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Warning: This is a long post.
So I was at my 24 hours ER shift as attending physician yesterday. The morning had been really good, no patients at all. So I was at the residency having a cup of coffee... Suddenly, at 11:30 AM...
Dr. Vargas, please call 412. Dr. Vargas, please call 412.
I grab the phone and ring the ER.
-Hello, Dr. Vargas speaking. What's up?
(a paramedic answers the phone)
Doctor, you have a patient. Nothing urgent though, it's a 60 year old female complaining of upper abdominal pain descending to her pelvis and legs... Strange thing though, her BP is 160/80mmHg, and she's desaturating at around 65%...
She didn't finish the sentence and I hopped out of the couch and ran to the ER, thinking "Nothing urgent though" my ASS... Looks like an AAA (abdominal aortic anneurysm)... A life or death situation; about 30% of people who have a ruptured abdominal aortic anneurysm survive long enough to get to the hospital, and only 50% of them survive the whole ordeal, including a major surgery to replace the aorta, the main artery of the human body.
So being the tall dude I am (1.93 mts) I got there in 5 leg jumps (LOL) and in exam room 1, there was this old, thin lady, looking extremely pale, her hands on her abdomen, grunting, and she opens her eyes wide when she sees me come, and says "doctor, please help me, I feel so cold, I'm in so much pain, think I am going to die..."
So I call the ER nurse and ask for a high-flow oxigen mask, blankets and monitorization. We move the patient to the ER reanimation room, as I try to calm her down as I begin taking up her history: Pain starts about 30 minutes ago, sudden sharp pain in upper abdomen, radiating down to her pelvis and legs, and shortness of breath. I begin examining her when the nurse starts to take the old lady's clothes off to dress her in a hospital robe, when she points at the lady's legs and says, "doctor, look.." She had livedo reticularis, which can be pictured as extremely poor distal blood perfusion. I take my hands to her legs, which are freezing cold... Cardiac tones are OK. Lung murmurr is ok. But as I take my hands to her abdomen, I feel a pusating mass. Blood pressure is inmensely different when taken in her arms and in her legs, and her pulses were asimmetrycal.
My suspicion was then confirmed: It was a AAA. But our hospital is small, for low complexity diseases, so I have no way to treat this: I've got to quickly refer this patient to our reference center.
So I say "Iris, call the EMT dispatch, we need an advanced medicalized ambulance to take this patient to our reference center... Plase let me know when you have them on the line. And keep an eye on the patient, I'll go talk to her family"
I go talk to the old lady's family, explain the situation and tell them I'm about to transfer her to my reference hospital, when nurse Iris yells "Doc, EMT dispatch is on the line, they want to talk to you!"
So I take the phone and, long story short: No advance transport available.
I had to make a decision... And so I did.
"Iris, take up the laryngoscope, tracheal tubes #7 and 7.5, oxigen, the ER monitor, the portable cardiac arrest drugs kit and call the ambulance dept, we're going to move this patient ourselves."
I call a colleague who was on her day off, explaining her the situation. She was in the ER 5 minutes later.
So we take the old lady to central hospital in a rush. 20 miles away, in 15 minutes (pedal to the metal is an understatement...) And the shift's surgeon recieves us. I tell him about the case, he examins the patient in a hurry and says "yeah, I think you're right, it is probably an aortic anneurysm... Good call. We'll take it from here. I'll ask for an angioCAT scan and if it is confirmed, according to her age and everything, I'm not sure if we'll be able to do anything... She's lived her life, man, and it might be a waste of resources to treat a patient of her age for a near-lethal disease such as this (my face starts to disfigure that very second... He stutters...) B-But you did your job, man, you did what you thought best. Good call.
...
I was so enraged on the way back to our hospital. I knew what was coming.
I call in the afternoon to know what happened.
"I'm sorry doctor, your patient was confirmed with a AAA but she got worse in the last hour and passed away before surgery".
Is that how you call this? A waste of resources? So you don't save a 60 years-old lady's life... because she's 60 years old, hypertense, and she might not survive the surgery?...
I felt betrayed, nauseated, enraged to the point of crying. I tried so hard on the little I had, and when in a hospital that has everything imaginable, she's left to die?...
