Medical Catastrophe

by Ronald W Dworkin

  trated, the more blood flowed from the small wound and poured over the

  sides onto the mottled neck. The patient’s anatomy was deranged, he

  declared, to justify his slow pace. After a minute, no real progress had

  been made. The resident began to poke aimlessly in search of hard carti-

  laginous rings. The patient was turning blue. Her heart rate dropped into the forties.

  Drops of sweat chilled my back. I looked at Dr. C. His nervous eyes

  had a hint of madness in them as he gazed back at me. “Perhaps we can

  give her some Atropine?” he panted with agitation. She didn’t need Atro-

  pine; she needed oxygen. But Dr. C injected the drug through the wom-

  an’s intravenous all the same.

  The ENT resident dug deeper into the mashed blue-blood tissues, the

  blood clots themselves impersonating vital structures, with light barely

  able to penetrate the dark incision. A drop of brow sweat fell into his right eye. He blinked furiously to regain his vision. In the background we

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  heard the patient’s heart rate rise on the EKG monitor. False hope: the

  Atropine Dr. C had given had artificially boosted the rate, although the

  underlying cause—lack of air—remained uncorrected. Irrational, delud-

  ing himself into thinking he had time when he actually had none, the ENT

  resident began poking about the neck with less urgency and with a clarity of mind that was useful but undeserved.

  Things were going nowhere. I grabbed an intravenous catheter and

  went to the side opposite of where the resident was working. My plan was

  to pierce the small cricothyroid membrane that covers the windpipe low

  in the neck, and to hook the catheter up to a high-pressure jet ventilator.

  That way I could force air into the lungs, although how air would then

  escape the lungs I wasn’t quite sure. I was counting on the resident

  carving a hole in the trachea by that time. My needle hovered over the

  patient’s neck below the site where the resident was working.

  Suddenly a man in street clothes darted into the room. He shoved the

  resident aside, grabbed a knife, and started cutting on the woman’s neck.

  It was the ENT attending who had been paged to come in from home.

  When he had heard what was happening he skipped changing into scrubs.

  Probably he had a more sober and accurate view of the ENT resident’s

  character than Dr. C did, adding to his sense of urgency. Within twenty

  seconds the windpipe rose out of the wound. The surgeon cut horizontally

  between two rings. He snatched a hook to spread the incision apart and

  then inserted a tracheostomy tube into the hole. I connected the tube to

  the anesthesia circuit and forced pure oxygen into the patient’s lungs.

  Everyone fell back for a few moments and gazed at the patient’s face,

  once blue, now reassuringly pale white—a mask that perhaps concealed

  some deeper damage within.

  We brought the patient to the recovery room. She had yet to regain

  consciousness. Dr. C looked around skittishly to see if any eyes accused

  him.

  I stood staring at the woman, girlishly pretty even in her critical state.

  She still wore her party dress. The arm that had reached up for the mask

  during the anesthetic induction lay on the gurney, its hand clenched tight.

  In all the swirling activity we had missed it, and I peeled back the fingers

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  to reveal a tiny locket with a young man’s picture in it. Evidently she had clutched the locket before arriving in the emergency room.

  “Who—who were you dreaming of in your hour of doom? Your boy-

  friend? Your brother?” I asked myself, my heart fluttering with uneasy

  curiosity.

  I looked at her again. Life was seething, surging, pulsating inside her.

  Her organs were healthy and fresh. Her brain was sunk in wearisome

  sleep, waiting, hoping to be awakened, but the many minutes without

  oxygen might prevent that from happening. Nausea welled up inside me.

  I closed the woman’s hand around the locket, deciding it was right for the locket and the woman not to be separated.

  We were in the realm of the indefinite, without certainty. I was un-

  comfortable—and yet discomfort captures the essence of what had gone

  wrong. When doctors become craftsmen, they narrow down their minds

  to materially determined magnitudes and formulas. To be certain about

  what they do know, they shrink down what they have to know. But a

  doctor-craftsman is dangerous, as the craftsman, unlike the monkey, has

  an ego that needs to be stroked; the craftsman may persist in an activity long after the monkey has abandoned it. When the craftsman’s work

  depends on knowing people, the situation grows especially dire, as people exemplify the indefinite more than anything else. The craftsman is not an artist; he or she has little understanding of other people’s lives; he or she has much perfect knowledge but little imperfect knowledge; he or she is

  uncomfortable with the indefinite. Doctors are sometimes called “crafts-

  men who love humanity,” but what good comes from loving humanity

  without knowing people? Far safer for a doctor to despise humanity but

  know well the people around him.

  Professional medicine largely ignores the problem of subspecialists

  suddenly thrust onto the general stage. Doctors confess their concerns to each other privately but rarely publicly. Most medical boards today issue time-limited certifications, requiring doctors to stay abreast of their fields and keep a hand in general practice, thereby giving lip service to the

  problem while covering themselves at the same time. The method is

  useless.

