“Do you think he’s in pain? I don’t want him to hurt. If you think he’s in pain, I’ll give him more medication. I only have this snapshot of him to go on. Tell me if you think he needs more medication.”
My window of observation was too narrow for me to make a call. Surely, his parents must know better than I could.
Their response was no different from that of the families of all the other Davids before, and I’d cared for many hundreds with this affliction. His parents explained that he always reacted that way. He was excited to see them. How they knew that, I couldn’t tell. I observed their son awake for a total of no more than a few minutes on either side of my anesthesia.
This behavior, for me, was typical of CP patients in the recovery room after a not-too-invasive surgical procedure. I could never communicate with them, I couldn’t tell how much discomfort they were in, and I guess I assumed their actions would be more demonstrative if they were hurting.
WITH MY SLEEPLESS NIGHT, and with my pain relief epiphany, all that changed. It dawned on me that I had undertreated David.
I awakened to a world I had misread for far too long. I had failed, until now, to consider that a person so physically impaired and unable to speak might be able to absorb the surrounding environment. The man in the documentary stunned me. An intellect, a poet, a writer, gainfully employed—and all because his parents had believed in him, insisted on educating him, and mainstreamed him through school, and then technology had caught up, allowing him to attend college and reach outside the body that trapped him.
My mind fast-forwarded to the moaning I had heard in the recovery room emanating from those unable to communicate their thoughts. I had misread their hurt, their anguish, as simply confusion brought on by the unfamiliar setting. I felt the sum of their pain as I realized that I was the one who had been unable to communicate. Whether their ailments were caused by cerebral palsy, genetic alterations, brain tumors, vascular accidents, or traumatic brain injury, hundreds to thousands of my patients existed beyond communication. How ignorant I had been not to listen to those soft moans! I hadn’t heard their attempts to tell me they were in pain.
Those taunts as a kid, after a botched play or a stumble on playgrounds and sporting fields: “You palsy!” It was right there. A failure of movement. It was right before me. I had heard it but hadn’t listened. I had never bothered to look up the definition. “Palsy”: “paralysis accompanied by involuntary tremors.” The definition mentions nothing of failed receptive capability, the ability to hear and to understand.
On my couch that night, I remembered a grade school classmate’s sister—a girl with CP—and her scissors walk, stiff legs never relaxed, struggling to and from school every day. I recalled the cruelty of the boys lobbing piercing comments at her. Her body prevented retorts, but she might have heard every word and understood everything. I remember the toes of her shoes worn from dragging the pavement—a stark contrast to her wide smile.
I found myself enclosed in a cloud of guilt. That I wasn’t the abuser didn’t exonerate me. I hadn’t defended her. In the dark, lit only by the TV screen, I decided I had to become a stronger advocate for any cognitively impaired person—regardless of the cause of brain injury—coming to my care. It’s left to me now to defend my grade school classmate through my patients of today.
MY AWAKENING CAME ABRUPTLY and in the dark. A brain trapped inside a box. Though able to perceive everything about him normally, he could not express himself.
After nearly fifteen thousand cases, I finally asked this question: Can cognitive ability (the means to perceive, to understand, the receptive capability) be separated from expressive ability (voicing thoughts and feelings)? Until then, I had assumed that if the reaction was not possible, neither was the reception.
Ashamed to admit it, I was halfway into my career before I actively pursued speaking with noncommunicative patients as if they were typical for their age and possessed normal thought process, regardless of how densely involved I considered their CP to be. Until proven otherwise, that’s how I proceed now. I always explain with great care every move I make, ensuring that there are no surprises.
The weight of this revelation led me to embrace a new nonnarcotic, nonaddictive medication for pain relief given by IV. The value of the drug, ketorolac—a pharmaceutical offering that, at the time, had only recently been introduced—is not so much that it is magnitudes more potent than Motrin (the widely used anti-inflammatory pain reliever available at the local drugstore), but that it is formulated as injectable, able to be given via an IV. Finally, here was a nonnarcotic pain reliever (with no risk of respiratory depression) for which swallowing was not necessary—the only available parenteral nonnarcotic anti-inflammatory that could provide strong pain relief.
My chance to step up materialized when another boy with CP came for tendon releases of his legs. Muscles in constant contraction cause tight joints with locked knees and legs unable to spread wide, making for difficult hygienic care. Life becomes so much better for parents, caregivers, and the patients themselves when the joints are relaxed, allowing for easier transfer from bed to chair and improved cleansing and dressing. Creating movable joints isn’t very complicated or intensely invasive, but it does necessitate incisions and cutting of tendons and requires pain relief following emergence from anesthesia.
After his procedure, I stood beside this boy in the recovery room. My emotions swung between satisfaction and anger. He, too, lay in that classic birdlike posture, his hands to the side of each ear. Except he wasn’t moaning. He was quiet. He was comfortable. He was pain-free. The joy at my ability to safely alleviate his pain was tempered by the recognition that for years, I had failed to understand or treat pain in my noncommunicative patients. I had failed so many patients.
