Medical Catastrophe

by Ronald W Dworkin

  ible. This is a quality in a dictator that is also vital in a doctor. The doctor must inspire the respect of his or her colleagues; if he or she cannot, there will be doubts and conspiracies. If the other residents had sensed that I wanted the intravenous simply to bill for it or to go home early, they

  would have thrown more obstructions in my path. Because my motives

  were worthy of respect, they did not.

  Impatience is a form of stupidity, but typically it is a form of normal

  stupidity. Dr. G’s impatience was an example of normal stupidity. After

  all, most people would prefer to earn more money or go home if they

  could. I certainly would. A doctor must resist such impatience. At the

  same time, he or she must do so patiently, so long as it is normal stupidity. A doctor must take name calling, eye rolling, and hostile body lan-

  guage into account, and rather than complain about them or opine that

  people should be without such faults, he or she must accept them. A

  doctor’s job is to make use of the people he or she works with—as they

  are and not as they ought to be.

  A doctor who pushes back against normal stupidity should never ima-

  gine that he or she does so for the last time. Stupidity never ends. A

  doctor meets someone like Dr. G every day, perhaps twice a day. He or

  she must know that firmness never brings lasting results and that it must be recommenced every morning.

  Medical practice is a dynamic process. Good medicine does not al-

  ways come pre-packaged; it also arises when one doctor pushes back

  against another, producing a stable equilibrium. On a good day, a cowboy

  doctor will thank the other doctor for helping to guide things onto a safer plane. On a bad day, the cowboy doctor will shout and scream and call

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  the other doctor names. But that goes with the business. A person cannot

  be a doctor unless he or she can endure being called an “asshole” several times a week.

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  THE TRAP OF OVERSPECIALIZATION

  Life in the hospital continued in its inviolable order. The scene was no different from what it had been several months before. A hospital does

  not experience seasons. Doctors and nurses wear scrubs all year round,

  and the smell of alcohol is everlasting; even the flowers in the waiting

  room are replaced fully sprouted. The great transition in a hospital is not from season to season but from day to night.

  This transition heralds an important psychological change. During the

  day an anesthesiologist rarely experiences a feeling of isolation because he knows other anesthesiologists are around to help him if he gets into

  trouble. Indeed, during a crisis, anesthesiologists swarm like bees. But at night, when he becomes the on-call anesthesiologist covering the entire

  hospital, the anesthesiologist is now completely alone, no matter how

  much fellowship he enjoyed earlier that day, and this has a marked effect on him. Sometimes he grows afraid. When putting a sick patient to sleep,

  his hands move as they did earlier that day, but sometimes they no longer seem to fully belong to him; they shake with a fine tremor and grow

  sweaty, as if disease were taking both him and the patient.

  Dr. C, my attending, was such a person. During the day he worked in

  the urological or orthopedic suites. This had not been his plan—he had

  trained in neuroanesthesia—but the department had been top-heavy with

  specialists when he was hired. Better to let a few people do neuroan-

  esthesia all the time, and get good at it, while others do something else and get good at that, the thinking ran. Dr. C soon found himself handling mostly cystoscopies and knee replacements. He became expert at spinal

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  C H A P T E R 3

  and epidural anesthesia, as these were the most common anesthetics used

  in such cases. Gradually his other skills faded. When he noticed this

  happening he fought to get into the other operating rooms, to rescue

  himself, but at a critical inflection point he realized that his skills were beyond saving, and he fought to stay out of those rooms. The department

  happily obliged him during the day, but at nights, when on call, he still had to function as a generalist, which scared him. Any case might walk

  through the door at night. Whenever the on-call resident presented him

  with a case in the evening, invariably the first question Dr. C asked, even before hearing the details, was “Can we do a spinal?” It came almost as a surprise to him that some emergencies had nothing to do with bladders or

  knees, and that patients had illnesses requiring general anesthesia. At

  such moments he would slouch in his chair and rub his forehead with his

  hand, as though he had a headache.

  Dr. C was a victim of occupational specialization, a well-established

  trend in American medicine that has intensified over the last few decades.

  In 1923, 11 percent of American doctors were specialists; in 1963, the

  number was 72 percent; by 1977, it was 87 percent. 1 Today, the general practitioner no longer even exists. What we call “primary care doctors,”

  including internists and pediatricians, were considered specialists a half-century ago. In the 1980s, rapid subspecialization took the trend to the

  next level—for example, internists focusing on cardiology or gastroente-

  rology, or OB/GYNs focusing on infertility or medical genetics. In the

  1990s, “sub-subspecialization” picked up steam as doctors confined

  themselves to a particular skill within their subspecialty—for example,

  gastroenterologists who worked only on food allergies, or cardiologists

  who worked only on heart failure. Although the literature says subspe-

  cialists and sub-subspecialists usually keep a hand in general practice, my own experience tells me this is less so now. To maintain income, solo

  subspecialists do need to keep a hand in other areas—but doctors are now less likely to be in solo practice. In the last eight years the proportion of doctors in solo practice has dropped from 62 to 35 percent. 2 As employees of large organizations, on salary, these doctors function more like line workers with a special technical skill. The problem, of course, comes

  when a line worker must suddenly become a generalist again, on nights,

  weekends, and holidays.

