As much as I write about the foibles, pseudoscience, and misadventures of cranks and quacks that endanger patients. However, never let it be said that I don't also pay attention to the foibles and misadventures of real doctors that endanger patients. Sometimes that occurs due to incompetence. Sometimes it's due to the persistent use of invasive modalities that have been shown not to work far longer than they should have been abandoned (e.g., vertebroplasty). Sometimes it's poor judgment. Of course, because I'm a surgeon, I tend to gravitate towards discussions of surgery when I leave my usual bailiwick of discussing alternative medicine, antivaccinationism, and various other skeptical topics.
So it was when yesterday I saw discussion of a post over at KevinMD by a surgeon who blogs under the pseudonym Hope Amantine (or apparently used to blog) over at Simple Country Surgeon entitled A lesson in the OR that prepared this doctor to be a surgeon. It is a story of training, a story that was clearly intended by its author to be a "real life" story of how a senior surgeon taught Dr. Amantine as a resident to handle a dangerous situation. The problem is that it was appalling on so many levels. You'll see why as soon as you see the story. As a surgeon, albeit one who doesn't do such large, risky cases anymore, I sort of understand what Dr. Amantine was trying to get at, while at the same time the story disturbed me greatly.
Dr. Amantine's article tells the tale of a case she did during her training. It was an elective repair of an aortic aneurysm. The reason surgeons repair aortic aneurysms when they grow to a certain diameter is because, beyond a certain diameter, the risk of rupture becomes unacceptable, and the larger such aneurysms grow the greater the risk of rupture. As you might imagine, a rupture of the largest blood vessel in the body is an immediately life-threatening occurrence. At first, the blood is contained in what we call the retroperitoneal space by membrane that lines the surface of the abdominal organs, the peritoneum. That can last mere moments after the rupture to even a few hours, but sooner or later the pressure will break through the peritoneum, allowing the blood to flow freely into the peritoneal cavity, basically into the abdomen. When that happens, the game is up. Exsanguination is rapid. Indeed, the vast majority of ruptured abdominal aortic aneurysms (AAAs) are rapidly fatal before the patient even has a chance of being brought to the operating room. A few, however, remain contained, and there is a chance to save them.
To achieve that, however, a vascular surgeon must not only be skilled but must not fold under pressure. Learning to remain calm and collected, to do what needs to be done, not to let his emotions affect his technical skills. It's the only chance to save the patient's life. Indeed, part of the reason I ended up going into surgery relates to an experience I had the very first day of my surgery rotation as a third year medical student. The first part of my rotation was on vascular surgery, and that very day a man with a ruptured AAA was brought to the OR. I remember it well, even though it happened nearly 30 years ago. I remember the blood everywhere. I remember helping the nurses in the OR check unit after unit of blood as the anesthesiology team tried frantically to keep up with the massive blood loss. I remember the skill of the surgeons as they labored to save this man's life and how, somehow, they didn't freak out, didn't yell, didn't lose their cool in any way. There I was, a third year medical student early in my clinical rotations, almost completely inexperienced, and I felt part of the team. The team failed to save the man, but it wasn't for lack of trying.
So it is through that lens, that memory, that I read this, with a mixture of understanding and horror, Dr. Amantine's account of how her attending surgeon reacted during an elective AAA repair as she dissected around the inferior vena cava (IVC). The IVC is the largest vein in the body and runs right next to the aorta. Now there's a difference between arteries and veins when it comes to repairing them. Arteries are muscular and thick. They are fairly easy to sew. Veins, on the other hand, are thin-walled and frightfully easy to tear. It is in general, all things being equal, actually more difficult to repair a torn vein or to sew two veins together than it is to repair an artery or to sew two arteries together. Now that you know that, judge this passage:
So here I was, handling the plane (the layer, or space) around the IVC with care to avoid ripping it. It seemed like the intelligent thing to do. My attending asked, “Why are you being so dainty with your dissection there?” I answered that I wanted to avoid ripping the cava because they’re so much harder to fix.
I take it he interpreted my comment as fear, and decided upon a teaching moment. He took his scissors and incredibly, before my eyes, and with no warning or preparation of any kind, cut a one-inch hole in the cava.
I was stunned. As I tried to process what I just saw, incredulous that he would actually intentionally make a hole in the cava, and as dark blood poured out of the hole, the tide rising steadily in the abdomen, he remarked, “Well, are you just going to stand there or are you going to fix that?”
And so I did. Whatever thoughts I might have had about his behavior, his judgment, and his sanity (and believe you me, there were many), I put my fingers on the hole to stop the flow. I suctioned out the blood that had already escaped, and irrigated the field, the Amazing One-Handed Surgeon did nothing to help me. This exercise was clearly a test. I got two sponge sticks to occlude flow above and below the hole which I instructed him to hold in position (which he dutifully did), and then I got my suture and I fixed the hole. No problem.
All he said was, “Good job.” And we proceeded to complete the case uneventfully.
Dr. Amantine went on to describe how appalled she was but correctly noted that the culture in surgery is very hierarchical. In fact, I tend to liken it to the military. There is a very defined chain of command, from intern to resident to senior resident to attending surgeon. You do not bypass the chain of command, and you do not question your superior without very good reason. Non-surgeons might not understand, but there are definite reasons for this culture. The surgeon in the operating room is absolutely responsible for the life of the patient in a very personal way. He is, after all, given the incredible privilege and power to legally take sharp objects to living human flesh in order to rearrange a fellow human being's anatomy for therapeutic intent. It's an honor that is hard to understand unless you've actually experienced it and a profound responsibility. While it is true that surgical culture is becoming more collaborative and less top down, with surgical checklists, time outs, and mandates that if anyone sees something going wrong or that isn't right it is his duty to question, there does still have to be a "captain of the ship." That will never entirely go away, although that role has become noticeably less authoritarian just in the couple of decades that I've been a fully trained surgeon. That is, for the most part, a good thing.
So, in the context of decades ago, it's not entirely surprising that Dr. Amantine reacted thusly:
Though I may not have agreed with his actions on that day, I do understand them. How do you teach someone to take charge when there is a crisis? I am certain that if I was put on the spot and shriveled and sniveled, and couldn’t control the bleeding, he would have taken over. And I would have failed.