Those unable to speak for themselves, like the man in the documentary, had no advocates for comfort. Their families were either incapable of understanding them or, like me, fearful of overmedicating. I changed from being a reactive analgesic administrator—depending on others beyond the patient to provide guidance for pain relief—to an activist, making pain relief my decision, with every intent to prevent as much moaning as possible. Instead of steering clear of overdosing, I came to define its limits with greater precision. It was all thanks to that brave man with CP who rose tall in his wheelchair and, as he presented his speech, enlightened me.
Sometimes I wonder how future generations will judge medicine, surgery, anesthesiology, and me and my actions as a physician. Will they view my career as barbaric, as I view the barber-surgeons of the nineteenth century?
CHAPTER 13
See One, Do One, Teach One
IN THE MIDDLE OF THE OR, IN THE MIDDLE OF A CASE, a colleague informed me that my wife was trying to reach me. On the wall behind my anesthesia cart, the light on the wall phone was blinking. I lifted the receiver and cautiously said hello. I knew she wouldn’t be calling to remind me of some event taking place that evening, or to ask me to pick up something on the way home.
“Nathan’s throwing up pennies.”
Standing in a procedure room nearly twenty miles from home, I was asked for a medical opinion on my own child, who was then just a toddler. Considering the size of a penny, I knew swallowing one wasn’t life threatening.
“Call me back when he’s vomiting quarters.”
With my response, all eyes in that procedure room turned to me. My reply may have sounded cold and uncaring, but after many years of a dedicated relationship, my wife and I understood and trusted each other.
Three minutes after first meeting, I ask patients, spouses, parents, children, and any others present to trust me with their own life or the life of a loved one. I expect that trust, and I need it.
The expectation of expertise comes with the approval of medical-center staff privileges. Becoming a staff anesthesiologist, or a staff member in any specialty, for that matter, requires holding a state license and usually demands further credentials, including board ce
rtification. For anesthesiology, completing an approved training program, logging the necessary number and variety of cases for the specialty, and passing a written examination are followed by the final hurdle: successfully mastering an oral exam that consists of two thirty-minute grillings by seasoned anesthesiologists on any topic in the specialty. I’ve spoken with many examiners, and most agree that the grade is determined within the initial ten minutes of the oral presentation.
Snap decisions are a reality. My patients and their families make them time and time again every clinical day of my life. And they do so without question. That surprises me, because I can count on one hand the number of times in my entire career that I have been asked to present my credentials prior to my care. It is wise for patients to research their physicians. I believe such investigation is more critical for physicians practicing outside the realm of credentialed facilities. I would prefer to be asked about my board certification and recredentialing.
Trust is elevated to another level in teaching hospitals. I train residents to become tomorrow’s anesthesiologists. I teach fellows, residents who have completed their training, homing in on expertise in pediatric anesthesiology. I supervise these trainees as they administer anesthesia.
A MOTHER CALLED ME about her daughter and an upcoming surgery. She was concerned about the anesthesia care for a fairly routine outpatient procedure. But when it’s your child, there are no “routine” procedures. She did what every patient or family should. She asked around to find the names of anesthesiologists referred by friends and caregivers.
That she wanted more information about my anesthesia plan didn’t surprise me. What does surprise me is how seldom I field calls like this. Within our department, a system is in place to answer phone calls and questions, with an assigned anesthesiologist scheduled to field questions every day. For me, this was not that day. This mother sought me out specifically.
Our office secretary paged me concerning an outside phone call. Just outside the OR suites, at the intersection of two great halls, on a wall phone down the least used section of hall, I responded: “Hi. This is Doctor Jay.”
“Hello. Thank you for talking with me,” the mother said.
Phone calls are similar to face-to-face time: too short, except with no eye contact. Peppering the conversation with a few pleasantries accomplishes two goals. First, the parent or patient is put at ease and encouraged to speak unrehearsed. Second, time takes on a different dimension. The time spent in conversation feels longer than it is. The person I’m speaking with believes that time is not the driving force, that I have their best interest at heart. I mine the information I’m searching for, in addition to some helpful side information that will allow me to form a bond more easily, and I do so without seeming to interrogate the person.
The mother eventually came around to asking this question: “Can we talk about anesthesia for my daughter?” She was calling to ask specifically if I would care for her daughter.
“For curiosity and nothing more, how did you get my name?”
She mentioned that she had asked around, and my name kept surfacing. That she needed to come to my hospital wasn’t unusual, since I practice at the most complete pediatric hospital in the region. We offer care for every conceivable childhood health care problem, and care for children from around the world. What I found surprising was that she asked for me.
She buffed my ego. Perhaps the person she had spoken to knew only my name, or the recommender knew nothing of my qualifications or ability. But I chose not to pursue it further and just accept the flattery. My experience has grown over the years in practice, and I have sat on committees, both regional and national. Still, most requests have come from people I knew. This was an uncommon cold call, and request.
