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“Confessions of a Surgeon” by Paul A. Ruggieri, M.D.

Posted Jan 04 2012 8:00am
“Get this thing out of my operating room!” The colon stapling device exploded into pieces when I hurled it against the operating room wall. I was fed up with its failure to work as advertised by the manufacturer. The stapler had probably cost less than $100 to make. The hospital paid $300 for it (and then billed the patient, or insurance company, $1,200). Now the thing didn’t even work. surgeon1 Confessions of a Surgeon by Paul A. Ruggieri, M.D.

I do not react well to imperfection inside the operating room. I cannot tolerate it in the tools I use, the staff assisting me, or myself. Defective devicesI can have them replaced. Unmotivated staffI can have them removed from the operating room. I haven’t quite figured out yet what to do with myself.

Surgeons are control freaks. We have to be. And when things don’t go our way in the operating room, we can have outbursts. Some of us curse, some throw instruments, others have tantrums. These explosions are a go-to reaction when we’re confronted with the ghosts of prior complications.

Several months earlier, I had performed the same operation on a 66-year-old patient, using an identical stapling device. Everything seemed to have worked perfectly until the patient developed severe complications four days after his surgery. We soon discovered the cause: the nonperformance of the stapling device.

When the stapler hit the wall, I had been in the operating room for more than four hours, struggling to remove a diseased segment of colon from someone I’ll call Mr. Baker, a 330-pound middle-aged man. Trying to keep his fat out of my way during the operation had been a continuous battle. The pain in my upper back reminded me that I was losing the fight.

Obese patients create more physical work for a surgeon during any type of procedure. The operations take longer, tie our upper body in knots and leave us with fatigue and frustration. Obese patients also automatically face an increased risk of complications like infection, pneumonia and blood clots during recovery.

If the difficulties posed by Mr. Baker’s obesity weren’t enough, he had been steadily losing blood during the procedure. His tissue reacted to the slightest graze with more bleeding.

Why does this guy have to bleed like this? As if it were his fault. Here I was blaming him, even though I was the one causing the bleeding. But in surgery, it always has to be someone else’s fault. It’s never the surgeon’s fault.

surgeon Confessions of a Surgeon by Paul A. Ruggieri, M.D.

After an operation, most surgeons tend to underestimate the amount of blood that was lost. Whether it's ego or denial, they can't help themselves.

Interestingly, after an operation, most surgeons tend to underestimate the amount of blood that was lost. Whether it’s ego or denial, they can’t help themselves.

The reality is that blood loss can be measured. Hospitals know which surgeons are losing blood, and how much, during every operation. They have data from their operating rooms, but the public cannot get access to this information. And this information matters, too. A

Like poker players and their cards, surgeons are sometimes only as good as the patients they are dealt. Obesity, excessive scar tissue from a previous surgery in the same area, disease that is more advanced than anticipatedany one of these physiological conditions creates more work and a more difficult environment for the surgeon.

Even before the surgery begins, underlying or chronic conditions such as a history of hypertension, cardiac disease or lung disease put patients at risk for complications. Today, based on your medical history, surgeons can usually analyze, quite accurately, your risk of complications (or death) before setting foot in the operating room. All you have to do is ask.

I had no idea how bad Mr. Baker’s colon disease would be until I opened him up and looked inside. It was a mess. If I were playing poker and this man’s anatomy were the hand dealt, it would be time to fold.

“That is one of the ugliest pieces of colon I’ve ever seen.” I grabbed the scrub nurse’s hand. “See, touch that thing. Look how inflamed it is.” When given the chance, scrub nurses love to touch organs in the operating room. “OK, don’t poke it too hard, it will start to bleed again.” Her hand drew back onto the instrument stand. I was in for a long night.

Tonight, the diseased colon on the menu was angry, cursing and taunting me: “Good luck, Mr. Big-Time Surgeon, trying to remove me.” Surgeons frequently have conversations with the body parts or organs they are trying to remove. We also have conversations with ourselves; it’s a way to blow off steam while our minds scramble to deal with the unexpected.

“By the time you are done with me, your back muscles are going to be in a heap of pain,” the colon went on. “Looking forward to that drive home in your new Porsche? Well, too bad. It’s going to have to wait. You better take your time or I’ll come back to haunt you in a few days.” I could hear the colon laughing at me. I was crying inside.

“Nurse, hand me a curved scissors.” Finally, I was granted a little success in freeing up one end of the colon. But that was short-lived. More bleeding. I hate this. And I had cut myself. I stared at my finger. “Nurse, I need a new glove.” The outer skin under my glove was breached, but not deeply.

“Almost got you,” the colon said. I could not shut the thing up. “How do you know I don’t have hepatitis or H.I.V.”

Just great, I thought. Now I have something else to worry about.

“You’re going to earn your fee tonight, Dr. Surgeon.” The colon kept talking. “I hope you’re not in this business for the money, like the last guy who operated on me. Between what Medicare pays you, the phone calls in the middle of night and the time you spend guiding my recovery, I figure you will make about $200 an hour for this operation. How does that grab you?”

Should have gone for my M.B.A., I mumbled to myself. Big mistake going into medicine, never mind surgery. If I could only go back and do it over again.

The colon’s rant continued: “Wait, subtract what it costs you in overhead to bill for this operation (double that if the claim gets rejected), plus malpractice costs for the day, and we are now at $150 an hour. And how could I leave out the biggest expense of all? The price of the mental stress from worrying about me after the surgery (and double that if there’s a complication). Now, I figure you’re under $100 an hour. Plumbers make more than that just to step inside your house. I bet they sleep well at night. Just remember, Dr. Surgeon, nobody put a gun to your head. You chose this profession.”

I could swear that the thing was laughing at me. “Forget about keeping those dinner reservations tonight. You and me, we’re going for breakfast once this is over.”

Adapted from “Confessions of a Surgeon” by Paul A. Ruggieri, M.D. (Berkley Books).

Via WSJ: Secrets of the Operating Room

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