Friday, August 14, 2009

A surgeon's story

Our chief of surgery, Jim Hurst, recently went through an extensive medical experience, and he said I could share his story with you. I have edited it a little but have tried to preserve Jim's folksy Southern style. In it, you get a feeling for the mixture of nervousness and affection felt by members of our staff while treating him. But you also see a surgeon learning new things about himself, those same staff people, and the medical system. Many thanks to Jim for allowing me to share this with a broad audience. (I have embedded links to several of the technical terms.)

Each day when we wake up, most of us think about juggling administrative and clinical duties. Hardly do we think about becoming consumers of our own art and craft. The following is a summary of just that: I became a consumer of the best BIDMC has to offer. Much of which follows has been recounted to me by either my wife or the nursing staff from the TSICU (Trauma-Surgical Intensive Care Unit). You see, either the severity of the illness or the drugs or perhaps both have rendered the time between April 2, 2009 and the first week in May 2009 a total blank, save for brief snippets.

I have had a number of major surgical procedures in the past. On many occasions, I have told trainees that I am convinced that every surgeon should have a major surgical procedure early in their career. It has clearly made me better able to relate to my patients over the years. The critical nature of this illness, however, has not only put a sharper focus on my own mortality, but on other aspects of our health care delivery system as well. From this, I am steadfastly convinced that, although we as health care providers may not be able to cure every disease process, two things we can provide; freedom from pain and freedom from the fear that many times surrounds the delivery of health care.

The day began, not unlike many others. My wife and I had been in Cincinnati to visit our family and to pick up a vehicle which we planned to drive back to Boston the following day. The first stop was to one of my favorite restaurants where we dined on a Southern boy’s delight of sausage gravy and biscuits. While some say it will stick to your ribs, more likely it would stick to one’s coronaries, or any other endothelial surface for that matter. Once all tanks had been filled; both ours and the vehicle’s, off we went on the 863 mile trip. Having made this drive previously, we planned to stop in Buffalo, which is exactly half way between Cincinnati and Boston, for the evening. The choice of locations provided two things I enjoy most: Famous Dave’s Bar-B-Q and Starbucks. You see, it takes little to keep a Southern boy happy.

When we arrived in Buffalo, it was only 2:00 p.m. Not wanting to waste five hours of daylight, off we went. We arrived in Boston around 9:00 p.m., tired but home. The following morning, my back was stiff. Having had back surgery previously, a stiff back is no stranger, given an occasional error in judgment, such as sitting in a car for 14 hours. Being the TSICU attending for the upcoming week, I figured it would work its way out. Monday was not terribly comfortable. Tuesday, being on call for trauma as well, most of the day was spent either in the emergency room or lying on the floor in my office. By the end of Wednesday, my administrative assistant made the remark that I was limping. Of course, this was steadfastly denied.

Then came Thursday morning April 2. Around 4:30 a.m., I awoke with one of the worst pains I can recall having. Back pain was not so much an issue as the radicular pain down the right leg. Not wishing to bother my colleagues, I waited until 6:30 a.m. to call Alan Lisbon (vice chairman of anesthesiology for critical care) to ask that he cover for me in the TSICU. He and I both agreed that a call to Mike Groff (one one of our neurosurgeons) was in order. Waiting for some time to pass, the call was placed. Mike was his usual cordial self. Pain medications were called into the local pharmacy with the directions to plan to come to his office is three days if the pain did not resolve. Prior experience told me this was likely.

Shortly thereafter, I began having crushing, substernal chest pain. With a family history of cardiac disease, I clearly thought the worst and agreed with my wife to call 911. This is where my memory begins to fade. There are faint recollections of the paramedics responding and placing me on a “scoop” stretcher. I recall what appeared to be an eight foot tall police officer standing over me as the paramedics loaded me into the squad. My wife later told me that the initial transport was to be to (a local hospital). After some heated exchange, and an initial normal EKG, they agreed to transport me to BIDMC. Suzanne was told by the officer that she should go on ahead, but do not panic when the squad passed her on the road. I have no recollection of the ride to BIDMC, but only that the paramedic said that we were pulling into the ambulance dock. After being taken someplace in the ED, I faintly remember vomiting all over myself and those taking care of me. I remember apologizing profusely. That brings an end to any other personal memory.