... I remember that's not how I was taught medicine was.
I'm sorry this post has gotten so long, but I needed to vent this...
THIS is the reality of the health system in my country.
Choices are made when they don't have to be. And that sucks, because you're either part of it or you're out.
I don't think "resource management" should go over patient care in cases like this.
Thank you for reading.
 
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I personally felt a little sick reading the conclusion to this. You did everything you could under your control.. But i don't know how that other doctor could live with himself.
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Thats just so bullshit, she could've lived another 20 years happily... If i feel angry after reading this i can't even think how enraged you were 
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I want to be a Doctor. I've done hospital volunteer work and, although I'm in my freshman year of college, have been doing MCAT prep seriously for the past two years.
But this is what scares me. The stories of Doctors who are compelled to make such judgement calls. Even worse, when they are no longer compelled at all, but are impelled from sheer weight of experience to let patients die. To tell themselves that not doing the utmost to help a human being live another day is, without hesitation, the right choice. To be able to sleep at night without regret whilst doing so.
D:
Keep at it Dr. Vargas, keep at the right thing even if it seems like it won't make a difference. Because it does. It really does.
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sad reality of healthcare, its like this to an extent or in different ways everywhere. i changed my career path after learning about the industry and how good doctors are overshadowed by commercial interests.
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Well if there are doctors like you in the system then there's hope there are other ones with the same mindset. Maybe things will get better!
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You did all that you could possibly do, and what you described is the situation of the healthcare of the majority, if not all, south american countries, in fact, I thought Chile was the best in that department
Basically, if you don't have a private healthcare plan (which are extremely expensive), you are screwed.
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The whole world is like this or worse when it comes to health care. My mom was an ER doc for most of her life (disabled now, skeleton kinda betrayed her T.T) and she can 100% confirm that the majority of hospitals do things in such a way to maximize potential charging.
Health care has gotten pretty close to just being about profits and gains, and has moved extremely far away from simply helping people who are sick and in need.
It's even worse in Utah, fucking Mormons >.<
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you did your best man, you can be proud of yourself!
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Dam man I give you madd credit for sharing this with us. I know now its not the best thing to be proud of but you nailed the ladies problem and did everything right on your part. Sometimes these things are out of our hands. Hope you feel better!!!!
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FUCK
I so hoped the story would turn out well.
But you seem to be a great doctor hopefully you get the resources you need to save as many people as you can in the future.
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All you can do is take pride in how you treated her. You did all that you could.
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Incredible anecdote... I'm still shivering dude.
Halfway through reading I copied "She had livedo reticularis, which can be pictured as extremely poor distal blood perfusion" to ask what it meant, but I don't even know if I care anymore...
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On February 16 2012 02:01 Symmetry wrote:
Incredible anecdote... I'm still shivering dude.
Halfway through reading I copied "She had livedo reticularis, which can be pictured as extremely poor distal blood perfusion" to ask what it meant, but I don't even know if I care anymore...
This is a mild case of livedo reticularis:
![[image loading]](http://images.paraorkut.com/img/health/images/l/livedo_reticularis-1864.png)
In cases such as the one I exposed, when blood flow isn't enough (i.e: blood gathering from the rupture in the aorta inside the abdomen), poor circulation forms this figures up in the skin.
It's an ominous sign, means shock is settling in, and we all know shock is very bad for your health...
Thank you for all your thoughts. I know I did what I could, but man, this drives me insane. I did not become a doctor for this... And it scares me on how people might be treated when I transfer them.
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I don't want to sound critical, but it's not clear from your story that the lady died because "resource management" decided it wasn't worth saving her even though they had the capability. It seems like AAA is so deadly that most people don't even make it to the hospital, let alone OR, so for all you know they rushed her as fast as they could but still lost her. Even if that wasn't the case, hospitals have limited resources, and sometimes you need to make a judgement call on which of two patients needs the OR more. There's never a right answer to that question, but you gave it your best effort, and that's all you can do.