  I am a living example. Before anesthesiology trainees start their resi-

  dencies they take the board certification exam, which they must pass

  three years later to become board-certified. The test at this stage is only practice; they aren’t expected to pass. But I did pass. People called it a

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  fluke. But I had read all the anesthesia textbooks the year before. It was no fluke. Nevertheless, the notion that I was a fully functioning anesthesiologist at this juncture was ridiculous. I had book knowledge but

  no experience in giving anesthesia. And I certainly didn’t understand

  people. I was unsafe. In the same way, Dr. C had book knowledge about

  pediatric anesthesia but no experience in giving it. And he didn’t know

  people. He could have passed a pediatric anesthesia certification test, but it would have meant nothing.

  Sometimes subspecialization in medicine goes so far that instead of

  fearing what they no longer know, doctors cease to know that they no

  longer know. They grow so removed from general medicine that they no

  longer take other fields seriously. This also causes catastrophes. I am

  familiar with several cases in outpatient surgery centers where gastroenterologists or plastic surgeons supervised nurse anesthetists, having as-

  sumed the role of anesthesiologist (which they are legally allowed to do, since they are MDs), resulting in a patient death. They watch the nurse

  anesthetists perform their technical tasks; the whole thing looks so easy, and pushing the anesthesiologist out of the picture saves money, so, these physicians think to themselves, why not take over the supervisory role?

 
Then a catastrophe occurs. In one case, a patient’s surgery was performed in the prone position under deep sedation, which most anesthesiologists

  would have avoided because of the patient’s large size. In another case

  the drug succinylcholine was not available to treat a patient’s laryngos-

  pasm when her vocal cords were touched under anesthesia, causing her to

  suffocate. Again, the gastroenterologist was supervising the nurse an-

  esthetist; no anesthesiologist was immediately present. Very few an-

  esthesiologists would have performed such a case without having succi-

  nylcholine in the room. But in this case it was the gastroenterologist’s

  call.

  Fortunately, my patient finally woke up in the recovery room, her

  mind intact. Catastrophe had been averted. At 8 AM we all went home.

  Dr. C learned nothing from the experience, except to be wilier in the

  future when ducking hard cases. His most trusted method came to be

  “discovering” a small thyroid nodule in a patient that he didn’t want to

  put to sleep, and then demanding a full workup, thereby punting the case

  to another doctor at a future date. Another method of his was to hide the patient’s chart before surgery to run out the clock. The nurse would waste time looking for the chart; the patient could not be brought into the

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  operating room without it; with every minute of delay, Dr. C was that

  much closer to being relieved by another doctor.

  I went the other way. I learned to keep a familiarity with general

  anesthesia practice and never to allow myself to become an exclusive

  sub-subspecialist. A doctor is not a craftsman, and a good doctor is more than just a good craftsman.

  4

  WHEN NO ONE IS IN COMMAND

  After I finished my training, I spent time at a hospital on the East Coast.

  It was a period of great turmoil in doctor-nurse relations. Some nurses

  viewed the age-old doctors’ right to boss them around and deny them

  patient care responsibilities as an unfair expression of doctors’ might.

  Some doctors, in turn, viewed nurses as uppity and rebellious, and schem-

  ing to put themselves on a par with physicians. Doctors and nurses, once

  allies, increasingly became rivals and suspicious of one another.

  During my fourth week on the job I worked with a nurse anesthetist—

  a noisy person, bitter and insolent. She was fielding a question from our patient as I approached from behind.

  “What exactly is the difference between a nurse anesthetist and an

  anesthesiologist?” the patient asked innocently.

  “Oh, about $300,000 a year,” the nurse anesthetist replied scornfully.

  I raised an eyebrow but said nothing. Later, during the case, I asked

  the nurse to measure the patient’s blood sugar. When I returned thirty

  minutes later the test had not been done. I told her I was angry. Without even bothering to look at me, she replied, “Oh, go suck an egg.”

  I was annoyed but said nothing. I went back to the lounge and sat for a

  while, nursing my grievance. When a more senior doctor walked in I

  explained to him what had happened. He wisely told me to let the matter

  drop. I said I wanted to talk to the head of nursing about it. He grew pale and said that would be dangerous. Nurse X, the head of nursing, he

  explained, was a real bruiser.

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  I had heard about Nurse X. She reportedly sat in a large office at a

  large desk with two framed diplomas hanging on the wall behind her, one

  her BSN, the other her MSN. 1 She behaved like a typical self-important bureaucrat, assigning committee work to subordinates and demanding

  weekly written reports, even though no such committees or reports had

  ever been needed at the hospital. Seared with an unshakeable hatred for

  the old system that had doctors on top and nurses on the bottom, she

  spoke often about the glorious future of nursing as if she were lecturing from a rostrum. Nurses and doctors were converging on a common professional role, she argued. On the wards she wore a long white lab coat,

  like a doctor. For medical people, a person in a different coat seems like a different person, and so her attire was significant.