  On this particular evening a two-year-old girl had been mauled by a

  dog, resulting in several deep wounds to her leg that had to be washed out

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  and sutured. When I told Dr. C about the situation, he froze. Of all the

  cases that struck fear in his heart, none did so more than pediatric cases, as he had not put a child to sleep in more than ten years. Very quickly his fear infected me, for up to that point in my training I had done only a

  handful of cases involving small children. When we walked to the pre-op

  area and spied the crying toddler, I felt nervous. While we interviewed

  the girl’s parents, the feeling grew worse. I looked over at Dr. C. His lips were dry and he could barely mumble. The parents sensed our anxiety,

  and the mother asked Dr. C if he was comfortable with anesthetizing

  children. “Yes . . . I mean, of course, I’ve done a number of them,” he

  replied in an embarrassed voice. It’s a line that doctors sometimes use to deflect attention away from their inexperience, since technically speaking they aren’t lying—their “number” is simply zero.

  We left
to go set up the operating room. I looked for the pediatric

  breathing circuit, which is smaller than the adult-sized version, but

  couldn’t find it. Dr. C became frantic. “You can’t do a pediatric case

  without a pediatric circuit!” he roared. In fact, you can, I found out later.

  But doctors out of their element often fuss about technology. They feel

  compelled to imitate the expert at all points lest they stray into utter

  darkness by deviating for an instant.

  We brought the little girl into the operating room. Dr. C gave her an

  intramuscular injection of Atropine, a drug that increases heart rate. The drug is useful in children because their circulatory system is so rate dependent. I asked Dr. C whether the drug was necessary in this particular

  case. Dr. C said nothing. I asked again. I really wanted to learn. Finally, he barked, “Shut up, Dworkin! This is what pediatric anesthesiologists

  do. OK? They give Atropine.” I fell silent.

  Dr. C was acting silly, but I blame the system for his silliness. Dr. C

  had put his faith in technical expertise because professional medicine

  equates expertise with good doctoring. It is why Dr. C had subspecialized in neuroanesthesia—to become a technical expert. Professional medicine

  tells doctors to master a small bit of terrain to the exclusion of everything else, and that by doing so they will reach the heights of doctoring, in both prestige and salary. Yet all this does is turn a doctor into a monkey who performs a special trick. Dr. C’s problem was that he had trained for a

  different trick. When the system pushed Dr. C onto the wrong stage, the

  monkey became an ass, which is a very different thing.

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  C H A P T E R 3

  I put the mask over the child’s face and slowly rotated the dial on the

  anesthesia canister. The child screamed. When she finally lost conscious-

  ness and entered the second stage of anesthesia, known as the “excite-

  ment” phase, her eyes diverged and she began to cough. To make matters

  worse her tongue fell back and obstructed her airway. I started to place an oral airway inside her mouth to lift the tongue off the back of her throat, but Dr. C stayed my hand. “Don’t! You’ll cause laryngospasm!” he

  shouted excitedly. (In laryngospasm, a complication of stage-two an-

  esthesia, the patient’s irritated vocal cords clamp together spasmodically, preventing air from passing through into the lungs.) What Dr. C said was

  true—in adults. Small children respond differently to an oral airway, a

  pediatric anesthesiologist had once told me. “Remember that,” she had

  said to drive the point home, as one day I might find myself in the very

  trouble I was in now. I explained this to Dr. C, who relented. The oral

  airway worked like a charm.

  When the child was deep enough, Dr. C inserted an intravenous in her

  arm. I tried to intubate her but failed. Dr. C also tried and failed. He then tried to breathe for the child with a bag and mask, but secretions elicited during the intubation attempts, combined with a return to stage-two anesthesia, caused the child to go into laryngospasm. Her airway was now

  completely obstructed. The child’s heart rate dropped into the fifties. Dr.

  C’s eyes stared into space with a newfound intensity. The surgeon scent-

  ed danger.

  “Do something!” the surgeon shouted.

  Dr. C hesitated. “Perhaps . . . perhaps . . . we can try some Atropine?”

  he ventured meekly.

  “She doesn’t need Atropine! She needs oxygen!” blared the surgeon.

  He was correct. Low oxygen levels cause a child’s heart rate to drop.

  I hurriedly injected succinylcholine, a rapid-acting muscle relaxant,

  into the intravenous to relax the girl’s vocal cords. Within thirty seconds Dr. C was able to ventilate her. The oxygen bolus quickly returned her

  heart rate to normal.