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On February 16 2012 02:18 Melchior wrote:
I don't want to sound critical, but it's not clear from your story that the lady died because "resource management" decided it wasn't worth saving her even though they had the capability. It seems like AAA is so deadly that most people don't even make it to the hospital, let alone OR, so for all you know they rushed her as fast as they could but still lost her. Even if that wasn't the case, hospitals have limited resources, and sometimes you need to make a judgement call on which of two patients needs the OR more. There's never a right answer to that question, but you gave it your best effort, and that's all you can do.
It might be because I'm still young (25) and want things to be done right...
Yes, it's true hospitals have limited resources, but you've got to draw a line: Operating on that patient meant she had a 50% chance of survival, a 50%... Or waiting for her death.
I might have understood if we were talking about an 85 years old little granny who obviously wouldn't make it through major surgery and has surpassed her predicted lifespan...
If you wanna flip a coin, you don't flip it because you don't want it to land on heads if you choose heads?
Maybe, but if that coinflip gives a person 10 or 20 more years of life... Flip the fucking coin!!
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On February 16 2012 02:35 UmbraaeternuS wrote:Show nested quote +On February 16 2012 02:18 Melchior wrote:
I don't want to sound critical, but it's not clear from your story that the lady died because "resource management" decided it wasn't worth saving her even though they had the capability. It seems like AAA is so deadly that most people don't even make it to the hospital, let alone OR, so for all you know they rushed her as fast as they could but still lost her. Even if that wasn't the case, hospitals have limited resources, and sometimes you need to make a judgement call on which of two patients needs the OR more. There's never a right answer to that question, but you gave it your best effort, and that's all you can do. It might be because I'm still young (25) and want things to be done right... Yes, it's true hospitals have limited resources, but you've got to draw a line: Operating on that patient meant she had a 50% chance of survival, a 50% . If you wanna flip a coin, you don't flip it because you don't want it to land on heads if you choose heads? Maybe, but if that coinflip gives a person 10 or 20 more years of life... Flip the fucking coin!!
I was thinking more about the scenario where you have one OR and two patients, one with a 90% chance of survival and one with a 50% chance. There's still no right answer, but you can see how someone might choose the 90% one over the 50% one. If there's the capacity to operate, though, I agree with you that any chance is better than nothing.
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That's really messed up. Sorry to hear about that. RIP old lady
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On February 16 2012 02:38 Melchior wrote:Show nested quote +On February 16 2012 02:35 UmbraaeternuS wrote:On February 16 2012 02:18 Melchior wrote:
I don't want to sound critical, but it's not clear from your story that the lady died because "resource management" decided it wasn't worth saving her even though they had the capability. It seems like AAA is so deadly that most people don't even make it to the hospital, let alone OR, so for all you know they rushed her as fast as they could but still lost her. Even if that wasn't the case, hospitals have limited resources, and sometimes you need to make a judgement call on which of two patients needs the OR more. There's never a right answer to that question, but you gave it your best effort, and that's all you can do. It might be because I'm still young (25) and want things to be done right... Yes, it's true hospitals have limited resources, but you've got to draw a line: Operating on that patient meant she had a 50% chance of survival, a 50% . If you wanna flip a coin, you don't flip it because you don't want it to land on heads if you choose heads? Maybe, but if that coinflip gives a person 10 or 20 more years of life... Flip the fucking coin!! I was thinking more about the scenario where you have one OR and two patients, one with a 90% chance of survival and one with a 50% chance. There's still no right answer, but you can see how someone might choose the 90% one over the 50% one. If there's the capacity to operate, though, I agree with you that any chance is better than nothing.
Sure, if your hypothetical case would have presented, you would have been absolutely right.... But knowing that ATM I got there with her that wasn't the case (there were 7/10 observation stretchers empty in the central ER, and 4/15 boxes occupied on arrival), I think the scenario should have been different. Hence my anger. I don't know what happened in the hours after she was admitted; it might have been that very case...
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I was reading your blog and got all excited, I was looking forward to a happy ending....
Jesus man wtf. You did everything you could though. It's just so sad that she didn't make it after all that effort.
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...I was really hoping that would end in a heroic triumph story.
=[
i hate life and people sometimes.
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She was only 60? 60 isn't old... my mom is 60 and nowhere near dead. Just curious, what was the surgery that should have been performed? They cut her open and remove the aneurysm I guess?
