Thursday, March 20, 2008

The Smart Doctors

This poor 77 year old guy showed up in the SICU one day as a transfer from some LTAC facility. He'd been in a car accident a couple of years ago and suffered anoxic brain injury, rendering him in a persistent vegetative state. Trached and pegged, and curled up tense and taut from contractures, he looked like the quintessential gork. One of his legs had been lopped off because of injuries sustained during the initial trauma. He was unshaven and gaunt-faced, temples completely wasted on both sides; a skeleton covered by skin. We were called because he wasn't tolerating his tube feeds and had developed abdominal distention. A CT scan suggested a distal small bowel obstruction and a possible cecal mass as the underlying etiology.

Normally in these situations, you explore the guy in the OR and resect the tumor. Or maybe colonoscopy first, if he isn't too obstructed. But this guy was merely existing. There was no life there. Cells and fluids and proteins supported by machines, maintaining a facade of humanity. We all knew better, but the family was entirely unreasonable. Multiple conferences with doctors couldn't dissuade them from a desire to "have everything done". They asked about transfer to the downtown medical mecca, if nobody wanted to operate on him at our hospital. Frankly, it seemed unethical to me to slice open this withered apparition. I figured reason would eventually set in, but no. The other day, life flight whisked him off to the downtown mecca. The internist at our hospital who arranged the transfer (reluctantly) told me that the surgeon accepting the patient told him that "we know how to do diverting colostomies at this institution." Just outrageous pompousness. First of all, if he'd looked at the films, he'd realize a colostomy isn't going to do anything about a cecal mass obstructing the ileum. Second, I also know how to do diverting procedures; it isn't hard. The hard part is deciding when to do nothing. Oh well.... I suppose when you're dealing with difficult family members, sometimes the best option is to give them what they want, i.e. second opinions from the "smart doctors" downtown.

9 comments:

Anonymous said...

ooh, ooh, surgical pomposity, fun. idly, one wonders if the "mecca" he ended up at is the one with the red shield-type logo or the cooler, more blue-green logo...

As a med student, I've only been at the county hospital. Gonna be interesting to finally go over to the East side of Cleveland for my surgical AI in July, see what all the fuss is about...

A, a fourth-year medical student said...

The other side of the 'outside hospital' jokes on YouTube is the 'ivory tower' and all the baggage that goes with it.

Good post, although I think it's hard for families to make decisions sometimes when they haven't seen the endpoint of endless meddling as often as we have.

The Happy Hospitalist said...

I had a similar patient in the distant past. A patient in their 90's who got pegged, trached and shipped.

Only problem was, family was so far out there in terms of rational expectations, that mamma had to ship many miles away to the nearest facility that would take her.

She ended up back in a hospital in their town. And their hospital docs wanted to ship mamma back to us. We said no.

Basically ping pong for the dead.

It's all quite sad.

Nobody wants to be the one that says no.

And get dragged through a lawsuit.

rlbates said...

Sad Buckeye. One of the scrub nurses I work with lost her dad this week. They worked with hospice to make his last days as comfortable as possible. She refused to let her family members "do everything possible" to prolong his existence. She feels like he had a "good death" and that she was lucky enough to be holding his hand when he passed.

Sid Schwab said...

Yeah. It's a good example of what I said recently about palliative surgery. And that what happens depends on the doctors as well as the patients/families. You were right. The "smart" doc wasn't.

Anonymous said...

"we know how to do diverting colostomies at this institution." Just outrageous pompousness"

About as "pompous" as you are relating to other subspecialties (see your next post)

PS: Thank God you don't work at my hospital.

Buckeye Surgeon said...

Thanks for the kind thoughts anon. Keeps me balanced.

Anonymous said...

"Just outrageous pompousness" That hospital downtown is known for outrageous pompousness.

The most arrogant doctors I have ever encountered was at that hospital.

Teresa said...

We all knew better, but the family was entirely unreasonable. --Buckeye Surgeon

I am SO glad I am not related to this family. I would hate for them to be in charge of my medical care decisions at EOL.