22 April 2007

What is it that we do in medicine?

There are mornings after a night of weekend call, that I find myself thinking about what I actually "do" when it comes to the practice of medicine. My first encounter with a patient on a call night is usually in the Emergency Department after one of the interns or Emergency Room physicians has asked for a surgical evaluation. Many times, especially if the patient presents in a complicated manner, the Emergency Room resident or attending will call me directly and bypass the junior resident. This is not because the junior resident is incapable of making an evaluation, but largely to save time.

When I get one of these calls, I usually beep the junior resident and we see the patient together with the junior resident taking the lead. It the junior is in the middle of something else, I will start the evaluation and fill them in when they break free of what is demanding their attention at the time. In general, I have no problem "picking up the slack" when a patient needs to be seen earlier rather than later. I also try to pull a medical student or two if there is something of an educational note (definitely in these cases) that I believe will contribute to their learning.

I generally will introduce myself to the patient and begin to ask questions. Last night, I found myself face to face with a gentleman who had a cold right leg. "Mr J, how long has your leg been like this?". "I don't know doc, I think since this morning. It started turning color about four hours ago". "Doc, I don't want to lose my leg." He began to plead with me not to "cut off" his leg. At this point, I begin to set in motion a series of orders to get anticoagulation underway for this gentleman. I also phone my vascular surgery attending who is heading in to the hospital. The interventional radiology fellow has the angio suite ready to go in case we need his services but a thorough examination of this gentleman spoke OR to me rather than angio. I quickly thought about my surgical approach and how I would do the embolectomy (removal of a blood clot) from a branch of the femoral artery by common femoral artery approach.

I reassure Mr J, that we are going to do everything possible to attempt to get some blood flow to his leg. I also explain the procedures and strategy which he accepts and understands. I am careful to explain that we have a very short window of time which may have already passed since he does not know how long his leg has been without blood flow. In cases like these, we treat aggressively unless we are sure that the time span is too long to be successful in the prevention of irreversible injury. Since nerves are the most susceptible to ischemic injury, level of pain is a fairly good indicator of injury. This gentleman had a fair amount of pain but not an overwhelming amount of pain.

As the patient was being prepped and anesthetized, I spoke with his wife who had now arrived and was in the surgical waiting room with the couple's son. She was certain that this problem had occurred no more than three hours ago (more encouraging for me) and that they had taken the time to speak with their primary care physician who encouraged them to call EMS and get to the hospital as soon as possible. I made a mental note to notify the primary care physician as soon as we were done with this case.

Back in the OR, my attending and I scrubbed and examined our operating field. I had asked the surgical technicians to "prep" the entire extremity as minimally, we would remove the clot but we might need to do more. The angio fellow stood by as we would assess our blood flow by intra-operative angiography. I made my incision and carefully threaded a Fogarty catheter into the vessel. I inflated the balloon and withdrew removing several large clumps of clot at the same time. Upon removal of the clot, there was a rush of fresh arterial blood which we promptly controlled. I continued to pass the catheter down both the superficial and profunda femoral arteries until we obtained a strong pulse at both the dorsalis pedis and posterior tibial areas. I also had good backbleeding too.

We shot a quick angiogram which showed both vessels to be open and I closed the arterotomy in the common femoral artery and closed the small incision that I had made to gain access to the artery. The patient would continue to receive heparin anticoagulant therapy and we would watch for signs of re-ischemia and reperfusion injury. The patient was transferred to the vascular intensive care unit.

I spoke with his wife and spoke with the patient's primary care physician. We would closely monitor this gentleman for signs of reperfusion injury. He might need additional angiographic studies once this immediate threat to limb had passed. I left him early this morning in the hands of the vascular service as I rounded on my patients and headed home. I have called the unit a couple of times and the patient's pulses are strong. It looks like this gentleman will go home with two legs.

What do we do? I performed an intervention that restored blood flow to a gentleman's leg. In the back of my mind, I remembered this man pleading with me to save his leg. I was also very careful to explain that even with the surgery, he might lose this leg at a later date. The fact that we were able to restore blood flow is a great sign that all will go well. In this gentleman's case, the loss of blood flow to his leg was sudden but because of his age (early 70s) he is likely to have some degree of atherosclerotic vessel disease that may need further intervention.

You see a patient in the emergency room and in many cases, you become a significant part of their lives. Your evaluation skills, your procedural skills and your experience immediately kick in and you do what you have been trained to do. The process is almost gradual and you do not realize that it is even happening. That process comes with seeing hundreds of patients and learning the best course of therapy for their problems. The process comes from hours of reading about the pathology of your patient and why you would choose a particular intervention.

I have a very strong interest in vascular surgery. To me, it is a wonderful branch of surgery with many elegant procedures and cases. I also love the patient population that is likely to come in contact with a vascular surgery (middle-aged to elderly gentleman with atherosclerotic vessel disease). These patient generally have multiple medical problems including hypertension, diabetes and some degree of lung disease (former smokers).

When a patient squeezes your hand, looks you in the eye and asks you to save a foot or leg, you know that you are going to do everything possible to do just that. Most of my best vascular cases have taken place in the Veteran's Hospital where vascular disease abounds. There just isn't a better population of patients that need the best care than veterans. This is what I "do" in medicine.


Anonymous said...


Jacqueline said...

My grandfather, father and husband are all veterans...thank YOU for caring for our veterans.

Anonymous said...

beautifully written!