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Don't settle if you're right | |||
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I still can't help but think that the only thing I did wrong was try to save his life. My 6-foot, 400-pound, helmetless, motorcycle-riding patient became a quadriplegic, and then died after four years of helplessness and pain. Did I miss something? Did I do something to cripple him? Kill him? I spent long days wondering. He was riding his motorcycle to work at two in the afternoon when the accident took place. A car suddenly turned in front of him, and he rammed into the side of it, reportedly at 40 miles an hour or higher. He landed on his head without any apparent loss of consciousness. He was brought into the emergency department yelling and belligerent. He had begun to panic because he was made to lay flat on his back, which he couldn't tolerate because of his size and chronic lower back pain. He also couldn't breathe lying flat. We decided to intubate him for his own safety and assess and treat his injuries. His post-intubation chest X-ray showed a bilateral pneumothorax. When his blood pressure began to drop, chest tubes were placed on both sides. He quickly began to stabilize. For the next two hours, he was in the radiology department being scanned from head to toe, literally. Then he was transferred to the ICU. He had received several units of blood and twice as many liters of fluids while in the ED. Within 30 minutes of arriving at the ICU, he became hypotensive and unstable. Six hours in the ICU: We did everything we could I stayed at his bedside in the ICU for six hours, feverishly searching for the reason for his continued hypotension. His injuries went beyond bilateral pneumothorax. Rib fractures with a flail chest. A fracture of the left scapula. Right open wrist fracture. Right-thigh laceration, 20 by 10 centimeters. Pelvic fracture with a symphysis diastasis of 10 centimeters. Left closed ankle fracture. CAT scans revealed that there were no skull fractures, intra-cranial injury, cervical fractures, or abdominal injuries. He was tachycardic; had warm, moving extremities; and no evidence of spinal fractures or cord injury. We worked systematically to make sure we weren't missing a reason for his state of shock. We had blood and fluids running through his IVs, along with dopamine to keep his blood pressure up. I replaced his bilateral chest tubes to treat the continued pneumothorax. We did a direct peritoneal lavage to rule out any delayed intra-abdominal bleeding. The orthopedic surgeon closed and splinted the right wrist fracture. I had already closed the right-thigh laceration. The cardiologist ruled out cardiogenic shock with a transesophageal echo. We ruled out neurogenic shock clinically. The only major injury that could account for his continued state of shock was the open-book pelvic fracture from which he was hemorrhaging. Throughout all of this he remained in spinal precautions. Herein lies one of many dilemmas. How do you keep a 6-foot, 400-pound man who lacks a visible neck in cervical spinal precautions? We had no collar on hand to fit him. He was as strong as an ox, and shook his head violently whenever he wasn't chemically paralyzed. We had to remove the head rolls to place a central line and perform a transesophageal echocardiogram. A nurse had to hold his head and neck in line to maintain C-spine precautions. Metabolizing paralytics faster than we could get them into him, he would periodically move. Any sedative or narcotic would drop his systolic BP below 90. An intensivist, an anesthesiologist, a cardiologist, and an orthopedic surgeon were working beside me to keep him alive. Working to get him transferred to a level one trauma center, where they had the expertise to place the external fixature to control pelvic bleeding. At one point we thought we'd have to go to the operating room to apply an external fixature, despite our lack of experience and equipment. We couldn't transfer an unstable patient. The nurses and operating room staff scrambled to put two OR beds together to fit his enormous girth and weight. Fortunately, he stabilized, and we summoned a helicopter to transfer him. The flight nurses walked into the ICU, took one look at the patient, and said he was too big to transfer by air. It took us more than an hour to find an ambulance big enough to take him. It was the same one that had brought him in 11 hours before. We moved him cautiously to the gurney, and sent him off wrapped tight for the one-hour ride. He was on dopamine, paralytics, blood, and fluids. I breathed a sigh of relief as I watched the paramedics roll him out the door. I felt certain he would survive. I felt certain we had done all that we could. I was proud to have been a part of this team of physicians who had worked so diligently to save the life of this critically injured man, who surely would have died if we had missed anything. I felt proud to be a doctor. This is why I had spent all those years in school and training. I went home and slept, feeling that I had done a great day's work. We're