We work with People. It’s what makes our work – Healthcare – so special and so great. Not spreadsheets, not bottom lines, but average human beings that are having anything but an average day.
It can be very tough, working in the hospital. But it also comes with very special rewards. Each night after a long shift, home and resting in your own bed, only we know that truly weightless rest that comes with spending your day in the service of those in need. When our work is good, it’s really good. It’s the beauty and mystery of our work.
The opposite is just as true, however, and when it’s bad, it can be really bad. We deal with people. And yet, we’re people too. We’re human. We make mistakes. And when we do, there are often very real and very serious consequences for those we care for. This is the sometimes tragic, and all too often humbling nature of our work.
Anyone involved in this business long enough eventually develops a story or two of their own about the time things went bad. Really bad. For me, I’m taken back 10 years in an instant. I can remember that night and those days that followed in great and vivid detail. I was a Surgical Intern at a busy Army Hospital. It was November and I was five months into being “Dr Ruiter” – and I was pretty bad ass. I’d worked my way through those first awkward, fear-soaked months by way of shear grit and determination. I was meant to be a “”Surgeon””, and dammit, I was going to do it, whatever it took. I had been working very hard over the first few months of internship and had developed, I dare say, a pretty solid reputation. Overall, I was feeling pretty good about my place in the world. And then, one night in November on call, I met Mr. Jones (not real name).
Mr. Jones was a 54 year old former Marine who now worked as a police officer in the community. Mr. Jones had been unfortunate enough to have developed his second bout of sigmoid diverticulitis, and back in those days, that meant Mr. Jones needed to have his sigmoid colon removed. Mr Jones walked into our hospital to have his sigmoid colon removed electively. The diseased portion of colon was removed, back to healthy tissue, and was then re-connected via a hand-sewn, colo-colonic anastomosis
As an Intern, I had nothing to do with cases such as Mr. Jones surgery, or any other surgery for that matter. My job was to tend to the wards, and keep the gears greased. Every day. We saw each patient. We wrote the notes. We spoke with each Nurse. We checked the vital sign logs and carefully reviewed and recorded the inputs and outputs from the night before, and then spoke with the nurse again. Looking back, it’s easy to see how the senior ward nurses on the night shift were very important people in our lives as Interns. They were there when no one else was around. They had the experience and the know-how that I didn’t. They told me what to do and I obeyed like the scared little guy I was – at first. And then I started to get the hang of things. I started to get my sea legs under me. A new confidence and pride began creeping into my routine – somewhere around November – five months into being a Doctor. I was starting to officially know it all.
Mr. Jones was now POD4 following his open sigmoid colectomy. Although I didn’t sew the anastomosis myself, I knew all about him. He was suffering from a post-operative ileus. Had a quiet but soft abdomen, so we were going slow with him. He had had a fever two days ago on POD2, but that had defervesced with some incentive spirometry and pulmonary toilet and he hadn’t had any trouble since. His white count was up just a smidge this morning, but all indications were he was doing fine. We were anticipating the return of his bowel function any time now.
It was around 2200, and I was on call. The nurse paged. Mr Jones had developed a low grade fever to 101. I went and saw him right away. He was resting in bed, and generally appeared to be OK. I asked this former Marine if he had any pain or discomfort, and he said he did not – he was doing alright. No complaints. I examined him carefully, noticing his heart rate was up slightly and he had developed this new low grade fever, but otherwise, I felt his exam was entirely unchanged. His lungs were clear and his belly was quiet, only minimally distended, and soft and nontender. I felt it was most likely atelectasis causing the trouble here and I asked Mr. Jones if he could get up out of bed and walk around the ward. He said “sure Doc” and sat right up and struggled just a bit, but got out of bed and trooped around the ward for a while. When he got back into bed, his temp had decreased, and I assured the nurses Mr. Jones was going to be just fine.
Around 0100, when I got another call from the senior nurse on that night, I reassured her. She persisted. His temp was back up, his heart rate was still a little high, and she was starting to get worried. I again came down and saw Mr. Jones, examined him carefully, and again was not impressed. He must be experiencing post-operative atelectasis, so we worked again with the spirometer. Mr. Jones sometimes took a sleeping pill at home, and asked for some help falling asleep at this point. I felt confident there was no signs of trouble, and even though the nurse asked me if I was sure, I had it under control. You bet. Ambien to the rescue.
