When the X-ray was posted, I stared at it wide-eyed. Something was definitely wrong; it just wasn’t what I guessed it would be. There was no pneumonia. Jill’s chest looked as if a basketball was resting right in the middle of the anterior view. It wasn’t a misshapen heart that would occupy the X-ray area in question. The radiologist’s interpretation was telling. The chest X-ray revealed a “prominence.”
A more definitive X-ray followed and coincided with a flurry of activity that found Jill first admitted to the hospital (hers was supposed to be an outpatient procedure), then soon after transferred to intensive care. A blood test confirmed that Jill was very, very ill. Jill was suffering from cancer.
That underlying problem revealed itself with even greater clarity when Jill’s belly swelled with a blood clot late in the evening. Jill had too few platelets, those bits in the blood that are the first line to forming a blood clot, and the cuts of the hernia repair were just large enough to push her over the bleeding edge.
I lost track of Jill after she left the hospital. That is, I knew she was in treatment and responding, but I had no more contact.
A year and a half later, as I stood speaking with a colleague at the entrance to our procedure suites, I noticed an older woman standing across the hall, staring at me for an uncomfortably long time. She turned away and a moment later returned, following a younger woman who was pushing a familiar stroller. Before I could register who it was, I heard the older of the two say to her daughter: “That’s the doctor who saved Jill’s life.” While most would be proud of a praise sung like that, I remain unconvinced. What mattered at that moment, though, was that Jill had completed her therapy for cancer. She was cured, and she looked marvelous.
If I had connected all the dots, put all the hints into proper perspective, might Jill have died? That was, and continues to be, my dilemma. By trusting without verifying, I placed Jill into the OR before making a diagnosis, albeit a crude one: no left-sided breath sounds. If I had verified the resident’s exam by listening myself to her breath sounds in the pre-anesthesia area, I would have recommended the case be canceled, and Jill would have been sent back to her pediatrician, who had also failed to connect the dots, or to listen to this forlorn mother.
Missing the diagnosis is not a major blunder on the pediatrician’s part. Statistically, this is likely to be the only such case that he will ever have. Jill might not have received care soon enough. It just happened to be that, by not performing at my most diligent, I saved her life. That reality has made me uncomfortable ever since. My story remains without an end, and my dilemma unresolved. Returning to the skill-versus-dumb-luck adage, does a superior outcome justify a less-than-stellar means?
As a side note, that pulse oximeter reading proved to be the vital sign leading to the discovery of Jill’s illness. Under my care, Jill never turned blue. The oxygen level in her blood never dropped low enough for her to turn from pink to cyanotic. By observation alone, Jill’s color didn’t change. But the monitor tone did, triggering my suspicion and search for a cause.
Having thought about it, I realize that to claim I saved a life is too bold. I didn’t. I expedited a cure.
A LEGEND IN MY CAREER, Frank Seleny, was the anesthetist in chief who accepted me into his program as a pediatric anesthesia fellow, trained me, and finally hired me. One day early in my career, he pulled me aside and advised me that it would take ten thousand anesthesia cases before I would understand the limits of my ability. To paraphrase Donald Rumsfeld: There are known knowns, and known unknowns, and then there are unknown unknowns. Frank taught me the value of recognizing and limiting the unknown unknowns.
The next step toward expertise is understanding that shortcomings should not provide avenues for criticism, but motivation for change. This revelation struck me midcareer. It called for me to open my mind to become willing to seek continuous improvement. To recognize that mistakes are not always a sign of incompetence that should be buried (no medical pun intended). As Niels Bohr, the Nobel Prize–winning physicist, put it: “An expert is a man who has made all the mistakes which can be made in a very narrow field.” I believe I’ve made them all, plus one.
One mistake from early in my career remains at the forefront of my memory—not for the injury to the patient, but for the damage to my ego. I was working with the Learned One, the brightest attending and the most particular about process. The surgeon was another legend of my career, Casey Firlit. At the end of the procedure, the patient took an unexpected giant breath just as I switched off the ventilator that had delivered his breaths throughout the case. There was but a fraction of a second for this to occur, but it was like trying to take a breath with a plastic bag tied tightly around the head. His chest sucked in as he used all the energy he could muster to take a breath. He developed a strong negative pressure inside his chest that injured his lungs, causing pulmonary edema. He emerged from the anesthesia, I pulled the endotracheal tube unaware of the injury brewing, and pink, frothy fluid poured from his mouth.
My heart sank as I realized I was the cause of his pulmonary edema; fluid leaked out of his lungs. His oxygen level started dropping, and the breathing tube needed to be replaced to create positive pressure in the lungs and stop the fluid leak. The Learned One just looked at me, but the pain was piercing. My care, or lack of it, had caused a patient to be injured. Casey said little. The patient was transferred to intensive care, and I had my first very difficult discussion with a family. Several hours later my patient was awake and fine. But I had let three of the most important people in my life at that time down: the patient, the Learned One, and Casey.
THE PRIDE I FEEL after a case of a critically ill patient ends successfully fills me to bursting. It’s true that not all of these cases end well. That’s the cost and the burden I carry as those patients forever inhabit my memory.