  Dr. C again tried to intubate the child. This time he was successful. He

  breathed a sigh of relief as he listened with his stethoscope to confirm that the tube was in the right place. Then he looked at me with smiling eyes.

  He seemed to feel a certain pleasure knowing that a big part of this

  important business was already over. He even grew proud enough to

  teach me a few pointers about pediatric anesthesia.

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  When the surgeon finished the repair everyone was in good spirits.

  Nothing else, it seemed, could go wrong. But catastrophes do occur at the end of a case precisely because it is a time when doctors and nurses relax and let their guards down. They think of other things and their powers of concentration wane. After the surgeon wrapped the little leg in gauze I

  removed the child’s breathing tube. Instead of breathing normally, as she had when the tube was in place, she held her breath. Maybe she was

  breathing but her breaths were too small to be detected, Dr. C mused

  aloud with a sad, almost wistful longing in his voice. He had been so

  happy; things had been going so well; it seemed almost unfair to him that with the case now over the gods would visit another complication on him.

  The temptation to ignore things at the end of a case is great—and Dr. C

  wanted to ignore them. But the child was definitely not breathing.

  Life tensed. I nervously repositioned the little head. Fortunately, a

  simple chin lift made all the difference, and the child began to breathe

  normally again. The operating room staff breathed a sigh of relief. But the jolt had robbed Dr. C of his celebratory mood.

  After the case I went back to my small on-call room, removed my

  shoes, and flung myself down on the narrow, springy bed. The air in the

  room was dry and stale; the stench of someone’s lunch from earlier in the day rose from the trashcan by the brown desk. From outside the hallway

  the fluorescent bulb’s vibrating hum sounded incessantly.

  On-call rooms vary little across hospitals. Next to the bed stood a

  brass desk lamp with a busted shade. Years of doctors waking up dis-

  oriented in the middle of the night, reaching for the switch in the dark, and knocking the lamp over had left the shade looking like a face

  smashed up in a fight. By the lamp lay a phone. A brown chair claimed a

  corner. There was no other furniture.

  I lay still on my back to avoid crumpling my facemask or losing my

  wallet out of my scrub shirt pocket. I wanted to sleep. When fatigue is the result of physical effort, sleep is easy, but if fatigue comes from mental effort, such as giving anesthesia, sleep is withheld despite being urgently needed. I tried to believe in my ability to sleep. I tried to imagine myself at home, spotlessly clean from a shower, in my own bed and rejoicing in

  my own linens. But for the next twenty minutes I stared at the red digits

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  C H A P T E R 3

  beaming out from the clock on the desk. It seemed to me I was the only

  person in the world at that moment not sleeping. I shifted my gaze toward the faint glimmer of fluorescent light peering through the bottom of the

  door. I began to feel the intense, clinging darkness in the room. Combined with the stale air, it felt like I had been thrown into a hole and earth was being shoveled on top of me. A heavy lump of dirt fell on my body, then

  another, then a third. . . .

  I anxiously flicked a switch near my head, causing the overhead light

  to flame across the room. The first thing I saw was a large color photo-

  graph of the Vermont countryside hanging on the wall, put there to give

&n
bsp; the night call doctor a chance to wander in another, more fantastic world.

  Gazing at the picture I found myself drawn into the beautiful scene. I felt like the person who is suddenly infatuated with some region of the world

  he has never seen, but about which he is determined to learn everything—

  through books, through photographs. A small cabin sat in the middle of

  the picture. Smoke rose out of its chimney. Perhaps a doctor lives there, I thought. After all, serious people who do important work often go into

  retirement from time to time. They have country houses, mountain cab-

  ins, and cottages by the sea where they throw off all responsibility. Solitude liberates them from the actual world and lets them enter into the

  world of the imagination, where mundane matters recede and wider

  thoughts take their place. Then I looked around me, saw the busted lamp-

  shade and overflowing trashcan, and the spell was broken. In a doctor’s

  call room solitude degrades.

  I stared at my stethoscope lying on the desk, the technological symbol

  of doctoring, and wondered about its meaning. Is a doctor a serious per-

  son? Or is a doctor just a technician? Was I playing a great role or a small role in life? A French philosopher once said that all those who live by

  their work, manual or intellectual, are proletarians; all those who live by their speech he called bourgeois. Lawyers and politicians are bourgeois in that they earn their living by persuading others to pay them. Mechanics

  and bricklayers, by contrast, do not need to persuade—the excellence of

  their work is sufficient to sell it; technical knowledge replaces amiability and a slippery tongue as the source of success. But if the doctor-technician is a proletarian, he does not need nice manners. He can be rough and coarse in speech; he can dress like a tradesman, in uniform; he has no

  constituents, no audience—all he needs is the power to endure and work

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  his machine. A bourgeois needs a pretty office; a proletarian can live

  amid trash in a call room.