Tuesday, November 8, 2011

Indecision Conundrum

"He's the best of the lot. He sees things others don't or at least things that others ignore & takes the final call." I heard a resident speak of a junior surgeon in my hospital the other day. He also commented on how others are scared of committing themselves to a line of treatment. Fellow interns, how many times have you gone through a file and read, "Dr.ABC has assessed the patient and suggested continuing conservative line of management with review if any change in condition"? It's definitely easier on the surgeon, it's easier on the relatives, but most importantly, quite often it's easier for the disease. 

Every few weeks, each hospital holds a Mortality & Morbidity meeting, to reassess what went wrong with the selected cases for review & offers advice on how to best manage similar situations in the future. I am yet to attend such a meeting, but have been told that every care is taken to be sympathetic to the state of the presenting doctor & avoid such terms as "accuse" and "blame". People die, that's the harsh reality of our profession, it's worse when they die due to human error; and mistakes do occur regularly. The worst errors are those of omission. But, sadly these are seldom discussed at these meetings. Not operating is often the easiest choice that a surgeon makes. This is most true when a problem is often complex and survival considered bleak. His morality rates are kept in check, he goes on perform surgeries where the prognosis is optimistic and everybody goes home happy, including the patient, albeit not for long. 

From what I can see, some of these surgeons ought to grow a pair. If they were so interested in watching from the sidelines, they should've become physicians instead. There's no sense of discovery, no enthusiasm of finding the unknown. What's so great about opening a patient for an appendectomy & finding an inflamed appendix? Nothing! Ever been in a massive surgery where they operated for something else instead? It's magical. You hope for a fruit and find a fruit tree instead; every surgeon's dream, or at least I used to think so. And while I'm at it, people need to stop treating the pancreas like it's the fucking plague. I agree it's insanely difficult, the protocols aren't well-defined & predicting a prognosis is often more difficult than the surgery itself; But, still! I'm sick of hearing people go on about what "should have" been done two, three weeks ago and how how the patient is now inoperable. This rant is dedicated this awesome surgeon who joined us at rounds today. I wish he'd come 10 days earlier, I would've witnessed one awesome surgery!


  1. Where'd my comment go? I am too lazy to re write it.

    Good post.

  2. Not finding an inflamed appendix on an appendectomy is not a proud moment.
    Operating for something else when a different disease process was suspected reflects poor judgment on the surgeon's part.
    It takes great amount of experience and confidence to do nothing.

  3. @mkk: Rather it is widely regarded if you don't achieve the standard "negative" appendectomy rates, you're being overly conservative with your diagnoses and missing out on potential cases.
    There're obviously times when someone's grossly screwed up a case. Just today I heard of a suspect TB Peritonitis turning out to be a Duodenal-Perforation. What I was mainly speaking of were exploratory laps. There's got to be a sense of adventure in tackling such problems rather than sulking about it through the surgery.
    And I'm not implying that every surgeon MUST be over-enthusiastic to cut, but abstinence from the scalpel is just plain stupid!

    @aayushi: Your comments seem to disappear a lot off late (suspiciously rolling moustache). Thanks

  4. You mean to say that there were times when an acute abdomen was managed conservatively? That requires even greater confidence than to rush the patient into surgery, given that the patient survived of course.
    It is not very clear what type of surgeries you were speaking about.
    Agreed about the negative appendectomies. But I have a feeling it was devised to justify the over enthusiasm of some surgeons. Haha.
    Was the mix up of TB peritonitis and D perforation that gross?

  5. The D-perf patient was an old case, dunno much about him apart from that he presented with a "sub"acute abdomen, ascitic fluid tapped seemed to have coagulum formation, started on AKT. Eventually though the Perf grew & drains revealed the problem, backed by the CT. Should find out if he survived.
    Mistakes happen. On the other hand, there was a patient of Ca Pancreas, not operated upon for 3 months, eventually after 2 weeks of intense workup, they opened and closed him immediately. Dumb! What were they doing for 3 months?!
    See the difference? Which one do you think is worse?

  6. I was a witness to four open and shut cases for Ca Pancreas. For once I hoped to see a whipple, but never was this ill fate due to a hesitant doctor.
    Anyways more details are required before I too start blaming the surgeons for the delay on your Ca patient. r/o contributory negligence.