“Embrace the struggle and let it make you stronger. It won’t last forever.”

Tony Gaskins

Motivational speaker and life coach

     With the pancreatitis guy settled in, we were ready to do rounds.  I paged the students, and Kenna and I headed up to the surgical floor to meet them.  Rounds were fast, and about half an hour later we were done.  I wrote some orders, then paged Jack to check out.  He was the intern on call and would be looking after all the patients in the hospital. We always went over our list of patients so the intern on call would know what patients might need attention throughout the night.   Now they were in the middle of rounds, so I would have to wait until they were done to check out.  I wrapped up some other details and about thirty-five minutes later Jack paged me.  They were done.  I headed back up to the floor to meet him and ran right into Kenna.

“Good, you’re still here.  Dr. Malone sent a direct admit that needs a history and physical and orders.  Smith is the name, needs antibiotics for diverticulitis.  See what his story is and page me.” 

     SHIIIITTTTTTTT!!  It was like a silent scream in my head.  I was so close to getting out the door.  So close.  One delay in getting out of the hospital seemed to have this steamroller effect – it resulted in a chain reaction of delays that just piled on top of each other and grew, until it was impossible to ever get done with your work and leave the hospital.  If I hadn’t gotten that damn four o’clock consult, we would have rounded early, then I wouldn’t have had to wait for Jack to round to check out, then I wouldn’t  have run into Kenna and I wouldn’t have one more damn admission to do before I went home.  I had last talked to Jed right before the consult and said I would be home for dinner.  Now it was almost eight o’clock.  And I had forgotten to call Jed, as I didn’t really realize how late it had gotten. 

     I briefly thought about suggesting Jack do the admission, since he was on call, but thought better of it.  She was already in a bad mood from the whole pancreatitis thing.  She would likely make some reference comparing me to Shahid, then tell me that I was the intern for this team, so it was my responsibility. 

     I met Jack and wasted ten more minutes of my time bitching about the admission.  Jack offered to do it, as expected.  But Kenna was waiting for a page from me.  I signed out and then headed off to find Smith’s chart.  I picked up the phone to call home, hesitating.  I put it back down, thinking I’ll call right before I leave.  Then when I am actually physically leaving the hospital I can say for sure, without any doubt, I am on my way home.  I got the admission settled in and finally left the hospital around 9:30 pm.

     I could already foresee the fallout from Kenna’s tirade at the medicine residents. About once every three or four weeks, she was the source of an official complaint to the Department of Surgery.  She was always pissing someone off.  Early Monday morning, the Chairman of the Medicine Department would be in Dr. Sanders’ office wanting to know why the surgery residents were so disrespectful and unprofessional.  Shortly after that we would be called to his office for our reprimand.

“When you get out in private practice, these are the guys who are going to refer to you, and if you piss off every one of them, you don’t get any patients.  You will never do a single hernia or gallbladder or breast cancer if you alienate every possible source of referral.  Most of our patients come from the primary care docs.  I know they don’t know how to take care of surgical problems, but we need to educate, rather than alienate.  They may be blithering idiots when it comes to surgery, but you must treat them professionally.  They aren’t surgeons.  That’s why they are consulting you.  When one of you behaves in a disrespectful manner, it reflects poorly on the whole department.  And more importantly, it forces me to waste my time groveling to the entire administrative staff of the Department of Medicine because the nasty, evil surgery resident made them feel bad.”

     September rolled around, and I was staying on the Blue service.  It wasn’t bad, at least I didn’t have to pick up a bunch of new patients.  Jack was scheduled to go to orthopedics for the month, so the surgery department could not put it off any longer –  Shahid was coming to the General Surgery Service.  He and Kenna would be on the Red Team, and Zayed was coming to Blue with me.  We were all anxious to see how Kenna and Shahid would do as a team.  Jack was overjoyed to be going to orthopedics and vowed he would not get sucked back to the Red Team when Shahid screwed up.

“They hired him, they can put up with him.  He has to do general surgery sometime.  He can’t do a general surgery internship and never be on a general surgery service,” he pointed out.

     Ed Simms was a new admission for me in room 810.  I had been warned by the nursing staff that he was an odd guy.  He was young, only about forty-two.  He was unemployed and drank too much.  He was by all measures a typical House patient.  But he actually had good health insurance.  He was still considered a dependent child because of some pseudo-psychiatric diagnosis, so was covered by his parents’ insurance.  The parents seemed like normal people, it was hard to figure out how this guy turned out like he did.  He had been admitted through the ER about three months ago with toxic megacolon.  This condition can be caused by infection of the colon, or low blood flow to the colon, or by a complete obstruction of the colon.  The colon becomes more and more filled with gas, and the wall gets stretched thinner and thinner as the colon distends up like an overinflated balloon.  Bacteria start to leak through the colon wall and can lead to septic shock.  If this goes on long enough, the colon can burst, releasing large amounts of bacteria and stool into the abdominal cavity. 

