Medical Catastrophe
Page 4
I woke the woman up thirty minutes later and wheeled her to the
recovery room. She clutched her baby happily to her chest and kissed it.
When I explained to her how sorry I was that we had to put her to sleep,
she ignored me. “Remember, you were nervous,” I reminded her. Glanc-
ing in my direction, and visibly annoyed with having to talk to me, she
replied, “Yeah, it’s fine.” Then, shifting her attention back to her baby, she smiled and cooed, “Isn’t he cute? So cute, my little one.”
I had almost caused a catastrophe. I felt awful. Another attending tried
to console me. He told me that it was good to make mistakes as a resident, so that I could learn from them, instead of later, in practice, when no one would be around to back me up.
True, I was only a resident at this stage. But inexperience alone was
not to blame. In the years to follow I would squirm whenever replaying
the scenario in my mind. Dr. S’s decision had been the right one. Its basis had been simple: “You get a bad baby.” But I could not say I would
necessarily make the same decision in a similar case, for the law was
unclear on the matter. A distraught mother who refuses general anesthesia has “rights” and “autonomy.” The law calls her a rational actor. But the
law also says that when a distraught mother signs the consent for an
epidural, the anesthesiologist is still liable for complications, because the mother is not in her right mind when signing the consent. She is in pain
and not a rational actor. Which is it? Is a distraught mother a rational
actor? I do not know. Neither does the law.
Yet the contradiction is not really the law’s fault. It is ultimately the doctors’ fault. Their confusion about what it means to be a doctor is what invited the law into the matter in the first place. Doctors feared behaving like Dr. S. They feared being thought of as overconfident brutes. They
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feared their iron tenacity might be interpreted as arrogance. They feared their authority might be interpreted as oppression. They feared their confidence might be interpreted as autocratic. They feared their impetuous
dash might be interpreted as insensitivity. They feared these things be-
cause they were unsure whether doctors should possess these qualities.
Indeed, they didn’t know what qualities a doctor should possess. At the
very least, they no longer knew whether a doctor should be tenacious,
arrogant, or authoritarian. So the law came in to sort out the mess, but it only caused more confusion. That the law did a poor job, however, is not
the law’s fault.
Herein lies the root of many medical catastrophes and near catas-
trophes that I was to discover over the years: In the deepest recesses of their minds, many doctors no longer know who they are. They have lost
the sense of themselves. They work with nurses and other doctors, they
deal with patients, more often than not these days they have employers,
and in all this they don’t really know where they stand. They don’t how
much authority they have, or, assuming they do have it, how much they
should wield it. They don’t want to seem paternalistic or bullying, but
they do want to do what they think is right. They don’t know if they
should follow their own judgment or, instead, conform to some practice
protocol. They don’t know what about being a doctor should make them
proud.
I exemplified all this. I was a textbook-smart anesthesiology resident,
but I didn’t know what qualities made for a good doctor. I didn’t know
how I should behave toward nurses, patients, or other doctors, other than to follow general rules of propriety. I didn’t know whether science was
more important than technique in medicine, or whether technique was
more important than disposition. I didn’t know if a doctor was like any
other employee who deserved to be checked by security for stolen bread
and toilet paper. I was walking a political tightrope, dipping my balance rod back and forth between right and left, desperate to keep my equilibrium. This made me dangerous. A doctor’s whole way of thinking be-
comes visibly undermined without a firm sense of identity, for his or her world is ultimately balanced on that cornerstone. I would not become a
safe doctor until I could say for sure what a doctor is.
This took time.
It is difficult to write honestly about what I have learned about politics and medical catastrophes during my years in practice, for politics is an
T H E P O L I T I C S O F A C A T A S T R O P H E
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ugly business. Some doctors are eager to show off the medical profession.
Something about being a doctor thrills them. But they lack confidence in
their pride; they fear that pride may take a fall if some bad points show up. I myself have never loved the medical profession with a lover’s
passion, a profession whose virtues are so many, and whose defects are
obvious. An honest discussion about the medical profession poses no
threat to my pride. But I do not write about medicine’s bad points to
expose doctors or to criticize them. On the contrary, my purpose is to help them, and their patients, by showing them who their real enemy is.
Many American doctors today feel under siege because of the changes
in health care. They see no real enemy to lay their hands on, but they
cannot help feel that such an enemy exists, that the enemy is invisible at their side, everywhere and at any time. That feeling gives rise to a passionate desire to argue—about government, about insurance companies,
about patients—but whenever they lash out and have a debate, it is never
really frank. They prefer to ignore the real issue, which beats within them and seems too shameful to discuss but is responsible for more medical
catastrophes than any flawed drug regimen or half-ignored infection-con-
trol protocol, and that is that no one really knows any longer what a
doctor is. Even doctors don’t know.
