Posts Tagged ‘medicine’

White Collar and Blue Collar Surgery

March 6, 2014

As part of our surgical residency, we are required to have some experience with transplant surgery.  In different programs this takes different forms (as an intern, a 3rd year or 4th year resident, etc) but it is a requirement all the same.  My home program does not do transplant surgery, and so for me it means traveling to another city to a bigger, much more academic hospital that does.  My roles on the transplant services at this hospital are somewhat vague but what is well understood is that I go on donor runs.  These donor runs represent only a small fraction of the resources that are devoted to the goal of taking organs from one person and putting them into someone else . . . but holy moly are they neat.

The general outline of how this works is a local hospital identifies a patient that might be eligible to donate their organs (they might be brain dead or the family wants to withdraw care) to the local donor network.  This local donor network team then contacts the patient’s family, and if they are indeed interested in donating, takes over care of the patient and begins the process of evaluating the patient’s organs for eligibility for donation, and distributing the information to different transplant programs depending on which program has a patient at the top of the recipient list.  It is then up to the on-call transplant surgeon to make the determination as to whether the organ (in addition to the immunologic matching) would be a good match for their patient.  Sometimes the organ is accepted, sometimes it is declined and the next transplant program with the next patient on the list is contacted and so on.  There is additional wrangling than I can’t pretend to understand, but if my program decides the organ would be a good match, then usually they send the procurement team to go get the organs and bring them back.

That’s where I come in.  Generally the “team” consists of a transplant fellow (general surgeon learning to be a transplant surgeon), a transplant coordinator, and myself.  These calls can come at any time, but when they do we all meet in front of the hospital, get into the chartered van which then takes us to the hospital (if it’s close) or to the airport (if it’s not).  If we go to the airport, we cruise through to the executive terminal and get on some small Buddy Holly-sized corporate-type jet and zoom off into the wild blue yonder to the airport nearest the hospital of interest.  Another chartered vehicle picks us up from the airport and off we go to the local hospital.  When you roll into the local hospital, it’s hard to get away from that action-movie, characters-all-walking-in-line-abreast-in-slow-motion-as-dramatic-music-plays vibe.  We’re like “The Transplant Team” (yes in capital letters) and you feel like a little bit of a badass.  But anyhow.

We go to the OR and get everything ready, check the paperwork, and then it’s go time.  The hospital staff brings the patient to the OR.  This patient is a person who has been declared brain dead and who had the desire to donate their organs in the event that they had no further use for them but others may yet benefit.  It’s very clinical, getting the patient positioned, shaved and prepared for the surgery.  But before it’s time to start there is always a moment of silence, where sometimes a passage that the patient’s family wrote about the patient is read or, if there is no such passage, everyone in the OR takes a moment and is quiet in respect.  I don’t know about the other people in the room but I’ve found these moments to be very poignant and a little haunting.  I am not a spiritual person, but that hasn’t kept me from sending good thoughts in the patient’s direction.

I always thought that this particular xkcd comic summed the whole donation philosophy nicely:

We then perform the procurement procedure.  There is a point in the process where the patient is ‘vented’ or all the blood is removed, the patient is cooled, and the organs to be transplanted are filled with a preservative fluid.  It’s at that point that the patient’s heart stops beating, and the anesthesiologist shuts down their machine and leaves the OR.  This is also something of an emotional landmark of the case, watching the heart wind down and then stop.  Intellectually you understood that they were dead before, but seeing the heart still in their chest makes it much more real.

Once the organs are safely in their boxes, we carry them back with us to the plane, go back home, and bring them to the hospital where the surgery team is waiting to transplant the organ into a waiting patient.  It’s a neat process, and I once was able to follow a kidney, removing it from the donor, back to the transplanting hospital, and then got to help sew in the kidney and see it start making urine.  No lie, it was pretty neat.

This also brings me to some of the differences in surgical training programs.  I read in a book somewhere, someone referring to themselves as a “blue collar” surgeon.  This appellation and the implication that there was thus a “white collar” surgeon and that they were somehow different.  The big, academic hospital where I did my transplant rotation definitely was training “white collar” surgeons.  Among the faculty were some of the world’s experts on transplant surgery.  The other surgery divisions also like-wise had some of the foremost experts in their field.  The residents all had some experience with some of the most advanced surgical techniques, procedures, medications, treatment regimens yet invented (and some still experimental).  The exposure these residents had, and the opportunity to learn about state-of-the-art, cutting edge surgery is amazing, and in some ways I was a little jealous.  Coming from my home program, which is located in a poorer county with a higher immigrant population, and with a less “academic” reputation, I could not help but feel a bit like a Crocodile Dundee.  A little rural and a little backwards, but nevertheless with my own, effective way of getting the job done. (You call that a scalpel?  THIS is a scalpel!)

