Doctor's intuition

[loveumms]

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I was involved with a case a few weeks ago. Don’t want to give too many details because the outcome was not good. Shortly, this was a middle aged man with a minimally symptomatic major vascular disease. This person was an alcoholic and right off the bat I just felt some bad vibes picking him up from the holding area. He was extremely pleasant and we joked around but, I just had this feeling in the pit of my stomach.

Get back to the OR, induce without any problems. Lines go in without difficulty. Surgeons start. Upon opening they get into some difficulty and end up having a complication … rupture of a non-vital organ. Surgeon decides he doesn’t want to go on with the case. I agree totally and we have a short discussion about doctor’s intuition and how we are usually right about feelings. About two hours later, changes his mind. I can understand his change of heart since they had made a HUGE whopping incision and at that point were not able to save the non-vital organ. Asks me what I think. I tell him I don’t think the patient is totally stable since we intermittently had him on pressors and urine output was so so but we were resuscitating him. My attending thinks the patient will be fine. We proceed. I end up getting relieved because I’m pre-call. And from what I hear after my departure the case went to total s**t. The pt was given 40+ units of products with massive bleeding. Went into DIC and ended up dying in the SICU early the next morning.

I was devastated when I heard this and felt really guilty because we, the surgeon and myself, both had “the feeling”. I’ve had this same feeling before in the MICU when I knew the patient was going to do poorly but, never with a surgical patient. Just wanted to hear if anyone else has experienced this.

 

[Planktonmd]

I was involved with a case a few weeks ago. Don’t want to give too many details because the outcome was not good. Shortly, this was a middle aged man with a minimally symptomatic major vascular disease. This person was an alcoholic and right off the bat I just felt some bad vibes picking him up from the holding area. He was extremely pleasant and we joked around but, I just had this feeling in the pit of my stomach.

Get back to the OR, induce without any problems. Lines go in without difficulty. Surgeons start. Upon opening they get into some difficulty and end up having a complication … rupture of a non-vital organ. Surgeon decides he doesn’t want to go on with the case. I agree totally and we have a short discussion about doctor’s intuition and how we are usually right about feelings. About two hours later, changes his mind. I can understand his change of heart since they had made a HUGE whopping incision and at that point were not able to save the non-vital organ. Asks me what I think. I tell him I don’t think the patient is totally stable since we intermittently had him on pressors and urine output was so so but we were resuscitating him. My attending thinks the patient will be fine. We proceed. I end up getting relieved because I’m pre-call. And from what I hear after my departure the case went to total s**t. The pt was given 40+ units of products with massive bleeding. Went into DIC and ended up dying in the SICU early the next morning.

I was devastated when I heard this and felt really guilty because we, the surgeon and myself, both had “the feeling”. I’ve had this same feeling before in the MICU when I knew the patient was going to do poorly but, never with a surgical patient. Just wanted to hear if anyone else has experienced this.

I am curious:
What was the "non vital organ" ??

 

[deleted77919]

…

 

[Gern Blansten]

I bet it was the "johnson" although that can easily be argued as vital.

As to "the feeling," yes I have had it also, but frequently the patients surprise me and do well despite poor protoplasm. So I am not sure how reliable my gut feeling is.

 

[Tenesma]

for me it was the opposite during training --- the patient's i was worried about ALWAYS did awesome, as if I were a rockstar... the patient's that made my hair fall out were the ones where I HAD NO FEELING whatsoever, convinced everything would fly right...

 

[Planktonmd]

for me it was the opposite during training --- the patient's i was worried about ALWAYS did awesome, as if I were a rockstar... the patient's that made my hair fall out were the ones where I HAD NO FEELING whatsoever, convinced everything would fly right...

Exactly, GOMERS don't die, only 20 Y/O ASA 1 patients die.

 

[pushthesux]

Exactly, GOMERS don't die, only 20 Y/O ASA 1 patients die.

I love that book.

 

[Arch Guillotti]

Exactly, GOMERS don't die, only 20 Y/O ASA 1 patients die.

They don't die but they do go to ground.

 

[rsgillmd]

...I was devastated when I heard this and felt really guilty because we, the surgeon and myself, both had “the feeling”. I’ve had this same feeling before in the MICU when I knew the patient was going to do poorly but, never with a surgical patient. Just wanted to hear if anyone else has experienced this.