2
IMPATIENCE AND THE URGE
TO BE MACHO
A few months went by. One afternoon, in between cases, while sitting next to the operating room command center, I watched several young
orderlies pass the time throwing paper balls into a distant trashcan as they talked about sports. A heavyset man sat on a plush office chair inside the command center, scheduling cases and fielding requests for the orderlies’
services. Whenever a call came in, he would write out the request and
place the paper in a wire holder for an orderly to pick up. He conserved
his energy by rarely getting out of his chair except to eat or go to the
bathroom. After several hours spent running around the hospital, some of
the orderlies envied his quiet, sedentary life. So did some of the doctors.
I heard an overhead page calling for anesthesia to come to the emer-
gency room—stat. I raced downstairs and saw commotion around one of
the stalls. Forcing my way through the crowd of residents and nurses, I
found sitting on a gurney an eight-year-old boy struggling to breathe, his chest wall retracting with each inspiration, his color dusky. A medical
resident was trying to fit a breathing mask around the boy’s face, scaring the boy and causing him to choke and sputter.
“Aspirated food. . . . Don’t know what. . . . Can’t see it,” said the
doctor. The speed of his diction exposed his agitation.
Twenty seconds later the boy collapsed against the bed. The medical
pumping air into the boy’s mouth. Because of the obstruction in the boy’s 2 3
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windpipe, none of the air made it through, although the doctor hoped it
would.
“Stop!” I cried. “You’re pushing air into his stomach! His belly’s
getting too tight for him to breathe!” I grabbed a laryngoscope and a
breathing tube, pushed the doctor aside, and used my fingers to scissor
open the boy’s bluish lips and peer into the little throat.
I had a decision to make. If the food could not be brought up, then it
had to be pushed down past the carina, where the windpipe splits into two smaller airways. The food would then go down one airway and leave the
other airway open, letting the boy breathe on one lung. But the food could also shatter on its way down, blocking both airways. Then the boy would
die. Perhaps, I thought, I should cut open the boy’s windpipe at the neck and try to grab the food? But I had no experience doing that; by the time I got into the windpipe, the boy might be dead. Even if I could get in, the food might be sitting below my incision. I decided to push the food down.
I inserted the tube amid cries of “What are you doing!” I felt a pop as I passed the tube through the vocal cords, and then looked up at the boy’s
chest, which, for the first time, rose rather than collapsed on the left side during inspiration. I pulled out the tube and put the mask back on the
boy’s face.
The terrifying glint of blue left the boy’s fingernails. Nevertheless, we had to get the boy to the operating room so the ENT surgeon could
remove the food under controlled conditions. When we arrived, I told Dr.
G, the ENT attending, my plan. “I’ll breathe him down with anesthetic
gas and intubate him. Then I’ll pass a suction catheter down his stomach
and suck out any air or extra food. Then I’ll take the breathing tube out and give him over to you. But you have only a minute for each attempt to
snare the food in his lung. In between attempts I’ll have to breathe for
him as well as give him some anesthetic gas through the open lung,” I
explained.
I pressed the black mask on the boy’s face and turned up the dial on
the anesthesia canister. After a minute Dr. G crowded in:
“Okay, that’s enough. He’s asleep. Let me start,” he demanded.
“Wait a minute,” I said. “Be patient. It takes longer to get someone
deep on just one lung. If you start now, he’ll wake up in twenty seconds
and start coughing with your instruments in his throat.”
Dr. G moved away and impatiently tapped his feet.
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Impatience is raw material for catastrophe in medicine. Sometimes in
medicine the need to act is urgent. But impatience can also have more
pedestrian origins. For some doctors, time is money. Other doctors are
just eager to go home.
Doctors for whom time is money want to be doing business, and they
are usually speeding somewhere, trying to cram as many patients as they
can into an hour, all while complaining about their office overhead or
how little Medicare pays them. One anesthesia department I rotated
through during my training exemplified this attitude. Each anesthesiolo-
gist in the group had certain days assigned to him when he would make
most of his money for the week. The operating schedule would list all the patients for that day—including their insurance coverage—and the anesthesiologist for whom it was “money day” got first pick, choosing as
many cases as he wanted and typically loading up on patients with com-
mercial insurance. The anesthesiologist would rush around from case to
case, cramming as many surgeries into the day as possible. No doctor was
more impatient than an anesthesiologist on money day.