My home program I like to think of as doing much more “blue collar” surgery.  There is no bench research where I come from, no mouse models or transplant surgery.  In place of that expertise, we become experts in treating the common surgical diseases.  Learning through volume what the rare presentation of a common surgical disease may look like, how to make headway in a technically difficult case, and making progress in the pursuit of perfection by the act of continuous repetition.  Furthermore, in a place with relatively few consulting services, many times it’s left to us to figure things out for ourselves, to learn how to manage aspects of patient care that might be otherwise consigned to a consultant.

Which model is the best?  It’s hard to say.  If I need my kidney transplanted, I would certainly choose the white collar.  But if I’m shot in the chest, I’d go with the blue collar any day.  They say that in the match you often find yourself going not to the program you want, but to the program you need.  Leaving the academic hospital and coming back to my home program, I could not agree more.  There are people perfect for one place, and people perfect for another, but I’m grateful that I found the proper place for my training.

Strength in Adversity

January 23, 2009

Once upon a time, I was a pre-med volunteer at the Harborview Medical Center Emergency Department (pink scrubs and everything; those of you who’ve been there know the pain of which I speak).  Sometime between collecting ED beds from around the hospital and re-stocking the soft restraints, I found myself listening to a conversation between one of the physicians and a patient who had amputated four fingers off his right hand in a skilsaw accident.  The doctor asked how he was doing and such, but what ultimately piqued my attention was when he asked which was his dominant hand.  “Right,” the patient said.  He continued lightly, “But I swear to God, after filling out all these damn forms you’ve set in front of me, I’ll be walking out of here a lefty.”  Perhaps my inadequate writing trivializes his words, but sitting there re-stocking some cabinet in the room, I was so struck by this individual’s courage in facing what was sure to be a difficult recovery.  This gentleman had woken up with ten fingers and the ability to button his shirts.  He’d be going to bed tonight with neither, and yet lying in his hospital bed he could summon the strength to crack a joke.  Melodramatic I know, but I don’t know if I’ll ever forget that.

I bring that up because lately our oncology and psychiatry courses have been inviting patients to speak to us medical students about their diseases.  They are all different, ranging from schizophrenia to alcoholism to prostate cancer, but to a person, they have all impressed me with their cool and collected attitudes towards their illnesses.  The most recent panel was a group of men living with prostate cancer, all of them I believe long past the stage where they can hope for a cure.  They spoke to us about their orchiectomies (castrations), how they went home and cried with their wives, and how they need to fight with their fatigue to get up and go about their lives.  I don’t know if I can imagine discussing something so personal with such humor and introspection.

I’ve seen this courage in other places too, in cancer patients with bilateral mastectomies learning of the return of their cancer and in heroin addicts relating their stories of addiction.  I was giving a Hepatitis vaccination to a patient at clinic (which serves mostly heroin users and sex workers) and going through the usual checklist I asked her do you have any allergies, any problems with shots in the past, etc etc.   Then I asked her, do you have any problems with needles, and she looks at me and she says “Honey, if I had a problem with needles, I wouldn’t be here right now.”  It never fails to amaze me, how these normal people who find that strength from somewhere to confront their illnesses.  These things that will kill, or seriously and irreparably debilitate them, they confront with a joke.

I can feel some of you shaking your heads and thinking perhaps that I’ve drank too much of the med-school kool aid.  That for every patient that makes it onto a panel or into my memories there are dozens who fight it badly, denying their illness and lashing out, unable to muster some personal grace.  Perhaps that is so; I am only a second year, and have yet to see that full measure of human adversity.  But I can only write about what I have seen, and I have seen some truly remarkable people who have shown me (corny as it sounds) just how strong people can be.

I think that patients spend a lot of time (whether worthy of it or not) respecting their doctors.  I am not sure how much time physicians spend respecting their patients.  So yeah, if only for a little bit here, I feel I can give some recognition to the strength of some of the people I’ve had the opportunity to meet in the last two years.

All For One, and One For All?

January 1, 2009

I was watching an episode in the first season of House the other day, where Dr. House’s patient is this Type-A personality executive, who ends up with heart failure secondary to her bulimia.  She needs a heart transplant, but House knows that because of her psychiatric history, she will likely be assigned a very low priority on the heart transplant list.  He lies to the transplant board reviewing her case, and she gets the transplant.  When he was asked why he lied, he states simply that she was his patient.

