every seasoned attending i know hates the thought of ER thoracotomies, let alone having to do one. heck most hate taking trauma call in the first place. but every med student/junior resident i know salivates at the thought of opening up some ribs and massaging a heart, futile as it may be most of the time. i use that example as one of priorities changing, cuz i'm sure the attending who now dislikes emergent thoracotomies was at one point like the med student/resident who wants to crack open some ribs. so question for the attending (or even chiefs)...does the mystique of surgery eventually wear off? like when you get comfortable with the operations u usually do day in and day out and know exactly what to do since you've done it so many times...does that take away from the mystique that the youngins don't realize yet? cuz the impression i get from the veteran surgeons is that they just wanna do their elective cases and on go home...they don't need/want the adrenaline rush anymore.
how have your priorities/perceptions about surgery changed as u gotten older?
- Thread starter PostCall
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Ah, you saw last week's episode of "House".
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Frankly, IMHO, there is enough ****ing adrenaline rush knowing that patients can and will sue you for any problem, real or imagined.
N
njbmd
Have to agree with this in general but I am finding "gee whiz" things most every day. I am also amazed at how "burned out" some of my colleagues are in primary care who haven't been in the business as long as myself.
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Contrary to popular opinion of my specialty, I see "gee whiz" stuff frequently as well (IMHO as a specialist, I get sent the weird stuff). However, they are intellectually stimulating but not an adrenaline rush and yes, I like my outpatient stuff - if only so I don't have to listen to patient complaints about stuff out of my control.
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The responsibilites and agendas of an attending vs resident vs medical student are significantly different.
clinical decision making and accountability, in a proper run clinical scenario are zero for a medical student, more for a resident (until attending on the scene or guiding care), 100% for the attending once he/she is "attached" to the patient.
A medical student ideally is on any given service to learn through observation and level appropriate participation. they have a finite period of time to absorb a vast amount of information... they may never have the opportunity to gain later (i.e. a radiologist/pathologist/?pediatrician/etc... may never get another opportunity after medical school to touch/massage a beating heart). so, as a medical student you are there for the "experience" and hopefully will learn the decisions and/or justification for what you observe/participate in.... but, you are not the responsible party.
Thorocotomies are nice and dramatic. But, depending on how you slice the data, they are more often then not a futile act of little more then pre-autopsy, autopsy. Further, to justify what may be called the epitomy of extreme measures on the epitomy of sick/moribund patients, it comes to reason it requires skill and experience. Both of which are often lacking in the majority of ED/Trauma thorocotomies performed. By their nature... they are infrequent. This results in unfortunate technique and/or poor judgement ranging from the aorta cross clamp at a community hospital in preparation for 45 minute patient transport to the cross clamp esophagus, to the thoracic aorta cross clamp of the ruptured ascending aortic root aneurysm, etc.... Thus, if one does not do the procedure or at the very least regular chest surgery as part of normal practice, it is as stated above, fairly futile procedure. This futility, often ignored for reasons not centered on the benefit of the patient but the benefit of the audience....
"It was very unlikely he/she would survive.... but it was a real good teaching/learning experience for the resident/students/ED nurses/etc..."
or the resident
"Yeh, he died, but I got my thorocotomy..."
Because of the comments above and other considerations, there are some state medical boards that actually review very closely almost every trauma/ED thorocotomy.... I think Florida may be one such example.
JAD
Why? For billing purposes? Exposure risk to health care workers? Presumably it's not because they think it provides a worse outcome for the pt.
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Because....
As for worse outcomes.... well, sometimes. In the hands of inexperienced and/or overzealous, I have seen improper application of this procedure. Rather then a slim chance of saving the patient's life, an unnecessary/innappropriate thorocotomy with... even less appropriate clamping resulted in avoidable death.
And, remember, just because a patient is dying (or dead but not declared yet), does not make their corpse a physician play thing....
As for billing... that is a reasonable question. Is it ethical to perform an ?unnecessary procedure, or non-patient benefitted procedure, etc... then bill as if you provided a service? I am NOT saying there is no place for emergent thorocotomies... I am saying their place is limited...
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