My specialty at war

The other week I was on "short call" at the hospital. I was reassigned to another room after my room finished, and I wrapped up that other case around 7:00 PM. The team captain was on the verge of telling me I could go home, when he received a call from a resident who was in a "triple A" case.

An AAA is an abdominal aortic aneurysm; a bulging of the largest artery of the body. The danger of the bulging is that the bigger it is, the more susceptible the artery is to rupture, which translates into instant death when the blood pressure drops precipitously to the brain and the heart. This gentleman's AAA was special, not only because it was huge at nearly 8 centimeters, but also because it was partially in the thoracic cavity. The higher it is, the more difficult to operate.

So this resident was calling because she was having trouble running an Activated Clotting Time on one of the little machines in the operating room. I knew how to properly calibrate the machine, so I offered to help her with it.

I knew that the case was more complex than those I typically do as a first-year resident, but I wasn't really prepared for everything in the room. The case had started nearly 12 hours earlier; the surgeons had clamped and unclamped the aorta multiple times, and the patient had died in the middle of the case (going into ventricular fibrillation arrest) and was rescucitated.

It was amazing just to count the number of catheters and devices entering and leaving his body: breathing tube, urinary catheter, a couple I.V.s, pulse oximeter, ECG leads, central line, arterial line, temperature probe, nerve stimulator, trans-esophageal echocardiagram probe. The room looked like a battlefield: bags of transfused blood littered the floor close to the anesthesia area. An instant lab hand-held device was on the anesthesia cart, and multiple infusion pumps were pumping in vasopression, epinephrine, and norepinephrine at times; nitroglycerin and nitroprusside at other times.

Most noticible, however, was the air of subdued panic. I exagerrate, of course, but it was clear that this case was not a controlled situation. The anesthesiologist, aided by one of the attendings, was essentially doing everything in her power to keep this patient alive. In addition to monitoring and treating his circulatory arrest, his labile blood pressure, his crummy oxygenation, his worsening acid-base status, and his calcium deficiencies, she'd had to transfuse about 48 units of blood. Imagine six 2-liter bottles. That's how much blood, or more than twice the amount of blood that someone usually has circulating through their vessels. In addition there was albumin and plasma transfused as well.

After his arrest, the anesthestics were essentially discontinued, as everything possible was being done to help support his blood pressure. He was given intermittent boluses of scopolamine and midazolam, which, instead of anesthetizing, were meant to provide amnesia and prevent new memory formation.

I stuck around and helped as a I could with the case; transporting the patient to the ICU was nearly as difficult as the case itself. I understand the patient lived a day or two, but then died in the ICU.

Frankly, I think we would have all been surprised it he lived to get out of the unit. The other weird thing is that the patient was very much an object from my perspective. I don't mean to sound cold or uncaring, but I was introduced to him as an interesting physiologic project and left him as such. I didn't meet him preoperatively (he walked into the hospital on the day of surgery), I didn't see the family gathered around his bedside in the ICU afterward. For better or worse, perhaps objectification is part of medicine, especially surgery and anesthesiology. We can't do our jobs well if, when things go poorly, all we can thing about is how the patient (or Jim or Nancy) is awaiting the birth of his first grandchild, or how he's going to surprise his wife with a trip to Hawaii soon, etc. Objectification is part of detachment, which is good.

But clearly there is a lot lacking if there is only objectification, as I experienced with "the triple A case". No one looks forward to telling family members that their loved one is dead, as I've had to do many times before. But it's part of being a physician, and part of being human.