“We can disagree with one another without being raging, judgmental, spiteful, self-righteous lunatics.”

Scott Stabile

Inspirational self-help author and speaker.

     Later that week, I got to present Mr. Dugan at our weekly M & M conference.  That was short for Morbidity and Mortality conference.  Every week, surgeons get together to review any complications and deaths that occurred over the last week.  Attendings, residents, and medical students attend, and all information and discussion is supposed to remain private, to allow free and open discussion.  A resident stands in front of the room and presents the details of the case.  The goal is to review every case that fell short of the expected outcome, understand why, and avoid repeating the same mistakes. It gives everyone a chance to learn how to improve care and achieve better results for our patients.  It has always been one of the most valuable learning experiences for residents, and attendings as well.  It is supposed to be an opportunity to discuss these cases with peers without fear of lawsuits, license revocation, or other punishment.

  However, M & M conference can get downright vicious, with attendings accusing other attendings of incompetence or malpractice.  Sometimes they would end up throwing things, yelling, calling each other insulting names.  Rarely this could even progress to a physical altercation that had to be broken up.  Surgeons had a reputation for arrogance and self-righteousness, and some were quick to anger, easily infuriated and incensed when their authority was questioned. Things could get pretty heated at M&M.  The poor resident presenting the case usually takes the brunt of the verbal abuse, even though they may not have had anything to do with the decisions that lead to the problem.  As a medical student at Ohio State University College of Medicine, I thought M&M was the most fascinating thing to attend.  The groups of surgeons were very divided and very loyal to their own partners.  The cases were supposed to be anonymously presented, but everyone always knew whose case it was.  The private practice attendings loved to skewer the academic faculty groups whenever possible.  Medical school academic faculty doctors are usually salaried by the university, so they have no financial incentive to operate a lot.  There is usually a variety of private practice doctors on the teaching staff, who generate all their income based on patient volume and teach residents.  The faculty members typically do not do as many cases as the private practice staff, but have more prestige, being “professors”.  This obviously makes the private practice guys mad.  They feel that they do a lot more operating and therefore claim to be better surgeons.  Then there is all the rivalry between different private practice groups because they are essentially in competition for the same patients.  So you throw all these surgeons into the same room, and make them start admitting their mistakes, and things can get really ugly.

     As a medical student, I saw residents reduced to crying at the podium, I saw attendings actually throw handfuls of papers up into the air and storm out, and witnessed shouting matches where they called each other morons, assholes, and butchers.  Once M & M was over, they all went back to being very civil to one another.  No one seemed to hold a grudge once M & M was over.  This was great stuff as a student, but now I would be the one up at the podium presenting.

     I had reviewed Mr. Dugan’s chart and had all his labs written down.  I knew every detail of the three days leading up to his wound coming open and I was ready to go.  I thought I might get off easy, because this was an expected complication in such a large guy who had an emergent operation.  I stood at the podium and gave my presentation, giving the details of how we closed the wound, what suture we used, and how we had packed it.  Before I could even get to the complication, the dehiscence of the wound, Dr. Adams interrupted me.

“Why did you wait a whole day to operate on this guy?  He came in with all the signs and symptoms of appendicitis, but you just sat on him.  You know, people did appendectomies before we had CT scans.  Did you have any surgeons around you capable of diagnosing an obvious appendicitis?  Do you need to rely on CT scans to make the diagnosis, or should you be able to figure it out?”  This was a clear jab at the attending. 

“Well, his exam was not exactly classic, and because of his size, it was very hard to determine exactly where his pain was located.  We thought the risk of operating on him was high, so we wanted to be more sure that he really had it…”

“If he is high risk for an operation for appendicitis, isn’t he at higher risk for an operation for a ruptured appendicitis?  You missed your window to get in there before this thing ruptured and he started getting septic.  He needed to be in the operating room the day he came to the ER,” he concluded. 

     Adams and Moezzi had a special feud going on.  Moezzi thought he was the only surgeon who should be doing thoracic cases, because he had always done them, and had always been the only one doing them here.  At that time, general surgeons did a lot of the thoracic, vascular, and oncology cases.  There was not the widespread sub specialization within surgery that exists now.  Adams joined one of the local surgery practices after a two-year fellowship in surgical oncology, where he had a lot of training in thoracic cases.  So of course, he did thoracic cases, which just grated on Moezzi’s nerves.  Moezzi tried unsuccessfully to sabotage Adam’s application for privileges at the hospital, and they took every opportunity to attack one another.  I was simply the means to an end, the avenue through which Adams would question Moezzi’s judgement and ridicule his surgical technique.   

“Why did you even attempt this laparoscopically?  Have you done a lot of these laparoscopically?  Is a five-hundred pound guy with a ruptured appendix and an abdomen full of pus the guy to learn on?” he continued.

     Moezzi immediately took the bait.  This was supposed to be an anonymous presentation, but he couldn’t keep his mouth shut. 

“That’s a ridiculous question.  That’s a stupid question.  He is the perfect guy to do laparoscopically.  I’ve have done enough of these cases to know who benefits and who doesn’t.  His whole problem is wound breakdown.  If we could have done him lap, we wouldn’t even be talking about him now.  He would have had three little incisions and been home by now,” he roared.

“That’s the point,” Adams countered.  “You couldn’t do him lap, you could have predicted that.  You just prolonged the case and wasted time.”

“That’s ridiculous!  If no one ever tried anything lap because there was a chance you couldn’t do it, we’d still be making big subcostal incisions for gallbladders!”