I know what you are trying to say. I heard one person say that these gut feelings are your brain processing information faster than you can consciously be aware of. In short, while my gut feelings are not always right, the tendency is in that direction. So I've learned to trust my gut feelings in those situations when I don't have the time to think through everything. This was especially true when I worked EMS -- trusting my gut feelings saved me several times.

Unfortunately when it comes to taking the oral boards, I don't think any of the examiners would accept gut feeling as being an acceptable reason for doing/not doing something.

 

[Planktonmd]

Unfortunately when it comes to taking the oral boards, I don't think any of the examiners would accept gut feeling as being an acceptable reason for doing/not doing something.

They will follow their gut feeling and fail you.

 

[loveumms]

My money is on spleen.

Right on

 

[G0S2]

I know what you are trying to say. I heard one person say that these gut feelings are your brain processing information faster than you can consciously be aware of. In short, while my gut feelings are not always right, the tendency is in that direction. So I've learned to trust my gut feelings in those situations when I don't have the time to think through everything. This was especially true when I worked EMS -- trusting my gut feelings saved me several times.

Unfortunately when it comes to taking the oral boards, I don't think any of the examiners would accept gut feeling as being an acceptable reason for doing/not doing something.

Read the book BLINK (0316172324), its all about unconscious decision making.

 

[pgg]

They don't die but they do go to ground.

If they do it from neurosurgery height, they'll only do it once.

 

[BubbleHead]

I was involved with a case a few weeks ago. Don’t want to give too many details because the outcome was not good. Shortly, this was a middle aged man with a minimally symptomatic major vascular disease. This person was an alcoholic and right off the bat I just felt some bad vibes picking him up from the holding area. He was extremely pleasant and we joked around but, I just had this feeling in the pit of my stomach.

Get back to the OR, induce without any problems. Lines go in without difficulty. Surgeons start. Upon opening they get into some difficulty and end up having a complication … rupture of a non-vital organ. Surgeon decides he doesn’t want to go on with the case. I agree totally and we have a short discussion about doctor’s intuition and how we are usually right about feelings. About two hours later, changes his mind. I can understand his change of heart since they had made a HUGE whopping incision and at that point were not able to save the non-vital organ. Asks me what I think. I tell him I don’t think the patient is totally stable since we intermittently had him on pressors and urine output was so so but we were resuscitating him. My attending thinks the patient will be fine. We proceed. I end up getting relieved because I’m pre-call. And from what I hear after my departure the case went to total s**t. The pt was given 40+ units of products with massive bleeding. Went into DIC and ended up dying in the SICU early the next morning.

I was devastated when I heard this and felt really guilty because we, the surgeon and myself, both had “the feeling”. I’ve had this same feeling before in the MICU when I knew the patient was going to do poorly but, never with a surgical patient. Just wanted to hear if anyone else has experienced this.

Just curious why you accepted relief if you had the feeling. Had the patient stabalized and you felt differently? I might pass up relief with an unstable patient.

 

[loveumms]

Just curious why you accepted relief if you had the feeling. Had the patient stabalized and you felt differently? I might pass up relief with an unstable patient.

The pt was on minimal NE (0.05) and we were weaning off. The urine output had picked up and they just made the decision to proceed with the intended surgery. It was 5 o'clock, I was pre-call. It was a more senior resident relieving me so I felt very secure that the patient would be safe. The real difficulty didn't begin until 2-3 hours after I left and it ended up going until 3 in the morning. Of course I made sure my relief was totally secure with the case before I left.

 

[coprolalia]

Back to the OP... don't trust "intuition". It has led many an intrepid clinician off course, sometimes in a good way for the patient... sometimes in a not-so-good way for both the clinician and the patient.

We've learned a lot of lessons, in anesthesia, from the airline industry. It has changed our safety practices. Overall, the biggest thing we've learned is to: use all the numbers, interpret the numbers properly, believe the numbers, don't blow-off the numbers. If you don't believe the numbers, you die. Intuition and "gut" feeling - either good or bad - can lead you astray...

Here's a story...

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-copro