Monday, August 9, 2010

Fighting The Last Battle

Generals, and nations, are often accused of fighting their last battle during a current skirmish.  For instance, after the Cold War ended, the U.S. military was still ordering giant aircraft carriers and nuclear submarines even though our new enemies were hiding in caves or melting into the civilian population.  Obviously the generals at the Dept. of Defense were anticipating future Soviet era style warfare when that was not the enemy we are facing.

Doctors also become trapped in this fallacy of confronting a (medical) battle based on a previous experience that may not prove to be entirely appropriate for the situation at hand.  When I was a medical student during the surgery rotation, one of the surgical residents made a brilliant diagnosis.  A patient came into the ER with excruciating abdominal pain radiating to the back, hypotension, and pulsatile abdominal mass.  He accurately determined that the patient had a ruptured abdominal aortic aneurysm and called the OR to get a room set up emergently for a AAA repair.  The patient was rushed to surgery and the resident was hailed for his outstanding acumen. He was beaming, strutting around the ward for days afterwards, retelling the same story over and over again.

Wouldn't you know it but the following a week another patient came into the emergency room with sharp abdominal pain radiating to the back, hypotension, and what the same surgical resident felt was a pulsatile abdominal mass.  Again he called the operating room to set up for an emergent AAA repair.  As we rushed to the OR we all commented on how remarkable it was that two cases of ruptured AAA came in so close together.  Once we got into the OR and opened up the belly disaster revealed itself.  As you may have guessed, the patient did not have a ruptured AAA.  He didn't even have a surgical abdomen.  The patient was later diagnosed with acute pancreatitis.  The following week the crestfallen resident was grilled by the inquisitors at M&M conference for taking a nonsurgical patient to the operating room.  Same battle plan, wrong scenario.

I recently faced a similar situation.  A few weeks ago I took a patient to the OR for a routine D+C.  This is a fifteen minute procedure that is usually performed as an outpatient.  No big deal.  I've done dozens of them.  Except this time it was different.  As soon as the gynecologist inserted the suction catheter, the patient bled out a liter of blood.  The patient's blood pressure dropped precipitously.  It became a full trauma level situation.  A Level 1 blood transfuser was rushed into the room and multiple units of blood were transfused.  The surgeon was unable to stop the bleeding and had to resort to an abdominal hysterectomy to control the bleeding.  One of the scariest moments in my life.

You can imagine my trepidation next time I was on call and had to give anesthesia for another D+C.  I treated the patient like she was about to undergo a coronary bypass.  I made sure she had two large bore IV's in her arms.  I typed and crossed her for multiple units of blood.  The surgeon was aghast.  Why are you doing all this, he demanded.  Because as any textbook will tell you, you have to be prepared for massive hemorrhaging with any D+C, was my Oral Board certification level answer.  Naturally the operation proceeded uneventfully.  In and out of the room in fifteen minutes.  Is over preparation also a crime in the OR?  It may appear that I had overcompensated but at least I had peace of mind.  It will probably take me several more D+Cs before I feel like it is another routine case again.

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