Friday, April 24, 2009

Surgeons v. Anesthesiologists II: Disagreement

The operation itself had gone smoothly, but after about half an hour in the recovery room the patient's heart rate had almost doubled and his blood pressure was low.

I went to check on the patient and found the surgeon already there.  "I've sent a crit," he said.  "He could be bleeding."  Crit.  Short for hematocrit.  From the Greek words hema, blood, and krites, judge.

Already the surgeon had asked the O.R. team to set up new instruments in an empty O.R. for an exploratory procedure to rule out post-op hemorrhage.  I followed suit, quickly setting up anesthesia equipment and drugs for possible emergency surgery.

Back at the bedside, the blood test had come back.  "Postop crit's a little lower than pre-op," the surgeon remarked.

I glanced at the numbers.  "Not by much.  After the amount of I.V. fluid he's had, that's basically an unchanged blood count."

"I still think he's bleeding from somewhere.  Are you ready to go?" he asked, looking as if he might wheel the bed to the O.R. himself.

"I'm ready," I said.  "But shouldn't we consider other possible causes - "

"He's actively bleeding.  There's no time."

I wasn't convinced, but we went to the O.R., and I anesthetized the patient for the second time that day.  I was able to bring the patient's blood pressure up some, with drugs, and get his heart rate down as well.  His oxygen saturation was perfect.  His exhaled carbon dioxide was right on the mark.  

"You fixed him," the surgeon said good-naturedly, just to lighten the mood a little.

"I wish!" I said, still busy with all the little tasks that added up to the kind of borrowed stability he was observing on the monitors - a cc of this in the I.V., a cc of that, ventilator adjustments, fluid status checks.

A nurse anesthetist named Mike came in to take my place at the helm but asked me to stay close by.  

"I don't think this is a bleed," I said to him. "I have a feeling it's cardiac."

Just then the surgeon announced, "Well, there's no blood in the abdomen.  It's gotta be in the stomach.  Guys, let's get endoscopy in here to scope out the stomach."

"He's not going to find any blood in there either," I said privately to Mike.

"How do you know?"

"I think something else is wrong.   Just a hunch."

"Patient's kinda young to have heart problems."

"Maybe.  But it's not out of the question.  We can't just write it off.  The EKG on the monitor's a little different from earlier."

The surgeon overheard and glanced over at the monitor.  "I don't see any ischemia," he said.  "Is the blood here yet?  Let's hang a unit of blood."

"Matt," I began, trying to open a discussion with the surgeon, "his crit's not that low.  We might want to hold off on a transfusion if - "

"He's actively bleeding!" the surgeon insisted.

"I just think we should consider a cardiac possibility - left ventricular failure, post-op myocardial infarction..."

"He's bleeding.  Hang the blood."

Quoting the latest critical care studies about conservative blood transfusion practices would have been futile. I whispered to the nurse anesthetist, "Go ahead and hang it, but go easy.  Volume resuscitation's gonna help the low blood pressure, but we don't wanna to go too fast."

The endoscopists arrived to perform the internal examination.  They passed a camera into the patient's mouth... throat... esophagus... stomach.  We could tell where we "were" by looking at the walls of tissue in the cavity the camera happened to be occupying.   Little dots, the papillae, on the tongue.  Smooth, pink mucosa in the throat and esophagus.  Characteristic rugae on the inner surface of the stomach.  No blood.  

Mike, the nurse anesthetist, looked at me and gave me a secret finger-point and thumbs-up.  "You were right," he whispered. "No bleeding."

"Get a post-op EKG and send enzymes when you get to recovery," I said.  "Still hard to say exactly what this is."  The vital signs were stable, more or less. The surgeons were closing. I left the room to meet with another anesthetist.  

Later I got a call from Mike.  "Hey, I just heard the upshot."


"Pericardial effusion."  A collection of fluid in the sac containing the heart, limiting its ability to contract effectively. No wonder the blood pressure had been low and the heart had been beating so fast in an attempt to compensate.

"How did you know?" Mike asked.

"I'm not sure.  It just wasn't behaving like a hemorrhage."

"The surgeon couldn't see it as anything else."

"He must be flippin'.  Did he admit the guy to the ICU?"

"They're still talking about whether to watch it or drain it."

The patient was actually doing pretty well, all things considered, and was alert and in good spirits.

"I wish I had insisted on more of a discussion before going back to the O.R.  I didn't think it was a bleed from the very beginning."

"You did try to tell him. He wouldn't have listened anyway. He never does when he gets like that.  It's his way and what he sees and what he wants.  Everyone else is wrong.  What can you do?"

I sighed.  I tried to picture myself trying to get this particular surgeon to listen to another opinion, to consider not getting fixated on one possible cause of the observed problem.  He was a good guy, but Mike was right:  he would not have been receptive.  It had been his operation, and it was his right to make the final judgment on whether it was necessary to go back and re-examine what he had done.

