm and being calloused is one of the requirements to pass the surgery boards, I am told. Anyway, I say all of this to give you the backdrop for the very rare trauma patient who is one of the rest of us. Usually these are either victims of the other trauma patients who are intoxicated and operating motor vehicles, or else they come in during normal business hours. Just yesterday, I was post call, which means I was up all night dealing with the drunken idiots who were out running into parking lot lamp-posts after a few drinks to calm their nerves. I was preparing to go home and was just holding the pager for the intern who was on call as he was in the operating room and I wasn't. Of course, as soon as I attempted to leave a trauma was called in. Now, traumas at 10:30 am on a nice sunny warm day make me think differently then the ones on cold nights after payday.
Anyhow, I was covering my partner on this trauma yesterday morning and the guy was nice. He didn't smell like a dumpster behind the liquor store, and had not a single tattoo on his body. Unfortunately for him he had fallen victim to bloody gravity. Fell from a scaffold and was paralized from the nipples down, also started loosing feeling and strength in his hands and arms as we were examining him. He never swore at us as we were poking and proding and inserting... probably because he was paralized. I have this theory, and it seems validated over and over. The nicest people get the most devastating diseases and injuries. The drunks total their vehicles, ride their motorcycles drunk at 1am and come out with scrapes and bruises and a few free meals. The honest law-abiding citizens who really do go to church end up falling off the stepstool helping the blind widow get some powdered milk off the shelf. They usually end up either paralized from the eyebrows down, or a vegetable on a ventilator from bleeding in their brain... Or they have no injury at all, but when they had the pan-man-scan to look for internal injuries they find the honest citizen has metastatic cancer all over and only has a few more weeks to live.
The other case that came in yesterday was a nice lady of 69 who was having trouble walking and had passed out a few times. She had a CT to look for bleeding and they found a mass in the lower part of her brain. I was working this evening with the neurosurgeon on her brain and we got to see the tumor and took it out to find it could be some form or lymphoma. Well, she was pretty upset when she found out we wanted to remove it because we thought it was a tumor. Thing was she had a son who died at age 42 after 7 years fighting off a brain tumor. Seems like I have it pretty good for being such a nice guy... Well, at least I thought I was, but since I haven't had any really bad disease or tragic injury I figured maybe I was meaner than I thought. Maybe it will be in my favor that I have ordered enemas on all of the medical patients just before I go on vacation. Not really, but it makes one wonder if karma wouldn't bother you so much if you used bigger needles than necessary, no lubricant for catheters, and three fingers for rectal exams.
To get back to the enemies of the surgeon. First, there are the patients who try to die without telling anyone or letting you know but are constantly disguised and hidden among the patients who are constantly crying wolf and feigning all sorts of serious diseases and complications. Next, the nursing staff calls you for anything and everything besides the important things, forgets to check the pulse and blood pressure of the only patients who really need it checked, and don't record the urine output of the patients who develop kidney failure because they need more fluid that you had ordered but they forgot to administer because the patient has been without an IV for some time now but they forgot to call you so they could start a new one, or they tried one but you were busy with all of the tylenol and benadryl orders for people who can't sleep. Finally, there are the families who figure you have nothing better to do than keep them informed on any change in their loved one's condition, and want an explanation. This wouldn't be any problem except that you have 28 people on your list to see and take care of, the operating room is calling you for the next case, the three nursing units are calling you for orders, the ICU needs transfer orders for one patient and central lines changed in two others, your chief resident needs you to check with the radiologist on some scans and you haven't had breakfast or lunch and need to use the little boy's room before surgery before you have an accident. If you just knew which patient that has shortness of breath had the clot in their lung, medicine wouldn't be so difficult.
I am starting to understand why many surgeons get so worked up about things. I have learned that you can't trust anyone, assume anything, and always keep your bladder as empty as possible. One other thing. Most surgeons can blow up in your face if you mess up like Mt. St. Helens. Most surgeons completely forget the matter and are your pal 5 min later. So far I have been chewed out about 7 or 8 times, but I never felt like the surgeon was unconcerned for my education and have always felt like they truly want me to be a great doctor and surgeon. Funny how if you get that feeling from someone you will take just about any tirade or attack and feel bad but not humiliated. I keep coming back to the fact that I am only responsible to God for my actions and responses. That sure helps.

Well, I have to run along to bed since I am on call tomorrow and have to be there early since I am rounding with the Chair of surgery on a bunch of patients I have never met so it will take me a bit.

David

November 06