Well, it was around 0300 that things started to change in a hurry for Mr. Jones, and for me. He had spiked a fever to 103, his tachycardia was increased and persistent, and this time the nurse notified me and my junior resident. We both arrived at the same time to find Mr Jones no longer looking like everything was OK. He looked sick. His belly examine was only slightly more distended and still quiet, soft and nontender. Yet he was going into shock. We called for a portable AP Chest and drew labs and cultures. Our x-rays were reviewed by residents at night, and just as we finished drawing all the blood, a radiology resident was on the phone, holding for us. I didn’t even know what pneumopericardium or pneumomediastinum was at that point in my training, but I certainly knew what free air in the abdomen meant… it meant Mr. Jones was in big trouble and would need to get back to the operating room STAT to have his belly opened again.
And then that sinking feeling…quicksand… set in. Swallowed me… sinking… The floor just gave way and I remember vividly clutching for anything solid to hold onto: ”But his belly exam was benign,” ”But he walked around the ward with me without any trouble,” “But he had no pain.” Sinking, sinking – and then, my junior resident snapped: “Why didn’t you call me earlier!?” The chart didn’t read too favorably for the physician caring for Mr. Jones…The chief resident asked harshly, “Why didn’t you call us earlier!?” Later, at morning report, the attending chided, “Why didn’t you call us earlier!?” We transferred Mr. Jones urgently to the ICU, started him on broad spectrum Antbx, sent him though the CT scanner, and ultimately ended up taking him to the operating room later that morning. His anastamosis had broken down and eroded into the retroperitoneum, as well as resultant purulent peritonitis. It was amazing to me to think back this tough old marine was able to follow my every request: deep breathing, ambulation, and ultimately sleep, with minmal complaints. After debriding the necrotic tissue, we had to bring up an end colostomy. Then it was over, and Mr. Jones was transferred back to the ICU.
Mr. Jones was now stable back in the ICU, and all the work had been done. The other residents were going home, to their beds and their wives or girlfriends, and I was sinking again, and I just couldn’t go home. I couldn’t do it. I slept in the hospital and stayed with Mr. Jones for three days. Sleeping and showering in call rooms. Spending ‘down’ time at Mr. Jones’ bedside. The hurt I felt cut so deep. I can still feel the warmth of shame, embarrassment and regret at my decade old mistake. I just felt so terribly bad. After three days in the ICU, Mr. Jones had improved, and was soon to be transferred back to the floor, and I was able to find my way home to my own bed.
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The worst was over for Mr. Jones as he continued to improve and ultimately went home several weeks later, returning later that year to have his colostomy reversed. Ultimately,I decided to leave surgery as a result of this case. I finished my internship year, but I notified the Chairman I wouldn’t be staying as a second year.
Looking back, now with a decade of experience (I didn’t quit forever), my delay of several hours in making Mr. Jones’ diagnosis was actually of limited clinical significance. The Chief resident and Attending surgeon that tied his Hand sewn anastamosis and then missed the evidence of its leak and breakdown for four days were far more culpable than I, but this is the nature of the perverse world of surgery – protect the surgeons’ ego and confidence at all costs, so he can go on with that same confidence, diving into the next belly, and the next, without second guessing himself. It’s part of the game and I was too naïve to appreciate when I was young and so wrapped up their approval. But I will tell you one thing, now 10 years later, having finally worked my way up to being a chief resident myself, I will NOT protect myself at the expense of someone lower down the food chain. I think its reprehensible that our profession routinely consumes its young, and no one should have to go through what I did.
And, now returning to the present day, I’ll share just a little about today, one of my finest… I matched. I’m finally earning the privilege to fulfill my dreams, and to study the art and the science of Surgery of the Hand and Upper Extremity. I’ve had my ups and my downs, my ins and my outs, but somehow, and only through God’s strength and direction I suppose, I’ve managed to stay the course. It’s the greatest achievement of my life, and it came only after, years ago, I learned to strip away my pride and my ego that had been holding me back.
My advice to doctors, nurses and anyone in healthcare, keep going. Stay the course. We work with People. It’s what makes our work – Health care – so special and so great. When times are at their darkest, strip down your ego, get on your knees, talk with God and confirm in your heart the path you’re on is the right one. Do all of this, and then Persevere.
About the author: Dr. Ruiter is finishing his Surgery Residency in Queens, NY. He also sells scrubs. Check out his company at XY Scrubs.com.
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