My Grandfather Coded Three Times After Surgery at Our Rural Hospital
This week, we're revisiting one of the most personal stories I've ever shared on The Rural American Surgeon. It's a story I've thought about countless times over the years, because it completely changed the way I approach surgery.
I was just four months out of residency at Mayo Clinic when I got a call from my grandmother one Saturday night. My grandfather was seriously ill, and I ended up bringing him to the small rural hospital where I was practicing. At the time, I thought we were doing everything right.
Looking back, I couldn't have been more wrong about some of the assumptions I was making.
Despite five years of excellent surgical training, there were things I completely overlooked. Things I would have recognized in almost any other patient.
But this wasn't just another patient, this was my grandfather. What happened over the next 24 hours was something I wasn't prepared for, either as a surgeon or as a grandson. There were decisions I wish we'd made differently, conversations we should have had sooner, and moments when I genuinely thought we were going to lose him.
In this episode, I share what happened, where my judgment failed me, and the lessons that have stayed with me ever since. If you're practicing surgery in a rural hospital, especially early in your career, I think you'll recognize some of the challenges in this story.
And hopefully, you'll take something away from my experience that helps you avoid making the same mistakes I did.
Key Takeaways
00:00 Welcome to The Rural American Surgeon
00:33 The Case That Changed Me
01:43 A Saturday Night Call From Grandma
04:13 Severe Cholecystitis and Sepsis
05:13 Deciding Whether to Operate
05:42 The Blind Spot in Preoperative Risk
07:20 “No Medications” Does Not Mean Healthy
08:31 Missing the Goals-of-Care Conversation
10:29 Code Blue in the Operating Room
11:49 Gangrenous Gallbladder and Cardiac Arrest
13:03 What Did Grandpa Actually Want?
14:33 A Third Code and a DNR Decision
16:39 Grandpa Wakes Up
17:28 Asking the Patient Directly
18:20 Choosing Aggressive Treatment
20:20 Another Cardiac Arrest
22:04 Severe Coronary Artery Disease
23:21 Recovery Against the Odds
24:40 Resource Limits in a Rural Hospital
26:04 How the Case Changed Randy’s Practice
26:52 Creating Personal Surgical Guidelines
29:05 Keeping Care Local Without Being a Cowboy
30:45 What Residents Should Learn Before Rural Practice
31:30 Better Options in Hindsight
32:32 Surgery Is a Decision You Cannot Take Back
33:10 Choosing the Lower-Risk Operation
34:05 Encouragement for Rural Surgeons
Resources Mentioned
Mayo Clinic
https://www.mayoclinic.org/
American Heart Association – ACLS
https://cpr.heart.org/en/cpr-courses-and-kits/healthcare-professional/acls
American College of Surgeons
https://www.facs.org/
American College of Cardiology
https://www.acc.org/
Episode Transcript
Dr. Randy Lehman (00:43):
Welcome back to another episode of the Rural American Surgeon. I'm your host, Dr. Randy Lehman. Today, I have an excellent episode for you. It's a solo cast, and we're going to be talking about the case that changed me. It's a personal, very close to my heart experience that is a true story that actually happened. And it clarifies... Resource limitations in a small hospital. And I learned so many lessons in somewhat embarrassing fashion, I would say. Received excellent training, Mayo Clinic, five years. I was really trying. My heart is in the right place. I'm trying to do the right thing. But yet there were some exposed blind spots from this case. And it turned out okay. But
Dr. Randy Lehman (01:30):
It wasn't i guess it just depends how you spin the story but i'm trying to be as realistic as possible to sort of expose my own blind spots and just be vulnerable and share um with you guys and it wasn't even my patient so let's get into it so basically it's a saturday night i'm living in a small town in indiana 1200 people My grandparents live the next town over about 25 minutes away. That's where my wife and I attend church. And I get a call on a Saturday night. Also, this is maybe four months out of residency. So everybody kind of knows I'm back and I'm practicing general surgery and whatnot. I get a call from my grandmother and she says,
Dr. Randy Lehman (02:12):
Hey Randy, I don't know if you heard, but Grandpa's been kind of sick all week. And first he was just kind of not feeling hungry, feeling sick, a little feverish, having some belly pain. Urine was kind of dark. But now, in the past day or so, he's really not been able to get out of bed at all. And now he won't drink anything. And he's not actually making any sense, and he doesn't know who he is or where he is, and I just checked his fever, and it's 103, and so I was just wondering, you know, tomorrow, if you're going to come over here and go to church, maybe you could just stop by after church and see him, and so...
Dr. Randy Lehman (03:00):
Of course, I said, Graham, I'm already in the car. I'm on my way. This sounds potentially catastrophic. And it was. So I headed over there. And I get there and he's laying in bed. And just like was described, doesn't really have any idea who he is, where he is, what's going on. Clearly has not been out of bed for some time. Uh, he's got some, basically a urine sample there, uh, which is quite dark and quite malodorous. And, uh, he didn't specifically complain of any pain, but basically, uh, washed him up a little bit, got some clothes on him and, uh, told him the deal. My grandpa, you have to understand, he doesn't want to see a doctor, obviously, unless he's dying.