I patiently awaited the real reason that she had called me. I suspected we were edging toward ethical quicksand, and I was in no rush to get there. Soon enough, after she asked whether I was available on the scheduled date and I assured her I would make myself available, she popped the real question: “And you’ll do the anesthesia yourself? I don’t want any residents involved.” She wanted me, alone, to touch her daughter. Trainees, if present, were to sit in the corner and observe.
A giant, circular argument opened, one that never comes to rest. It’s the argument of teacher versus student.
I’m not sure if there is a service in the hospital that doesn’t frequently hear the request for only the attending surgeon to hold the scalpel. For only the attending pediatrician to start an IV or draw the blood. For only the attending anesthesiologist to anesthetize and intubate the child.
The saying in medicine is: See one, do one, teach one. Before any of this, learning begins with reading. Observation follows, but expertise doesn’t come with watching. Observation yields only so much information. Hands must be laid upon the human body to move beyond the wisdom that book learning imparts.
A pianist doesn’t master a piece by Bach or Beethoven by watching a video over and over. Those fingers must touch the piano keys, just as the physician’s hands must touch the body, to learn. Inexperienced hands have to be given the chance to palpate what’s normal and, equally important, to distinguish what’s not.
What of the parents requesting—or worse, demanding—that only the attending doctor, and not the resident, touch their child? The response varies from doctor to doctor, hospital to hospital. Many oblige, responding simply: “Sure.” Behind closed doors, nobody but those in the room knows who actually touches the patient. Nobody in the room except the one questioned might know of the request.
Since fewer than twenty percent of all hospitals are teaching hospitals (that is, hospitals with resident training programs) and many of these teaching hospitals have limited residency programs covering only a few specialties, the issue of requesting that no residents be involved arises in only a minority of health care settings. But in those settings, it surfaces often. Patients and families have options. A community hospital might be a better alternative for attending-only care. Regardless of the setting, care is by teams consisting of physician assistants, technicians, and advanced practice nurses. The concern that no residents practice on someone is couched in a different cloak, but it still remains. Physician assistants and advanced practice nurses do provide patient care.
The tipping point motivating patients to seek out teaching hospitals—the university systems and medical schools—is that these are considered to be leaders in health care, the research centers expanding the envelope of medicine. Experimental procedures and the newest techniques developed in these hospitals might not be available elsewhere. The academic setting represents the cutting edge of health care, where physicians aren’t under the continuous pressure to generate bills and are allowed to apply creativity to the practice of medicine through research and clinical studies that consume both time and money.
Nearly every hospital nationally ranked for any specialty is a teaching hospital. Seven of the top ten hospitals surveyed in one urban area are teaching hospitals. Patients entering these halls of medical learning should understand from the outset that trainees are a fundamental part of the process.
My response to attending-only requests is rote: “No. Don’t ask me to change my practice.” My care is built around a training program. Asking for attending-only care alters my process, and that increases the likelihood of mistakes or missteps. If blame for the failure of care is to be placed for any reason, blame me; but don’t ask me to change my process. Besides, the trainees’ hands are an extension of mine.
My trainees evaluate and examine the patient. They perform the same rituals that I have followed for many years. After the assessment is completed, a plan is developed. Before this plan is put into action, the resident and I discuss everything. I confirm the history, physical, and all data obtained, then approve the plan or offer an alternative. In my system, two physicians evaluate the patient. Why not take both of us?
To this particular mother, I said: “Please don’t a
sk me that. You know this is a training program. And I’m telling you, I take full responsibility for your daughter’s outcome. If you have a problem, you bring it to me. You need to trust me. I won’t alter the process for you, but I’ll tell you the surest way that I can provide your daughter’s best outcome is to let me do it my way.”
Her response was delayed. I heard her take a breath; then she acquiesced.
On the day of the procedure, I met her with her daughter for the first time. I reiterated my intentions. I reconfirmed that if there were any problems with the anesthesia care, they were mine and solely mine. And then I added: “There will be no problems.”
Her daughter navigated the system without issue.
How far should a resident be allowed to go in the learning process? A resident who is unable to demonstrate an understanding of the health condition at hand or the necessary technique of care is bumped to the side and offered a seat as a spectator. Once an understanding of the condition and the required care is clearly demonstrated, the limit is to never, ever allow injury to a patient. Hard stops—cases where I prevent the resident from trying—occur, among other times, after three missed attempts at an IV, or two attempts at inserting the breathing tube. “Do no harm” is a constant voice in my physician mind.
I WALKED INTO MY patient’s room and wandered into a maelstrom. The sliding door was open, but the privacy curtain was closed. As I swept the curtain aside, the parents’ tension was unmistakable.
A little boy, about three years old, was jumping up and down on the cart. His father stood next to him with both hands on his son, preventing him from falling. That alleviated my fear that this boy would leap from the gurney.
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