Just when I thought I’d “seen it all,” someone came to the rescue and proved that old line wrong once again.

I was working in the GI suite one day last week: in our room was the patient, the doctor, the nurse, the tech, and me. I had just induced the patient for the proposed procedure, a colonoscopy, with Propofol (your friend and mine). The patient was lying on his left side, facing me, with his gown open in the back.

The doctor was getting his scope ready, and I was watching the patient while charting a few vital signs, when, out of the corner of my eye, I detect the nurse getting very “busy” on our patient’s back.

“What’s going on back there?” I ask.

“Oh, I just hate blackheads.” She quite matter-of-factly replies.

“What are you DOING BACK THERE?” I repeat.

“I do this all the time!” She giggles.

“Do you know what the definition of assault and battery is?” I ask her.

“Hey,” she gets defensive, “it’s just blackheads.”

Yep, I kid you not, she was popping zits on this sleeping man. True story, I could not make this stuff up.

After she returned from her suspension, said nurse was last seen attending risk management’s remedial classes on  proper conduct on the job. Eek.

There is a surgeon who comes to our hospital who performs only one type of surgery. Nothing unusual about that, is there?

He actually is on staff at several area hospitals, doing surgery at each one about once a week.

But what distinguishes this surgeon from all the others is the nature of his business. He is known as the nursing home surgeon, or more fondly, Dr. Gome from the Home. His clientele are the patients who cannot speak for themselves, and frequently have no one to advocate for them. They have been turfed out to nursing homes, where their sub-par care expresses itself in large (did I say MASSIVE?) bedsores that require his excavation services.

Which is exactly what he does. These patients, with varying levels of consciousness, are put to sleep by us in order that Dr. Gome may scrape out their gaping sacral and hip wounds. Most of them have incurred strokes or other insults that have reduced their mental capabilities, are all bent up and contractured from months of just lying in bed not moving or being turned, and are not all that aware of their surroundings or their situations. 

Now, this isn’t the first time I’ve written about these defenseless patients, but I can never take care of them without wondering about Dr. Gome. How does one do this for a living? What are the perks and satisfactions besides his paycheck? How does he view his role? He is basically a technician; he establishes no relationship with these people. He can’t; they are like meat.

So, um, er, I gingerly asked him one day about the task that he has at hand, and how he views it. His reply:

I’m just the clean-up guy. I didn’t see ‘em before they got like this, and I never see ‘em again after this.

Which is true. And there you have it, folks. Dr. Gome, the clean-up guy. For the family that wants everything done, and for the patient who has had nothing done for them. Until now.

After a brief hiatus, I am back.

Don’t miss this month’s Pain Blog Carnival at How to Cope With Pain, where every month the best of the blogging about pain is collected. A wonderful edition, of which I am glad to be included.

The sun goes down, but the OR lights do not go out. Most people pursue a break in the action on the weekends, but no so for the Operating Room. The unexpected and uninvited operation can occur ANY time, and usually does! Surgery after hours . . . .

Buckeye Surgeon knows all too well what it’s like to do surgery after hours. He tells us about two cases of peritonitis that very well may make your own stomach do flip-flops. Emergency surgery has no regard for what time or what day it is.

Rlbates receives a weekend phone call from a patient whose wound has opened 6 weeks post-operatively, due to a freak accident. What are the odds?

Dr. Wes’ first time in the Operating Room was truly a Maiden Voyage. He could not have been prepared for his response to the surgical arena during an emergency off-hour case.

LuLuGal, at HowISaveMoney didn’t have surgery after hours; no, she had a surgical experience that took two days to complete. If I may say so, an eye-opening experience.

Bongi, over at Other Things Amanzi, relates his story about a shootout at the OK Corral in South Africa that factors revenge into the after-hours surgical equation. Violence begets more violence, and revenge is its mother and father. Sad.

On a lighter note, Bongi shares the story of a young intern who didn’t realize that she was milking the procedure she was performing for all it was worth. She learned the, er, uh, hard way.

Orac, at Respectful Insolence instructs us that the educated consumer is a wise one to know how to interpret hospital statistics of zero mortality for certain operations.

All it took was a few inadvertent needle sticks during surgery for Nathan at A Jolly Company to realize that a career as a surgeon was not in his future.

The SterileEye performs a blunt dissection of a bacalao, and if you don’t know what part of the body that is, well, you’ll just have to read the article to find out. Definitely food for thought, SterileEye!

As a final entry, I will add my own article from this past June, where I wrote about the different names we are known by, and giving anesthesia for labor after hours.

That’s the roundup for SurgeXperiences for this week. I hope you had some enjoyable reading; I know it was fun for me to host. Thank you to all who submitted. I did not include all submissions - only those that stayed close to this week’s theme. So a big thank you anyway to Hyperhidrosis, Everyone Needs Therapy, and Beyond Horizon Coaching. 

Don’t miss SurgeXperiences #114 next week, where it will be hosted at Anesthesioboist.

Keep healthy!

Alvaro at Sharp Brains is hosting Grand Rounds this week, with a timely briefing to our next Mr. or Mrs. President about all of the medical blogosphere’s health concerns and questions. Excellent presentation, and great reading. I feel honored to be included.

Thank you for all of your responses so far. And just a reminder to anyone else interested in submitting an article: this edition’s theme will be called ”Operating After Hours,” and, as the title implies, please share any stories you have about surgical experiences that have occurred after normal operating hours.

