Friday, November 10, 2006

Losing My Virginity; Part One

In all my years of practice, my dad called me at the office only twice. The second was to inform me of a horrible family tragedy. The first -- well, I guess in a small way you could say it was the same.

"I hear you joined the club," he said.
I had no idea what he was talking about. I'd recently moved from Oregon and was early in my new practice. I thought maybe he was talking about the local country club -- I'd left my first job in part because I'd not gotten as busy as I'd hoped. I was in a very small clinic, and when I'd suggested they needed to hire more primary care docs (Note to self: this aspect of clinic practice might be fertile ground for future posts), they'd told me if I wasn't busy enough I should join the country club. ("Nice golf swing, doc!! How 'bout taking out my gallbladder?") First problem: not only do I not golf, I'm definitely not the country club type. Second problem: same goes for my wife. Third problem: what an idiotic idea of how a surgeon gets referrals.) So, I thought, maybe my dad had wrongly heard I'd sunk to a new low to shill for work in my new job.

"I hear you joined the club," he repeated. "I read in the paper today you're being sued." I nearly dropped the phone and fell over. It was a local paper in Oregon to which he referred, no longer part of my world. I'd heard not a damn thing about it; didn't know by whom or over what. But it hit me like... well, it hit me like a lawsuit. And it was only the first blow in a series that lasted over a couple of years, wrenching me back and forth, up and down, tearing me apart in every possible way. Robbing my sleep, souring my outlook, breaking my cherry in the most bloody of ways. At the time my dad was Chief Judge of the Oregon Court of Appeals. My brother was (and is) a very big-time lawyer. Neither of them ever understood how or why it was so deeply painful. "Why are you taking it so personally," they'd ask, completely seriously. "It's just the way the system works."

I forget how long it was between the phone call and the time when a county sheriff strode into my office and, in front of the patients in the waiting room, asked my receptionist where I was. "Sorry, doc," he said as he handed me a subpoena. I absolutely do remember how my hands shook as I opened it. "Wanton... willful... malicious... gross negligence...," I read, my heart both racing and sinking (where we now live there are hydroplane races every year. I'm aware it's possible both to race and to sink.)

So now I knew: it was a horrible case, the worst case ever, one which gave me and will always give me nightmares, whether I'd been sued or not. I'd been called one evening by a family doc in a nearby town, asking to transfer a patient he'd been caring for for a couple of days. A man in his forties, he'd been admitted with vomiting, some diarrhea, minimal pain, and treated for presumed gastroenteritis. After a two or three days with no improvement, he was transferred to me late one night. I first saw him after midnight, at which time his vital signs were OK except for a slightly rapid pulse, consistent with his obvious dehydration. His belly was distended but not remarkably tender; lab work not scary other than signs of dehydration; and his Xray looked like an early bowel obstruction. I decided he needed an NG tube (yep, that's the one time when it's really indicated!) and vigorous rehydration, and a recheck in a few hours. When I saw him at six a.m. he hadn't decompressed his belly in any way, and his vital signs were worse (pulse up, blood pressure down.) I called the OR and got him there as fast as possible.

Having had another abdominal operation only a couple of months earlier, somewhere else, it had been a reasonable assumption that his obstruction was due to adhesions therefrom (in fact, his doc hadn't mentioned the recent surgery when he'd called me, perhaps to justify his diagnosis of stomach-flu.) So it was a big surprise to find volvulus of the right colon (cecum); shocking in fact. Cecal volvulus has a quite characteristic appearance on XRay, and there had been no sign of it on his. Dusky and congested, the colon nevertheless looked viable: the options are to untwist it and see if it is OK after re-perfusion, or to remove it. "How's he doing?" I asked the anesthesiologist: I didn't want to resect and reattach if the man was shocky -- more chance of healing problems. "He's OK," I was told. "Making lots of urine, good oxygenation." As is the case with volvulus, the right colon was nice and floppy, meaning a piece of cake to remove it. Also, avoiding untwisting it meant preventing accumulated bad stuff from being washed back into the circulation -- and it also would guarantee against recurrence. I clamped off the twisted blood supply, snipped out the right colon quickly and easily, and sewed the end of the small bowel (ileum) to the transverse colon beyond the point of resection. Sewing ileum to colon is called "ileocolostomy." (Keep that word in mind, would you?)