So on that day, when the vascular attending cut that hole in the cava, he was preparing me, both for the oral exam, and for life as a surgeon. He wanted to see if I could handle it.
I guess I made the cut.
Which is absolutely the wrong attitude. Yes, I, too, can understand how an established surgeon might romanticize such an incident as having "forged her in fire." Here's the problem. There is another aspect of being a surgeon that is at least as important as her ability to perform under pressure, if not more so. That is, very simply, the Hippocratic admonishment not to do intentional harm to a patient. When we say, "First, do no harm," that is our promise to the patient that we will do our best for him and we will not do anything intentionally to cause harm. That is not to say that the patient will not be harmed. Surgery in and of itself is controlled harm, as cutting into the human body inherently causes trauma and harm. Every time we operate on a patient, we are committing a form of controlled assault that causes some harm. In this case, even under the most charitable assessment of what the attending surgeon did, at the very minimum the patient was harmed by the additional blood loss (remember, Dr. Amantine described blood welling up in the abdomen, which doesn't sound like a trivial additional loss of blood to me), more time under anesthesia to complete the repair, the necessity to occlude the IVC during the repair, and the placement of a repair in the IVC that put the patient at risk of bleeding to death if the repair were to fail. There is no excuse.
We do surgery not because we wish to do harm, but because the damage to the tissue we cause is outweighed by the therapeutic effect of the surgery itself, the aforementioned forcible rearrangement of the patient's anatomy. Key to that is not to cause unnecessary damage, and what is intentionally making a one inch hole in the biggest vein in the body but causing intentional harm? That it was allegedly done in order to train Dr. Amantine to be able to fix the IVC if ever she accidentally cut into it during a case doesn't matter and doesn't justify such a betrayal of the patient's trust.
I can't help but contrast this to how a surgeon with whom I trained as a resident handled it. Like the surgeon described by Dr. Amantine, he was supremely confident and skilled, the very epitome of the "cowboy surgeon." Indeed, he intimidated the residents mightily. As we would struggle through a case, he would guide us through, but he did have a tendency to yell. I didn't understand it then, but I do now. It was just that he was frustrated. He knew he could do what we were doing so much more easily, so much more gracefully, and so much less clumsily. But he was so dedicated to teaching that he would let us as residents blunder through the case, trying to guide us along the way, to show us the way, realizing that to learn we had to find at least part of the way ourselves and to figure out how to get out of trouble. He could do this because, as he sometimes said to us, there was no trouble, surgically speaking that we could get into that he couldn't get us out of, and there was no way he was going to let us get into trouble that threatened to cause serious injury to the patient. Sometimes he just couldn't help himself and his frustration watching us newbies blunder got the better of him.
He had our backs, though. I'll never forget one Morbidity and Mortality conference in which we were discussing a case I did with him that was complicated by bleeding that necessitated a return trip to the operating room. When I was being questioned about it, he interjected, "I made that decision" (because he did) and got me off the hook. Some attendings let residents twist in the wind at M&M, but not this surgeon.
Now here's the kicker. The reaction to Dr. Amantine's post was furious and uniformly negative, both in the comments and in the Twittersphere, and yesterday there was an addendum:
Author’s note 7/8/2015: This is a fictional article. No one was harmed, then or ever, in my care or in my presence. I apologize for any remark that may have been misconstrued.
I call BS. Here's why. First, the doctor doth protest too much. There is no surgeon who can accurately say that no one has ever been harmed in her care or in her presence. We have all inadvertently caused harm, and we have all had patients whom we operated upon and probably shouldn't have, thus resulting in harm. Our goal is to make the number of those patients as tiny as possible, but the number will never be zero. Claiming that a patient has never been harmed in her care or presence is either a delusion or a lie, unless the qualifier "intentionally" is added, which it was not. Second, in response to the criticism in the comments, Dr. Amantine responded:
I completely understand your shock and horror. As one of the other commentators remarked, it was a different era. Time will tell if we are better or worse off today... I can tell you that since much has changed in the last twenty years, surgical residents today touch instruments much less often, and many report feeling unprepared for the rigors of attendingship when they have finished their training. Their work hours are restricted, their experience likewise, and I have seen more than a few young attendings that can't operate their way out of a paper bag. They have been trained in a kinder, gentler environment, and that is great as long as every operation goes as planned. They're rock stars with computer keyboards, however...!
In answer to your objection, the only stake in the game is the well being of the patient - the one on the table, and every one whose life I will ever be responsible for. Don't think for a moment I take that responsibility lightly.
When there is a computer simulation that adequately prepares surgeons for unexpected anatomy, findings, and intraoperative unplanned "events," I will be the first one to sing Hallelujah. It hasn't been invented yet - so until that time, you better pray that you never get a hole in a cava. But if you do, you better hope that the person holding the knife can actually fix it in less than the five minutes it will take for you to bleed to death.
Dr. Amantine's response sure doesn't sound to me as though her story was fictional. Neither did her other comments after her article. If the story were fictional, why didn't she just come out and say that right away? Why was the story not labeled as fiction? Instead, she made excuses about how it was a "different era," how surgeons today can't operate, and how there is no good way to teach a surgeon how to remain calm and perform when disaster strikes. Yes, as surgeons, all of us have accidentally gotten into a large blood vessel at one time or another, and it's critical to know how to control the bleeding and repair it. Making holes in living patients undergoing elective surgery is not the way to teach residents to be able to do this. Yet that's what Dr. Amantine seemed to be making excuses about.
It's also impossible not to note that it was only after the criticism came raining down on her on Twitter did Dr. Amantine claim that the story was fictional. Maybe it was fictional (it does have the air of being apocryphal about it), but if it was fictional she sure didn't give any indication until after the shitstorm got really intense. Then she deleted her blog (which is gone as of this writing, as is her Twitter account). Also, as a surgeon myself I have encountered enough other surgeons over the years whom I view as potentially arrogant enough to do something like put a hole in the IVC in order to see if a resident can repair it.
