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JoNightshade
07-15-2008, 08:52 PM
Yes, it's JoNightshade with another odd medical question.

I need some serious help on this one. I've got to construct a scenario in which my character, a surgical intern, 'kills' his first patient. The details:

- A child is injured and needs a life-saving surgery. (eg she's been in a car accident.)
- The surgery is simple, so the surgical intern is allowed to do it.
- He screws up. (Ideally it would be some split-second decision he has to make, and he makes what is clearly the wrong choice.)
- The child dies, directly as a result of the intern's action. (Although it would be great if he and the attending surgeon worked for a couple hours to try to fix it and fail.)

So, at the bare minimum what I'm going for is my character knowing that if nobody had done ANYTHING, the kid would have died - but if he had made the right choice, she would have lived. Easily.

SOOOOO, what could the injury be, and what is his mistake? Anyone? :)

Shwebb
07-16-2008, 06:52 AM
Okay. Let me say that although I have some medical knowledge, I'm not a surgeon.

However, surgeons can mess things up, of course. One way would be by nicking an artery; she could bleed out quite quickly. Since arteries are (of course) everywhere, it wouldn't matter so much where her injury is.

If you want her to live for a bit and she has had abdominal surgery, you could have the surgeon nick the bowel. She would end up with peritonitis; it would be rather nasty, most likely. Here's a link (http://www.nlm.nih.gov/medlineplus/ency/article/000651.htm)to what would be secondary peritonitis.

If you want it to be a dramatic surgical situation, I'd recommend the artery thing. I can imagine it would be quite easy for a doc, if there was some sort of distraction when others look away (maybe he drops an instrument or knocks over something) he could stick his scalpel into the right spot if the incision is already been done. Then he could pretend he can't find the source of the bleed.

Or he could go venous and make a very small hole. The blood loss would be less obvious at first. He could even close her up and then have to reopen her.

Does that help? Or are you looking for something else?

Horseshoes
07-16-2008, 08:00 AM
Mebbe have the kid have a pre-existing medical condition yet undiscovered --more astute doc might have caught it, intern missed it, resulting complications killed kiddo.

Grab Carol Cassella's novel, Oxygen.

While you'll have your own scenario and execution, there's a great example. Anesthesiologist's life flips when she loses a kid--a bit of character study, a bit of mystery, bit literary-just really well done.

GeorgeK
07-16-2008, 09:18 AM
It's not plausible in a US hospital for an intern to be there in the operating room without supervision. That is called "Shadow surgery" and is illegal.

A procedure at the bedside is a different story, like placing a central venous catheter. He could drop a lung (pneumothorax) and not realize it, not do a Chest X-Ray, misread the X-Ray, etc. Having the patient be a kid however makes it more difficult because there are regulations as to how high the staff to patient ratio must be at all times. If it has to be a kid.......mmmm.....misplacing the kid who is sick and therefore deprived of life saving care would be the most plausible. For instance, he misreads the kid's arm band, and basically sees the wrong kid, it's a busy night in the ER and he tells the head nurse to discharge the kid in bed 10 and follow up in the clinic on tuesday.

I've seen non lethal results of this happen when those in the medical profession fail to use the patient's name and instead say things like, "Go see the gall Bladder in bed 6"


Addendum: I thought of a scenario where it might happen in the OR. The attending or the attending surgeon designee (like an upper level resident) is supposed to be there from the time of incision until the time the patient is removed from the operating table. I have known some surgeons who were lax about it and might let the intern "close" unsupervised after the "case" was finished. In laparoscopic surgery, that means pulling out the scopes, checking for bleeding and putting in a few stitches. Historically it has happened that there was bleeding from a muscle at the time of the trochar assisted scope placement, but was unrecognized initially because the scope was putting enough pressure on the vessel during the surgery such that it didn't visibly bleed until the scope and operating ports were removed. If the intern failed to watch through the scope at the time of instrument removal, (s)he might miss that there was a bleeder. Bleeding follows the path of least resistance. If there is a hole in the abdominal wall fascia connecting to the abdomen, an abdominal wall muscle bleeder can bleed into the abdomen rather than appearing on the oputside as a hematoma. All that might be noticed is pain (which is expected after surgery) and then a few hours later the heart rate starts to climb from hypovolemia, but the intern thinks it's from pain and gives the kid pain meds instead of IV fluid and blood. About an hour later the patient's blood pressure suddenly falls and then a code is called.

