The Trouble With Surgeons

This post is actually something I wrote for my own purposes, documenting an incident that occurred during my overnight shift on Saturday. Even with my matter-of-fact reporting and medical jargon, the drama of the moment is more than apparent, so I decided it would make an interesting blog entry. I've gone through and made annotations in green for all my nonmedical friends.

Saturday night a 23-year-old male presented to the ER with progressively worsening shortness of breath and low-grade fever following several days of febrile illness and flu-like symptoms. On arrival to the ER he was supremely tachycardic (fast heart rate) (150’s/160’s - normal is less than 100), tachypneic (fast respiratory rate), unable to urinate (from decreased kidney perfusion, I thought at this point from dehydration), and intermittently hypoxic (inadequate oxygenation). I treated him for dehydration with IV fluids, ruled out pneumonia and then, when he remained tachycardic and dyspneic (short of breath), ordered a PE (pulmonary embolus, i.e., blood clot in the lung) CT. I had initially noted diaphragmatic tenderness, possibly secondary to coughing. Around 2am while waiting for the PE CT results his mother came out and said he was having left shoulder pain (Many things can cause this, but it is significant here because in retrospect this guy had referred pain from his diaphragm and spleen, which often goes to the shoulder). It was around 2:30am when the radiologist called with the results of the PE CT: Lungs were clear but there was fluid around the spleen and under the left diaphragm, from a ruptured or lacerated spleen.

I immediately went back to the patient's room to repeat his abdominal exam, and he had increased peritoneal signs (usually indicating a surgical emergency in the belly) compared to his exam on arrival hours earlier, with pain in all 4 quadrants, guarding and rebound (these would be the peritoneal signs). He also was still tachycardic in the 130’s despite aggressive fluid hydration (over 3 liters by that point). I immediately called the surgeon on call (Dr. X), and I ordered O neg blood ("universal donor" blood -- can be given to anyone regardless of their blood type in an emergency), a type and screen (to determine his blood type for type-specific blood transfusion), a monospot (the test for mono infection, which causes enlargement of the spleen and makes it more prone to rupture), and a repeat hemoglobin (blood count).

Dr. X didn’t call back. We wondered if there was a mistake on the call schedule, as is often the case, and paged Dr. Y. Dr. Y immediately called back and listened to my brief case history. He explained that he wasn’t on the call schedule, but agreed to come in given the patient’s emergent medical condition and our inability to contact Dr. X. I continued to page Dr. X. It was just before 3am when Dr. X called back, and I gave him the same case history I had given Dr. Y. Specifically, I explained to him that I had a patient with a ruptured or lacerated spleen, diagnosed by PE CT, and that the patient needed a surgical evaluation as soon as possible because of his worsening peritoneal signs and hemodynamic (related to blood circulation, as determined by pulse and blood pressure, among other things) instability. Dr. X was incredulous that I had called him regarding a splenic rupture diagnosed on PE CT and told me neither he nor any other surgeon would operate on a spleen without an abdomen pelvic CT. I assured him that I was not asking him to operate without an abdominal CT, and re-iterated how the atypical presentation had led me to make the diagnosis via a PE study rather than an abdominal scan. Dr. X asked more questions and focused on the fact that there was no history of trauma and that the patient’s hemoglobin on arrival was 18 (Way above the normal value of 12, though this guy's hemoglobin was probably concentrated from his severe dehydration). I kindly reminded him that I was the one at the bedside with more intimate knowledge of the patient’s condition, and he therefore should defer to my clinical judgment. I urged him to come as soon as possible, offering to get the CT while he was in route or to re-discuss the existing CT images with the radiologist. He stated that it would be unacceptable for him to wait in the ER if the CT wasn’t already done by the time he got there. He was so irate that I had called him without an abdominal CT that he requested the name of my medical director. I gave him his name, and he hung up on me. (Later I found out that instead of coming to the ER like he should have, he proceeded to call and wake up my medical director at 3am to scream at him like a prima donna. My medical director totally had my back, though.)

Just after he hung up on me, the nurse informed me that the while I had been on the phone the patient’s blood pressure had dropped to 80’s systolic (too low... you want that number to be 100 or more) and the repeat hemoglobin had come back at 12 (down from 18 hours earlier). I rushed back to the bedside and found the patient with a systolic blood pressure of 60. I had considered transferring the patient to a more accommodating surgeon, but did not feel he was stable for transport at this point. While we were securing more IV access for even more aggressive fluid resuscitation and blood, Dr. Y, thankfully, walked into the ER and assumed care of the patient. His blood pressure began to respond to fluids. He remained tachycardic, though, and his abdominal exam continued to progress.

Dr. X called back closer to 3:30am, and I updated him on the patient’s status and told him Dr. Y had assumed care. At this point Dr. X said that if it were up to him, he would have advised me to do a DPL on the patient and call him back. (Diagnostic peritoneal lavage: an obsolete procedure in which you cut a small hole in the belly wall, squirt saline into the abdominal cavity and then suck it back out to see if there is blood in it. If there is enough blood, the surgeon needs to take the patient to the OR. They don't even really teach this procedure in residency any more... that's how obsolete it is. It would have been an unnecessary and unsafe delay to definitive treatment for this patient.) The recommendation for DPL was despite my explanation that the patient was unstable and that there was an obvious bleed both by CT and by my clinical assessment. I chose not to dispute this point with Dr. X, but if there had been any doubt in my mind that this patient had intra-abdominal bleeding, the FAST bedside ultrasound exam (a quick and easy 4-view ultrasound of the belly looking for free fluid) would have been the preferred screening modality, not the DPL. He said it was a mute point by then and I agreed. The patient went to the OR for an emergent splenectomy with Dr. Y not long after. (I was 100% right... He HAD needed a surgeon stat.)

If Dr. Y had not come in, this incident could have been detrimental to the patient. Other patients could have been adversely affected as well, because at the same time this incident was occurring, another patient with chest pain was ruling in (having a heart attack) by Troponin (the enzyme that is elevated in your blood when there has been cardiac tissue damage, usually associated with a heart attack) and needed my critical attention as well. (So take all this drama and double it.)

I hope in the future the surgeons on call to the ER will be more willing to render their services emergently and without delay when the ER physician expresses an acute need, regardless of what imaging has or has not been done at the time that they are called. (Translation: Quit whining, get off your ass, and come in already!)