So is this story true? Hell if I know. It rings true to me as a surgeon, having seen misbehavior such as thrown instruments in the OR on occasion, but on the other hand I've never witnessed a surgeon intentionally injure a patient that way. I also can't help but wonder how one would dictate that part of the procedure for the operative report. Dictate the truth, and it's there what you did in black and white, for all to see. Claim it was an accidental injury to the IVC (which can certainly happen during a AAA repair), and you've lied in the medical record. In the end, I conclude that Dr. Amantine probably did relate a true story and only backtracked when the criticism became too intense, and Kevin Pho, the Kevin in "KevinMD" let her:
Author's addendum added: A lesson in the OR that prepared this doctor to be a surgeon http://t.co/tC4AIuzT2n
— Kevin Pho, M.D. (@kevinmd) July 8, 2015
Which drew a response so spot-on that I have to include it:
@kevinmd Either this is true and an appalling lapse in medical ethics or false and an appalling lapse in journalism ethics.
— scott jenks (@scottjenks) July 8, 2015
Or, even if the story is indeed fictional, it was a monumental screw up to have published it without labeling it as fiction. Truth be told, I've noticed over time that KevinMD.com has gotten more uneven in the quality of blog posts that it publishes. There are still some great posts, but I've come across more and more stinkers like this. (There's even been the occasional infiltration of medical pseudoscience and rants by doctors complaining that evidence-based medicine is an affront on physician autonomy.) Perhaps Dr. Pho should spend more time on quality control. Strike that. There's no "perhaps" about it. KevinMD used to be great; now, not so much.
As for Dr. Amantine's story, I think of it this way. I've been in medicine 30 years now, counting medical school, and I can't imagine a time when intentionally cutting a hole in a major blood vessel in order to provide teaching fodder for a resident would ever have been considered acceptable behavior by a surgeon, although I have encountered surgeons who, I thought, might be capable of doing such a thing. I find it heartening, however, just how negative the reaction to this story has been among physicians and surgeons. Maybe Hope Amantine and Kevin Pho will get the message and come clean about (1) whether this story is fiction or not fiction and, if it was fiction, (2) why it wasn't labeled as such and (3) why Dr. Amantine responded in the comments to criticism in a way that sure sounded as though the article had been nonfiction, which really makes me think she was lying when she later claimed the story was fiction.
Dr. Amantine's and Dr. Pho's readers deserve no less.
ADDENDUM: Kevin Pho has removed the story from KevinMD.
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One of the constraints on fiction writers is that their stories have to be plausible, in a way that isn't always true for real events. Dr. Amantine's story illustrates this point: it's too implausible to be good fiction. Surgeons as a group have a reputation for being jerks, but intentionally cutting the vena cava (when one is not performing surgery on it) is way over the line, even for a surgeon who takes jerk characteristics to extremes.
Of course individual surgeons can be nice people, and I have no evidence that Orac is a jerk. But the stereotype exists for a reason.
As I see it, wheather the story is fiction or not is for the most part secondary. It is appaling either way.
The message of the story - wheather it happened as described or not, is still the same. Even if the whole thing is just a short story created for a blogging purpose by Dr Amantine it still containt praise of such irresponsible and unethical behaviour, that it is hardly believably a surgeoun could endorse it even as a fiction.
Obviously the idea this could have really happens only adds to the horror of this story, but the reason it was published and the intention of romanticizing training at the cost of causind additional harm is and of itself enough to make all the backlash and criticism more than valid.
My impression is also that this story only became "fiction' after the intense blowback.
"I can tell you that since much has changed in the last twenty years, surgical residents today touch instruments much less often, and many report feeling unprepared for the rigors of attendingship when they have finished their training. Their work hours are restricted, their experience likewise, and I have seen more than a few young attendings that can’t operate their way out of a paper bag."
You run into this attitude in other writings by surgeons, and it may well be true that in earlier times, heaping pressure on surgical residents and drastically curtailing their sleep (compared to now) made them tougher (as well as nastier) and better able to cope with emergencies. I just can't help but wonder about outcomes for the poor bastards being operated on by sub-qualified zombies during the learning process.
Over at Pharyngula, one of the commenters copied a bunch of Dr. Amantine's Tweets before she took her Twitter feed offline:
Yup. I'm now more convinced than ever that she was lying about the story being fiction and that she lied in response to the justified criticism she was receiving.
I'm a veterinarian, not a physician. I can do surgery, but I would never call myself a surgeon, although I have been the frantic person searching for the bleeder in an abdomen of a dog hit by a car--and then found it and managed it. In my role in research, I've been called upon to assist "real" surgeons, and in that venue, had an instrument or two tossed at me. (Be assured, they went back the same direction, with greater velocity and the pointy end aimed at the "surgeon.") I hate to say it, but this story rings true. And I'm horrified that I believe it.
I'm pretty sure the incident happened, but I hope that it's been exaggerated in the telling. An inch long scar in the VC places the patient at increased risk of complications for the rest of his/her life.
I have been a practicing Cardiothoracic Surgeon for 30 years. As such my training was very rigorous in the late '70s and early '80s. In fact I had some very tough demanding instructors. I have never seen or heard of such an incidence. I really question the whole point of this "story". If the point is to show how much more difficult training then is to now it certainly could have been done better by detailing the long hours of doing scut work and getting little education from it. If the point is to show the surgeons of that era were arrogant jerks and now they are not that is like arguing sports heros of the past are not as good as those of the present. In any event I found it to be a pointless story. One best left untold.
I've been reading about this since yesterday. Good on you, Orac, for calling it out, and making sure Kevin Pho confronts the damage these kinds of stories bring to the medical profession.
I think it's part of the commitment to skepticism that we are as vigilant about evidence-based medicine practitioners behaving badly as crystal healing gurus who shove needles in people's skins and burn flowers in their braziers.
I apologize for any remark that may have been misconstrued.
"Misconstrued" is an odd way of blaming people who believed that she was telling the truth when, apparently, they should have immediately assumed that the story was a lie.
You do not bypass the chain of command, and you do not question your superior without very good reason. Non-surgeons might not understand, but there are definite reasons for this culture.
