Medical Catastrophe Read online

  M E D I C A L C A T A S T R O P H E

  Also by Ronald W. Dworkin

  Artificial Happiness

  How Karl Marx Can Save American Capitalism

  The Rise of the Imperial Self

  M E D I C A L C A T A S T R O P H E

  Confessions of an Anesthesiologist

  Ronald W. Dworkin, MD

  ROWMAN & LITTLEFIELD

  Lanham • Boulder • New York • London

  Published by Rowman & Littlefield

  A wholly owned subsidiary of The Rowman & Littlefield Publishing Group, Inc.

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  Copyright © 2017 by Rowman & Littlefield

  All rights reserved. No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without written permission from the publisher, except by a reviewer who may quote passages in a review.

  British Library Cataloguing in Publication Information Available

  Library of Congress Cataloging-in-Publication Data

  Names: Dworkin, Ronald William, author.

  Title: Medical catastrophe : confessions of an anesthesiologist / Ronald W. Dworkin.

  Description: Lanham : Rowman & Littlefield, [2017] | Includes bibliographical references.

  Identifiers: LCCN 2016031394 (print) | LCCN 2016031790 (ebook) | ISBN 9781442265752 (cloth : alk. paper) | ISBN 9781442265769 (electronic)

  Subjects: | MESH: Medical Errors | Practice Patterns, Physicians | Interprofessional Relations |

  Physician-Patient Relations | Physician’s Role | Personal Narratives

  Classification: LCC R729.8 (print) | LCC R729.8 (ebook) | NLM WB 100 | DDC 610.289—dc23

  LC record available at https://lccn.loc.gov/2016031394

  TM The paper used in this publication meets the minimum requirements of

  American National Standard for Information Sciences Permanence of Paper for Printed Library Materials, ANSI/NISO Z39.48-1992.

  Printed in the United States of America

  For the doctors I have known

  CONTENTS

  Author’s Note

  ix

  Acknowledgments

  xi

  1 The Politics of a Catastrophe

  1

  2 Impatience and the Urge to Be Macho

  23

  3 The Trap of Overspecialization

  37

  4 When No One Is in Command

  55

  5 When Patients Become Consumers

  77

  6 A Tale of Two Offices

  97

  7 When Doctors Lose Control of Their Own Personalities

  127

  8 When Doctors Lose Control of Their Own Rules

  147

  9 The Problem of Going Part-Time and When to Retire

  163

  10 I Come Full Circle

  179

  11 What Is a Doctor?

  189

  Notes

  201

  Bibliography

  205

  About the Author

  207

  v i i

  AUTHOR’S NOTE

  The cases and events in this book are true, with dialogue often verbatim, but names, dates, places, timing, and other identifying details have been altered to preserve confidentiality. All names are assigned random letters.

  It should also be noted that Dr. F, who appears in chapter 7, actually

  represents a composite of two doctors; the Dr. F who speaks Japanese is

  different from the Dr. F in the rest of the chapter. The patient-centered care meeting that appears in chapter 5 is a composite of two meetings on

  this subject. In chapter 1, the first case is a composite of two obstetrical catastrophes, one involving a breech delivery and the other a shoulder

  dystocia, while the subsequent meeting between attendings and residents

  actually arose out of a third catastrophe.

  At all times, when referring to doctors, I have tried to use the plural

  “doctors” or “he or she,” but to preserve the narrative pace and avoid

  wordiness, I have sometimes used the word “he” alone. No offense in-

  tended to female doctors, who now make up half of the medical profes-

  sion.

  i x

  ACKNOWLEDGMENTS

  I would like to thank Suzanne Staszak-Silva, my editor at Rowman & Littlefield, as well as senior executive editor Jonathan Sisk for making

  this book project possible. I would also like to thank Professor Maria

  Frawley and the entire staff at the George Washington University Honors

  Program for opening up a new chapter in my professional life. I would

  like to thank Alexandra Roosevelt for coining the phrase “artificial happiness,” in regard to a previous book project, as well as Grace Dworkin for suggesting the dedication for this book.

  x i

  1

  THE POLITICS OF A CATASTROPHE

  One night in the 1980s, during my anesthesiology training, I was sitting in the doctors’ lounge with the on-call obstetrics resident. He told me that a woman had just arrived on the labor and delivery floor for a probable

  breech (feet-first) birth. I casually asked him if he had notified his attending. He rolled his eyes, which was code among us residents for “Of

  course not,” as his attending, like mine, expected to sleep while on call. I grinned but worried in the back of my mind about whether my night mate

  had the wherewithal to deliver a breech baby.

  I understood his predicament. Before turning in, my attending had

  warned me that to call him was a sign of weakness. Yet when I gave him

  a few blank anesthesia records to sign in advance, for cases that might

  arise during the night and that in theory he would be responsible for, he demurred, joking, “I don’t sign blank checks.” This left me in a bad

  position. Calling him about a case would anger him, but if that case went awry, he could always say I had forged ahead without his permission.