Another scenario would be, the attending leaves, the intern starts to close and then the nurse say's, "there's a lap pad (surgical towel) missing from the count."

The intern doesn't want to reopen the half closed wound so (s)he feels around, finds it and pulls it out triumphantly and finishes closing, without remembering that that pad had been placed there as a means of putting pressure on bleeding from a raw area early on in the case and they all forgot to go back and check the area to find the bleeder.

In the intern's defense: the attending is supposed to be there, so it's never going to truly be only the intern's fault unless the intern is doing something without the attending's knowledge, but then the anaesthesiologist is going to say, "Where's the attending?" The only way around that I can think of would be if the case is over, the attending tells the intern to close, but after the attending leaves, the intern takes a look around and decides to cauterize a minor oozing from something which turns out to be a major artery. 1-2 days later the inflammatory effect from the cautery clots off the artery resulting in a dead organ and then another 1-2 days later, multisystem organ failure from disseminated intravascular coagulation (DIC). At the autopsy, (which would be mandatory) the pathologist would find the damaged artery and the attending would realize that (s)he had deliberately left that area alone, knowing the oozing was minor and would have stopped on its own. The intern should not have gone back in and started cauterizing things, but also the attending should not have left the intern alone and allowed such a thing to take place.

JoNightshade
07-16-2008, 09:42 AM
Yay! Replies! I thought this thread might go unanswered. :)

Shwebb: Great ideas! Yes, I was thinking a nicked bowel or artery - maybe in a critical area or something that is hard to patch up... Maybe she has some internal damage he's trying to repair and he nicks the bowel. They start to see evidence of fecal matter and they're trying to find the leak, but the bowel is tricky that way. She's already in a delicate situation because of the accident, and her system can't stand the overload. Or perhaps the fecal matter gets into whatever organ he's operating on and she can't live without it. Okay, hmm, what's around the bowel area? Off to find an anatomy chart...

Horseshoes: This would be so much easier if my character was an anesthesiologist...! My mom actually knows one who killed his friend's kid. But for other story reasons, I need him to be an actual surgeon, hands-on sort of thing...

JoNightshade
07-16-2008, 09:50 AM
GeorgeK, I wasn't going to have my intern character doing this by himself. I was in fact thinking of having his attending surgeon there, but they have done surgery many times together and the surgeon trusts him. He's not just a totally green intern, he's been there for a while, maybe almost a resident. So this is something he's done before with success, and maybe this time the surgeon lets him do it himself; he is looking away not paying attention or something.

I do have a question though, maybe you can help me out. This is the first death my intern is responsible for. I assumed this would be the level at which enough responsibility would be given to lose someone he treated, but based on your comments I'm wondering if I should bump him up to resident status? Is that more reasonable?

GeorgeK
07-16-2008, 10:37 AM
GeorgeK, I wasn't going to have my intern character doing this by himself. I was in fact thinking of having his attending surgeon there, but they have done surgery many times together and the surgeon trusts him. He's not just a totally green intern, he's been there for a while, maybe almost a resident. So this is something he's done before with success, and maybe this time the surgeon lets him do it himself; he is looking away not paying attention or something.

He maybe scrubbed out for 10 minutes to go to the bathroom


I do have a question though, maybe you can help me out. This is the first death my intern is responsible for. I assumed this would be the level at which enough responsibility would be given to lose someone he treated, but based on your comments I'm wondering if I should bump him up to resident status? Is that more reasonable?