not bad guys hiding behind medical licenses Several days later I called to check on his condition. The intern stated that he was stable and doing well on the ventilator. Several weeks passed and I called again. A nurse informed me he was a C5 quadriplegic, most likely from a cord contusion. My heart sank. I was devastated. Five years later I found myself walking into a courtroom to face charges of medical malpractice. The suit said that because of my negligence, a man had been a quadriplegic for four years and then died of sepsis after a decubitus ulcer became infected. The litigation put my career on a stage where lawyers exchanged verbal jabs, each trying to get in a punch for a knockout. To watch this pugilistic debate was mesmerizing. I sat on the edge of my seat, watching nonmedical people try to explain to 12 lay people what I did or didn't do wrong. This experience forced me to realize how much my life was out of whack. I had no balance, no boundaries. All I did was work. I took a close look at what was really important to me. Could I accept the sacrifices I made to be the very best that I could be? Putting other people's needs in front of my own? Would they do the same for me? It was profoundly enlightening to realize that my career was in the hands of 12 strangers who were expected to understand and interpret in three weeks what had taken me 10 long years to learn; and even longer to practice and internalize. Maybe it was akin to a 400-pound man coming to me as a stranger, asking that I save his life and keep it as it was before he was thrown off that motorcycle going 40 miles an hour. I testified in court for four grueling hours. I was well prepared but nevertheless terrified I would say something wrong. I felt the need to repeat what took place over and over again just to make sure the jurors understood the sequence of events. The plaintiff's attorney—attractive, articulate, and dressed in an expensive suit—tried every trick in the book to get me to slip up, to say something she could twist into a lie. Anything she could to make me look inept, inexperienced, evil. Yes, evil. During closing arguments she played a scene of the Lord of the Rings: The Return of the King and equated the doctors in the case to the monsters. I sat there astounded that someone would actually say that I was an evil person wreaking havoc on innocent people behind the guise of a medical license. What has the world become, to think this of doctors? Are we the bad guys now? Somewhere along the line, we allowed things to get out of control. Somehow we allowed our profession to be vilified. While we were busy saving lives, our reputations and abilities came into question. We're losing a war that we didn't realize we were fighting. Medicine will never be the same for me I was found not guilty. It was a bittersweet victory. I was relieved that the jury believed I had done all I could for the man. I was relieved that I could continue to practice. But I was also sad that a patient of mine had died, tortured and unhappy, thinking I had done this to him. Emotionally spent, mentally exhausted, it was all I could do not to break down and cry. I have never been the same. I have never practiced the same. Now I'm more careful about my documentation. I discuss things ad infinitum with patients to make sure they understand. And I order more tests than before. Some people would call this defensive medicine, but it's what we've been forced to do to protect ourselves. I walked away from my experience hardened, less trusting of patients, and stripped of my idealism about helping others. But I'm trying to restore what was lost. I'm transitioning from general surgery to breast cancer care, which is what I want to do exclusively. I enjoy this subspecialty, and my patients sense that. I've also cut back my hours to take care of myself—to exercise, for one thing. So you'll find me bicycling around town more. But what about our uneasy relationship with patients these days? I don't think we do enough to win back their trust. One way to do that is to refuse to settle malpractice lawsuits when we know we did nothing wrong. A lot of people view these suits as a kind of get-rich-quick lottery. We add to that perception when we settle for no good reason. We have to stand up for our profession and fight to put the honor back into being doctors. Our patients won't respect us if we don't respect ourselves. So please think twice about settling a lawsuit because you don't want to lose time and money from work. Because you don't want to go through the embarrassing ordeal of sitting in court. Because you don't trust 12 lay people with your life. Because you don't want to take the chance of losing. Remember, people take a chance on you every day when they come seeking medical help. They have faith that you'll do the right thing for them. Sure, it's difficult when some of them turn around and file a lawsuit, but we can't give up on our profession. What we do is an honor and a privilege. Treat it that way every day. Fight for it every day. Don't give in. Work to gain back the respect we deserve. |
