Challenges in Private Practice

Although as a whole, community practice patients are healthier and less complex than those at tertiary academic centers, we do get our challenging cases. On call two different nights, I am asked to do two similar emergent cases. A 90 year old man who has so far survived two heart attacks, a coronary bypass procedure, kidney failure on dialysis, and two leg amputations for uncontrolled diabetic infections is admitted from the emergency department with belly pain. Exam and imaging are consistent with dead bowel; without surgical resection, he will not survive. Over the last few hours, he has been started on three different vasopressors to marginally support his blood pressure. His heart is racing at 120 beats per minute (pretty much close to the maximum expected heart rate for a 90 year old), and he is breathing fast and deep with the assistance of a pressured mask (BIPAP). The second patient was similar, a 90 year old man with a critical aortic valve stenosis who presented with abdominal pain. His heart valve stenosis was so severe that for years, his cardiologist recommended a valve replacement, but he kept on refusing. On the telemetry floor, he has a code blue when he is unresponsive, requiring CPR and intubation. Further imaging suggests that he, too, has dead bowel. He is on two vasopressors supporting his blood pressure.

I really enjoyed anesthetizing these two cases. It reminded me why I went into critical care; I like the hardest parts of medicine. And it's not only the medicine and procedures; these cases challenge me to consider whether these patients really needed surgery, to have that hard discussion with families about the risk and seriousness of the patient's condition, to communicate with surgeons about the plan. In these cases, I really took ownership. These patients needed my utmost care and attention; they forced me to use skills that I don't routinely think about. In fellowship, I became proficient with assessing the heart with ultrasound. I learned how to mitigate risk in line placement. I learned how to anticipate and treat complications before things got too late. These were cases where I was never bored; I was always moving, thinking three steps ahead. They were the type of cases where we would be nearing the end before I even picked up my charting. They develop a rhythm and cadence, where I am fully immersed. All my thoughts outside the operating room were on hold; it is how imagine surgeons feel when they are in the most critical parts of surgery.

Both patients were (at least physiologically) better and more optimized at the end of surgery and anesthesia. At the end of the night, I knew, had convinced myself, that I had done all I could to my utmost ability. Satisfaction in medicine comes in many different forms, but some of the most profound moments occur when I am fully immersed in a challenge and surprisingly happy.