     When Ed had come in, he was as close to having his colon explode as you can get.  Dr. Moezzi had taken him emergently to the OR for “blowholes”.  Small incisions were made in the abdomen and the distended colon was opened and sewn to the skin so it could release gas and stool externally, protecting the abdomen from the impending rupture.  He had a blowhole, more formally known as a loop colostomy, on each side of his abdomen.  It’s the quickest way to solve the problem if a patient is not stable enough to endure a longer surgery, like removal of the whole colon.  If the patient does well, the colon distention resolves, and over many weeks, the bowel wall returns to normal.  After everything returns to normal, a second operation can be done to put everything back together, so the patient no longer wears bags to collect stool and gas.  Ed was ready to have his second operation to get rid of the colostomies and restore the colon. 

     He had become well known for his strange behavior on his last admission.  Dr. Moezzi had left strict, almost paranoid, instructions that everything go smoothly – no screw-ups.  He wanted to get this case done and then never have to see the guy again. 

I went in to examine Mr. Ed Simms and get the admission done so I could get back to preparing my presentation for this week’s M&M conference.  The room door was open, the privacy curtain was pulled back, and there he was in bed, buck naked.  His hospital gown was on the floor, and his sheets were crumpled to the bottom of the bed.  He had an ostomy bag hanging down on each side of his abdomen.  I pulled the sheet up to cover him.  This became routine, as the man refused to keep his hospital gown, or any other type of clothing, on while in the hospital.  He would not cover up with a sheet, and he would not keep his curtain or door shut.  The first thing I would do as I came into the room twice every day was try to get him covered up.  Even as I talked to him and examined him, he kept trying to inch the sheet down, to uncover himself.  I got him admitted, went over the bowel prep instructions with him, and talked to the nurse myself about how paranoid Moezzi was about this guy.

“If something goes wrong and he can’t get this guy operated on tomorrow, he is going to freak out,” I said.  She assured me they would all do their best to make sure he was ready.

     I got to the floor for rounds early the next morning, and the nurse found me, looking a little worried.

     “I need to tell you something, about Mr. Simms.  You’re covering him, right?” she said.

     “Yes,” I answered, bracing myself for what was obviously going to be bad news.

     “Well, he has an order for nothing to eat after midnight.  But, um, we’re pretty sure he ate most of a pizza around four am.”

     I just looked at her for minute, to let that settle into my brain.

     “Why is he getting a meal in the middle of the night?   How did that get by?  Who took it to him…his chart says NPO, his orders say NPO, he has the NPO after midnight sign on the door.  They don’t even serve meals in the middle of the night!  Who brought him a pizza?  Why didn’t they see the NPO sign on the door?”  I was getting a little frantic, already thinking about the conversation with Dr. Moezzi.  Anesthesia would cancel his case now, since he ate.  They wanted the patients to have not eaten anything for eight hours pre-op, to ensure their stomach was empty and decrease the risk of vomiting and aspirating stomach contents into the lungs during anesthetic induction and intubation.

     “Well, they may have seen the NPO sign, but they wouldn’t have known what it meant.  It didn’t come from the hospital.  No one from here brought it.  He called out from his room and had it delivered.  From Dominoes.  I didn’t even see the delivery guy.  The unit clerk saw him bringing the pizza, but figured the night staff had ordered it, and didn’t think anything of it.  When we checked him for morning vitals, the box was sitting in bed with him, and it was almost all gone,” she informed me.

     “He called out and had a pizza delivered?  A pizza?  Delivered right into his hospital room?  He ate a whole pizza three hours before he is supposed to have surgery, after I explained fifty times that he can’t eat anything after midnight,” I repeated, as if trying to make the whole thing sound reasonable.

      The nurse gave me a sympathetic look. 

     “Oh, shit.  This is somehow going to be my fault,” I sighed.

     I walked back to Ed’s room.  Sure enough, there was the large box, with two little squares of dried-up pizza left.  I pulled the sheet up to cover him.  He was naked as usual, without a care in the world.

     “Did you eat this pizza?” I asked.

      “I sure was hungry – you guys haven’t let me have nothin’ but juice for two days,” he replied, as if I was some cruel sadistic beast.