I would welcome any Oracian perspectives on Dr Gawande's Checklist Manifesto.
Of note, Kevin Pho removed the Hope Amantine story:
#1 Eric Lund:
Would just like to echo this sentiment. If this was a story about learning to deal under pressure, it would have run something like:
Same basic sequence of events, entirely reasonable noob mistake (I think? Actual surgeons correct me if I'm wrong?), resident learns a valuable lesson without the wildly unethical decision-making. If the point was "it didn't matter where the hole came from, it was my job to fix it," then why phrase it as an act of irresponsible, unlikely malice?
What actually struck me is that the attending surgeon admonished a trainee for being too delicate with tissue. Going back to Halsteadian principles, delicate tissue handling good surgical technique because it causes less cellular damage and results in less of an inflammatory reaction. While it is true that there is a fine line between being delicate with tissue and being too tentative, of basically farting around because you're afraid to proceed, obviously what the attending is said to have done is not the way to handle this failure in a resident.
As for pushing a trainee to the point where she accidentally makes a hole in the IVC, actually if you're going to teach a resident this lesson it would actually be far safer for the patient to do what this attending surgeon did. There's no telling where or how big a tear in the IVC made accidentally will be, and a big one on the posterior surface could be very difficult to repair. No, I'm not excusing what the attending surgeon did. It was unethical and horrifying. However, I was pointing out that a controlled incision on the anterior surface of the IVC is much easier to repair than an injury who knows where and who knows how big on the IVC.
scott jenks absolutely nails it. This is wrong whether it was real or not. And the worst part is that either way, she described it as something that was ultimately beneficial to her, and that is only not done now because it is a different time. My grandfather was a general surgeon who served in WWII and Korea in that capacity; I think this would horrify him as well, so exactly how old are we supposed to think Amantine is, that there was a different time when she could've been training where this was acceptable?
Ah yes. The notpology. That certainly caps off my opinion of her.
I remarked on another blog that not only police, but also surgeons, ought to wear body cameras. I wasn't kidding.
Here's the Archive.org link to the post as it originally appeared on Hope Amantine's own blog.
More justification from the surgeon after this action was characterized as malpractice by a commenter:
A pint of blood? That's a unit of blood. She's brushing off an additional blood loss of one unit as though it were nothing. Such additional blood loss, when added to the unavoidable blood loss of the rest of the operation, can mean the difference between needing a transfusion and not.
Speaking in the capacity of a non-surgeon, I'm incensed by this story. If I found out this happened to me, or to someone over whom I had legal responsibility with respect to medical care, I would immediately set about suing the attending into the ground.
Also in the firing line would be anyone in the OR or hospital administration who let it happen without either immediately complaining (even if it violated "the culture" or got them booted from the OR) or notifying the admin that the attending had deliberately endangered a patient. (Obviously, this includes Dr Amantine.)
As noted by herr doktor bimler, Dr Amantine (weakly) defended her acquiescence with:
This, of course, is perilously close to "I was just following orders", which as Dr Amantine should well know is not exculpatory. Unless she directly confronted the attending about his deliberate endangerment of a patient, or at the very least reported the incident to hospital administration so as to make clear what he had done, she is complicit.
Secondly, it's disturbing that Dr Amantine did not, when reflecting upon the experience these many years later, conclude that deliberately endangering a patient constituted a "very good reason" to "question your superior" after all. Perhaps she did, privately, but in that case why not just say so?
Lastly, it's worth noting that in her attempt to defend this piece (fictional account or not), Dr Amantine resorted to a "kids these days" (*) argument, in effect claiming that today's "kinder, gentler environment" (**) is somehow inferior to her "deliberately endanger patients to make a point" (***) training environment.
Since that defence has, presumably, been taken down, there's no way now to see if she provided any, you know, evidence that this is the case, other than "in my experience".
(*) quote marks used in this case to denote a definition of the type of argument, not a quotation from Dr Amantine
(**) quote marks used for direct quotation
(***) scare quotes
As a final word, I can't help but wonder whether Dr Amantine is the type of surgeon who expects extra respect and consideration from wider society for her profession.
I'm happy to say that doctors and surgeons are in the main deserving of extra respect (without being put on a pedestal or made into saints; otherwise we couldn't hold the Dr Oz...es of the world to account). But if this story is a true story, Dr Amantine has IMO forfeited any claim she had to same.
If I had to guess, the original story was true, and the author now claims fiction to avoid being compelled to reveal the identity of the offending surgeon and damaging his career. and possibly hers as well.
It possibly might not qualify as -malpractice- because the damage was clearly intentional (and any financial penalty for subsequent damages that could have been resulted might not have been covered by malpractice insurance for the same reason), but it seems to me to be assault with a deadly weapon and thus a felony. (IANAL)
The statute of limitations for such is usually around 3 yrs, but what are there time limitations (if any) for complaints to a state medical board for medical malfeasance?
And I would argue that, like the culprit in the main story, he was a bad teacher. Yelling at a student because you, as teacher, are frustrated is exactly the same class of reaction as a student fumbling and waffling because of uncertainty. Both are markers of not being able to do the required job properly. The student will probably learn eventually. The bad teacher probably won't.
I couldn't help but notice that the surgeon in the photograph is holding a hemostat (?) in his left hand incorrectly.
Odd for a post about surgery,
Thank you "Hope Amantine," for adding to the reasons I will probably be refusing surgery for several conditions for which it has been suggested, because I think I'd rather spend the rest of my time in a wheelchair receiving palliative care, than to take a chance on being "cared" for by alleged medical professionals like you. It also makes me wonder about the problems my oldest son had with his last vascular surgery. Was someone like you his doctor?
@doug: Nope. He was an awesome teacher. He taught me more about how to actually operate in a few months over my five years than many attendings taught me the entire five clinical years I was there. Only he, for instance, taught me to use the knife to take down abdominal adhesions, rather than scissors. When it's done properly with the knife, it's so much less trauamatic. And, frustration or not, he always had your back.