  The other resident left and I dozed off in my chair. I was awakened an

  hour later by commotion in the hall. Surprised by the unusual noise, I

  hurried toward the door. Someone opened the door before I got there and

  I heard a nurse’s voice calling in a nervous shout:

  “We have a breech!”

  I hastened my steps and called out, “Where?”

  The next moment I knocked against a nurse, who was running down

  the hall. “Please, here, in the OR . . .” she panted, putting her arm on my shoulder.

  1

  2

  C H A P T E R 1

  I followed the nurse to the entrance of the operating room. The bright

  overhead light glared in my face and momentarily blinded me. I shaded

  my eyes with my hand and scanned the operating room table. I saw the

  terrified face of a woman; her gown bunched up around her breasts; the

  legs and trunk of her baby’s body hanging outside her birth canal; and

  finally the obstetrics resident standing between the women’s spread legs, mute with astonishment, his eyes dilated. The baby’s legs twitched horribly, alternately flexing and extending as if working a bicycle, their color turning the hue of metal. They stopped for a moment, then, along with the baby’s trunk, shuddered convulsively.

  The attending obstetrician rushed in. I put the woman to sleep, hoping

  the anesthetic gas woul
d relax the uterine muscle squeezing the baby’s

  neck, while the attending and resident went to work down below.

  Eventually the team proceeded to cesarian section, but it was too late.

  The delivered baby lay on the bassinet, glassy-eyed, unwakeable, its hair covered with blood clots, its tiny body wrapped in a blanket and growing

  cold under the warm lights. The cloying smell of death and decay was

  already coming from it. Possessed by a bestial curiosity and that secret

  fear that all human beings experience before the mystery of the dead, a

  medical student slowly advanced toward the bassinet to see what the baby

  looked like. He took one glance and turned sharply away. “Lord Je-

  sus . . .” someone sighed from a distance.

  The woman woke up on the table with a dozen eyes staring at her. She

  lay still for a minute, still feeling the effects of anesthesia, looking around at the eyes while listening to whispers coming from different corners of

  the room. Disoriented, she struggled to get off the bed, her arms barely

  able to bear her weight. I restrained her. She tried in vain to push me off, kicking the air violently with her exposed legs. In her post-anesthetic

  delirium, her imagination began to conjure up incredible visions based on her greatest fears:

  “Let me go! . . . Who are you? . . . Where is my husband? . . . Don’t

  you like me? . . . Water! I’m so thirsty!”

  Not another word did people say. Once turned on her side, her cheek

  pressed hard against the bed, the woman stopped struggling. She passed

  her eyes in a long, slow stare over the bassinet. “Why doesn’t he . . . ?”

  she asked. She took in the pinched nose, the tiny dark lines underneath

  the vacant eyes, and the blackening face. Sensing the grim, unalleviated

  tragedy, she began to sob, her mouth twitching with suffering. Finding no

  T H E P O L I T I C S O F A C A T A S T R O P H E

  3

  outlet in movement, she clung tighter to my arm. She spoke a few more

  words, but her voice grew hollow and less defined, as if she were going

  farther and farther away. A nurse rushed over and lifted up the motionless bundle in the bassinet. The baby’s helplessly drooping head fell in all

  different directions until the nurse stabilized it with her hand. Then she turned toward the wall, shielding the baby from further view. The loath-some scene of unnecessary death, the mother’s groans, my frenetic eyes

  staring uncomprehendingly out at the world were overwhelmingly op-

  pressive, and the medical student moved quickly toward the side door,

  hastening to get away from the memory of what he had seen.

  When I finished work the next day, the darkness was already closing

  in over the city. A wind sent the clouds scurrying and tore them apart to reveal a sad-looking moon and a few meager stars. I went home and

  fumbled for my key under the orb’s uncertain light. I drank several beers.

  At around nine o’clock I got out of my chair and, with a heavy, bearish

  swaying gait, went into the bedroom and lay down on the bed. Within

  seconds, I was asleep. But I slept badly that night, turning over and over, gripped by the horrible images of the previous evening.

  This was a catastrophe. It is an experience that all doctors in training

  prepare for. Yet this catastrophe seemed totally unnecessary. I wanted to blame someone. I zeroed in on the obstetrics attending for going to bed

  early that night, and I argued with my anesthesiology attending about it

  the next day.

  “That obstetrics attending should have been there from the begin-

  ning,” I remarked.

  “The resident should have called him,” my attending shot back.

  “You guys get mad if we call,” I replied.

  “If he needed help, then he should have called,” said the attending

  sharply. “A doctor can’t be afraid to ask for help.”