My instincts had been on the mark that time, but I told myself they could easily have been wrong.  There could very well have been a hemorrhage, one that surgery could have corrected and stabilized, in which case going back to the O.R. quickly was the best thing the surgeon could have done for his patient.  I can't really fault a physician for being too cautious; only for being too cavalier.

And yet.  Part of me wished there had been time for a real discussion to take place, and the inclination to listen on the surgeon's part.  I had been in a similar position with this surgeon before. I once diagnosed an intraoperative occurrence as a common and easily treatable respiratory event and tried to reassure him, in my capacity as a consultant and airway expert, that it would be safe to proceed, but he had insisted on reversing the anesthetic, waking the patient up, and sending the patient to a specialist, who subsequently assessed the incident as the common and easily treatable respiratory event I had previously identified.

"Better safe than sorry," the surgeon had said to me after that.  Well, okay, sure.  I'm an anesthesiologist, after all - a physician obsessed with safety.  That's practically our mantra whenever we set up for any given case. 

But shouldn't all our years of hard work and training allow us to have some trust in our own discernment?  Sure, everyone's terrified of making a bad judgment call.  Making the wrong call.  Making a mistake.  Those cost lives in medicine, and engineering, and aviation, and a whole host of professions.  But we've spent so much time and energy learning how to gather information, put it together, analyze it, and interpret it.  Shouldn't we be practicing with those intellectual skills, instead of making decisions mainly out of fear? Defensive medicine is understandable in this society; but it's costly, not only in monetary terms but also in other, less tangible ways.  We sell ourselves short by failing to implement our hard-earned clinical judgment.

I am still figuring out how to advocate effectively for patients in these types of situations and conversations without committing an error myself, missing valuable input from colleagues, or escalating tensions.  I'm sure I don't always say the right things in the right way, or make perfect decisions.  The process is not as simple as people might imagine.  But I'm learning, and I suppose it's going to be a lifelong series of lessons.


The Girl said...

That must be quite frustrating for you. Well done on picking what was the matter, though!

Elaine Fine said...

I remember being in a hospital for something (it was somebody else's something), and I remember having a discussion with a nurse who told me that she always trusts anesthesiologists over anyone else when it comes to surgery.

It might be because you people have to consider the whole patient all the time in a huge variety (as I have learned from reading this blog) of circumstances, while a lot of surgeons (obviously) have specific tasks to think about and perform, and don't have the "luxury" of having years of observation upon which to draw intuitive conclusions.

Anyway, I loved reading this post.

T. said...

TGWTBS - yes, a little frustrating, but I wanted the surgeon to feel supported too (suspicion of a complication is NEVER any fun). It certainly made me pause to reflect and mull and chew and ruminate.

Elaine - so glad you enjoyed it! I'm never sure about posting stories like these - a little stressful, a little on-edge - so it helps to know some folks get something out of them.

And you reminded me of a good point - we see what we're conditioned to see, and that's perfectly natural and understandable after all. Thanks!

ER dude said...

That's too bad. A quick auscultation confirmed by echo could have solved the mystery.

Was the case later presented in M&M? Pericardiocentesis vs. another open abd surgery, not to mention liability at stake.

Truth been told, i'm among the "let's go!" type; just hate to see patients decompensate on my watch. Thanks for sharing the case.

Resident Anesthesiologist Guy (RAG) said...

Hard situation. Hard surgeon with which to rationally discuss your concerns. I've heard it said, and honestly believe, that anesthesiologists keep watch over the entire patient. Surgeons, though they care about their patients, also care about their OR schedules, the surgery they want to perform, and often become myopic. I've seen it in just a month in the ORs this year more than a few times.

debster said...

I love your blog, but I have to disagree with you on this one---and not just because I'm a surgeon. You know that the acute HCT doesn't mean anything, and that a 'young' immediate postop pt crashing and burning is going to be, MOST of the time, bleeding unless something else is obviously wrong, and the risk of a negative lap is much less than that of letting the person bleed out. The patient needed to be back in the OR stat, and the fact that it ended up NOT being a bleed doesn't make it any less so. (BTW, not disagreeing at all with your reluctance to run blood once there was no blood in the belly, I think that the surgeon was pulling it out of his **&(#$ to think that it was an upper GI bleed causing hypotension in a guy not puking it up.)

T. said...

But the patient wasn't "crashing and burning." I suppose we can second-guess ourselves to death, but I really think an alert patient, feeling well, not acutely decompensating, can be given a quick exam and a brief discussion can take place before we go crashing back into the O.R.

Pithy said...

He must have seen and done things inside which were making him apprehensive- even asking for an endoscopy!

You were not assailed by his doubts and based your correct judgment on clinical parameters.

What operation was it and why was he so ready to go in again? Did you ask him?