Two times I have been accused of medical negligence, and both anger me. In both cases I was part of a team that tried to preserve a life, and both times I was soon dropped from the suit. But the accusation is enough to hurt, and regardless of the lack of proof, I still must list both cases when I apply for privileges anywhere.
Far worse and more haunting than the two claims of negligence was the case of Spencer. Multiple congenital defects required multiple surgical procedures on multiple parts of his anatomy, from the top of his head to his hips. Early on, a tube was inserted into the trachea in his neck, bypassing a blockage above, and it remained until a surgically improved airway was obtained.
He came for a finishing procedure, the tracheostomy removed and healed. I placed the breathing tube with difficulty and an improvised technique. The procedure went as planned, and I transferred Spencer to the intensive care unit with the breathing tube in place. My intention was to allow Spencer to recover fully from any and all residual medications that might alter his breathing, and I left with orders to contact me prior to removing the tube.
The following morning, as I was in the procedure suite providing care, the endotracheal tube was removed without my knowledge. Spencer died. While I stood one hundred feet away, Spencer died. Nobody could manage his airway in the manner I did. I failed to be clear or persistent enough to prevent an overzealous physician from going rogue. Personal beliefs prevented the family from pursuing a claim.
SOMETIMES THE PAIN of failure extends past the patient.
The fact that anesthesia is iatrogenic—I am not a healer—elevates complications to another, higher level of guilt. One of my worst complications came through an extension of my hands.
A misshapen head is a curse borne by the owner but noticed by everyone. Surgeons have gone to great lengths to correct a deformed skull. Not all have achieved the desired effect. Long before I came to meet Carter, he underwent surgery and therapy that left him with defects—holes—that exposed his underlying brain to trauma. A strike in the right place would not be deflected by the bony skull. With his skull exposed for a lengthy procedure, and with significant blood loss, Carter’s t
emperature dropped. My resident became concerned, despite my assurance not to worry—that near the end of the procedure we would correct the hypothermia. Without discussing his plan with me, the resident placed a warm compress on Carter’s skin. When the surgical drapes were removed, a patch of skin was left burned and leathery.
I wanted to let go a primal scream. My resident’s action had been stupid. Even though he was the one to place the compress, I was the one accepting all responsibility and the one to accept the blame. I didn’t yell. There were no “goddamnits.” There was a parade of “shit, shit, shit, shit, shit.” My talk with the family gave new meaning to the walk of shame.
Carter’s family was, beyond all expectations, reserved and understanding. He and his family refused to file a malpractice claim. Instead, when he returned for some follow-up surgery on his head, the plastic surgeon repaired the burns. I cared for Carter several more times at the family’s request. After the third or fourth procedure, I asked his family: “Why do you always request me? This was one of my worst complications.”
The response at first stunned me, then became clear: “That’s easy. Now, every time he goes to the OR, I know he has a guardian angel.”
They were so right.
CHAPTER 10
In Wait
“GODSPEED.”
Despite having plenty of time to find the right words to express my love, and despite my abundant experience in these situations, my mind froze. In that moment, at the point of separation, all I could muster was that single word. Do better words exist?
I surrendered my son. They took him from me. I remember that exact thought racing through my mind as we were separated. Whether one’s child is three years old or thirty (as my son was) or older still, the anxiety a parent feels when the child undergoes a medical procedure does not lessen. With a kiss on his forehead, a one-arm shoulder-to-shoulder bump hug, and that simple, single-word prayer, he was wheeled away.
I considered telling Jason “Good luck” but caught myself and stopped. I considered how I move my patients to the operating room. To families who say “Good luck” at the moment of separation, in my role as the anesthesiologist I always respond: “Luck is for sports and betting. Mine is a world of skill.” During surgery, luck is not a trait to depend on.
The back of the cart where Jason lay was raised slightly, and as he was wheeled down a hallway I could see his shoulders extending over the sides and the short brown hair on the top of his head swaying slightly to the left, then back. I imagined he was speaking with his attendant. Jason’s larger-than-life personality grabbed the attention of everyone near him. I prayed that on this day this trait would not be taken from him. His form on the cart shrank with every step until he drew near the automatic double doors, which snapped open and then shut as he entered the operating room.
I was caught on the unfamiliar side of an all-too-common scene, one that repeats itself across the country 150,000 times on an average day. Spouses, mates, parents, children, and friends exchange hugs and kisses with a loved one who is about to enter into an unknown, sequestered space—where senses are reversibly altered to allow a body to undergo an invasive and painful procedure out of medical necessity.
OVER MANY YEARS, I trained to be the physician accepting the responsibility of providing safe care to patients while ensuring their comfort during an invasive medical procedure. Safety always trumps comfort. Specializing in anesthesiology and pain relief, I normally wait on the inside, preparing to care for those passing through the double doors pasted with colored warnings, black on yellow and red on white: “Authorized Personnel Only.” Care may last from as little as fifteen minutes to more than fifteen hours, but the length of time doesn’t mean much. The shortest cases may be the most critical, while the longest may be benign. Regardless, my pledge as an anesthesiologist—in concert with the physician performing the procedure—is always to return patients to their families in better condition than on separation.