"Nice work," my partner said. "He's going to thank you for it. He should do great." He didn't. His blood pressure had, it turned out, been low during the whole operation: the anesthesiologist hadn't mentioned it because every other parameter had been fine (not that it would have changed much in the long run had I known.) And it remained low for the rest of his life, which was about five days. From the recovery room I transferred him to ICU; got consults from every specialty imaginable. Remaining profoundly hypotensive, he required massive amounts of fluids which ultimately ended up in his tissues, swelling him beyond recognition as a human being. All supportive measures -- ventilation, antibiotics, blood-pressure drugs -- failed to bring a response. His family was dumb-struck, as was I. His degree of sepsis didn't make sense under the circumstances, until an Xray a day or two later showed air in his portal vein. The portal vein drains blood from the gut and into the liver. Very rarely, in the face of infection in the belly, the vein can become clotted and infected, essentially a universally fatal condition called "suppurative pyelephlebitis." It's the only case I've seen, despite caring for people with massive intra-abdominal infections, large portions of dead bowel, conditions way worse than this man's.

Every hour of the day and night when I wasn't required elsewhere, I was at his side in the ICU or at his family's. It was agonizing for everyone, and it was soon clear there was no chance of survival. When he died, I felt drained for weeks.

The main issue in my mind was whether I should have operated immediately when I saw him: did I miss the volvulus on the Xrays? Would those few hours have made the difference? I went over the Xrays with every radiologist in town; I discussed every aspect of the case with every surgeon. The films, they agreed, didn't show it. And they all felt the seeds had been sewn during his hospitalization before the transfer. Undoubtedly the portal vein was developing clot even then: it was one of those rare and awful things for which there'd been no solution by the time I first saw him. Small comfort, even if true.

It was and remains the worst case of my career: a death in a previously healthy person (he was probably an undiagnosed diabetic, according to labs during his hospitalization -- it might have increased his susceptibility) from an initial condition that shouldn't have been fatal, for which the operation itself was smooth as could be, and about which there will always be questions in my mind. I've lost other patients; but never so unexpectedly, so frustratingly, so hauntingly. It would have been on my mind forever, no matter what. But with the lawsuit, I found myself in a battle against people I thought were my allies: the referring doc, the hospital, a battery of lawyers, nurses. It opened my eyes, I suppose, to the realities of the world of medical malpractice. Knowing reality is good, so they say. But it also shut my heart part way to the love I'd had for what I do. In the next couple of posts, I'll try to tell you how....


scalpel said...

Lawsuits are emotionally draining because of how much of our own hearts we give to patients like that. Perhaps it wouldn't hurt as much if the suit involved a patient who we really didn't give everything we had to try to help. If I made a clear screw-up, I could learn from it and not feel wronged by the process.

But to be sued over a judgement call on a patient that you not only did your best to help but provided appropriate medical care to shatters our faith in what we do, regardless of legal outcome. And it does make us bitter, and it does change our approach to patients.

Empress Bee (of the high sea) said...

such a terrible pain you feel, it comes across in your writing yet today my friend. i certainly do not know the answer but i can offer my sympathy.

what would you have done in that family's circumstance? have you asked yourself this question? maybe the answer would give you comfort.

unfortunately, there are doctors out there that should not be. and i believe the ama covers up their incompetence. i strongly believe this. so i do believe that doctors should be allowed to be sued, but then there are cases like this one and again, the waters are muddied.

I can only hope that if i, once again, need surgery, that i get lucky enough (again) to have a wonderful compentent caring physician - like you my friend.

Anonymous said...

I always hate to read things like this, but in many ways, it makes me feel better that other people (stronger, wiser people, with classicly superb training, and whose blogs I read) also get sued and also feel emotionally devastated. From just this first part, it doesn't sound as though even through the retrospectroscope, you could have done anything else. I'll wait to read part two and then share my stories of woe.

Anonymous said...