Suzanne said that the initial efforts centered around pain control and efforts to further define the nature of the problem. After growing four out of four bottles of blood culture positive for Staph. aureus, coupled with a deteriorating neurologic exam, it was off to the OR for an 11.5 hour procedure. This included pedicle fixation at three levels and posterior interbody fusion of L4-L5 and L5-S1. Findings included a diskitis at L5-L5 and an epidural abscess at L5-S1. This ultimately grew out Staph. aureus, fortunately methicillin sensitive.

Suzanne said that returning to the TSICU looking like Biff the Michelin man, I remained intubated overnight. The following morning, I was ready for extubation. Protocol calls for determining a RSBI or rapid spontaneous breathing index. The post-op course was complicated by both hepatic and renal failure. Thankfully, both were rather mild and resolved spontaneously over time. I have no recollection of either being intubated or being awakened in preparation for extubation. The next 7-10 days is a blur with only a few moments of clarity. Red Sox Nation would be pleased to know that one of those moments was recalling the delivery of a Red Sox home jersey -- #31 Jon Lester’s. I recall making demands that it be hung on the wall by the bedside for all to see.

The next setback came on April 14. Pam McColl removed my sutures and uttered that word no one likes to hear, "Hmmm." I hate that word. This time, it meant another trip to the OR for debridment. The second procedure lasted 5.5 hours. This time Dr. Kevin McGuire (an orthopaedist) joined Dr. Groff. The debridment again grew Staph. aureus. A PICC line was placed for administration of twelve weeks of intravenous antibiotics. After three days, I was discharged home with pain control being the major issue at this point.

Suzanne said, although I was seemingly coherent, in the final analysis, I had little orientation to time, place or person. She said the most telling of the moments was when I asked how to operate the TV remote. Being someone who will likely be buried with a remote in hand, this was highly uncharacteristic. Looking back on this one event, she said this should have been a warning sign of events to come. Only snippets of visits by friends linger during this first discharge.

After a time, pain control became a bigger problem. Around 9:00 p.m., a Saturday night mind you, I reluctantly allowed Suzanne to phone Mike Groff. Not only was pain out of control, but now I was in acute urinary retention. Instead of telling wife to go to the ED or call 911, he came over to our home, helped my wife carry me down the stairs and assisted her to the ED. He had called ahead to give the ED staff a heads up. Intake, MRI and disposition was done in less than one hour. At intake, the nurse asked if I would like a male attendant to put in a Foley catheter. At that time, I could have cared less, but the offer was touching. I would bet few neurosurgeons have taken the measures he took that evening.

Again, I found myself a patient in the TSICU. The usual smattering of studies were ordered, and the acute pain service was again involved. On Saturday, after the second procedure, the infectious disease consultants ordered a an Indium-111, tagged white cell scan to search for other sources of infection. That was, of course, after trans-thoracic as well as trans-esophageal 2D-echo looking for cardiac sources. This required a central venous line. Alan Lisbon drew the short straw and was responsible for starting the central line. I, to this day, do no know who suffered the most, him or me. I truly felt sorry for him; however, his spirits were lifted when he proudly proclaimed, after reviewing the chest X-ray, that the line was in good position and that there was no pneumothorax. I must admit, there was more than a little relief on my part as well. I would liken this test to be about as pleasant as sliding down a forty-foot cheese grater into a vat of alcohol. The pain service became engaged and found a combination of medications that seemed to do the trick. During this time, my memory was again fuzzy, no doubt, secondary to the multitude of drugs on board.

Amidst all this, a few comical stories are in order. First, let us call her nurse S asked if I liked strawberry shortcake. Of course, who doesn’t? She brought in what looked like a piece of strawberry shortcake, adorned with whipped cream, that looked at least a foot tall. Magically, it disappeared.

Ah, yes, hospital cuisine. Coming to the rescue was Joe Rizzo from the department of surgery finance office. Seems he is a wonderful cook. With a last name ending in a vowel, you guessed it, Italian food. Well, the chocolate cake didn’t hurt either. So much for the food stories.

Not wishing to bother the nursing staff when I wanted to ambulate, I would simply unhook myself from the monitors and attempt to stroll around the TSICU. Of course, I forgot that unhooking the monitor set off alarms all over the place. This proved to be an unpopular idea.