  He had a point. I felt myself on the defensive. “That attending didn’t

  have to go to bed so early,” I countered.

  My attending fell silent. His glance became thoughtful. He was really

  thinking very hard about something. “They don’t pay us enough to stay

  up all night,” he answered drily. “Private practitioners make twice as

  much as we do.”

  “How much should they make?” I asked.

  “They should make what I make,” he replied.

  4

  C H A P T E R 1

  “But we residents do all the work for you,” I said, pressing my advan-

  tage.

  My attending looked down and inconspicuously held onto the end of

  his little finger. Then he glared at me as if I were a worthless sort.

  “Dr. Dworkin, as a resident, you will learn to eat shit and enjoy the

  taste of it,” he snapped, before walking away.

  Politics killed that baby. When I speak of politics I don’t mean parti-

  san politics, such as Republican versus Democrat, or liberal versus con-

  servative. I mean politics on the most basic level: how people relate to

  each other in everyday life, and how, as a result, people think about

  themselves. The obstetrics attending had resented his poor pay; he went

  to bed early to avenge himself; the resident was too afraid to ask him for help at a crucial moment; the baby died. Politics.

  I always knew I would one day see death as a physician. I did not

  know how I would react when I did, except to feel sad. But with this

  death my mind smarted with a hurt of another kind. I felt ashamed.

  I also felt uneasy. I began to question whether I had entered the right

  profession. After all, I had gone into medicine to avoid politics, as I was not a master of that complicated art. Anesthesiology seemed especially suited to my tastes. Politics is about relationships, but an anesthesiologist generally works alone and supervises himself. Moreover, if a patient

  grows talkative or annoying, an anesthesiologist can always put that pa-

  tient to sleep, which, again, makes for one person—me—working alone.

  Indeed, the dearth of doctor-patient conversation in anesthesiology has

  long attracted foreign medical graduates to the field because it makes

  knowledge of English superfluous. Such borderline misanthropy may

  seem odd in a doctor, but, as my father and grandfather, who were also

  doctors, often told me, there is room in medicine for all sorts of personalities. I liked science. I also wanted to do something useful. But I was not a

  “people person.” I wanted to be left alone with my smarts and my hands

  to take care of patients and not to worry about what other people were

  thinking and feeling, other than my patient, to whom I could always give

  more drugs.

  Two decades of practicing anesthesiology have shown me my error.

  Politics in medicine cannot be ignored. In fact, good medicine, safe medicine, turns on politics. Politics is often the decisive factor in medical catastrophes and near catastrophes. Politics can even be found lurking in

  T H E P O L I T I C S O F A C A T A S T R O P H E

  5

  catastrophes seemingly caused by a lack of vigilance, a missed detail, or an error in judgment. The breech birth catastrophe was no anomaly.

  The public knows none of this. The Centers for Disease Control

  (CDC) collects mortality statistics for medical catastrophes. The breech

  birth death would have been classified as a “neonatal death secondary to

  complications from delivery.” None of the politics would have co
me out.

  My own specialty divides patient deaths into broad categories such as

  “anesthetic overdose” or “difficult intubation.” Again, no category for

  politics exists. This is because doctors do not see politics as a systemic problem, while researchers who might pick up on the trend cannot do so

  because of how catastrophes are reported. When a catastrophe occurs, the

  hospital medical staff meets to discuss it, usually in a quality assurance meeting or a root-cause analysis meeting. If the politics comes out at all, it is there. But the meeting’s minutes are kept private by law so that staff can speak freely. When a doctor talks politics with his or her malpractice insurance carrier, again the discussion stays private. The state medical

  boards and health departments, however, get official reports sanitized of politics, while the CDC gets a number. Researchers have no way of

  uncovering the role of politics in catastrophes. And yet politics is invariably present. It is why I wrote this book. Patients think their lives depend solely on science and technology, or, in the case of error, on a backup

  system that double-checks a doctor’s work. They do not. They also de-

  pend on politics.

  The baby’s death haunted me for several weeks. One of the hospital

  wards was shut down at the time, its lights turned off, with only the broad outlines of white sheets covering idle equipment visible from the main

  corridor. I would often pass by that ward unthinkingly, but now, with

  death uppermost on my mind, the scene engendered in my imagination an

  uncomfortable suspicion that mounds of dead bodies lay underneath

  those sheets. I was also worried about litigation. But a friend of mine who knew a trial lawyer allayed that fear. I was not a witness to the conversation, but my friend told me with precision what happened. My friend told

  the lawyer about the event. Playing with his cigarette, the lawyer said,

  “Nothing to worry about. The baby died.” Apparently a live but brain-

  damaged baby risks a much higher jury award than a dead baby does. The

  6

  C H A P T E R 1

  issue was so critical that halfway through their conversation, the lawyer anxiously turned to my friend and said, “You said the baby died, right?”