The call from the ED awakened me at 2:15 on a Monday morning. I wasn’t on call, but an Internist who regularly sends me patients had specifically requested me when his patient needed a surgical consultation. His patient was a bit of a train wreck, a 69 year-old-man with chronic heart disease, a history of heart failure with an ejection fraction of 20%, diabetes, morbid obesity, a pacemaker, and now an incarcerated ventral hernia causing a bowel obstruction.
Dr. F., the ED physician, apologized for the hour and offered to pass a nasogastric tube and write holding orders for the patient so I could see him in the daylight. Something about the way he presented the patient, maybe the repeated mention of the man’s pain level or his low grade leukocytosis, made me say, “No, I’ll come in.”
When I got to the hospital 20 minutes later, the patient looked like he’d been ‘rode hard and put away wet’. We’ve all seen it. Patients whose vitals and labs don’t look that bad, but who just look sick. I decided that despite his relative stability, he needed to go to surgery right away.
The operation was challenging. The patient was morbidly, and the hernia was truly massive. The point of obstruction was a dense band within the hernia sac itself surrounded by a wad of matted bowel that looked like someone had gotten careless with a bottle of epoxy glue.
“The first pop-up was a warning that the patients admitting diagnosis, ventral hernia, did not meet inpatient admission criteria…”
Fortunately, I had a good scrub tech, a circulator who had been a nurse since God was an intern and a stellar anesthesiologist. Every suture, tie, or instrument I asked for was readily at hand. I was in the zone despite it being 0:Dark30 and everything went smoothly. As we started to close, the monitors were beeping smoothly, the closing suture was up and ready, the first count was done and correct and the Eagle’s ‘Hotel California’ was playing in the background (ever notice that whatever station you program into Pandora, eventually you work around to ‘Hotel California’?). I realized that I was having fun. This was the type of thing that I had trained for, that I have spent 30+ years honing my skills to do—take care of critically ill patients with complicated surgical problems.
We finished about 6:00 AM and I accompanied the patient to the ICU. I planned to keep him intubated for a while and monitor him closely for fluid overload or respiratory failure before attempting to extubate him. I called his cardiologist; spoke to the nurse about urgent labs and x-rays and parameters for calling me, all the while feeling that postop high that all surgeons know after a difficult case has gone well.
Then I sat down at the computer to write orders. The first pop-up was a warning that the patients admitting diagnosis, ventral hernia, did not meet inpatient admission criteria and I could either place him in observation or provide additional diagnoses to justify admission. Then it was the Medicare ‘two midnight’ certification that needed to be attested. Then the pop-up telling me his tobacco screen was positive (two cigars a month) I needed to go to the health maintenance section of the chart and document that I’d counseled him on smoking cessation. Then pop-ups warning of drug interactions, and on and on. I felt the energy drain out of me as if someone had unplugged my power cord.
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Bruce Davis, MD, is a Mesa AZ based general and trauma surgeon. He finished medical school at the University of Illinois College of Medicine in Chicago way back in the 1970’s and did his surgical residency at Bethesda Naval Hospital. After 14 years on active duty that included overseas duty with the Seabees, time on large grey boats and a tour with the Marines during the First Gulf War, he went into private practice near Phoenix. He is part of that dying breed of dinosaurs, the solo general surgeon. He also is a writer of science fiction novels. His works include the YA novel Queen Mab Courtesy, published by CWG press (and recently reissued by AKW Books as the e-book Blanktown). Also published through AKW Books are his military science fiction novel That Which Is Human and the Profit Logbook series, including Glowgems For Profit and Thieves Profit.
The Website: www.thatwhichishuman.com
The Blog: www.dancingintheor.wordpress.com