Then one evening, after 10:00 p.m. meds, I dreamed (must have been) that someone was calling me to come to room #17 (frequently used as the emergency OR during off hours). Convinced I was dreaming, I ignored the call. Who knows how much time had passed when I thought I heard the same call punctuated by a tap on the shoulder. Not to be thoughtless, I began unhooking all monitoring devices once again. Remembering the gentle reminder to stay “connected,” a call to my nurse to tell her where I was going was in order. Nurse B entered the room, but my explanation and sortie were short lived. She pointed her finger and sternly said, “Now listen. It is not about you, it is about us. You fall and our licenses are gone.” Needless to say, that convinced me that the red nurse call button was at the bedside for a reason.

Ah yes, now came physical therapy. While we hurriedly enter a “PT” order in POE (computerized provider order entry system), rarely do we give a second thought to what actually goes into a PT consult. Mary Beth and her staff, all of whom I am convinced deserve to be saints or knights of the realm, may be the unsung heroes of our patients’ recovery. When pain gives one little motivation to get out of bed, much less exercise, they face a real challenge. Learning to walk with a cane and assistance is a real blow on so many fronts. Nonetheless, given goals that were necessary to meet in order to be discharged, the game was on. Climbing stairs, a normal process during rounds, became like climbing a mountain. Then there is the infamous yellow elastic band, used as a resistance trainer. Being quite proud that I had mastered the art of the yellow ribbon, I managed to let the band slip off my foot and smack me squarely in the face. Once the pain had subsided, we all had a real laugh. This was perhaps the first time I had actually laughed in over a month.

Physical therapists have the uncanny ability to push you to the brink of determination rather to the edge of frustration. They are truly a remarkable component to our health care delivery system.

I left the TSICU for home on May 4. There were many valuable lessons learned during this time. The first is how one feels with an hematocrit of 23. We push our patients to get out of bed, be mobile and “get with the program.” However, with an hematocrit of 23, a walk around the bed is an all-hands evolution. Brushing one’s teeth is a task which requires a total expenditure of energy. A shower and shave is about a 1.5 hour evolution. Most importantly, I got to know the night staff well. Unless we admit patients in the evening, we sometimes have little contact with the night staff. This was a wonderful thing: to talk about families, learn likes and dislikes, and to realize what a wonderful staff with which we are lucky to have. One afternoon, a nurse with whom I worked as an intern was in Boston. She paid a visit. The outflow of emotion was overwhelming. I was an intern 37 years ago.

Finally two sobering events occurred during the hospitalization. A psychiatrist may have a field day with these two, but again they may have a field day with me at any rate. One afternoon according to my wife, she arrived to visit finding me sobbing uncontrollably. She asked why? I told her that I had seen all the patients who had died on my operating table. They were coming to welcome me. They were not angry or hostile, but expressed understanding and understood it could happen to anyone. Lastly, I have seen “the light.” It was perhaps the brightest light I have seen. Though bright, it was not harsh, but soothing. I know it was not the OR lights, for I have operated under them for many years. I offer no explanation to either event, but rather the observations. You are free to draw your own conclusions.

My goals were simple. Walk up the stairs without a cane. Walk to the end of the block. And finally, shower and shave without assistance. The dedication and compassion of the team involved in helping me reach these goals is overwhelming. It is difficult to express gratitude to those who have saved your life, preserved your ability to alleviate suffering and alter the course of disease. Thanks is simply not enough.

Later, when discussing the whole experience with one of the TSICU nurses, she asked whether I minded being admitted to a unit in which I work every day. The answer is quite simple: Why would I want to be admitted elsewhere when I know the knowledge, dedication and character of those with whom I work daily? When I see the length to which they go for my patients, the answer is a no-brainer. I am now back to work, full-time, thanks to a wonderful supporting health care delivery team. They are simply the best.

11 comments:

mmmyoung said...

No matter what our experience a doctors, being ill comes as a severe shock! My belief is that to do the job we must do properly an element of denial is required - an "I'll never be like that" attitude. Thanks for your honesty!

Dr. Jon Mikel IƱarritu said...

Thanks for sharing this nice story!

catsandmusic said...

I am so glad that Jim came through his ordeal. His amazing sense of humor is sure intact. It is great to see him charging around campus again. I always feel better after getting a hearty greeting from him.

I would like to offer another testament to all of the staff who cared for him, one which should put at ease all of us who worry about the confidentiality of information about our illness should we wind up in the hospital we work at. I had heard that Jim was hospitalized. but even though I work in a dept at BIDMC that interfaces regularly with Jim's department and with the clinical floors, I knew not one single detail of Jim's illness until I looked at this blog today, and read his own account. Which is as it should be.

