Tuesday, January 11, 2011

A Surgeon and His Son Meet The Medical Establishment Head-On

A Surgeon and His Son Meet The Medical Establishment Head-On

NOTE: this is quite long and has some technical language.  It was sent (without the names redacted) to the Washington State Medical Board, along with a formal complaint.  This accomplished nothing.  The peacock surgeon is still plying his deadly trade.

On December 5th my 25 year old son, Andy, was involved in a head-on collision with a semi-truck.  His injuries were horrific, and life-threatening.  But his medical care was almost equally so.  I am writing this both as a father and as a trauma surgeon for 32 years.
I was called about 1 hour after his accident, and informed that he had a broken leg and was being transported to a small rural hospital in Northern Idaho.  Given my history, I jumped in the car and headed up there ASAP.  But first I suggested to the nurse that she make sure he had two IV’s started.  I have seen too many trauma victims succumb to shock from inadequate fluid replacement, especially in small hospitals.
When I arrived, he had had a CT scan, and x-rays of his left femur.  The CT scan showed multiple fractured ribs, sternum, back fractures, but no severe internal injuries.  They had ignored the right leg, but this turned out to have not one but two fractures of his femur.  His BP was in the 80’s and the FP said to me, “it can’t be too bad, his blood count is still normal (39)  Since with three breaks in his femur, he had a minimum of 6 units of blood loss (half his blood volume) I  knew that he was in deep trouble.  His blood count should have been ½ of normal, if they had replaced enough fluid to compensate for his blood loss.  Therefore they were at least 3 liters behind, and losing ground!
By this time, an orthopedist who happened to be at the hospital had diagnosed and stabilized the femur fractures; the life-flight from Spokane was there, and off we went. In the Spokane ER, he was completely re-evaluated.  By this time it took 6 liters of fluids to bring his pressure up and start his kidneys functioning.  The damage had been done though, and because of the inadequate fluid replacement, he could not have any IV dye, and so working up his internal injuries was limited.  It was found that he had internal injuries in the area of the duodenum (this is critical later.)
He had to have an ultrasound done through his esophagus to make sure that he had no aortic injury (because dye was contra-indicated as above.)  Since he was too unstable for anesthesia, I had to talk him down and hold his head steady while this was done awake.  He was a real trooper though and did great. 
Then it was off to the OR where the orthopedist put rods in both his femurs.  He was then taken to the ICU and kept on the ventilator, because by this time he was in fulminant Adult Respiratory Distress Syndrome
Over the next three to four days, his temperature was never below 102 and often up to 104.  Along with this was a white count of 23-25 thousand; three times normal.  I asked the trauma surgeon what this was due to (I was suspicious that he had intra-abdominal injuries, as there was no other logical explanation for this.)  It was ignored.  He said it was normal; yah, right!
Eventually after a week on the ventilator, his temps came down, his lung function improved, and he was able to be taken off the ventilator.  During this period of time his fluid retention was extreme, even for a trauma case.  He gained more than 70 lbs (sic) from his pre-injury weight.  This was another indicator of something seriously wrong.
Shortly after this, he was transferred to a surgical ward, and physical therapy came up to start getting him up.  At about the same time the wound on his left leg, where the femur had poked through began oozing several hundred cc’s of fluid a day.  The next day a, “wound care specialist” came up, opened up the superficial part of the wound, and said that it was just superficial and nothing to worry about,  He packed it tightly (a big no-no) and said he would be back the next day to change it.  He never came back.  Two days later, I knew that if I wanted to get this wound taken care of, I would have to get him out of that hospital, so we took him home. 
My wife had made arrangements, including a hospital bed, commode, walker, and wheelchair so we could do this at home.  As soon as I go him home, I opened up the wound.  The tract was all the way down to the femur; a depth of at least 6 inches (the length of a medical q tip) and it drained large amounts of fluids over the next few days.  I changed the dressing, and cleaned out the wound four times daily and eventually it. If it had been left alone and not opened, the femur would almost certainly have become infected.
He was on antibiotics, and these were stopped after a total of two weeks.  When this happened, the diarrhea he had had, and which we were attributing to the antibiotics, stopped.  Unfortunately so did all bowel activity.  His abdomen became progressively more distended, with severe cramping pain.  When, a day later, he developed a mass in his right side, with peritonitis, I knew that he was in serious trouble.  I took him to the local hospital, where a CT scan showed a ,”markedly dilated right colon with large amounts of stool, and a thickened transverse colon and meso-colon consistent with either diverticulitis, or more likely an injury from his prior accident.”
He went back to Spokane where he sat in the ER all day from 0800 until 5 in the afternoon.  At that time, Dr. X (names redacted to protect the guilty) decided that there was nothing wrong with him, and he was just having trouble dealing with the pain. 
I should note here, that two days after he came home, he stopped his narcotics, began physical therapy including working on a stationary bicycle.  This despite two broken femurs, multiple fractured ribs, and multiple back fractures.  As I said, he is a trooper.
So he was given laxatives, with minimal results, and attempts were made to wean him from the narcotics he needed to control his pain.  His abdominal mass was still present. Eventually he decided that since nothing was being done, he would go home.  However he was unable to tolerate  the severe pain, and had to return the next day.
Again Dr. X  insisted that there was nothing wrong with him.  When Andy and I commented to the resident that we were in a bind, because we knew something was wrong, and that Dr. X would not believe us, Dr. X came in and, there is no other way to put it, had a fit.