I found that to be an extremely compelling answer, and representative of a central tension (in my opinion) in medicine.  Ideally, doctors are charged with the welfare of their patients; getting the best for the individual that sits in front of them.  But in many cases, what is best for the individual is not what is best for the group.  Like Dr. House’s patient, she DID have a psychiatric problem, and she ruined her heart because of it.  There are many other patients out there with failing hearts and otherwise spotless medical records who would be much better candidates for a transplant.  With a limited supply of donor hearts, as a society you want to make sure that those that do get it have the least chance of squandering that resource.

And therein I feel lies something of a tension in medicine.  On one level there is the doctor who is compelled to do everything he or she can for their patient, and on the other, there are the policy makers who must make those hard utilitarian decisions that reduce the beneifit to some in order maximize the benefit to many.  What sane doctor wouldn’t want to lie, cheat and steal to get their patient a life saving treatment?  It isn’t their responsibility (not directly anyway) to care about another patient in a hospital down the street; their charge is the man or woman in the bed in front of them.

And so I wonder to myself, was Dr. House wrong to lie to get his patient a new heart?  I don’t know.  I was told once that if you wanted to save the world, you shouldn’t be a doctor.  And to a large extent, that is true.  There are over six billion people in the world, and over 300 million in the United States.  Physicians help individuals; it is the policy makers of the world that will save millions.  And yet, there is something important in doing what is best for the individual, even if it does inconvenience the masses.  The Americans With Disabilities Act and our nation’s staunch support of minority rights being just two of the many ways we all stick up for the individual even if it means less benefit for the many.  I grant you that spending money on a wheelchair ramp isn’t the same thing as ranking a heart transplant list, but surely they are related on some level.

Anyway.  This wasn’t meant to be a full-fledged entry, more just a chance to think about something that maybe hadn’t occurred to you before.  Best wishes for the coming year to all of you!

Knowing Too Much/Not Enough

December 20, 2008

We’re nearing the end of our second year of medical school now; time for me to witness a second round of medical school interviewees waiting in the lobby with their name tags and black suits.  A lotta learning has happened in the year and a half that separates those pre-meds and myself, but the fact of the matter is, most of that education has just shown me how much farther there is for us to go.

A few days ago, a friend of mine told me that a near relative of hers had to be hospitalized with a disease that we had literally taken the final on less than a day before.  I think that by itself, it is a terrible thing to go home to and confront.  But it is made even worse by having that academic knowledge suddenly become so mortally relevant.

Thinking on the situation, I couldn’t help but feel disgusted that life would be so cruel as to force my friend to confront what had been a page in Goljan’s, in a member of her own family.  I think on some level while we are learning about these diseases in class, and we see the faces of the stricken patients on our power point slides, we know that these diseases are not good things, and that they affect real people.  But for most of us, those faces are anonymous, and more important than how crippling and mortal these lymphomas, leukemias, fractures, and infections  are, is what our instructors are going to expect us to know for the examination.

There are so many diseases out there, so many terrible ways to get sick, that while we are learning them, we have to tune out just what this costs in human currency.  One of our pathology professors was presenting a case to us, about a girl who was currently in the hospital.  She had a malignancy, but nobody could figure out exactly what was wrong.  Our instructor described the course of her disease to us, and showed us slides of biopsies that had been taken and such.  She concluded the presentation by sort of shrugging her shoulders and telling us that still no one could really figure out what was wrong, and that ‘she wasn’t doing well.’  Sitting in the audience, it occurred to me that what that really meant was she was going to die.

Hearing about that girl I’ve never met was difficult enough, but when something like that befalls someone near and dear to you, it must be very hard.  It makes me want to shout indignantly that we shouldn’t have to deal with these things.  Not yet.  That we are still students, that it is difficult and stressful enough without being confronted by the painful reality of what we are learning.  That we’re not ready to start facing the morbid fact that people we know, good people with lives and histories who laugh and have families will get these diseases.  But I guess this is real life, and life is not always benevolent.

And making this hard introduction to the reality of our curriculum even more difficult, there is nothing we can do about it.  At this point, we know just enough about these diseases to know what it means when they say that our relative is intubated, in an ICU, has a particualr diagnosis, but we don’t know nearly enough to be of any use to anyone.  All we can do is watch and comprehend, but we cannot help.