In many facilities, a chief resident (minimum of 5th year, or maybe a 4th year if the chief is on vacation) can be the attending's designee. Lower than that and the anaesthesiologist won't knock the patient out. When I was a chief I had one case where the attending asked me to start the case because he had some staff meeting where he had to complain about something. He said to call if there was any trouble, but this was expected to be a six hour case and he expected to be there within an hour, long before I shoudl get through all the scarring and actually expose the rejected transplant for removal. It was after hours, the intern had gone home sick. The ER paged saying they needed us. You can't leave a patient on the table, so the attending, being at the other hospital already, said he'd see the one in the ER and I should continue. An hour later he scrubbed in and said, "let's have a look." He looks around and finally said, where's the transplant? Did they put it deeper than the X-Rays suggest?"

I said, "It's under the towel."
He said, "But I don't see any packing in here."
I said, "No, the towel on the back table. It's already out. All that's left is to close."
He inspected the wound, the parts removed and said, "What the hell do you need me for?"
He still stayed to help close.

That patient did great, there were no complications. However, with a different resident, things might have gone differently. But yeah, the resident should be at least a senior resident (4th year)

I used to get a monthly news letter regarding malpractice cases explaining the nature of the case, the defense and prosecutor's summary, the verdict and a commentary. I only know of one case where a resident was sued and the attending was dismissed from the case. That was a chief resident where, as the story goes, the attending had never even seen the patient. The chief saw the patient at the indegent clinic, never sent papers to the attending, never called him, scheduled surgery under the attending's name. When he got into problems the scrub nurse called the attending and said, "Are you going to be here at all, because this case is not going well?" The attending asked, "What are you talking about? I don't have any cases at that hospital today."

JoNightshade
07-16-2008, 11:16 AM
:Hail:

Thank you thank you thank you! Okay, I am going to model my scenario on the incident you described (but going wrong).

Essentially, this is setup for the main story, which doesn't involve medicine at all. The kid dies, and of course the attending takes responsibility - but the main character knows it's his fault. He flees the hospital, thinking he can't handle being a doctor, and the ensuing story takes place at home. The death hangs over his head, and he gets some phone calls from the attending to warn him not to speak with the family - they're filing a suit, and the hospital will give them a reasonable settlement if the MC just STAYS OUT OF IT. For various other reasons he never makes it back to the hospital, so I don't have to really detail the repurcussions.

Tsu Dho Nimh
07-17-2008, 05:38 AM
Have him get so focused on a damaged liver or spleen or finding bowel bleeders that he forgets to check the aorta and heart.

Aorta is damaged because of the force of the accident (it rips) and suddenly he's got a dissecting aorta, crashing blood pressure and a screaming emergency. It's especially likely in children (under 8 or so) because they "compensate" ... their blood pressure and vitals hangs steady and then it's like they fall off a cliff and it all goes to hell and they are in shock and die.

GeorgeK
07-17-2008, 07:44 PM
:Hail:

he gets some phone calls from the attending to warn him not to speak with the family - they're filing a suit, and the hospital will give them a reasonable settlement if the MC just STAYS OUT OF IT..


Actually the call would come from the attending's attorney, the hospital's attorney, or the hospital Risk Management Supervisor or some combination. For the attending to tell the resident to be quiet could be construed as conspiracy if it went to trial. Also if the resident did go talk to the family it could be construed as witness tampering, and he would have been warned about that too.

JoNightshade
07-27-2008, 11:29 AM
Okay, so I now have an actual scenario I'm hoping you (George!) can verify is reasonable. The actual event happens before the start of the book, so now my main character, a resident, is recounting what happened.

They have a little girl come into the ER from a car accident, she's thrown out of the car or something. They have to take her into surgery really fast because she has a foreign object (possibly multiple foreign objects) in her abdomen. A surgeon and this resident go in and start picking pieces out and they discover that although her condition is a bit fragile, only one of her kidneys has been hit. They are just finishing the delicate work when the surgeon has to use the bathroom (say he ate something bad the night before). He trusts the resident, who is known as being exceptionally young and talented, a kind of wiz kid. So he tells him to take care of the rest while he scrubs out to use the john. The resident, in all confidence, continues-- and then he fumbles. He drops and instrument and it slices clean through an artery. He panics, tries to sew her up, but it's not in time. It's too much for her system and she dies on the table just as the surgeon is rushing back in.

