i·at·ro·gen·ic adj. Induced in a patient by a physician's activity, manner, or therapy.
My first exposure to the dangers of modern interventionalist medicine was that same year I think I saved my first life ... the guy with a shard of glass in his groin plugging a laceration in his femoral artery. Well, okay maybe I didn't save his life, but my instinctive choice to not remove that shard of glass certainly contributed to my not killing him.
First do no harm.
During my two weeks of attachment to a vascular surgical unit I was involved in the care of a man who travelled from interstate with his suitcase ("positive suitcase sign") for an outpatient consultation. He suffered from poor circulation in his legs, producing a condition called intermittent claudication. Basically he could only walk a limited distance before his legs became painful and the pain was only relieved by rest. By all rights his symptoms were in fact not too bad and could probably have been managed conservatively but because the vascular registrar felt sorry for the man she admitted him to the hospital and booked an angiogram. For that a needle was required to be inserted directly in to the artery of his groin so a radio-opaque dye could be injected and X-rays of the legs (with the dye highlighting the arteries) performed.
The angiogram result confirmed the clinical impression that the arterial disease the man had was mild and surgery was not going to be required in the near future. Plans were set in place for his discharge home the following day.
Seven o'clock that evening the nursing staff reported to the consultant that the man's right leg had gone blue and cold and no pulses could be felt below the knee ... typical of a full below-knee arterial occlusion. As the registrar had left to go home (one of her rare nights off) I was the only extra pair of hands to assist the consultant with that man's emergency surgery to save his leg.
A piece of internal artery wall had been dislodged by the angiogram needle and found its way down the leg to a resting place of its own choosing. The vascular surgeon found it, removed it and the man's leg rapidly returned to its normal colour and foot pulses, although weak, were again palpable and probably in their normal state of semi-vibrancy for that man's vascular disease state. The man left the operating theatre with a viable leg and I with a sense of achievement.
Two hours later the nurses made the same phone call to the same consultant about the same patient who had redeveloped the same acutely ischaemic leg.
Back to the operating theatre. The whole mid-thigh main artery had completely clotted. The man's leg was severely compromised and in order to save it a bypass with plastic tubing was required.
That man eventually safely left hospital with souvenir groin-to-knee scar, plastic tubing, and persistent intermittent claudication in his untouched leg.
First do no harm.
In that same hospital, same year, same rotation I was the student of a unit that was looking after an elite level footballer who had become unwell. His diagnosis was Hodgkin’s disease, a malignancy requiring aggressive treatment. In order to decide on the "best" treatment regime a "staging" had to be done to determine the extent of the disease and which organs were involved.
In those days staging was done via laparotomy, a major abdominal incision, physical visualisation and palpation for lymph nodes in the abdomen and the performing of a liver biopsy. The liver biopsy was performed under direct vision, with the correct technique, by the surgical registrar.
The biopsy needle hit a blood vessel in the liver and the anaesthetised patient, oblivious to the event, bled profusely. Because the biopsy was done at laparotomy where the bleeding point could be surgically attended to, the patient survived. Normally liver biopsies are done by passing the biopsy needle through the skin and abdominal wall under local anaesthetic. I dread the thought that similar profuse bleeding can occur with such a "closed" biopsy. Liver biopsies are mostly done in patients with liver disease. Liver disease by itself can increase the risk of bleeding. Being my first "liver biopsy" I will always wonder how many liver biopsies done for any other of my patients now and into the future will result in a bleed that requires emergency surgery to repair.
First do no harm.
Years later I spent three months as a trainee anaesthetist and as one does, we talk about latest cases to learn and hopefully avoid adverse outcomes. I remember one day my mentor talking about a young woman who was at that time being cared for in a long-term care facility in a semi-vegetative state. She was a young mother of two young children at the time of a "routine" D&C performed as a diagnostic procedure for erratic menstrual bleeding. She suffered an anaesthetic complication but due to the diligence of the anaesthetist she survived. I finished my anaesthetic term and chose not to further any training in that area.
First do no harm.
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