This loss, the pain of discovering "the real world," immediately brings my mind to Blake:

Youth of delight, come hither,
And see the opening morn,
Image of truth new-born.
Doubt is fled & clouds of reason,
Dark disputes & artful teazing.
Folly is an endless maze,
Tangled roots perplex her ways.
How many have fallen there!
They stumble all night over bones of the dead,
And feel they know not what but care,
And wish to lead others, when they should be led.

Sorry for the throwback to English lit, but it was what I felt when I read your post.

Rita - Supporting Safer Healthcare said...

Thank goodness there are people brave enough to become surgeons.

Sid Schwab said...

enrico: beautiful. Thanks.

bee: I can't disagree that coverups occur, but I do disagree (small point, perhaps) that the ama has much or anything to do with it: they just don't reach down to the hospital level where such things occur. And for better or worse, one thing that's resulted from the climate of malpractice is a definite and welcome tightening of quality surveillance of physicians, credentialling, etc. If there were similarly effective tightening of the net to filter out unjustified suits, the world would be a better place.

scalpel: yeah. The issue is the difference between a bad outcome and bad care. I can honestly say that my bad outcomes and errors were NEVER the result of laziness of thought or effort, of inadequate preparation, of failure to assess a problem in a timely and thorough manner. When choosing among options, as I've said elsewhere, we play a sophisticated game of odds; and nothing is 100% predictable.

Anonymous said...

I am aware of a Doc. that could sure use this site, at this moment. The truth of the matter is always this..we are immortal until G_d calls us home. Your time is predestined, wether or not, you realize this. Surgeons can only do what they know, and are trained to do.The rest isn't up to you.

Medblog Addict said...

Great story. (It kinda makes me feel bad about the post I wrote yesterday.) Looking forward to your next post.

Anonymous said...

And yet! You brushed yourself off, and contuinued doing what you love.

Anonymous said...

I'm a medical student. We were recently given a lecture on what to do when we get sued. The lecturer had been sued 8-9 times (never settled, never lost, but was always devastated until number 5 or 6). He told us that lawsuits are always done this way -- a complete surprise that announces itself noisily, in front of a full waiting room. The document is always the same -- the language is an attempt to strike fear into the hearts of those with deep pockets. His advice to us: keep seeing your patients. Do not read the document. Let your lawyer deal with the whole thing.

bee: I don't know about how things were done in the distant past, but it may make you feel a little better to know that what we medical students are taught these days is that if we -ever- even -think- about covering up a mistake we can expect to hang for it. No AMA, no backup from colleagues, no reputable expert witness; in fact, you can expect the other parties being sued to provide the rope.

Anonymous said...

Medical student: There is something you can do now to lessen the likelihood you'll be sued. To put it simply: WHen you go out in the rain, do you bring an umbrella or raincoat? You plan ahead, right? Well, you're p[robably in the process of choosing a specialty. It's obvious that certain specialties are being "raped" by lawyers; OB-GYN, Neurosurgery, General Surgery, Emergency Medicine. My Uncle is a vascular surgeon, a Full Professor of Surgery at a great University, and he's been sued 8 times. Never for an error, always for a bad outome. Bottom Line: Pick a specialty that doesn't get sued. I know it's romantic to "fall in love" with a specialty, but once you're done with training, if you're in a "raped" specialty all you do is worry about being sued. So go into internal medicine, or psychiatry, and enjoy your life. Just my 2 cents.

Anonymous said...

Anonymous medical student again in reply to anonymous offer of advice:
Yep, going into pathology. But still... Path is considered "safe" from lawsuits, but the average pathologist will still get sued once every 12 years. So you can say 'pick a specialty that doesn't get sued for malpractice' and I will say: yes, being as smart as I am, I should have gone into law.

The fact is, though, I still have that passion to heal (in the roundabout way that pathologists do, at least). That's why I read Dr. Schwab's blog -- I see docs who manage to keep the fire burning somehow and hope I can do the same.

Anonymous said...

Dear Dr. Scwab,

I can only hope I receive care from a surgeon as thoughtful and compassionate as you. Unfortunately not everyone is as compassionate, ethical or as competent. EVERY profession has their own baggage but the medical profession must own up to this fact and police their own.