S. :) said...

As one of the nurses who cared for Dr. Hurst during his hospitalizations in the TSICU, I also have the pleasure of working with him on a daily basis. I can tell you without hesitation that every single nurse in this unit has the utmost respect and love for him. His jovial, compassionate approach to caring for his patients does not get lost on all of us. We think he is an amazing surgeon, colleague and person, and we are thrilled that he is back to work after a full recovery (even though there were several humorous moments while he was here as a patient!:) So glad to have you back, sir!!

Toni Brayer MD said...

This is a lovely rendition of a terrible experience. Thanks for sharing it with us and best wishes for a full recovery.

Paul Levy said...

For those of you who don't read this blog on my Facebook page, I want to share the many heartfelt comments I received there.

Nancy:
Required reading for anyone in healthcare - thanks for sharing - nothing is more powerful than the personal story...

Cyndi:
So cathartic to get pen to paper, such a thought provoking experience, and I saw Dr. Hurst wheel his walker through PACU back to T-SICU one Sunday morning, he had a smile as big as the chesire cat... and an entourage full of patience and love, we are all blessed to have him back in our lives and in our medical center.

Monique:
This is an amazing read - and the comment "Physical therapists have the uncanny ability to push you to the brink of determination rather to the edge of frustration. They are truly a remarkable component to our health care delivery system." really hit home for me, and I'll have to quote that to my daughter, who hopes to become a Physical Therapist - she'd excel at that, I believe. Thank you for sharing!!!

Karen:
Bless Dr. Hurst, his family, and his medical family. This is an amazing story of survival as much as it is a story about the wonderful people who deliver health care every day.

As a chaplain I have been with many people like Dr. Hurst in their darkest of moments. I have been with care providers as they have anguished over a bad turn of events. It seems to me that the patient that is treated for x, y, and z is also a human being and this is what I see happening here.

Jeff:
It's always a privilege to be around Dr Hurst, and it was even more so to take care of him, even during his darkest moments.

Harriett:
So comforting to learn that Dr. Hurst has been the lucky and grateful recipient of the expertise and compassion of the BI's medical staff who lovingly provides superb care to its patients every day.

Jason:
Thanks for posting Dr. Hurst's story, Paul! There is no better role model for young physicians, than Dr. Hurst. BI is lucky to have him.

Sharon:
As a patient of BIDMC, not an employee, I loved this story. There is a book in the making. Bur seriously, I have had numerous dealings w/BIDMC & have found it exactly as written. I hope Jim is doing well.

Lena:
Wow, quite an experience. I hope his recovery is going well!!

Carol:
Paul,
Thank you for sharing Dr.Hurst's experience. It is hard to believe how sick he was. He is one of a kind! BID is lucky so
have him.

Elizabeth:
I have to agree with Jeff, we are beyond lucky to work with Dr. Hurst and helping him through his recovery was one of the scariest, yet most meaningful experiences of my career so far. We are happy to have him back, caring for the patients who need him most. He truly epitomizes the concept of "health care TEAM".

adena said...

fantastic post. thank you.

Anonymous said...

I did a clinical rotation at the BIDMC and got to know Dr. Hurst. Like everyone else, I fell in love with his humor, knowledge and willingness to share that knowledge and his kindness to everyone he came in contact with. I am so pleased to hear that he has come through this experience feeling well and doing what he likes best.

Laura said...

As another student who had the privilege to work with Dr. Hurst during my surgery rotation, I am so glad to hear he's back in business. I'll never forget his enthusiasm for teaching, his kindness, and his southern hospitality. The best part of it all was when he invited his tutees over to his house for a home-cooked meal, after which he quizzed us on our oral exam cases until 11:00 pm. What a gent! Thank you for allowing him to share this story and for reminding me why I loved my 3rd year at the BIDMC so much.

Nell said...

This was a very touching story and I am glad you posted it.

I recently graduated with my masters in public health. I took a course called Inequality in Health Care Delivery my first year. My professor (an MD/MPH) asked us to watch a movie called "The Doctor" during our break.

The movie was very effective and I think all medical students should take the time to watch it.

Anonymous said...

Great story with a happy ending. I glad Jim is doing well. We all miss him in Cincinnati where he was a good friend and collegue. I still think of him often as he did my vasectomy in our procedure suite while telling me old Navy stories. Even a surgeon gains some perspective while looking at the business end of the scapel.