On that day, with my son, I was on the other side. His dream of being a physician lay at risk. A clump of abnormal blood vessels of underwhelming size on imaging—but potentially life-altering, if not deadly—sat in a precarious location near the part of the brain controlling movement, poised to burst and possibly deprive him of the use of a hand and his career. Jason chose bravely to have the vessels removed. He needed to know—not to live wondering every day if it would be his last. He chose surgery.
In a preprocedure room no different from the thousands I had entered before, Jason rested on a cart positioned in the center with just enough space for one person to move along each side. Three thin walls enclosed the room, with the fourth consisting of sliding glass doors and privacy curtains. The lighting was sterile fluorescent, blue and cold, lacking comfort. Three people, my son included, crowded into the prep room, and I was not one of them. I peered in through the doorway as I stood outside the circle of trust, while overcome with a complete sense of helplessness.
Excluded from the discussion of intended care—not checking his chart, test results, and consents—I remained outside the glass doors and in the hall, dodging the flurry of movement around me. Receptionists escorted patients and families to assigned spots, nurses readied patients, checklists, and all, and physicians performed physical exams, obtaining consents and entering notes into the record for what was to follow. In his room, Jason appeared unaffected by the commotion. Perhaps he was calm because his decision had been made. His responsibility was complete. Now came the time for the anesthesiologist and surgeon to step up.
In the halls of the pre-anesthesia area, people are always nearby and talk is rampant—especially in the early morning, with all the first-scheduled cases vying to start. Privacy is nonexistent, curtain or not; everyone hears everything. Not within the circle of care, not a member of his health care team, and forced to stand outside with all the others denied entry, I watched my son be led away by someone I really didn’t know.
I NEEDED ANESTHESIA MYSELF ONCE.
It was our annual Turkey Bowl, a friendly Thanksgiving morning noncontact football game with friends and colleagues. A rush of testosterone, a crash with the largest opponent and then with the frozen ground, and a midcareer anesthesiologist became one of the forty million who receive anesthesia every year. I expected this reversal of role, doctor-turned-patient, to fuel a revelation and ignite great changes in practice. It didn’t.
I stood in amazement as my colleagues, including surgeons, radiologists, and anesthesiologists, wanted to put me on one side of a fence and yank my arm back into place from the other side. They had watched somebody repair a dislocated shoulder this way on some TV show.
“Are you nuts?”
Their response was a shrug.
I found myself in a pre-anesthesia space as a patient. I not only knew my anesthesiologist, I had trained him. I had already placed my faith in him. My three minutes of face-to-face time expanded to five, but not with the exchange of useful information. We just shot the bull.
As a believer in the philosophy of don’t do to others what you won’t do to yourself, at least to the extent possible, I have stuck myself for an IV. Slick and quick is my motto. I dedicate myself to declaring “I’m done” before the patient flinches. The discomfort can be lessened, though, by a technique that mimics the whoosh sound produced when a soda can is opened. The J-Tip is a tiny syringe filled with a small amount of local anesthesia in saline. A carbon dioxide propellant creates the sound of a soda can being opened. Without a needle but with the push of a lever, the mixture is painlessly propelled by the gas into the skin. I demonstrate this technique on myself to reassure dubious patients. The resulting pencil eraser–sized welt is deadened to pain. (My issue with this technique is that it encourages people who start IVs to abandon the slick-and-quick approach and be less efficient.) Then the IV stick itself doesn’t hurt.
With the IV in, I watched as morphine flowed into the line and thought: That’s a hefty dose. With so much access to so many drugs, an
esthesiology leads the specialties in substance-use disorder. People who have been hooked on these drugs say that if you see a bullet heading straight for your eyes, grab for a narcotic; there’s no more comforting feeling. So I was expecting a rush. But I felt nothing.
The surgeon said: “You can’t go home today. There’ll be too much pain.”
I didn’t argue. I expected substantial discomfort. At issue was the use of patient-controlled analgesia, or PCA, to control my pain. Policy entered decision making. Substandard care becomes possible when policy dictates physicians’ orders for care. Because my procedure was classified as outpatient surgery, I could stay in the hospital no more than twenty-three hours. Extending the stay would cost me thousands of dollars via an insurance denial as, by definition, I would transition from outpatient to inpatient care. The effect of PCA might last too long and potentially delay discharge. Four hours after surgery, I pressed the nurse call button for pain relief and was offered a pill. I expected pain relief via as-needed intravenous medication. Hell, I could be home medicating myself with better effect than that single pill offered.
The orthopedics resident stuck his head in the doorway to my room and, not wanting to debate the issue, asked: “Doctor Jay, what do you want?”
“Four mg morphine IV q 2 hours and add 30 mg Toradol IV now, please.”
The blunder was mine. I failed to follow my own recommendation, to discuss postprocedure pain relief before the procedure.
I received the morphine and Toradol and, as the sun rose the next morning, my surgeon walked into my room with an announcement.
Counting Backwards Page 11