He stated that he was insulted that we went behind his back;  there was no need for a second opinion, and that we were welcome to take him anywhere in the country for one. 
I briefly toyed with the idea of putting him in the car and driving to Seattle, but was not sure he would survive the trip; he was that sick!  Instead I asked if we could have a GI consult.  Dr. X reluctantly agreed to this.  However when the gastroenterologist scheduled a colonoscopy, Dr. X called him up and told the gastroenterologist that he was risking his career because he, the all knowing Dr. X, felt it was neither necessary nor a good idea, and he, Dr. X would bring him before the peer review committee if he dared to go against his exaltedness.  He was still so insulted that anyone would dare question his judgment that he was willing to let my son die to defend his, “honor!”
Andy, a coach of junior-high football players, summed up this confrontation accurately and succinctly.  “My kids don’t act that immature!”
At this point I demanded to speak to administration; demanded someone be found to take care of my critically ill son, and this was done.  Dr. Y came and saw him, colonoscoped him the next day, and found a severely damaged transverse colon with almost total obstruction.  The pediatric scope he used; about the size of a sharpie pen would not fit through the small opening.  That is how tight it was.
The next day his right colon was removed.  He was found to have a perforation in his cecum along with an abscess due to the length of time it had been obstructed, .  Another day or two and he surely would have died!
During this entire time, ever since the second hospital admission, I had been telling Dr. X, the nursing staff, and anyone who would listen that my son was in terrible nutritional state.  No one would listen to me.  All they saw was a fat kid.  They would not believe that he had lost 60+ lbs (sic)  Even the second surgeon, when I mentioned this to him, laughed and said, “You can’t have lost much weight.”  When I said he had lost 60#, I was ignored.  At no time did a dietician see him; no nutritional workup was done, and this despite lab values that clearly indicated starvation (albumin of 2.1-2.4; prealbumin of 6-7, and BUN of 3.  All indicators of Dachau-like starvation state.)
After his second surgery (colectomy) his pain improved, but he continued downhill.  He had no high calorie feedings, his nutritional status continued in a downward spiral.  The first day after surgery he walked all the way around the surgery ward.  By three days after surgery, he was so weak he could walk no more than 20 feet without stopping to rest.
The surgeon wanted him to go home.  When I suggested that he was getting weaker, and I was very worried about his general well being and especially his nutritional status, the surgeon’s response was, “We cannot have this kind of relationship!”
What does that mean?
I can’t be a concerned parent?/ Or I can only be a concerned parent if I act like an obedient idiot, kowtowing to the all-knowing surgeons??
Eventually he relented, put a feeding tube in Andy and started him on high calorie feedings.  After this he improved quickly, and dramatically, and went home, still on the tube feedings two days later.
It is now three months since his accident, and he is progressing, though slowly.  He goes to physical therapy daily, and can be up and around for several hours a day.   The last round of delayed surgery and a week of living with a perforated bowel and abdominal abscess have set him back at least 2 months.  Fortunately he is young, and should eventually recover from this whole episode.
This entire episode has given me a whole new light on medical care.  I myself have been a patient, and have had several major orthopedic surgeries, and know the frustrations of being a hospitalized patient.  But never have I seen the total fragmentation of care, and disregard for the patient that occurred.
The nurse daily reported that Andy had a distended abdomen with severe RLQ pain and guarding; all signs of peritonitis; but evidently they were too afraid to say anything to the surgeon.
I say afraid, because there was an episode that brought this all out.  When Andy was in the ICU, the attending decided to put in a PICC IV, and remove his central line because of his high fevers, thinking the central line might be infected.  I was asked to leave during this procedure.  I came back later and noticed that he still had his central line in.  When I asked the nurse why he had both his PICC and his central line still in, I was told it was because there were no orders to remove the central line.
When I told her that the attending had discussed with me that the ONLY reason for putting in the PICC, was so they could get out the possibly infected central line, I was told again that there were no orders.  When I suggested that she call the attending (it was 6 PM) to get an order for this, I was told that under no circumstances would she do this.  The potentially infected central line was left in until the next morning.
So it seems, at least at this medical center, the old fashioned system of, “fear the physician and the hell with the patients,” rules.  The idea of teamwork, check systems, and cooperation just never happened.  I have only described the most egregious events, but on a daily basis the attitude was, “I take care of my sphere, and don’t ask me to do anything else.”  This was true whether it was asking for water, another pillow, a clean gown, etc.  At one point we waited an hour for a wheelchair so he could be allowed outside for a short time.  Once the nurse had called transportation, her job was done, and she was off taking care of other patients.  All to be expected in a busy hospital with overworked staff, but frightening when you are sitting watching your son die day by day.  The lack of caring by most of the hospital personnel was made more obvious and poignant by the opposite extreme, of the good nurses and aides who put their all into their jobs.
What lessons have I learned from this tragic and almost fatal melodrama?  We in the medical profession cannot be too careful, and must leave our emotions and egos at home, where they belong.  When caring for critically injured people, we need all the help we can get.  more important, people like this should NOT be supported by the medical establishment. The medical board reminds me of the police "investigating boards." whose sole job seems to be to protect their colleagues from having to answer for their acts.

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