Would this be a believable scenario? Is the kidney close enough to an artery (say they have her all opened up to remove the other crap) or should I use another organ? If it is close, do you know what artery it would be?

Thanks in advance!!!

Tsu Dho Nimh
07-28-2008, 04:07 AM
Keep in mind that by the time you are a resident, you have been through med school and your internship. You have seen way too much surgery to not have the right instincts.
Not believable ... all he'd have to do is clamp the bleeder and sew it up. Also, even dropping a scalpel wouldn't usually sever an artery.

You really need to look at some anatomy books ... the kidney has a very LARGE artery leading right to it, called the renal artery. Sever that and you have to clamp it immediately.

I remember one accident in surgery where the renal artery was not in its usual position and got nicked during a bowel resection. All the surgical resident did was pinch it with his fingers to stop the bleeding and ask for a clamp. Then he stitched it up and kept on resecting.

JoNightshade
07-28-2008, 04:22 AM
ARGH! Okay, so I'm nowhere then. I've been looking at anatomy charts, watching surgical videos, etc. etc. for days and I still have no clue, I'm not a surgeon.

I don't care if he's a resident or intern or what. I just need a scenario where he kills a kid, right then, on the table, and even though it's the surgeon's responsibility legally, the guy knows it was his fault.

This scenario accounts for a grand total of THREE paragraphs in my entire book but it has to be accurate and it has to be right.

Suggestions?

JoNightshade
07-28-2008, 10:14 PM
Another scenario would be, the attending leaves, the intern starts to close and then the nurse say's, "there's a lap pad (surgical towel) missing from the count."

The intern doesn't want to reopen the half closed wound so (s)he feels around, finds it and pulls it out triumphantly and finishes closing, without remembering that that pad had been placed there as a means of putting pressure on bleeding from a raw area early on in the case and they all forgot to go back and check the area to find the bleeder.


Okay, so if I were to use this example - I would like the guy to have a little more responsibility so let's say he's a 2nd year resident? He's at the end of a long shift so he's pretty tired. Let's say the attending is in a hurry to be somewhere or do something. The injured child was basically impaled on a piece of splintered wood, her kidney is damaged and she has large splinters in her abdomen. Surgeon saves the kidney and starts picking out pieces, then gets impatient and tells the resident he can take care of this and close up, right? Resident, who is kind of a hot-shot, says sure, he can handle it. One of the nurses questions, but the attending says 'I would trust this guy with my own life.' Resident picks out the last splinters and is closing when nurse says the lap pad count is off; he reaches in and pulls it out, forgetting it was there to put pressure on a bleeder he meant to cauterize before he closed up.

So he closes up, kid seems fine, resident goes off-shift. He's in the shower or something when suddenly he remembers about the pad. He calls and races back to the hospital, but it's too late. The person who took over his shift gave the girl pain meds but she bleeds into her abdomen and dies.

Is this reasonable? It's okay if it's stretching a bit, I just need it to sound reasonable and not make every doctor who reads it burst into laughter. ;)

GeorgeK
07-30-2008, 10:37 AM
Okay, so I now have an actual scenario I'm hoping you (George!) can verify is reasonable. The actual event happens before the start of the book, so now my main character, a resident, is recounting what happened.

They have a little girl come into the ER from a car accident, she's thrown out of the car or something. They have to take her into surgery really fast because she has a foreign object (possibly multiple foreign objects) in her abdomen. A surgeon and this resident go in and start picking pieces out and they discover that although her condition is a bit fragile, only one of her kidneys has been hit. They are just finishing the delicate work when the surgeon has to use the bathroom (say he ate something bad the night before). He trusts the resident, who is known as being exceptionally young and talented, a kind of wiz kid. So he tells him to take care of the rest while he scrubs out to use the john. The resident, in all confidence, continues-- and then he fumbles. He drops and instrument and it slices clean through an artery. He panics, tries to sew her up, but it's not in time. It's too much for her system and she dies on the table just as the surgeon is rushing back in.

Would this be a believable scenario? Is the kidney close enough to an artery (say they have her all opened up to remove the other crap) or should I use another organ? If it is close, do you know what artery it would be?

