Monday, August 15, 2016

Pediatric Surgery, Life and Death, and Other Pressing Matters

I haven't dealt with life and death -- or with death, anyway, thanks to the God who controls such things; that will come soon enough --  much since my stints on the hospital floors began six weeks or so ago.  I'm not looking forward to seeing death up close and personal. We all saw it in a sense during anatomy lab times, but there's a palpable difference between pulling a cadaver out of a drawer designed for cold storage of expired bodies and actually watching a person take his or her last breath or experience his or her final heartbeat on one's watch, or even while one is close enough to observe it. None of us are technically high enough on the food chain yet that the death of a patient would be considered our responsibility as long as we didn't so something like carry  a knife into a ward and stab a patient. Someone higher-ranking should still be around to absorb the responsibility even if one of us were to have the misfortune of standing nearest the departing patient when the big event goes down. I'd still prefer not even to be inadvertently standing closer than anyone else, but sometimes those things are the luck of the draw.

Despite all the checks and balances in place so that not one of us is yet placed in a position of responsibility for the life or death of a patient, the unthinkable could happen.  Someone codes out and the call is made. No one shows up very quickly. What does a third-year-medical student do?  He or she does not, at least at this stage of the game, reach for the defibrillators. Chances are they're not even within reach and will arrive with the crash cart, but even were they available, lowly third-year students, at least at this stage of the year, should keep our grubby paws off the equipment until instructed to do otherwise by someone in authority. So what does one do? The correct answer is to begin chest compressions as soon as possible. If the hospital is functioning even close to as it should be, someone with more knowledge and experience and greater skills should be there to take over for you very soon.  

My situation for the next two weeks  -- outpatient pediatric surgery -- should be one in which the life or death of patients is not even in question. Yet we know that anytime a patient goes under the knife -- particularly when general anesthesia is involved --  serious risks including death are present. Some of us remember the situation in which Jahi McMath, a thirteen-year-old girl, entered an ambulatory surgical center for a tonsillectomy. She came out of the anesthesia at one point, but then had bleeding complications, which led to cardiac complications, and the rest is history. I believe she has been legally declared dead, though the status of the death certificate is currently under challenge. She is still being kept artificially alive by machines as her family and the system argue over the level of her brain activity.  (This is neither here nor there, but I have a living will. In the event that no one finds it and I'm found in any state between persistently vegetative and functionally brain-dead, all life-support measures need to be suspended. I want whatever drugs will make me comfortable [ideally 100% unconscious] , and I want hydration. I'll die of starvation but not of dehydration. I think my family understands and accepts this, though, even if they don't find my Living Will document.  And I'm not making a judgment call against the family of  Jahi McMath, who underwent the tonsillectomy and failed to recover. I'm merely saying what I want if my body finds itself in similar circumstances.)

The procedures of the patients for whose surgeries I will be scrubbing in are all relatively routine. As I once stated in another blog, however the very definition of "minor" surgery is that which occurs on someone else or on someone else's child. Things go unexpectedly wrong. Even though children facing outpatient surgery are in most cases are stronger and healthier than their older counterparts, potentially more variables exist.  Just as adults neglect to inform their physicians and surgeons of health conditions, medications, and other contributory factors, parents do the same  in relation to their children. Children withhold information fro their parents and, in many cases,  from their doctors as well.  Conditions that might be relevant to a patient's surgery are more easily overlooked by children, who in some cases are too young even to be aware of the conditions themselves, much less the significance of them.

This is where we, the third-year-medical students, come into play. We're the first personnel in the doctor chain-of-command to speak with the children on the day of the surgical procedure.  Children between the ages of eight and eighteen are arguably more likely to confide in us things they wouldn't tell their parents or other doctors. It's more important than ever than we take complete medical histories both from the parents and from the patients themselves, and that we speak with the patients out of the presence of their parents. We need to be aware of nonverbal cues that may indicate a need to press just a bit harder for information.

If it sounds as though I'm taking the job my counterparts and I do in paediatric outpatient surgery even more seriously than it needs to be taken, such is probably the case.  I don't want to come across as a conspiracy theorist when it comes to underage patients. They're not all hiding drug abuse, sexual abuse, inadvertent illness, or anything else from their parents, surgeons, and anesthesiologists.  There's usually nothing for them to hide.  At the same time, if they were hiding anything,  the third-year medical students, if they were to do their jobs well, would quite possibly have the best chances of uncovering whatever it is that the young patients were attempting to conceal.  

We, as the youngest members in the doctor chain-of-command, potentially (though such is not always the case) have the opportunity to most easily build rapport with young patients. We can often allay their fears and reassure them more effectively than can even those interns just a few years older than most of us, though most of them are more like seven years older than I am.

Any advantage we have in terms of rapport with patients, we more than lose in terms of credibility with parents. For that reason, we deal with patients more than parents in most instances. A notable exception to this might be  if something unexpected were to occur in the O.R., and the lead surgeon or anesthesiologist felt it was in his or her and the patient's best interest  to remove all extraneous personnel from the surgical suite. Were such to happen, a third-year resident would be assigned to sit with the parents in the waiting room and to answer questions and to be a source of support to the parents as best we could, which would probably be not all that well since we just spent the previous hours avoiding the parents because our communication skills with parents were typically somewhat lacking.  this is the sort of thing we hope and pray does not happen. We all want "routine" surgeries to remain as such. We all want the best possible outcome for all patients, but probably in no case is this more true than when the patient is a child or an adolescent.

I apologize for monotonous medical concerns. I will begin my outpatient pediatric surgical rotation in just a few short hours, and I'm more than a little nervous.

pediatric post-operative procedures


  1. I worked in a post-thoracic surgery floor back in the 70s and we lost about one per week. The rest got out of there, even if only for a while. Mostly cancer, but other issues as well. Death is never fun, but often it's a relief. You will probably get to know it better than you want to. It just is.

    1. I'm looking at a week of non-cardiac thoracic surgery followed by a week of cardiac surgery in the next two weeks. It would seem overly optimistic to expect everyone to make it out of there alive.

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  3. I find surgery scary, even the routine ones. Hope your rotation is going well.

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