Captain of the ship

From the Buckeye Surgeon archive, original post date 8/4/08

I’ve written ad nauseum about the burgeoning problem of having too many cooks in the kitchen with regards to critically ill surgical patients. Standard operating procedure for a patient who arrives in the ER toxic from peritonitis: Consult GI, the hospitalist, ID, nephrology, a pulmonologist/intensivist, and, what the heck, a general surgeon. Patient has a surgical problem. Patient undergoes emergency surgery. Nurses spend the next two weeks pulling out their hair trying to keep straight all the conflicting orders written on the chart from the various consultants. That’s life in American ICU’s.

I recently wrote about a vasculopathic lady who presented with an infarcted sigmoid colon. Post operatively she sort of limped along. By post-op day #5, she still hadn’t turned the corner and, in fact, seemed to be deteriorating. I just didn’t like the way she looked. And her abdomen was more tender. And her WBC count kept rising. So I took her back for another exploration; sure enough, patchy areas of ischemia were apparent throughout the remaining colon, especially in the area of the cecum. I performed a completion colectomy and gave her an end ileostomy. There were palpable pulses in the mesentery, but the vessels were hard, calcified pipes. Clearly, this was a case of Non-occlusive mesenteric ischemia (NOMI), with the disease affecting the blood supply at the level of the arterioles. Classic teaching is that this form of mesenteric ischemia carries the worst prognosis because there are no real interventions to reverse the problem. All you can do is resect the dying bowel and hope the disease is limited to the colon.

I wrote in the chart an honest appraisal of her poor overall prognosis. The first 48hours were rough, but she was hanging in there. The stoma looked pink and viable. She was maintaining her blood pressure. Not a perfect picture, but at least some semblance of hope remained. The hospitalist called me early that Monday. He had read the notes I left in the chart. He was picking up the patient from his colleague and he wanted to know my feelings on the overall outlook. I reiterated that, although the prognosis wasn’t good, she actually wasn’t doing bad, either. Apparently, a conversation ensued later on that evening between the hospitalist and the family and there was a decision to implement comfort care measures and a gradual withdrawal of all supportive care. This was a decision that was made without my knowledge.

I came in the next morning and I was a bit mystified to find my patient lying alone in a darkened ICU room with all the monitors shut off, no IV’s running, completely disconnected from any form of supportive care. What’s going on? I inquired. They made the patient DNR-CC last night, the nurse replied. I see. So they did.

I flip through the chart and read the hospitalist’s note. After a discussion of the likely outcomes, the family decided to start withdrawal of care. The orders read as follows: DNR-CC, d/c labs, d/c dialysis, d/c TPN, d/c antibiotics, transfer to regular floor when bed available. At this point my temporal artery is pounding in my forehead and I’ve broken out in a cold sweat. But very calmly I sit down,take a few deep breaths, and I start to make some phone calls. I arrange for the family to meet me at bedside. I tell the charge nurse to give me a few hours before sending her upstairs. My patient is sleeping comfortably in bed. I check her blood pressure; 112/65. She’s saturating 99% on 4liters of oxygen. She opens her eyes and smiles when I say her name. The stoma has started to put out green enteric contents.

Basically I have to ask the family to reconsider probably the hardest decision they ever had to make. She’s maintaining her pressure. She’s breathing on her own. Her GI tract is starting to work. We may have something to work with here, I told them. I’ve been with her from the beginning. You know me; I wouldn’t try to mislead you. I think she may have a chance. The poor husband just stared straight head, eyes glistening, shaking his head. He’d spent an hour talking to a priest the previous night, second guessing his decision to make his wife DNR-CC.

In medicine there has to be a captain of the ship. One voice. One person to speak to the family. My mistake was taking it for granted that that role would fall on me, as the operating surgeon. The hospitalist, not to be too hard on him, was simply doing his job. He read the chart, spoke to me on the phone, and made a decision based on his interpretation of the situation. Perhaps he went a little too far, but in these ICU patients where there are no clearly defined boundaries for each specialist, how do you know when you’ve gone too far?

The family agreed to re-institute full care. I spent the next hour frantically re-ordering everything that had been stopped. My patient had been without any form of support for 16 hours; valuable time had been lost. They dialyzed her later that night. Antibiotics were restarted. Aggressive pulmonary toilet was implemented. After a couple of days, she started to turn the corner. She’s on the regular floor now. She’s eating and slowly getting back her strength. I think she might make it. And I almost lost her because I wasn’t adamant enough in seizing control of the ship. There is a time for collegial collaboration and a time for dictatorship when a patient’s life is at stake. The challenge is to find that delicate balance in one’s practice……

OnSurg thanks Dr Parks, Buckeye Surgeon author for permission to re-post from his blog.

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