Respectful Insolence

24: The On Call Edition

Finally.

My week on call, including the entire holiday weekend, is over. It started out pretty bad and didn’t get all that much better. I suppose I should be grateful that at least I was getting sleep again by this weekend. In any case, I thought that one particular day was almost worth of a 24-style treatment. OK, it’s not as exciting as watching Jack Bauer kick terrorist butt, but, given that Jack isn’t coming back until January, it’ll have to do. So, without further ado, I present select episodes from:

24: The On Call Edition (a.k.a. a bad day in the life of an academic surgeon)

(Note: Some details of the case below have been changed to protect the innocent, and no names are used.)

12 Midnight to 1:00 AM

The following takes place between the hours of 12 AM and 1:00 AM.

Beep-boop, beep-boop, beep-boop, beep-boop, beep-boop, click, click, click, click, click (OK, it’s my lame attempt at imitating the sound of the clock that introduces each segment of 24. I promise not to do it anymore.)

12:00-12:15 AM: Orac zones out watching television, brain fried after a rough several days before, during which he had submitted two grants due the day before.

12:15-1:00 AM: Orac sleeps.

(OK, perhaps I needed to start the series with a more exciting episode.)

2:00 to 3:00 AM

The following takes place between the hours of 2:00 AM and 3:00 AM.

2:30 AM: The screech of a pager shatters the silence in the darkness of Orac’s bedroom. Half conscious, Orac fumbles for the pager. It’s the hospital. He dials the phone. On the other end, it’s one of the residents. A patient he had been consulted on the other day had taken a turn for the worse. He had started complaining of severe abdominal pain and had a respiratory arrest requiring intubation, resuscitation, and transfer to the ICU. It looks very much like intraabdominal sepsis. A prolonged discussion with the resident follows regarding the patient’s condition.

This patient was a 60 year old who had been diagnosed last summer with leukemia. He had had a particularly rough course during his first induction course of chemotherapy and had almost died of a necrotizing fasciitis. My partner had followed him for many weeks during that course. Surprising everyone, this patient had finally recovered, apparently leukemia-free.

Until a few weeks ago, when he returned with relapsed leukemia.

He was admitted and reinduction chemotherapy started. About a week before this day, he started experiencing abdominal pain. A CT scan at the time showed some inflammation of the small intestine. In the meantime, in response to the chemotherapy, his bone marrow shut down temporarily. He became pancytopenic, meaning that he had a white blood cell (WBC) count of nearly zero and a platelet count of around 10,000 (which is very low). He was clearly very prone to infection and bleeding and at a very high risk for any sort of surgical procedure.

About a day and a half before this call, we had been consulted for fevers and abdominal distension of several days’ duration before the consult, which had started around two weeks after his reinduction chemotherapy. The patient by this time had a severe ileus, with abdominal distension requiring nasogastric decompression. He had still had a bit of liquid bowel movements, but not much else. His abdomen, although distended, was not tender. A new CT showed worsening of the bowel wall thickening in large stretches of the proximal small bowel. We made a diagnosis of probable neutropenic enteritis, a condition that is not uncommon in leukemia patients undergoing big gun chemotherapy to the point where their WBC count drops dramatically. He did not have the typical pattern (inflammation in the distal small bowel and right colon), but nothing else fit as well, and neutropenic enteritis is not limited to those places.

The management of neutropenic enteritis is somewhat controversial, and, unfortunately, one of the areas where evidence-based medicine doesn’t help as much as we’d like, because the studies presently available in the literature are not randomized and consist mainly of case series. This is one situation where the literature can support a number of management options. Some surgeons advocate immediate operative intervention in these cases; most tend to recommend more of a wait-and-see approach for most patients, unless complications such as perforation or unrelenting sepsis occur, because most of these cases will resolve when the WBC count comes back up. Because this patient had such a benign abdominal examination and, although febrile, was not tachycardic, and because so much of his bowel seemed to be involved that any surgery would likely require removal of large portions of his GI tract, we had nervously elected to follow him closely, and not operate unless our backs were to the wall and we had no choice.

We now had no choice.

3:00 to 4:00 AM

The following takes place between the hours of 3:00 AM and 4:00 AM.

The decision to operate urgently is made. However, because the patient has such a low platelet count and was severely septic, rushing off to the OR immediately was not an option. Consequently, we planned to resuscitate the patient with fluids, give lots of platelets, and give fresh frozen plasma to correct his other clotting abnormalities, the plan being to operate in an hour or two.