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Tough one. Chile is really going to shit IMO, I went there last winter to visit my family and the prices in the supermarket were almost the same as in Europe while the minimum wage is probably 20 times lower.
Which hospital are you in, assuming you're in Santiago? I went to see my grandpa (who's very important to me) in the hospital Felix Bulnes, and he was in a shitty old military hospital in Providencia because the regular hospital had been damaged by the last earthquake.
I was also staying at the house of my mom's friends who are a very successful couple of doctors (he's an urologist in the Clinica Alemana and she's a radiologist) and it was just another world, completely disconnected from the rest of the country. It actually looked like the suburbs of Atlanta in the US, while dirt roads and people lying on the streets was just one hour away by bus. She really angered me at some point, we were discussing the problems of the country and she said that poor people didn't have money because "they were lazy". Those people go to a German clinic and to a French school, how the fuck can they call themselves chileans? I'm more Chilean than any of those idiots!
Man this really worries me, my grandparents are around 70, I'm seriously going to murder anyone who lets them die just because it's not profitable to save them. And if I can't I'll just sue the shit out of them, pay the fucking judge to throw these assholes back to the ghettos they don't even know they exist.
Fucking shit place, became a fucking third world country with all this stupid bullshit.
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I wish I was in Santiago, dude.
I'm in southern Chile, near Puerto Montt, roughly 800 miles south from Santiago... In a very small and poor hospital, where your cleverness and improv skills do most of the job...
And away from the capital, shit just gets worse...
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On February 16 2012 03:30 Uranium wrote:
She was only 60? 60 isn't old... my mom is 60 and nowhere near dead. Just curious, what was the surgery that should have been performed? They cut her open and remove the aneurysm I guess?
No... Actually, you open up the abdomen, dissecate through to the back of it, putting aside all the intestins and viscerae, to get to the anneurysm; the aorta is basically put up against the spine... way, way in the back of the abdomen, in between the kidneys; then, assuming it isn't broken and you have to find your way in a pool of blood inside the abdomen, you clamp the aorta just above the anneurysm and just below it, and cut that portion out; after that, you replace that segment of the aorta with a synthetic graft... And then, the shittiest part, you've got to start attaching all the major blood vessels coming out of the aorta that you had to take out, back into the graft... All in under 3 hours, so the organs irrigated and the legs don't get hypoperfusion injury (i.e: don't start dying due to lack of blood for 3 hours).
This stuff is serious shit. Might be, besides open skull brain surgery and open heart surgery, the biggest one a person could endure. It's like saying "oh, the main water pipeline to my house broke, let's dig a hole in the ground, and in between the artificial lake made by the leaking pipe, try to seal both ends off and replace the shit out of it in less than 3 hours without letting the sinks in the house run out of water"... Standard.
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Yeah I've lived in Chiloe for a few months as a kid, but I havent been south of Concepcion since. I do have some family around I believe.
I did stay for some time at San Antonio at my grands house and it was way, way worse than Santiago, true. Small roads going up the hills, I have no idea how ambulances are supposed to get there in time.
Good luck man, and heads up for saving lives in such an environment
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You did everything you could, and you're a hero. Rest in peace to the poor lady, but just remember that it was through no fault of yours (not that a doctor needs me to tell him this).
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Thank you again for your kind words. They kinda put me at ease for now.
I'm no hero, though. I'm just a man doing what he loves despite all the downsides.
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Holy shit you're an amazing doctor.
Be proud of yourself, the situation was out of your hands and there just wasn't much you could realistically do beyond the lengths you went to (which, in my opinion, were above and beyond).
Sadly, life or death decisions can come down to economics in almost every country. Take comfort that you did everything in your power to do what was right.
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Good to know that there are doctors who genuinely care about the patients (you). Despite your best intentions, things may not always go the way you want it to. May the deceased lady rest in peace.
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So I asked a friend of mine about this (he's a medical professional in the UK with years of experience as a resuscitation officer) and his response was that there was basically nothing more to be done than what was done and she was almost certainly dead either way. In a way that sounds quite sad to write, but it's certainly better than just not using the resources to bother trying so I thought I'd share.
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EPT