     Ann was giving me the signal to just keep presenting, so I went on to tell the rest of the story, how we found intestine sticking out of the wound, he went back to the OR, and they were not able to close anything.   There was an abscess at the site of the appendix, which they had cleaned up and irrigated.  His bowel was dilated and swollen to the point they couldn’t get the belly to close.  The tissue was too friable to hold a stitch anyway, and they had thought about retention sutures, but there was no needle large enough to get all the way through the abdominal wall.  They had used an old trick where they got a sterilized plastic IV bag, cut it open and placed it as a protective barrier over the exposed intestine, tucking it way under the abdominal wall all around the wound.  They covered this with a packing of moist gauze.  Next came several large drain tubes, then all this was covered with sterile towels and a big watertight adhesive plastic drape.  The tubes were hooked to suction, creating a vacuum to remove fluid and hold the wound together.  This “Vac Pac” had to be changed in the OR every couple of days.  The hope was that the bowel would gradually become less dilated and swollen, the tissue would become healthier as the infection cleared, and eventually the belly could be closed safely.  This method of temporary closure of the abdomen was commonly used in trauma patients or patients with catastrophic infection in the abdomen precluding any type of permanent closure. 

     He was back in the ICU now, on the ventilator.  He was showing signs of going into ARDS (acute respiratory distress syndrome, where the lungs could not exchange oxygen and carbon dioxide adequately) and was going into renal failure. 

     Adams jumped right back in as soon as I had finished.  Budros and Trevino both backed him up, saying that using the open abdomen technique was wrong, and that Moezzi had obligated this patient to several additional trips to the OR and more general anesthetics when he was too high risk to keep going back to the OR.  They thought he should have had his abdomen closed with retention sutures.

“I have never encountered an abdomen I could not close. With proper technique and patience, any abdomen can be closed. Then this patient would not need to return to the OR every two days. He is going to die from all these needless trips back to the operating room,” Budros declared, with a tone of condescension and arrogance.

     Moezzi’s face flushed deep crimson. He looked ready to explode. Having his surgical judgment and expertise challenged was more than he could tolerate.

“You are full of shit!!” he shouted.  “There is no way this abdomen could close.  You have never operated on a five-hundred pounder with pus all over his belly!  His bowel was so dilated you couldn’t get those edges anywhere close together!”  Someone suggested putting in retention sutures that encompassed half the depth of the abdominal wall, which was ridiculed by most of the attendings there.  Someone brought up the possibility of using a biosynthetic mesh to bridge the gap and close the belly, but no one had much experience using that mesh at the time.  The Blue Team bickered back and forth with the Red Team for a while, then thankfully, Ann just got up and started presenting the next case, basically ignoring the audience.  I hadn’t done too badly, but I was glad to be out of the hot seat.

     Almost a week later, I went up to the ICU one night when I was on call to see how things were going for my 550 pound appendicitis patient.  Ash was on call, and I plopped down next to him in the nurses’ station to see how things were.

     “He looks like barely-warm shit,” Ash said.  “He stopped urinating, his BUN and creatnine are rising, he is on ninety percent FiO2 and his peak airway pressures are in the fifties.  He is not gonna make it.  And worse, he is gonna take a long time to die.”

     Ash was one of the third-year residents.  He had done all his ICU rotations last year and was now in the lab for a year.  In our program, we all did a year of bench research between our second and third years of training, in one of the Yale University research labs.  We didn’t see a lot of the lab residents at the hospital, but they took SICU call to alleviate the second year schedule a little bit.  Ashton Patel was a big, tall Indian guy, who on first impression seemed sort of soft spoken and sane.  Nothing could have been farther from the truth.  He was outrageously, outlandishly irreverent and hilarious. 

     We were now about two weeks into the August rotation, and I had pretty quickly learned to maneuver the peculiarities of the Blue Team Attendings.  Once I understood the basic personality dysfunctions, they weren’t all that bad to work with, and I was able to learn some valuable lessons about general surgery.  But Dr. Kaczanek, our program director, continued to confuse me.  No one was able to really predict what he might do at any given time.  There were several nights when I would get a call in the middle of the night from the hospital operator, and she would tell me Kaczanek was on the line, looking for the resident on call.

“Did he say what he wanted?” I would ask, half scared.  She never knew what he wanted.  I don’t think he did either.  This would occur at midnight, two am, four am, any random time, when normal people should be sleeping. 

     He would come on the line and just chat for a while.  Then he might start grilling me for information on his patients.  Thankfully, he usually had only one or two in house.   

“What was Mrs. Grant’s hemoglobin A1c?” he demanded.

Crap, I don’t remember.  That test was done four days ago, was normal, and we had no good reason to even do it.  I don’t know the exact fucking value in the middle of the night when I have twenty-four other patients to take care of!

“It was in the normal range.  It was back a few days ago, but I would need to look up the exact value.”

     Then an unreasonable outburst would follow, about how I needed to know my patients, and how people die because interns don’t pay attention to details, blah, blah, blah.  He seemed genuinely enraged, like it was inconceivable to him that I did not have this information front and center in my brain.  Then, as suddenly as the outburst began, it was over, with no lingering evidence that he had been pissed off at me.  Jack and I had discussed this odd behavior, and were convinced he was at home, drunk and bored, so he just phoned the surgery resident to torture them for amusement.  He did not seem to even remember it the next day; he never brought it up.  We had him pegged as a closet alcoholic.  Or we thought he may be schizophrenic, perhaps afflicted with a much more severe Dr. Jekyll/Mr. Hyde type disorder like Dr. Adams.