With respect to Dr Amantine's comment on her own blog cited by Orac (about malpractice), and the Tweet Orac mentioned in which she deflected the question of what would have happened had the patient died (by refusing to consider the hypothetical), it seems to me that Dr Amantine has a bad case of "success morality" in this case - it all worked out in the end, so all's well that ends well, no harm done, eh?
And this was going on even as she was saying that it wasn't her intent to justify or defend (as it were) the attending's actions.
I guess it comes down to "we're all the hero of our own story". Even though maybe she should be engaged in some introspection à la Mitchell and Webb instead.
This story reminded of the time I was flying across the country and suddenly the Boeing 737 with 121 souls aboard pitched up 30 degrees and entered a stall. The sudden maneuver must have turned on the intercom, because we heard the captain say to the trainee first officer, "Well, are you just going to sit there or are you going to fix that?"
This was many years ago, and trainee pilots today are so coddled what with their work hours restricted and their kinder, gentler training environment. I bet they're rock stars at the flight control computer keyboard, though!
Oh no, wait, that didn't happen because putting other people at risk is not how you train people to deal with a crisis, and getting rid of the macho cowboy bullshit in the cockpit, reducing working hours and mandating rest, using checklists, and incorporating computers and automation has made airline accidents so incredibly rare that they are big news items.
While I think this is a true story, this isn't the first time an article of fiction has been posted at KevinMD. I can't recall a particular article since it would have been over a year ago that I read there religiously, and the volume of articles makes it almost impossible to find.
But the one that stands out in my mind was one where a few of the physicians were commenting on it as if it was true and then the author and others had to remind them that it was fictional. The comment direction then went to why write a fictional account as if it were real. Why not just make your point with a true anonymized story or with reason (note that I haven't read any comments on this except for here but it wouldn't surprise me if this was being said in some of comments on this particular KevinMD thread.)
The content of the fictional articles I've read there were nothing as appalling as this but I suggest that if any site that normally publishes true accounts yet wants to throw in a few fictional stories to meet the need of physicians who are into creative writing, that they segregate them to a separate section of the blog.
Did you notice the comment from Anonymous praising "Dr. Amantine"?
I have to admit, Dr Amartine's tale sounds quite a bit like a bad episode of House MD. I could see it happening. Some young surgeon-to-be is being too cautious, so cantankerous egotistical Dr House just nonchalantly snicks a hole in the IVC, so as to cause Dr Neophyte a high-pressure "save" situation.
But if it were a real surgeon who did that, I would want to know. They need to be slapped on the wrists. Or punched in the nose. Or both.
(oh bother. I typoed the name. Dr Amantine . . . whoops.)
Dramatic. I sure am glad the only corrective action the obscenely presumptuous surgeon would need to take in these modern times is to push 20cc of organic Barr's Vena Cava Stop Leak™
"Dialasis? My God, what is this? The dark ages?"
I felt physically sick when I read that. That sort of arrogance is unforgivable. I'm reminded of when I worked at a UK hospital back in the 80s when surgeons were considered as demi-gods walking among us. A certain world-renowned transplant surgeon* would often be seen striding majestically through the corridors, a pair of lackeys clearing the way, opening doors ahead of the great man, an entourage eager at his elbows and a gaggle of hangers-on trailing behind him. I would often see him in the hospital bar (!) at lunchtime, downing a pint of Abbot Ale (a fairly strong bitter beer) to steady his hand before surgery. I hope times have changed!
Incidentally, I highly recommend Sky's 'Critical': it's a (sometimes a little too) realistic* UK TV drama about a hospital trauma unit featuring the marvelous Lennie James (Morgan in 'The Walking Dead') playing a trauma surgeon - it was on Sky, so should be findable by most. Not for the squeamish; the episode in which a patient turns up with horrific dog bites and a live dog with locked jaw still attached was especially fun. Having watched 'Critical' gives me some idea what a nightmare it must be sewing up any vein, least of all the IVC.
* I observed him doing a liver transplant once and, as I have mentioned here before, the amount of blood they got through was frightening, as liver transplants were in their early days and only very sick patients whose blood barely clotted, were considered. That was before cell-savers had been developed; the blood bank staff would have conniptions when word went out a liver transplant was imminent.
I was also horrified at the so called "teaching moment".
I was a corpsman in the US Army working in an OB ward at Ft Stewart GA in 1973. I remember it was routine for the OB surgeon, Dr David Smith, to puncture the patients butt cheek with a large towel clamp and ask if she felt that, to test a saddle block. The puncture was deep and nasty enough to cause quite a bit of bonus pain after delivery when the anesthesia wore off. The cruelty made me wince and it was NOT doing no harm.
Also, when I saw this I was not "offended," I was angry. The problem isn't that she called people names, it's that either she (and possibly her editors) are liars who think it's reasonable to present fiction as truth, or the person training her intentionally risked a patient's life. I suppose "offended" might, if stretched thin, cover "and of course I didn't report him afterwards."
Yes, there's a hierarchy. But there are also the Nuremberg principles: she wasn't in a position to decide whether to obey an unlawful order, but she was in a position where she decided that her continued position as a trainee was more important than the fact that a surgeon had deliberately harmed a patient in order to teach her a lesson.
Well that does paint him with a new and improved palette.
Teaching complex and difficult skills can be at least as difficult as learning the skills. I've certainly known people who were very good at what they did who, were it up to me, I wouldn't let anywhere anyone trying to learn the ropes.
I also realize that my position that yelling at students is not a good thing is somewhat at odds with my past occasional desires to choke the very life out of a student or two.
Was this surgeon's last name 'House' by any chance?
Regardless of the veracity of the story, certainly sounds like attention seeking behavior. Well, she got it...
My mouth dropped open in horror when I read it. Appalling was definitely appropriate. I suspect back pedaling as well. Sadly not much to add. Just more of everyone else's comments.
I agree that this was not malpractice. It was a serious crime. In the opinion of this non-lawyer it was aggravated assault, one of the definitions of which is "...when that person attempts to: cause serious bodily injury to another person with a deadly weapon". Even the most lazy DA could win on an additional charge of "possession of a weapon". The equivalent in the UK, is called "inflicting grievous bodily harm.