  She carried out her revolution through signed memoranda. In those

  early days of change, nurses wielded power not by taking charge of

  patients but by writing policy. Some policies involved manpower and

  resource allocation, affecting everyone in the hospital, including doctors.

  A surgeon, for example, couldn’t operate unless the operating room was

  open and a nurse was available. This depended on policy. Other policies

  governed how people behaved. Here, Nurse X wielded less power, since

  she couldn’t actually command a doctor to do anything. Even in the

  operating room she might strongly encourage a doctor to put up his mask,

  but if he refused, she could do little about it, while if an orderly or

  technician refused, he could be immediately fired. Nurse X put out sever-

  al memoranda a week covering the entire range of hospital policy, with

  every document signed with her name, followed by the appellation,

  “BSN, MSN.” Employees coughed and fidgeted when reading her me-

  mos, sometimes laughing nervously among each other, referring to Nurse

  X as simply “BSN, MSN,” and with an uneasy feeling that they might

  have something to fear from this person in the future. Fear as such had

  not yet manifested itself, except for those assigned to one of Nurse X’s

  committees, but it was somewhere on the way, like a storm cloud billow-

  ing in from the distant horizon. Doctors also sensed trouble and avoided

  her as much as possible.

  I decided to forget the nurse anesthetist’s insult. The vast majority of

  nurse anesthetists I had worked with were solid professionals, and not

  like this nurse, so why not? However, two days later I found myself

  working with her again. Our patient was an elderly woman going for a D

  and C, 2 and possible laparoscopy, depending on what the surgeon found

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  during the first procedure. The patient was anemic (the gynecologist

  thought from postmenopausal bleeding); she also had a pacemaker, di-

  abetes, and a history of congestive heart failure. The nurse anesthetist was about to bring the patient into the operating room when I told her to hold off, as I wanted to make a few phone calls to check out the patient’s

  pacemaker. The nurse anesthetist rolled her eyes and impatiently asked,

  “What for? It’s working.”

  “If the gynecologist uses the electrocautery, we may have to put a

  magnet on the pacemaker,” I replied.

  “So . . . we’ll have a magnet ready,” the nurse anesthetist declared

  mockingly. “Besides, the gynecologist won’t be using cautery during the

  D and C. Let’s just go in.”

  I explained my concerns. First, I didn’t know how old the pacemaker

  battery was. Second, if we put a magnet on the pacemaker so that it

  worked with the electrocautery, it would convert the pacemaker to a fixed rate. Typically that’s not a problem, but if the pacemaker were a sequential model, causing the patient’s atrium to beat first and then her ventricle, the fixed rate mode would lack the atrium compon
ent, which some heart

  failure patients need to maintain blood pressure. I couldn’t tell the pacemaker type from the EKG strip, as the patient’s heart was still beating on its own. Third, the patient’s pacemaker might be one of those that must be reprogrammed after a magnet has been applied. I needed to find these

  things out.

  The nurse anesthetist remained unconvinced. “But we’re not even

  going to need the magnet,” she pleaded. I held my ground. The nurse

  replied, “Listen, Ron, you’re fresh out of the university. I’ve been doing this for twenty years. I’ve never even used a magnet.”

  The nurse’s counterattack was cleverly two-pronged. First, she had

  called me “Ron” and not “Dr. Dworkin.” As a resident I had allowed

  several nurses to address me in this way, thinking that the casual, informal, we’re-all-just-friends mode was best for working relations. I realized my error during a near catastrophe when I had to order a nurse to send for blood. The nurse, lulled into believing we were professional equals, and

  thinking it rude for friends to order each other around, refused to obey me because she thought the blood transfusion unnecessary. Only by growing

  officious and harsh, and threatening her with a charge of insubordination, did I make her comply, although my harshness neutralized her contempt

  and turned it into hatred. A doctor must inspire respect and sometimes

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  even a little fear among subordinates to get them to respond quickly

  during a crisis. Subordinates must know there are consequences to not

  following orders. This means preventing subordinates from taking liber-

  ties even privately, such as using a doctor’s first name. True, it is hard for doctors to keep the right balance between the reserve and solemnity necessary to their positions and the affability required of them in working

  with subordinates, especially in a democratic society. But that just shows how a doctor must be more than a craftsman. He or she must also exercise

  tact.

  By using my first name, the nurse anesthetist had tried to equalize our

  relations so that I might be more easily swayed. Citing her greater experience was another strategy. To her mind, twenty years of experience can-