Rationally irrational: Physicians taking care of family
Dr. Afshar is Resident Physician, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California.
“We need an additional large bore IV in the other arm, run the fluids wide open, draw a STAT CBC, coags and cross-match, and call for blood,” I calmly told the postpartum nurse as I looked at a pale woman who became acutely hypotensive to 60/30 and tachy to the 140s as soon as she heard a “pop” in her abdomen along with a bout of emesis, several hours after her cesarean delivery. I STAT paged the OR while getting the ultrasound to bedside. During the modified FAST scan I saw a significant amount of blood in the paracolic gutters, and I collectedly explained to the patient and her partner that we would need to go back to the OR for an exploratory laparotomy and evacuation of hemoperitoneum. We did a quick pelvic exam and placed the Foley catheter in anticipation of moving back to the OR. I explained the possibility of a hysterectomy and that we may/may not ever find the source of bleeding, but that we needed to go back. En route to wheeling her to the OR, the patient’s hemoglobin was reported to have dropped 5 units and we had already started a massive transfusion on her. The woman’s postoperative course was uncomplicated and she did great.
Residency has trained me to respond and approach any acute decompensation without skipping a beat. Calling for the next step is starting to come naturally and I feel confident in knowing when to ask for help. Every time we are urgently called to the PACU or the ER, by way of a brief one-liner about the patient, we use the time we walk/run over to consider the worst-case scenario and to anticipate and rationalize what is going on. Most of us have no trouble doing this at work. We rationalize the differential and go through the algorithms.
I live for intensity and high-acuity patients, but I’ve realized that I want that part of my life to stay at work. Not because I wish any illness on another soul, but because I understand why physicians are proscribed from being intimately involved in taking care of their friends and family.
I am haunted by memories of being in the hospital when my younger brother spent days in the ICU after a near-fatal car accident, comatose, intubated, and on pressors with multiple casted extremities.