Proof of the act alone would probably win a large sum of money, which might include exemplary damages and punitive damages, even if there was little evidence of actual economic loss.
So I have to amend one of my earlier comments, due to an error on my part.
It transpires that I attributed a comment on surgical hierarchy to Dr Amantine that was in fact made by Orac, and in a different context (the context of understanding her conduct, rather than defending it).
So my apologies for the error in attribution.
A better text to use would have been, from Dr Amantine's own blog:
(My broader point that, by falling in line with hiercarchy in this case, Dr Amantine was complicit in deliberately endangering a patient, stands.)
' attention seeking behavior' - sure.
And notice how she does the repair well and then congratulates herself.
I wonder if it were really the IVC or another less vital vein
IF this event indeed happened.
I have to disagree with some of the folks saying it was not malpractice. I think there could be a case for such a claim, based on the elements of malpractice:
1. A duty was owed (patient-doctor relationship)
2. The duty was breached (doctor failed to adhere to standard of care)
3. The breach of duty caused harm (patient lost excess blood and required additional surgical repair that, if not for the breach of duty, would not have been required)
4. Deviation from accepted standard (it is not standard care to purposefully cut the IVC during an AAA repair)
5. There was damage (there was blood loss, potential emotional damage if the patient ever learned of the event, weakening of the IVC, etc.)
The difficulty would be proving #5 considering the repair was supposedly successfully performed.
Another ethical question here regards the monetary cost to the patient. I have no idea how this sort of thing is billed, but given that a bag of saline that costs two dollars from the vendor can cost the patient hundreds, that surgeons (not to mention others on the team) don't work for minimum wage and that ORs are a finite and expensive resource, I can imagine this little exercise cost the patient plenty.
I think this was a "teaching moment" - just not as intended and long after the fact.
Old Rockin' Dave @38 (and your location):
Thinking about Firesign a lot since now two of them are gone. Their condensed and fractured history of the United States had this little gem:
Immigrants (in odd accents and ragged unison) : "We were small, angry men, with heavy faces, and burning feet."
Narrator: They came from such places as :
And the far flung Isles of Langerhans.
KevinMD turned me off based on his staunch opposition to healthcare reform. He's all about the clicks.
"Surgical hierarchy is rigid and absolute, and even second in command does not comment on the general’s decisions, and furthermore, that is the only way it can be. There are no committees in the operating room."
This quote (attributed to Dr. Amantine), reminds me of the major changes commercial airlines have gone though with the implementation of Crew Resource Management (formerly, underlings were loath to forcefully bring up problems (or, god forbid, challenge senior pilots) over developing situations which threatened disaster).
I truly hope that this business of never-challenge-the-general-in-the-OR is a gross exaggeration of modern surgical practice. If this truly reflects Dr. Amantine's philosophy, I would never want her to be my surgeon.
As a nurse, if I saw a physician do that, it sure as heck would have been documented in the OR notes AND reported to my head nurse. The heck with not confronting the doctor! Even foot soldiers (should) have learned that you don't obey an unlawful command, after Mai Lai...
And negligence hinges on the standard of care.
Then there's no problem disclosing the hijinks to the patient, right? Malpractice lawyers, as I understand the situation, have to be pretty choosy, but I have a certain sense that a case in which one damn well doesn't want the facts disclosed in court has "settlement" written all over it.
Oh, and something something negligent infliction of emotional distress something. (This is actually a much weaker case than the hypothetical one, which – under this theory – would seem to call on defendants to show that any such distress over future harms is unreasonable.)
And, as the RIgulars know, IANAL. Then again, neither is Amantine.
^ Shorter version: The core assertion appears to be that it's not actionable because if some consequential harm resulted in the future, the patient would never be able to pin it on us.
And Robert Hawkins in "Jericho," which is where I first encountered him. I have little time for television these days, but I'll be checking out "Critical," thanks.
"Assault with intent to maim or kill" is the term that I would use to describe what that idiot of a surgeon is supposed to have done, that is to say if this far-fetched story is indeed true. Of course, as we both know, there are surgeon colleagues of ours, whose love of surgery is not reciprocated and whom we would never trust with operating on our worst enemy (if we had one? :) ). But this time Orac, I have to disagree with you and call a bluff on this self-upheaving fable of Dr. Amartine's.
I am a GI/trauma-surgeon myself with over three decades of experience. I have burnt-in images in my mind of a couple of instances of large intraoperative tears in the VC. Of course, if the patient is exsanguinated at that moment, the Cava-wall is just lying there flapping and rather amenable to delicate suturing... but If the patient has any venous filling at all, "the house" fills quickly with blood and you bloddy[sic] well have to be a God-damn good and, above all, experienced surgeon to manage such a situation.
Naaahh, no way. It takes considerable practice and a very steady hand to sew the VC. And even if you did manage the situation, you would be causing a risk of thromboembolic and other complications that would cost several tens of million dollars in liability, which would be almost certain as any of a number of OR staff would not be able to keep quiet about such a breach of ethics and moral.
I forgot to add that in most US jurisdictions, the charge of reckless endangerment would also be brought, in which actual resulting harm need not have occurred and lack of intent to harm is not a defense. All that needs to be proven is that the conduct was heedless of potential grave risk to another.
That son of a bitch should have been stripped of his license, imprisoned, and fined.
Some people questioned whether the surgeon committed malpractice. Probably not, as that is an accidental injury. Instead, he committed assault, which is both a civil wrong and a crime. The odds of getting damages for the assault are minimal but the surgeon could have done time for the crime of assault.
I moonlighted in a private non-teaching hospital where the doctor in the story below was staff and he was the surgical on-call for the weekend. When a patient went into frank heart failure the other PA and I went to work on her and paged him. His lack of basic knowledge and his unwillingness to institute what we knew were necessary measures because they were "too complicated" were appalling. I told him to write the chart note because both of us PA's didn't want our names anywhere near this incident. I knew him under his real name, but when the newsreader said "Iranian-born gynecologist" I knew who it was. http://www.nytimes.com/1995/08/09/nyregion/abortion-doctor-guilty-of-mu…
Dr. Amantine's attending was only one step below Dr. Benjamin's in my eyes.
palindrom, I have to admit it wasn't Firesign I was thinking of. I first made that joke before I had ever heard them. I miss them now. Along those lines though is an old book titled (I think) "Through the Alimentary Canal with Gun and Camera."