I don’t know.  I bring all this up because I was a bit rattled by all of this.  Saddened and worried about my friend and her family, and confronting in my own way what this sort of thing really means.

Anyhow, I hope that wasn’t too morbid for everyone this close to the holidays.  I have a fair amount of free time this vacation, so hopefully more upbeat writings to come.  Take care everyone.

Those We Don’t Like

December 2, 2008

A quick preface to the following blerb:

I wrote this as the closing remarks for a presentation a fellow medical student and I gave at an undergraduate conference on “Cultural Competency.”  Read the following with the understanding that I’m not the best writer (nor orator) in the world, though it never hurts to dream at times ;).

We have done our best to tell you guys about the drug user culture that we see at [my clinic], and to educate you as to why they receive second class treatment from many medical practitioners.  We wanted to show you the facts of the matter, but I feel that this is a problem that cannot be completely described by statistics alone.  In the medical profession, we all signed up because we wanted to help other people, to heal their hurts and cure their illnesses.  You might be asking yourselves, how someone can have those ideals but still exhibit this differential treatment of their patients?

I think that on the surface, we do it because we are afraid that they are going to dupe us, because we don’t like how they smell, or because they come out on the wrong side of that cold utilitarian calculation telling us how much medical care they should receive.

But I suspect that the real reason might be simpler, more visceral even than that.  I suspect that those may well be superficial observations, excuses covering an uglier side present in all of us – not just doctors – that we refuse to admit to in ourselves.  It is the reason why we ignore the homeless on the street when they ask us for money, or walk past that bum wheeling his grocery cart with our eyes straight forward and our conversation uninterrupted, refusing to even acknowledge his or her existence.  These, the people who need help most of all, we brush past with masks on and eyes turned inward.

Maybe we do it because we feel we cannot help them; because our willingness to help our fellow man goes just far enough to join that facebook group, but not far enough to spare a glance to the guy sitting on the sidewalk.  We come up with all sorts of excuses to ourselves, saying in our heads that they’ll just spend the money on booze, or that their problems are too big for me to fix by dropping a few coins into their cups.  These excuses are just covers for the fact that something in these people repulses us, and causes us to pull back into ourselves.

While unpleasant, this might be okay for every day people.  But as physicians, once you put on that white coat and drape the stethoscope around your neck you no longer get to use these excuses.  When someone reaches out to you because they are sick, and they want you to make them better, we are duty bound to help them.  When they come before us, whether standing on their own two feet or sitting in a duct-taped wheel chair, we must help them, because we are doctors, and as doctors we do not get to choose which patients are worthy of of our care and which are not.  Everyone is human, everyone gets the best treatment we know how to give, and as doctors that is what we strive to do.

But as we see patients, many many patients, we get burned sometimes.  The patient we thought to be in excruciating pain turns out to have been seen by a colleague before, under a different name but persistently seeking the same narcotic.  We treat the same alcoholic as best we can over and over again, and over and over again he spits and yells and screams obscenities at anyone who comes near.  These experiences cannot but hurt us, leaving scars that make it harder to treat the people who remind us of them.  It is hard to feel good about wasted efforts or failed interventions.  It is even harder to treat someone who, on some basic level, is distasteful us.   But all the same, as doctors we must be able to see past that ugliness, and trust that there is a human being inside who is hurting and needs you.  Just because it doesn’t feel good, just because it isn’t easy, doesn’t mean that we can shirk our duties as physicians; to treat them with the same basic dignity granted to all people.

It is easier to ignore these people, to push them off to the side, easy to treat them quickly and move on.  What is hard is to treat every single patient with compassion, to remember that no matter how smelly, rude, ugly, sick or downtrodden, they are still people.  It is a simple lesson, but one I think that too many of us both in this profession and in the world at large have forgotten.  But we owe it to our patients, and to those people who are not so lucky as us, to remember.

Why I Want to Be a Doctor, Part 2

July 5, 2008

A few months back I wrote an entry in my old xanga, sorta re-evaluating my reasons for going into medicine. In a nutshell, I was saying that one of the big draws for me was that you really get to feel and experience things that not everyone gets to do on a day to day basis. The feelings that you get are not necessarily good or bad feelings, but they are strong, and I think that that is an important part of being alive/being fulling present in your life.

I bring this up because in this entry, I wanted to talk a bit about a patient I saw a few weeks ago. At my school there is a surgeon doing a study with trauma patients, and part of the study requires someone to make sure that blood is drawn just when they come in the door. With a medical school full of eager-beaver first and second year students just next door, we were the natural choice to be the ones to get them. The way it works is one medical student gets a trauma pager (we have a monthly schedule as to who has it what day), and when a trauma comes in, they and the trauma team get paged, and scurry down to the ER to meet the patient.