Other doctors are impatient because they want to go home. Medical
practice bores them. They also think the federal government is out to get them, that patients disrespect them, and that malpractice lawyers want to break them across their knees. They come to work each day wanting to
leave. Outbursts of impatience among them merely show how strained
their mental powers are.
I saw an example of this during a job interview in my last year of
residency. A large chalkboard hung on the wall in the lounge, listing all the anesthesiologists working that day, with those at the top leaving before those at the bottom, the position of each doctor determined according to when he or she was last on night call. When an anesthesiologist went
home, his name was crossed out, putting the next anesthesiologist “on
deck” and ready to be sprung. Doctors in the middle of the list felt a
growing excitement as they moved closer to being relieved, and they
glanced at the chalkboard every few minutes during breaks to see whether
any downward movement in the line had occurred. Doctors closer to the
bottom looked upon the list with quiet distress, knowing that they
wouldn’t be going home for hours. Each doctor dreamed of being on top
of the list so he or she could go home early. Some doctors purposely put
themselves on night call to grab the top position the next day; they were like men at sea piling onto a lone piece of driftwood, each man trying to
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save himself, one man on top but for a moment, then disappearing under-
water as another man climbed on top of him. With so much attention paid
to this particular wall with the chalkboard, and with so much yearning
and hope associated with it, it was dubbed the Wailing Wall.
A lack of understanding between physicians is a third reason for impa-
tience. As physicians grow more subspecialized, they increasingly know
more about their own specialty and less about any other. When another
specialist acts in a way that impedes their ability to get back to their
offices or go home, they resent it because they do not understand it. They argue with the offending doctor, or simply roll their eyes and cross their arms in disgust.
Dr. G’s impatience drew from the first and third reasons. To look at
him, one would hardly think he was such an aggressive person, but be-
neath his amiable exterior, lightning was hidden. He had once tried to
push me into doing a Medicaid case to get it “out of the way” so he could get back to his more lucrative office practice. The case involved a woman with a history of asthma and a recent lower respiratory tract infection,
now scheduled for tonsillectomy. The anesthesia literature at the time
recommended careful consideration before putting such patients to sleep,
lest an asthma attack be provoked. When I delayed the case to check the
patient’s white blood cell count, Dr. G erupted in a fury, noting that the ENT literature made no such recommendation. He seemed almost embarrassed by what he perceived to be my stupidity.
I spent three minutes letting the boy inhale anesthetic gas. Out of the
corner of my eye I could see Dr. G glaring at me. By the fourth minute his impatience had started to work on me like a slow poison. I began to doubt myself—after all, the boy looked like he was asleep—and once a doctor doubts the strength of his position, especially when confronted by an
impatient colleague, he inevitably increases the scope of his doubts, and then it becomes hard for him to stop.
<
br /> Dr. G moved in closer after I intubated the boy. “Wait a minute,” I
said. “I need to suck out his stomach.” But my tone was more begging
than commanding. Dr. G crowded in on me again. This time I relented
twenty seconds earlier than I otherwise would have.
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Right before Dr. G took over at the head of the bed, I tilted the table to the right. Dr. G grew annoyed.
“What are you doing?” he asked impatiently.
“If you grab the food, then lose hold of it halfway out, I don’t want
any of it falling back into his good lung and blocking it,” I replied.
“Ridiculous. I’ve done lots of these cases and that’s never happened,”
boasted Dr. G, as he rolled the table back to level. “The tilt just makes things that much harder for me,” he added.
The more I tried to explain to Dr. G my reasons for tilting the table,
the more I felt as though my explanation was a pack of lies, although I
was telling the simple truth. Dr. G cross-questioned me and demanded
specific evidence. “Have you ever seen a case where this has happened?”
he demanded, puffing up his chest theatrically. “No, I haven’t,” I replied meekly. “You’re getting in a panic over nothing,” insisted Dr. G. “Well,
I don’t know . . .” I squeaked. Finally, losing patience, Dr. G shrugged
and said something rude and personal: “Dworkin, you’re a real Chicken
Little.”
I said nothing.
I had become quite unrecognizable in a very short time. It is a danger-
ous moment for patients. A doctor is full of confidence and vigor; sud-
denly his right hand loses its cunning; his tongue sticks in his mouth
every time he has to utter a decision; his eyes lose their luster and are no longer able to sway his coworkers; his knack for guessing the right move
is irretrievably lost. The doctor knows all this, and yet, in spite of it, he feels unable to change course. Why?
To stand up to a colleague, doctors must have something inside them-