Putting Them Under, For Good

[SamaraMorgan]

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[powermd]

This might be a little off topic but I'm wondering what experiences you may have had with patients who pass away during surgery. Specifically, many I have seen through my work in the OR seem to be overly optimistic about surgery. Whatever they feel, they seem to act like it's not a big deal that they may never wake up. I haven't seen anyone listen to surgical risks and then start calling everyone they know to say they might not be around tomorrow. Is this a common reaction for patients in other hospitals/practices?

In my estimation, yes. Patients never truly understand the risks they take in having surgery. We are at times in an awkward position when a surgeon downplays serious risks, glossing over the whole "death" and "serious disability" issue by making it sound like routine pre-op information, when there is a non-negligible chance it could really happen.

Immediately prior to leaving for the OR for a aortic dissection surgery, a patient's spouse asked me "is this serious?" No one had informed this person, or the patient, that this was a genuinely life-threatening event, and very risky surgery. Not from the outside hospital where the condition was diagnosed, to our institution where surgery was planned. I took this person aside and said "this is as serious as it gets." This person's comfortably ignorant attitude quickly adjusted to reality, as I reassured that up to this point the patient was very lucky, and that everything possible was being done. Without revealing much more detail, the outcome was not a good one despite excellent care throughout surgery.

I always make an attempt to realistically convey the risks of what we do, without scaring the patient. They seem that much more grateful when we return from the OR, the procedure having gone well.

 

[VolatileAgent]

This person's comfortably ignorant attitude quickly adjusted to reality, as I reassured that up to this point the patient was very lucky, and that everything possible was being done. Without revealing much more detail, the outcome was not a good one despite excellent care throughout surgery.

you seriously may have prevented yourself from getting sued. neophytes, take notice.

 

[SamaraMorgan]

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[VolatileAgent]

This is exactly what I see. I'm not sure if the surgeons are downplaying the risks or are being confident. Would more patients object to surgery that could save them if they were scared away by how risks are presented to them? Does anyone know of any books or authorities on this topic? I've just always been surprised by how casual most patients are when being put under for major surgeries.

well, samara, it's not actually the being "put under" part that is the riskiest part, but often what people are most afraid of.

i've occassionally battled the overconfident, casual attitude that a lot of surgeons have. personally, i attribute this to their "fighter pilot" mentality. many surgeons, as a breed, tend to remember their heroic saves and great surgeries and forget their bad outcomes 2-3 days later in the sicu. they don't seen always see the "connect" between the surgery itself and the patient's morbidity.

but, it's a mentality, frankly, we share sometimes too as anesthesiologists. and, i think the best you can do is just remind patients that surgery is serious stuff. the irony is that the patient may have a really bad longterm outcome, even death, following a surgery. but, many perceive that if they make it through and "wake up" from the procedure that the surgery must have been successful.

 

[Planktonmd]

This is exactly what I see. I'm not sure if the surgeons are downplaying the risks or are being confident. Would more patients object to surgery that could save them if they were scared away by how risks are presented to them? Does anyone know of any books or authorities on this topic? I've just always been surprised by how casual most patients are when being put under for major surgeries.

The way you present the risks to the patient without scaring them to death is what makes you a good doctor.
There are many people in this specialty who lack basic bed side manners and while attempting to be realistic with patients they forget that these are human beings under very unusual circumstances, who deserve all the compassion they can get!
It's a delicate balance between two aspects of your personality: The scientist versus the healer, and you either master this balance or you don't.
I don't think anyone can teach you this art, some people have it and some people don't!

 

[SamaraMorgan]

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[cchoukal]

I think one really tough part of having this conversation, at least at my level of training (CA1), is that I don't really know what the statistics are. What percent of emergent AAAs DO die before they leave the hospital? How often DOES the surgeon blow through the IVC with the lap trocar? I recognize that these are surgical risks, not anesthetic ones, but you get the idea...

 

[Lonestar]

you can look at statistics all day long. But when you get out you will have to go with the clinical picture presented and base your decisions from there (sometimes you don't have a choice). 78 yo with AAA (ruptured?) s/p two codes on the way to the hospital, intubated, BP 78/30, HR 144 on multiple pressors is not going to do well no matter how you guess it. Believe it or not, the family still wanted surgery for this pt knowing that 99% of these pts don't make it through surgery. I was involved in this case and was not surprised about the results. Surgeon thought he could help alleviate the family's concerns by doing the surgery and anesthesia had no choice since this was labeled as an "emergent" surgery in the wee hours of the morning. So, basically we butchered this poor woman during the last few hours of her life. I don't think we (team) healed anyone that day.