Thanks in advance!!!

Sorry for the delay, I've been sick.
Yes, that is believeable (except for maybe the part about dropping the scalpel unless the resident had nerve damage, but then he shouldn't be in surgery. Most catasrophic intraoperative bleeding is not going to be the result of dropping an instrument, but rather overzealous dissection or a byproduct of the patient's disease. In this case the patient was presumably healthy going into the injury). An unrestrained passenger (no seat belt) can easily be ejected from the vehicle and can easily get impaled on trees, traffic signs, whatever. An unrestrained child getting injured is the fault of the driver.

If the attending is only gone for ten minutes, then you might make the proximal cause of death to be injury to the renal vein or even the vena cava, since exposure of the renal vein will require that you can at least see part of the vena cava. That is much harder to repair and since veins for all practical purposes have no muscle they do not spasm or slow down bleeding when cut and an inexperienced person could very quickly get in over his head. The proper thing for him to have done would have been to simply wait until the attending to return before proceeding. Failing that, he could pack the wound with gauze to put pressure on it, but improper packing of such a wound can fail to stop the bleeding (death on the table), or could occlude the vena cava which in turn could result in dead bowel (death a few days later with a very painful and rocky post op course)

GeorgeK
07-30-2008, 10:41 AM
I remember one accident in surgery where the renal artery was not in its usual position and got nicked during a bowel resection. All the surgical resident did was pinch it with his fingers to stop the bleeding and ask for a clamp. Then he stitched it up and kept on resecting.

He sewed off an anomalous renal artery or repaired it?


Keep in mind that by the time you are a resident, you have been through med school and your internship. You have seen way too much surgery to not have the right instincts.

Not believable ... all he'd have to do is clamp the bleeder and sew it up. Also, even dropping a scalpel wouldn't usually sever an artery.

.

That's not really true since the basic story is about somebody who left surgery for personal reasons. The story is regarding someone who panicked and some people do panic. There are people who quit surgical residencies. There are people who really don't belong in the operating theater. There are some active attending surgeons who don't belong in the operating theater. As a surgeon I have more empathy for someone who quits as opposed to the one who doesn't but should have.

Another thing is that one of the biggest parts of surgery is proper exposure. If the attending is out of the room, that means a tech or nurse is doing the retraction for the resident and it is very plausible if not even expected that they will not be as good as a trained surgeon in terms of actually assisting. In a facility that has surgical residents the scrub nurse may not even see what's going on and may have spent their career only passing instruments.

GeorgeK
07-30-2008, 11:06 AM
Okay, so if I were to use this example - I would like the guy to have a little more responsibility so let's say he's a 2nd year resident? He's at the end of a long shift so he's pretty tired. Let's say the attending is in a hurry to be somewhere or do something. The injured child was basically impaled on a piece of splintered wood, her kidney is damaged and she has large splinters in her abdomen. Surgeon saves the kidney and starts picking out pieces, then gets impatient and tells the resident he can take care of this and close up, right? Resident, who is kind of a hot-shot, says sure, he can handle it. One of the nurses questions, but the attending says 'I would trust this guy with my own life.' Resident picks out the last splinters and is closing when nurse says the lap pad count is off; he reaches in and pulls it out, forgetting it was there to put pressure on a bleeder he meant to cauterize before he closed up.

So he closes up, kid seems fine, resident goes off-shift. He's in the shower or something when suddenly he remembers about the pad. He calls and races back to the hospital, but it's too late. The person who took over his shift gave the girl pain meds but she bleeds into her abdomen and dies.

Is this reasonable? It's okay if it's stretching a bit, I just need it to sound reasonable and not make every doctor who reads it burst into laughter. ;)

That's also a believable scenario. Normally a bleeder requiring cauterization will clot on it's own and it would be a bleeder that required sutures that ultimately allows someone to bleed to death, but kids are smaller and so they might potentially bleed from something that could have been cauterized. They can also have a delayed bleed from something that was cauterized which really should have been sewn. The cauterization can act as a temporary mechanism of hemostasis. That's why the last part of surgery before closing is to go back and re-look at everything.