 Everyone is invited to contribute. Please send all submissions here, no later than Friday, January 18, for this Sunday, January 20th’s edition.

In the news this week, the Supreme Court began hearing arguments over the inhumanity of lethal injection as a modality for the death penalty. Presently, 36 out of 37 states that advocate the use of the death penalty utilize lethal injection (the 37th state utilizes the electric chair - Nebraska).

As an anesthesia provider, I am intimately familiar with the present drug trilogy (sodium pentothal, pancuronium bromide, & potassium chloride) that is currently administered for the death penalty. We actually use two classes of these drugs everyday in general anesthesia. All three of the drugs are given in “mega-doses” for an execution, i.e., in much much larger doses than is safe and compatible with life.

Sodium pentothal, the first drug, is a powerful barbiturate, and, when used to induce general anesthesia, causes unconsciousness and apnea (cessation of breathing). Its onset of action is 30-40 seconds, and its duration of action is about 10-15 minutes. Pancuronium bromide is a long-acting muscle relaxant causing total paralysis of all voluntary muscles, with an onset of action of 3 to 5 minutes and duration of 60 minutes or more. Potassium chloride will cause cessation of all electrical activity in the heart - it will stop the heart from beating. Medically, it is given in very small doses for low serum potassium levels, and in high doses directly into the heart during open heart surgery to stop the heart from beating.

This trilogy of drugs was concocted to ensure a humane end to a life. When administered in the proper sequence and through a patent vessel, the person condemned to die should first become unconscious and stop breathing, then stay apneic, while concurrently, the heart will stop beating. When blood no longer circulates and ventilation and oxygenation no longer take place, cell death begins within 2 minutes. This is well-documented. Brain death and permanent death occur within 4 to 6 minutes after cardiac arrest. Drugs sitting on receptors cannot be washed away or redistributed by non-circulating blood. Consciousness cannot be regained after 10 minutes of anoxia. A heart arrested with a mammoth dose of potassium chloride will not decide to spontaneously beat 5 - 10 minutes after its administration.

While it is not the purpose nor the message of this blog entry to weigh in pro or con about the death penalty, the lethal cocktail that is currently the standard for death by injection, when administered according to protocol, should be a painless passageway to death. The ASA (American Society of Anesthesiologists) has weighed in about their stance against physician participation in execution.

But an interesting counterpoint can be found at California Medicine Man’s blog. While I am not about to reveal to you what my opinions are about the death penalty, I think that California Medicine Man’s point is well taken that if, as a society, we condone public executions, then it is incumbent upon us as a society to ensure that they are carried out in a humane and painless manner, “with compassion and decency.”

Another great selection of articles can be found at this week’s host of Grand Rounds, pathtalk.org. A really fascinating blog, too. Thanks for my inclusion.

On call this past weekend, I was paged to the post-partum floor to evaluate a young woman who had vaginally delivered a healthy baby boy 16 hours ago. Her chief complaint? Intractable back pain.

[Background: She had delivered 2 babies aided by an epidural block in the past, and complained of back pain during this pregnancy, which she totally attributed to her previous epidurals. She admitted to no previous social or drug abuse history in the past. When she arrive to our hospital in labor, and it was determined that she could have an epidural, the CRNA covering OB tried multiple times, unsuccessfully, to insert one. Both the nurse anesthetist and the anesthesiologist were unable to locate the epidural space. She had what is known as a “difficult back” in our business. She went on to deliver naturally.]

But now, despite 4 Ibuprofens, 2 Tylenols with Codeine, and 2 Percocets, she was still complaining of back pain. I was summoned to see her.

Her pain was completely localized to where her needle punctures were (lower lumbar back), and the area was painful to touch. No redness, no swelling, no bleeding, and no pus was observed. She had no numbness, tingling, or weakness in either lower extremity. She denied headache, stiff neck, or blurred vision. She ambulated in the room without difficulty, and had encountered no problems voiding or moving her bowels.

She claimed to have back pain throughout her pregnancy, but not like this. When she told me that she wanted something liquid like Morphine for the pain, I blinked. When she said that that’s the only thing that helps her when she has bad pain, I blinked twice. Then she told me that Morphine is what they gave her once when she came to the hospital with bronchitis. Blink. Blink, blink.

Direct quote: “I just want to feel knocked out. None of those other drugs are helping me.”

If her pain persists or worsens, she will undoubtedly undergo some radiologic studies and a neurological evaluation. But how does the presentation of her symptoms and her story strike you?

I always believe my patients until given reason to believe otherwise. I do not doubt AT ALL that this woman’s back was sore. But she received enough pain medication to relieve the pain of several patients, IMHO.

I left her room feeling saddened. She did not receive her “liquid pain medication” as requested, only more pain pills to carry her throught the night, and some feeble reassurance on my part that we would take good care of her and get to the bottom of her pain.

The Sterile Eye is hosting the latest edition of SurgExperiences. Enjoy some fascinating surgery-related blogging - cut to the chase!

And speaking of SurgExperiences, I am proud to announce that the next edition (#113) will be hosted by yours truly, here at Counting Sheep, on Sunday, January 20, 2008. For this edition’s theme, I thought we would try something a little different. I’m calling this edition Operating After Hours, and as the title implies, please share any of your surgical-related tales that have occurred after “normal operating hours.”

Please send all submissions here. Deadline for your articles will be Friday, January 18, 2008. ALL are welcome to contribute. SurgExperiences is really a cut above.