When I see your nom de Net, it always brings up an image of Sarah Palin in a tight superhero costume jetting off from her secret airfield to go fight liberals - "Quick, Todd , to the Palindrome!"
In Orac's photo two of the surgeons in the operating room are wearing natural rubber latex gloves.
The nurse nervously whispers, "The patient has a latex allergy."
The surgeon replies with respectful insolence, " I don't give a sh*t, we can't stop now".
In my opinion, using natural rubber latex gloves knowing the patient has a latex allergy is medically unethical and the insolent surgeon should be terminated.
Two nitpicks, but I hope with some useful payload: First, the name is pretty much "medical battery," not assault. (States vary in their criminal definitions; all the ones I've had reason to investigate defined the latter as causing threat of imminent harm.)
However, "accidentalness" is not necessary to establish malpractice: breach of duty + causation + damages is the formula. From a hypothetical plaintiff's position, this is an easier case to make (see here a discussion).
There's also the separate issue of what the hypothetical consent looked like. This is skimmed, along with "gross negligence," here, but it's obviously a (sub-) W—dia source that's good only as a starting point.
Old Rockin' Dave @ 54 -- Way back when I made a name up for myself, I actually was thinking of using a palindrome (e.g. "axomoxa"; "rats live on no evil star") but then decided intstead to use "palindrome", but mistyped it, leaving off the "e". The thought of Sarah Palin in a Wonder Women costume didn't enter into it at all, oddly enough.
MJD - Eric Lund's statement in the first comment -
But, hey, on the bright side, your fiction is as good as your poetry.
Listen, I know from weird foreplay, but this isn't setting my trousers alight.
I am a registered nurse and spent time in the OR. I have seen a vascular surgeon do something similar. I was still in training and he decided to give me a "learning opportunity." While performing a carotid endarterectomy he pointed to a strand of tissue and asked me what it was. I said it looked like a nerve. He then proceeded to put me on the spot and kept asking the name of the nerve. I went through all the possible cranial nerves I though it might be. When I said one of them he said "I hope you're wrong" and cut the nerve. I think he then said something like "it was in my way." Nobody in the OR said anything and I have been horrified ever since. That surgeon is also known for being a complete jerk, arrogant, the type to throw things across the room. I have no doubts Amantine's story is true. I'm also relieved to know that this behavior is considered unacceptable by other surgeons.
More on the trend away from such rigid hierarchies in potentially dangerous situations:
The more collaborative approach is absolutely how it's done operating nuclear reactors in the Navy. Watchteam backup is stressed early and often. To the point where carrying out an order you know is a bad idea (malicious compliance) can get you severely punished if it causes enough of an issue. Briefing an evolution even NUBly McNuberson whose sole role is going to be to sit up on a mezzanine and monitor a tank level for 7 hours is in the full brief and specifically asked if they have any questions/concerns/recommendations.
Ah, yes, coming down from mushrooms with a (hard to account for, in retrospect) supply of Mini Babybel Gouda.
A girl I know once woke up plastered with Camembert.
That's because she fell asleep eating an entire cheese, though. Long story.
THe Safety/Quality Manager, nurse and human in me is horrified. Utterly horrified. "another era" - yeah, ok, still doesn't excuse the intentional harm done to the patient!
I also wonder if the disclosure was made to the poor patient as well, under the "well, we're a teaching hospital so I was teaching" explanatory note.
Yes, I'm joking. Sort of. There was an era where patients weren't told much either.
Such an abuse of the trust and privilege bestowed upon a surgeon.
Palindrom @ 57: I feel rather queasy now.
A girl I know once woke up plastered with Camembert.
I was dressed in a little Brie for Thora T, but that's a whole nother story.
MI Dawn #46
This (now retired) nurse, and his sister who is still one, would have shopped ANY medic pulling a stunt like that in an instant (or anything else that constituted an assault and unethical behaviour given that I was MH).
MJD: nice piece of fiction, wouldn't ever happen.
First of all, on any admission, patients are asked specifically about latex allergy (in my experience as a nurse AND as a patient.)
Secondly, the doctors don't pick their gloves in the OR; the OR nurses set them out. If a patient has a latex allergy, the nurses would not have put latex gloves - or ANY latex - anywhere in that OR. There are special OR kits with no latex, and sterile gloves in every size that are latex free. So there is no way the doctor could "reply insolently".
But it was a cute piece of fiction.
In today's meded environment,, suturing a vein can be taught in a surgical laboratory, or a simulator. In my day I did see surgeons doing things like this. Fortunately things are much better, now.
Definitely a true story. I worked with an arrogant and ignorant surgeon who twice deliberately injured a patient before our eyes in order to demonstrate his skills in repairing the damage. One patient was a mother of five children and she almost died. The surgeon was clearly mad. Nobody said or did anything. It preys on my mind still.
#45 re airline CRM: I once worked with a young intern for his fear of flying (I'm a clinical psychologist). His father was very senior in our local College of Surgeons, and once visited a session unannounced. I made the decision to allow him to stay as they were soon to fly interstate together and it would be helpful for both. Importantly he revealed he had convinced his College to visit QANTAS HQ to speak with the airline's safety culture department to learn how to use decades of experience in the surgery setting, CRM becomes SRM.
Sorry, if this has been brought up in the last half of the thread that I had to stop reading, but does anybody not now question the oversight and/or journalistic ethics being practiced at KevinMD? How did an article like this get approved and left up for as long as it was before being brought down ONLY after a deluge of Twitter complaints and four separate analyses by actual doctors? Was it not obviously appalling on a first read by Kevin Pho? Does he not read the stuff he allows to be posted to his own site? How does just removing it and leaving the anonymity of the "doctor" in place do anything to assuage the concerns of mortal laymen like myself, who have read the original story and seen the bungling of updates and retraction? Does Kevin Pho even know the credentials of people that post to his site? Can anybody post anything there as a "doctor"? At this point I plan to never voluntarily go to a teaching hospital, and I'm not thrilled about any at the moment. If I end up on the table of someone like this, they had better hope their "teaching moments" kill me then or that I never find out.
