Monday, September 24, 2007

Curses

[This post is inspired by (though barely related to) one from that eminently readable medical blogger, Dr. Rob.]

If I didn't know better, I'd say there's a curse: when a new surgeon arrives in town, he or she will have a very weird or embarrassing case within a short time, while all eyes are still upon him/her. I've seen it repeatedly. (With me, far as I can recall, it wasn't too terrible: my first operation after I moved to my final destination was a very routine hernia repair. I recall the anesthesia person mentioning something positive about how quick and smoothly it went. And his snarky smirk when, for the only time I can remember with an inguinal hernia repair, I had to bring him back an hour later because of bleeding.) One guy, even more arrogant than the typical surgeon, whom I came to dislike more and more over the years until he went elsewhere, began his career by leaving a sponge in an otherwise routine gallbladder patient. Another, whom I liked from the beginning and whom I admired more and more as the years went on, had, within a couple of months of each other, two patients who presented with peritonitis and suggestion of intestinal leakage, without ever finding the source.

I helped him on the first one. The abdominal cavity was funkified with the fibrinous, gooey and liquid stuff that one sees with perforation. Globular glops of gunk gluing together loops of bowel, thickened stubs of omentum pulled and stretched and stuck everywhere. The normally shiny and slippery-pink surfaces of the viscera were dull and thickly-red. Fully to inspect the entire intestinal tract from esophagus to rectum takes a while under the most favorable circumstances. You can't see the backside of the stomach, for example, without cutting your way into the lesser sac. Normally easy -- and among those favorite secret spots that we learn along our path to competence -- it can be hard to identify, much less work through, when everything is swollen and stuck. Same with the mid-portion of the duodenum and much of the colon: the very act of cutting them loose enough to be sure about them risks damage of another sort.

There's an entity known as Spontaneous Bacterial Peritonitis. Pretty much limited to people with fluid in their abdomen from liver disease, after our fruitless search it was tempting to invoke it as an explanation. Except that there'd been "free air" seen on the man's Xray before surgery, indicating perforation. (To me, it's not inconceivable that bacteria could generate enough gas to show similarly on an Xray.) Try as we might, no definite source was found. We cleaned the man out as much as possible, tucked in a couple of micro-suspicious areas, covered him with big-time antibiotics, and he eventually recovered with no explanation.

"You won't believe this," Dr. J said when we saw each other in the doctors' lounge a few weeks later. I was girding for the day, glugging coffee and reading my mail, the latest directives from the hospital overlords. He'd walked in before heading home, after a long night in the OR. "I just had another case like that first one. Perforation with no source. How many of those can there be? I never saw a single one in training! I spent hours looking, and couldn't find a damn thing. It's like I'm cursed..." And then, vibrating like a dinner bell, tattooing his feet on the floor like a kid ready to go into tantrum mode, hands clenched white, he said, "I hate this. I hate this. I hate this."

I suppressed the urge to laugh: he was so vulnerable, so honest. So... cute. "J.," I said. "I think it is a curse. Seems like every new guy goes through it. And really: if you didn't feel like this, I wouldn't want you to be my partner. Everyone's going to have tough cases and bad outcomes. What would bother me is if you didn't care this much. I'm sorry for you and your patient, but I've worked with you enough to know you're an excellent surgeon. You're gonna be fine. This, too, shall pass."

And, like the curse of the Bambino, it did.

10 comments:

rlbates said...

I can still remember my first case as a solo surgeon. There was that "fear" that I might miss something and not have my "chief" to catch it. All worked out okay I'm glad to say.

Nice post.

Greg P said...

Not sure I can relate fully to the surgeon's point of view.
As I look back, what naivete I had about things was being overconfident that I knew what was going on, expected the treatment would work well without side effects or complications, and that I had answers for all the questions.
After a time you realize you're not entitled to good outcomes, you have to earn them by being prepared for things to go from bad to worse.

Anonymous said...

Interesting post. Just yesterday, I was involved in a case where we took a woman in her mid 30s to the OR with epigastric tenderness and free air about 10 days out after a pneumonectomy. Totally normal ex lap. The thoracics folks think she might have had some air in her mediastinum that tracked down into the belly (not seen on CXR). Odd.

Lynn Price said...

Sid, I just checked. My dictionary has no listing for funkified.

Rob said...

Well Sid, My dictionary has your picture next to the word "Funkified."

Speaking of curses, did you notice that your link to my name is a broken link? How appropriate!

Sid Schwab said...

Rob: I hadn't noticed, but I have fixed it. I'm sorry. And I think funkified is a perfectly excellent word.

Rob said...

It is a Funkalicious word.

ER's Mom said...

Thank you, thank you, thank you! You perfectly expressed what the first attending year feels like. I've had several cases since residency where I feel like saying WTF?

I swear, it's a bigger learning curve than intern year.

Rita Schwab - MSSPNexus said...

Globular glops of gunk... Gross!

Sometimes I think I'm learning way too much about surgery by reading your blog...

SeaSpray said...

Interesting post Dr S. and also nice how you encouraged your partner.