Half of U.S. doctors mum about incompetence: survey
WASHINGTON (Reuters) -
By Maggie Fox, Health and Science EditorMon Dec 3, 2:07 PM ET

Nearly half of all U.S. doctors fail to report incompetent or unethical colleagues, even though they agree that such mistakes should be reported, researchers said on Monday.

They found that 46 percent of physicians surveyed admitted they knew of a serious medical error that had been made but did not tell authorities about it.

"There is a measurable disconnect between what physicians say they think is the right thing to do and what they actually do," said Eric Campbell of Massachusetts General Hospital and Harvard Medical School in Boston, who led the survey.

Doctors are also surprisingly willing to order unnecessary -- and often expensive -- tests such as magnetic resonance imaging or MRI scans. Just 25 percent said they were looking out to ensure they did not unintentionally treat someone differently because of their sex or race, the survey found.

In 2000, the U.S. Institute of Medicine reported that up to 98,000 people die every year because of medical errors in hospitals alone.

Campbell and colleagues surveyed more than 1,600 physicians in 2003 and 2004 for their report, published in the Annals of Internal Medicine.

Up to 96 percent of those surveyed said they should report all instances of significant incompetence or medical errors to the hospital clinic or to authorities. The exception was among cardiologists and surgeons, with just about 45 percent agreeing.
And 85 percent of most doctors said they should tell patients or relatives about significant errors.

But this did not translate into practice.

Forty percent of the doctors said they knew of a serious medical error in their hospital group or practice but 31 percent admitted they had done nothing about it at least once.

Doctors also did not always practice what they preached ethically. While 93 percent of doctors said they should provide care regardless of a patient's ability to pay, only 69 percent actually accepted uninsured patients who cannot pay.


While most of the doctors agreed they needed to keep up with changes in the profession and have their competence reviewed, only 31 percent had undergone a competency review in the past three years.

Dr. James Thompson, chief executive officer of the Federation of State Medical Boards, said one problem may be that doctors know there is not much that can be done to help doctors who are struggling to be competent.

"There are very few places where they can send them for remediation," Thompson told a news conference.

And medical boards may not have the resources to punish errant doctors.

"There are restrictions on state medical boards that inhibit their ability to go after physicians aggressively," Thompson said.
"There are state medical boards that don't even have their own teams of investigators," he added. "There are state medical boards that are, quite frankly, underfunded and understaffed."
But he said medical boards cannot act unless someone reports a problem doctor.

"State medical boards only react to complaints -- they are not a policing agency," Thompson said.

(Editing by Will Dunham and John O'Callaghan)

Sid Schwab said...

Anonymous: there's no doubt we have a long way to go. However, I think it's fair to say there's no profession as regulated or scrutinized, or whose reimbursement is so tied to compliance with myriad rules and regulations. Your article mentions that "only" 31% had been subjected to a competency review in the last three years. What profession has more? Having served as chairman of a surgical quality assurance committee, I can tell you that although imperfect (like everything else in the world) there is in fact a LOT of scrutiny of care being given, and it's increasing every year -- not always to the benefit of patients or doctors... Blowing whistles isn't easy, nor is it a perfect system, anywhere.

drcharles said...

Fantastic post, and series. Being sued is one of the most damaging things I've experienced. It has made me a lesser doctor and soured my optimism with the taint of injustice.

We do the best we can, and we are neither perfect nor omnipotent.

Why does no one ever name God in their lawsuits?

Anonymous said...

I think it is very important to realize that doctors need to separate themselves from the hospitals, as the latter are more often to blame.

As in this case, the physician malpractice attorneys and the hospital attorneys are the "repeat players" who know each other, and so they "say" to the doctor that the plaintiffs would love to see two defendants fighting. However, in many cases there should just be ONE defendant -- the hospital!

I see a lot of conflict of interest problems that are brushed under the carpet when hospital attorneys and doctors' attorneys advise a "common front." I think in this case, the hospital was clearly to blame, and our good surgeon should not have been tied to the hospital by his OWN ATTORNEY.


Moving this post to the head of the list, I present a recently expanded sampling of what this blog has been about. Occasional rant aside, i...