     “You weren’t supposed to have anything after midnight.  You are supposed to have surgery this morning.  Do you remember?”

     “Well, I don’t care.  I’ll still have my surgery, I don’t mind.”  He didn’t see that there should be a problem at all.

     “The anesthesiologist will mind.  You’re going to be cancelled now,” I grumbled as I left.

     I held onto the false hope that maybe Zayed would call Moezzi and explain the whole situation.  Of course, as soon as I told him, he laughed.  Then he told me to call Moezzi to tell him we were canceling the case.

     “What do you mean, he ate a pizza?!  How does this happen?” Dr. Moezzi roared after I explained the situation.  “Why wasn’t he NPO?  What are you people doing, are you paying any attention to the patients at all!?”

     When he was mad at us, Dr. Moezzi always referred to us as “you people”, like we were from a different planet or something.

“He was NPO…” I started to explain but was promptly cut off.

“No, he wasn’t.  I don’t think pizza is part of an NPO diet, is it?  Do you know what NPO means?!  NPO stands for nos per orum, which is Latin for nothing by mouth!!  So how can you say he was NPO when you just told me he ate a pizza?!  That’s not NPO at all.  What is your definition of NPO? Because eating a damn pizza is not my definition of NPO.”

He was starting to get hysterical.

“The order was on the chart, but he had a pizza delivered to his room in the middle of the night.  He called from his room.  No one knew he had done it, he just did it on his own…”  I managed to get out before being interrupted again.

“Who the hell was watching this patient?  Do you people think patients just disappear at night and no one needs to worry about them?  Are you all in your lounge watching your new TV, while patients just do whatever they want?”

     Oh my God, here he goes again with the you-residents-are-no-good-slackers speech.  He continued to rant as my mind wandered off into an alternate fantasy conversation.

“Yes, Dr. Moezzi, I was just watching movies with my feet up, eating chocolates all night,” I would sarcastically reply.  “You know, you are not the only surgeon in the whole world who has patients we take care of.  If you would pull your head far enough out of your ass to see that other people exist in the world besides you, you would see that I admitted four people and did a trauma alert last night, plus scrubbed into the OR for a case.”

“Well that’s no excuse.  When I was a resident, things like this didn’t happen, we paid attention to details…” he would say, but then I would interrupt him.

“Maybe the program should hire twenty-five more interns, so that each and every one of your patients who is supposed to be NPO could have a physician sit at the bedside the whole night to make sure he doesn’t order a pizza.  Like we have nothing better to do than worry about your psychotic patients ordering take-out the morning of their surgery.”

“It’s your job to see that these patients are ready for surgery, you people cannot even manage a simple thing like keeping someone NPO,” he would say in that condescending irritating tone.

“Listen, jackass, if I actually liked you, or had any respect for you as a surgeon, or thought you were a decent human being, maybe I would do a better job.  But since all the residents are sooooooo irresponsible, maybe you should just take care of your own damn patients and resign from the teaching service, because you are nothing but a complete idiot,” would be my response.

“Hello, are you listening?  Are you there?” Dr. Moezzi blurted out.

     Jolted back to reality, I did the best I could to appease him, then called the OR to cancel the case.  The Blue Service was starting to get on my nerves.  Two months was a long time to spend with this group of attendings.  We finished rounds, then headed down for M & M conference.   

     I was back up at the podium at M & M, presenting Mr. Dugan and his continuing series of complications.  Last week I had to present him for post-operative renal failure, respiratory failure and sepsis.  I tried to argue that these complications stemmed from his second operation, which I wasn’t involved in, so I should not be the one presenting him.  This argument got me absolutely nowhere.  I would be presenting him every week indefinitely until he got better or died.  Events last week included the development of a blood clot in the deep venous system of his left leg.  The blood clot from his leg had broken off and lodged in his lungs.  He was now on heparin, a blood thinner that would help dissolve the clot, or at least prevent it from getting worse.  His sepsis seemed to be resolving.  He was not on any medications now to support his blood pressure, and his white blood cell count had started to trend down towards normal.  It had been about four weeks since his appendectomy, and he would need to go to the OR for a tracheostomy soon, as we couldn’t leave that endotracheal tube down his throat forever.  He was making no progress at all on the ventilator, and his pulmonary status continued to deteriorate. 

“Should we stay tuned for next week’s edition of the five-hundred pound lap appy gone bad?” Adams asked.

     I assured him I would be returning weekly for the latest update.  He and Moezzi had sort of beat this issue into the ground, so my presentations didn’t generate much discussion anymore, thank goodness.