I had been paged down to the ER for an unrelated patient, and was just on my way out when it was announced that another person was coming in with CPR in progress. I decided that, having nothing else to do other than study in the on-call room, I’d stick around and watch. As I was settling down into a corner and trying to be out of the way and inconspicuous (in the best traditions of my pre-med volunteer days), I was spotted by one of the residents. She asked me if I was CPR certified. I told her I wasn’t (how’s that for another medical irony; a med student that doesn’t know how to do CPR), and she responded, well, do you want to learn? I had to pause for a moment, and stammered out something to the effect of, sure I want to learn . . . but I don’t want to make things worse than they already are. Don’t worry, we’ll watch you, she said as she pulled up a stool next to the bed for me to stand on. You want to do your compressions right about here, she told me, tapping my chest just left of my sternum, make sure you put your weight into it and lock your arms so you don’t tire out as fast. Feeling faintly ridiculous standing on a stool waiting for the patient to come in, I took a moment to reflect how strange it was that one could get tired while trying to keep someone else alive.

The paramedics burst into the room, with one sitting on the stretcher performing CPR. They quickly transferred the patient to the bed, and I was told to take over the compressions. I did so, pushing down as hard as I thought appropriate on the man’s chest, but apparently it wasn’t hard enough, as one of the nurses had me step down, while she showed me just how strongly and rapidly you need to push on someone’s chest for the CPR to be even faintly effective. Climbing back up onto the stool and taking over from the nurse, it then became clear to me how this can be a tiring activity. Even with my arms locked and all my weight put into pushing on his chest, I could feel my abs and shoulders burning.

The poor man was a mess; he had thrown up, and had a good deal of vomitus on his face, in his hair and his half-open eyes. The doctors were trying to suction his mouth and throat clear enough so that they could intubate him, while others were pumping him full of epinephrine and other code-drugs. Their efforts ineffective, they shocked him, (yes they really do call ‘clear’ before they do it) and no lie it’s an uncanny thing to see his limp body tense and his limbs jump when they do. I took turns with another nurse continuing CPR, but given the fact that the patient had been down for a good time before CPR was even begun in the field, and that he wasn’t really responding to the code, after about half an hour the doctor in charge straightened up and asked the room if anyone had any other suggestions. I guess it is something of a tradition in the medical field to ask if anyone else has something that they want to try before they stop their efforts at reviving someone. But no one had anything to add, and so the patient was declared dead. The nurse who had relived me doing CPR stopped his compressions, and stepped back from the body.

I thought I would write about this because (not surprisingly) it was an emotional experience. I’d seen people die in the hospital before, but this was the first time I was actually involved in the failed revival effort. Anytime someone comes into the ER with CPR already in progress, their prognosis is pretty grim. I think the big feelings for me during all this was this mix of sadness/helplessness; this poor man’s body was winding down towards death right in front of me, and the best that I or any of the doctors could do was wail on his chest and pump him full of drugs. In a way, it’s like when someone tells you ‘mate in 6,’ you know what’s coming, but you need to play it out anyway, just in case something was missed, or there is a chance there that no one saw. It is a strange sensation to be standing there, feeling this man’s life ebb away beneath your  compressions.  There was nothing to be done for it, but all the same someone has died, and you can’t help but feel sad because of it.

Medical school is a lot of studying. And a lot of the time, studying is boring. But then something like this comes along, so crazy and intense, that it brings you back to your senses and reminds you why you’re doing all this in the first place. While I definitely didn’t sign up for medical school to watch tragedy in the ER, I think it is part of a greater education; what it feels like to participate in something so sad, to learn how I react to it, and to observe the reactions of others. Experiences don’t always need to be happy ones to be meaningful.

Anyway, I hope that wasn’t too morbid for you. This particular patient has been on my mind for a while, and I thought it would be good to sit down and write a bit about him. I feel like med school isn’t about being happy all the time; it’s about feeling and doing intense things, be it studying like mad-crazy or watching human drama play out on a table in front of you, for better or for worse. I feel like life isn’t about being happy all the time either; everyone has ups and downs, successes and tragedies, and I think all that can be asked from life is that it be intense, that we get to be present and feel what is going on around us. Med school certainly does that, and so I think, at least in part, that is why I want to be a doctor.