I change clothes and head into the hospital.

4:00 to 5:00 AM

The following takes place between the hours of 4:00 AM and 5:00 AM.

I arrive at the hospital and heads straight for the surgical intensive care unit (SICU). The patient’s abdominal exam has worsened considerably since yesterday afternoon. He is now so distended that he looks as though he will burst. I call the patient’s wife to inform her of the dire turn of events and to obtain consent for urgent surgery. The woman speaks no English at all. Fortunately, we have a translation line, and I am able to make the woman understand what is going on.

While the last of the platelets and FFP run in, I go to the doctor’s lounge and get a big cup of coffee. I prepare myself for what is likely to be a very unpleasant case.

5:00 to 6:00 AM

The following takes place between the hours of 5:00 AM and 6:00 AM.

The patient is taken to the O.R. By around 5:20 AM, we are cutting skin. Fearful that this patient has massive amounts of dead gut, we only make a small incision, expecting what we in the surgery biz call a “peek and shriek” (you see lots of dead bowel for which nothing can be done other than to close and let nature take its course–in other words, you peek and then shriek). We are greeted with grayish, dusky-looking bowel. It’s not dead, but it doesn’t look very healthy. We’re forced to open more. What greets us is not pretty. We see purplish-black loops of intestine. There is indeed dead bowel.

But how much?

Only one way to find out. We systematically run the bowel. It turns out that the entire ascending and transverse colon (more then one half of the colon) are purplish black.

Dead.

Large amounts of small bowel are dead, as well, starting right up at the Ligament of Treitz and including the entire jejunum. Nearly the entire small bowel other than the grayish area that greeted us when we opened is dead.

This may not have been a “peek ‘n’ shriek” in the strictest sense, but it is worthy of a shriek. It’s one of the things that general surgeons hate the most, because we are powerless to do anything. You can’t resect 90% of the small bowel, at least not in someone with no WBC and no platelets, and expect any sort of long-term survival. Even in young, healthy individuals, the effects of such a resection are devastating: short gut syndrome and dependence on intravenous nutrition.

6:00 to 7:00 AM

The following takes place between the hours of 6:00 AM and 7:00 AM.

Realizing that there is nothing that can be done, we start closing the abdomen. The patient is transported back to the SICU, and I try to get a hold of the wife. I learn that she is on her way in. I dictate the case, and the resident writes orders. I haven’t felt so tired in a long time.

7:00 to 8:00 AM

The following takes place between the hours of 7:00 AM and 8:00 AM.

While waiting for the wife to arrive, I do paperwork on the case and then go to get some breakfast.

8:00 to 9:00 AM

The following takes place between the hours of 8:00 AM and 9:00 AM.

The wife arrives with a friend who translates for her. I explain to her that her husband’s problem is not one that can be fixed and that there is nothing further we can do for him. She breaks down sobbing. Quietly, I recommend that all extraordinary support be withdrawn and comfort measures only instituted. She agrees. We ask her if she wants to stay. She is so distraught that she doesn’t. Instead, she goes into her husband’s room one last time to say goodbye, her friend supporting her. The sobs come in waves from deep within her, almost knocking her over each time. She leaves to make funeral arrangements. I write the order to withdraw support.

9:00 to 10:00 AM

The following takes place between the hours of 9:00 AM and 10:00 AM.

I attend Grand Rounds. I can hardly stay awake. I wouldn’t have even gone if it weren’t for the fact that this particular Surgical Grand Rounds was by a very prestigious visiting professor. Around 9:45 AM, I’m called to let me know that the patient had passed away.

10:00 to 11:00 AM

The following takes place between the hours of 10:00 AM and 11:00 AM.

I head back to my office. On the way over, I run into one of my partners. I learn from him that a paper we had submitted to Cancer Research had been rejected outright. Never mind that it was better than half the stuff I’ve seen in that journal. Normally, I’d be annoyed, but right now I’m numb. It’s a petty annoyance compared to what happened overnight. I go to my office, close the door, and turn out the lights. Because I have cases starting at noon, I try to catch some sleep on the floor of my office. I vow once again that I need to buy myself a sleeping bag to keep there for this purpose. Thankfully, the office is carpetted.

[NOTE: The next several episodes encompass me doing a variety of elective cases between noon and 5 PM.]

5:00 to 6:00 PM

The following takes place between the hours of 5:00 PM and 6:00 PM.