Journalistic ethics? On a blog? Maybe I am confused...
Pho cross posted the piece from Amandine's own personal blog. We can speculate all day long about why he picked that piece for cross-posting, but let's not treat Pho like he's running a scholarly journal or even a news aggregator. It's a blog...nothing more, nothing less. Caveat emptor.
I don't think you need to be at a certain level of professionalism, or income from your work, to have an ethical responsibility not to lie to your readers. Yes, the main responsibility was Amandine's, to be honest in the first place, not Pho's to assume that she might be lying and ask her for a signed statement that it was nonfiction.
The thing is, your "caveat emptor" puts it back on Pho, not to assume that anything he cross-posts from another blog is true, because at that point he is the potential "buyer."
On the other hand, maybe you think of blog comments as part of a blog, or as even more casual and with fewer ethical constraints. So I have to assume that you may not think you owe us honesty either. Maybe you're "just trolling to get a reaction" and actually know why Pho picked that piece for cross-posting, or have had detailed discussions with Amandine about her motives.
"Requesting permission to blow the DCA, sir!" -- NUBly McNuberson
"When we say, “First, do no harm,” that is our promise to the patient that we will do our best for him and we will not do anything intentionally to cause harm."
I guess that doesn't apply to administering vaccines.
ORAC, CAN I COUNT ON YOUR HELP TO RESTORE THE SAFE MULTI-USE VACCINE VIALS containing the original amount of Thimerosal?
PLEASE HELP OVERTURN CALIFORNIA'S VACCINE BAN NOW!
If It's good enough for Africa,
It's good enough for CALIFORNIA!
So, if deliberately cutting a hole in the IVC when it is not warranted does not constitute malpractice, doesn't constitute assault and (possibly) battery?
Just a word: I used to read Kevin MD voraciously as the posts rang as authentic. Later, more histrionic entries began to infiltrate the site. Finally, I no longer went there for the very reasons which created the furor noted above. Kevin MD is a website and not a peer reviewed professional journal so don't believe everything you read on the web. However, if you want to talk about KNOWN and PROVEN violators of the oath, lets restrict our comments to, say, the vile comments made by Dr. Tiffany Ingham, the glib anesthesiologist who was thankfully and successfully sued for 500K in damages. Or Joan River's ENT who took a selfie of her famous, unconscious and now dead patient before she proceeded to undertake a procedure that the facility was NOT CREDENTIALED to do and to which Ms. Rivers had never consented. Stand by for a massive malpractice award for Melissa and her son. Doctors behaving very badly? No doubt about it happening all the time. However, our patients expect better from us. They pray that the night before their surgery that we eat a good dinner and get enough rest. They expect us to take the high road. Those who defile their professionans by making up stories on blogs are immature. They are writers of fiction, stupid perhaps but not criminals. That the web is full of fiction is well known. But I will never forget what a long-ago lab instructor told our class: He stated with all sincerity and gravity that we must 'treat every patient like YOU EXPECT your child/parent/spouse and grandparent will be treated. If you forget this maxim - you'll eventually become a substandard practitioner....the sort you PRAY you'll never have the misfortune to need and then you''lll begin to despise your patients, your work and by association - yourself. This will mean you are no longer qualified for this noble profession because you will have become unsafe and unworthy to treat patients."
Kind of says it all, no?
First impression: that patient should have ended up owning the hospital.
If it's not specifically malpractice, and if it's not some obvious felony for which civil damages can also be assessed, then it certainly falls under the heading of "general torts," and the hospital would likely settle for serious $$ to avoid the publicity.
Among the reasons we feel such horror when reading about these kinds of instances, is because they're rare, and because they so obviously violate professional ethics. Contrast to the depredations of quacks, where the higher incidence of bad outcomes and the well-known absence of professional ethics removes some of the shock from the horror.
It seems to me that the root problem is macho culture, in a wide range of professions, and an obvious part of the solution is the entry of women into those professions.
I also find it highly objectionable to subject trainees in any profession to deliberate emotional manipulation by creating or faking an emergency without immediate prior informed consent. "Tested under fire" is a self-reinforcing dynamic that becomes a truism, rather than a tested and supported hypothesis. That is, the advocates of such methods are either ignorant or willfully-ignorant of other methods of teaching that have lower risks to all parties concerned. It's as if the drama itself is a motivator: "something dramatic happened, therefore it was worthwhile." "Success ethics" applied to emotions.
As for the person who wrote that blog entry: sounds like the classic case of the person who talks about bombs while on an airliner, and then when the plane makes an unscheduled landing and they're greeted by a half dozen FBI agents, says they were "just joking." Sorry, but you don't get to make bomb jokes on airplanes.
My doctor committed medical malpractice and part of what he did, "ghost surgery:" was what he has admitted to in his biography related to another patient, a woman who had just given birth and who had a brain tumor.
The resident wanted to operate on the tumor and at first Dr. Jannetta, the attending neurosurgeon said "No" but then agreed to let the resident operate. His refusal was because it was too dangerous for the patient. The woman died on the table. Dr Heroes, the resident, (from the book;s anecdote) then called Dr. Jannetta who not only had not been in the OR, he had not been in the hospital.
This too was a way to teach, to let residents operate without the attending attending, not even in the hospital where he oculd at least have come to the OR in a speedy fashion if (when) something went wrong.
There is a lot wrong with Dr. Amantine's story but the fact is a lot of "teaching" is done with the patient's care and well-being the las and leastt of the concerns of the doctors, surgeons.
While I am a simple pediatrician and not privy to the secrets of the OR, even we have our "teaching moment" moments. As an intern in the NICU, I had a baby extubate herself. As a dutiful intern, I attempted a couple times to replace the tube and failed. I then called my senior resident and informed her of the situation. She responded that this was an excellent teaching moment and that I would just have to get it in. To this day I am convinced that the fact this happened at 3am was part of the reason for this. I was able to get the tube in, but was furious for some time over the attitude of my superior.