I finish up the last case of the day. The resident informs me that we have a new consult.

Lovely. No rest for the wicked.

It’s a 25 year old with massively metastatic testicular cancer. I ask why they are consulting us. The resident tells me that the oncologist wants to “have surgery on board.” Why? No one knows. The oncology fellow can’t explain why. I’m too tired to argue and don’t really feel like calling the oncology attending; so we see the patient, see that there is nothing for us to do or recommend, and I slap a perfunctory note on the chart.

6:00 to 7:00 PM

The following takes place between the hours of 6:00 PM and 7:00 PM.

I’m in my office, returning patient phone calls and doing paperwork. I fill out the billing slips for the cases I did that day, dictate the one that I didn’t get to, and then enter them all in our database.

7:00 to 8:00 PM

The following takes place between the hours of 7:00 PM and 8:00 PM.

I head home. Too tired to want to deal with dinner or to care about anything healthy, I stop at McDonalds on the way home and load up on grease to take home with me. Sadly, I also tempt and corrupt my wife from the straight and narrow and bring her home nice big greasy McDonalds burgers and fries as well.

It was all very tasty.

8:00 to 9:00 PM

The following takes place between the hours of 8:00 PM and 9:00 PM.

Paradoxically wired and not that sleepy, I check my e-mail. I immediately wish I had restrained myself until the next day, because there, on the screen, was my second rejection of the day. Well, not exactly a rejection, but a de facto rejection. Reviewers for Molecular and Cellular Biology are requesting so much extra data before they would consider publishing the manuscript that I had submitted a month or so ago that, in my exhausted state, I was highly tempted to whip back a note informing the editor that, if I had the data his reviewers were requesting, i would have submitted the paper to a higher tier journal, like Genes and Development.

Thankfully, I restrain myself. Even in my depressed, defeated, and sleep-deprived state, I have more common sense than to do something that stupid.

9:00 to 10:00 PM

The following takes place between the hours of 9:00 PM and 10:00 PM.

Before turning in in utter exhaustion, I decide to look at the blog.

I immediately regret it.

I spend around 15 minutes composing a not-so-respectfully insolent response to what had annoyed me.

I then head for bed and crash–hard–realizing that I still had several more days to go. I also realize that most private practice general surgeons have days like this far more often than I do. But then they don’t have to worry about research and trying to get grant funding. I also remember that, as bad as this day has been, at least I’ll have the chance to have more bad days like it. Sadly, the same can’t be said about the patient whose deterioriation started this day out.

The remaining two episodes have been left out; Orac just couldn’t make it through two more hours. I guess he just isn’t as tough as Jack Bauer. But, then, who is?]

Comments

  1. #1 Janne
    May 30, 2006

    A haunting and depressing description. It brings to the fore a question I sometimes want to ask: what makes someone decide to become a physician? Not a pre-clinical researcher, or lab-type person, or a radiologist or other more hands-off work, but working clinically (if that is the term). The way you describe it here you would burn out in ten years on the outside. What drives people – not to become physicians, but to remain in the job?

  2. #2 Catherina
    May 30, 2006

    I was highly tempted to whip back a note informing the editor that, if I had the data his reviewers were requesting, i would have submitted the paper to a higher tier journal, like Genes and Development.

    Commiserations, been there, felt just that. I wonder what would happen if we all just gave in and wrote those letters to the editors.
    At least you have breakfast, and dinner – more than I’ve ever seen Jack Bauer have in a day ;)

  3. #3 M. Dyspnea
    May 30, 2006

    I’m still early in my education and am beginning to get involved with research. I’d like to be a surgeon in 7 years. I’m very curious about the differences (as you see them) between your life as an academic surgeon versus that of a non-academic, and your suggestions for those interested in either. If you ever sit down to write that outline (or warning) I’ll be excited to read it.

  4. #4 epador
    May 31, 2006

    Been there, done that, have the long-sleeved T-shirt. And now I’ll be having flash-backs for the next week.

    Kudos for you for sticking with it. I bailed Medical Oncology after 17 years. I have to admit to getting “surgery On Board” once or twice too – usually treating the last patient rather than the one I wrote the consult on, in as usually a sleep-deprived and emotionally numb state as you describe.

    Also an excellent description of how insane we are to try to pull 24 hour shifts, something we’d never let an airline pilot do, certainly not on a regular basis.

  5. #5 beajerry
    June 1, 2006

    Doctor schedules are insane.