Dr. Randy Lehman (03:45):
And so he has basically put this off a little bit and it requires some coaching and some coaxing, I would say, just to get him into the car. Now, just at that point, basically, I'm loading him up and he doesn't have any recollection of any of this. Um, but basically we got him dressed up, loaded in the car and said, we're going to take you to the hospital. So I took him to the hospital that I was working at small town, critical access hospital, took him to the emergency department, called them, give them a heads up that I'm bringing them in. We bring them in his white count. It's 37,000. He's febrile. Uh, his heart rate is 140 sustained and
Dr. Randy Lehman (04:25):
Blood pressure soft, lactate, whatever, four and a half, something like that. And I thought he had urosepsis probably would be a common thing, especially because they were using some specific urinary complaints and whatnot. Well, he gets a CT abdomen pelvis and turns out he's got acute cholecystitis, severe acute cholecystitis and obviously septic. And so I was pretty proud of our hospital. I'm just, this is exactly what we're here for, to make this diagnosis and to make a difference in this person's life. And now it's my grandpa and I'm back home and I'm in the middle of it. And I just love that. I was not on call. Obviously, I would not operate on my own grandfather,
Dr. Randy Lehman (05:11):
But it's also fortunate that I wasn't the on-call surgeon. So then I called my partner who was on call, explained the situation, and he said, well, you know, it sounds pretty bad. And he made it very clear. He said, do you want me... To do this. Do you want me to consider operating on your grandpa here? Is that what you want? Because the veto power he was given to me, which I thought was very wise, and we could separate ourselves even further from the personal component of this case. And I said, yes, I do. And then we were talking about his fitness for surgery. And this is where I made, I exposed my blind spot.
Dr. Randy Lehman (05:51):
And this is an example of, I would say, clouded judgment. And I said, they're asking, you know, what's his functional status? And I said, he's healthy, takes no medications. One of the stupidest things I've ever said. My grandpa had a motor vehicle accident and he had an injury. It kind of messed up his leg. What his baseline status actually was, he didn't look unhealthy to me, but I never saw him walking down the street or anything. He moved around his house with essentially a wheeled chair, walker thing. But I thought that that was because of his leg. I didn't really think about,"Okay, can you walk a block without getting short of breath? Or can you walk around your house without
Dr. Randy Lehman (06:41):
Grandparent, or if it was now, I would say I would have a much better understanding of physical fitness and cardiac fitness. So I have a lot of patients that come in and I talk to them. I said, can you walk up a flight of stairs and walk a block without stopping now? And they'll tell me I never get short of breath, but I have arthritis in my knees and I can't walk. And then you can kind of get a sense of whether that's true or not. And you can always give them a... Chemical stress test. And then you'll find those, those types of things out. Maybe they do have a
Dr. Randy Lehman (07:11):
Good heart and they truly just have arthritis. But in this situation, I think my, if you would have asked, probably my grandpa would get short of breath with minimal exertion. Okay, and never sees a doctor, just because he's not on any medications doesn't mean that he's healthy. It means that he's never seen a doctor, so he has potentially untreated chronic illnesses. Anyway, I think I guided a lot of that decision making with my own sort of, just sort of clouded bad judgment. What then happened is my grandpa got two liters of fluid and some antibiotics, and immediately... Is awake and oriented and sort of confused about what had happened but he knows what's happening
Dr. Randy Lehman (07:52):
Now and he knows what's going on with his gallbladder he's asking me very appropriate questions about that but then also to the point where he says hey uh you know my elbow's been hurting me for about uh 13 years you think while i'm in here they could just get an x-ray of it So like back to his old self, basically, is what I'm trying to say. And obviously, we didn't chase down the x-ray elbow problem, right? Still not with a complete awareness of his overall septic picture. So anyway, the patient, my grandpa's admitted to the PCU status. We give him IV antibiotics and fluids and resuscitate him overnight. And with a plan for the next morning, Sunday morning.
Dr. Randy Lehman (08:32):
A laparoscopic cholecystectomy by my partner. The other big thing that we did not do a good job on this case is clarifying and communicating, and this totally should have been me of all people that did this, but clarifying my grandpa's wishes. If things didn't go according to plan. And I'm much better about that. I mean, generally, I'm good about that with my own patience. But, you know, there's all these other little pieces when it's somebody that's close to you. So you're thinking about all these other things. And that basic thing sort of, I wasn't thinking about it going bad. And I think that's the reason why you don't operate on your family members is because it's different. It's totally different than when you...
Dr. Randy Lehman (09:15):
When you're operating objectively on another patient and you're thinking about the regular routine things that you normally would do. And rural surgery, you can't not operate on anybody that you don't know, you know, like just because you know them, but you kind of have to know that, I think, in your own head of, am I able to maintain objectivity? In this scenario or not. And like for me, I guess it would depend on the case. And it would depend on the relationship. So there's close friends, you know, that I wouldn't do much on. And then there's family members that are a little further related from me that I probably would, you know,
Dr. Randy Lehman (09:54):
And so it all depends on the relationship. And then whether it's anesthesia or not, that's probably the big determining factor on the case. You know, obviously lumps and bumps and skin things and stitching people up. That's just, I guess, a joy of being able to provide that service for your close friends and family members in the small town. But once it gets to putting somebody to sleep for anesthesia, doing major abdominal surgery, especially emergency surgery. That's something you obviously should stop and think really hard about and probably not do. So long story short, we didn't have a goals of care discussion. And it was just obvious you got acute cholecystitis, that gallbladder needs to come out.
Dr. Randy Lehman (10:29):
And by the next morning, white blood cell count was significantly improved. His vitals were significantly improved. He was feeling much, basically said he felt pretty much fine. Pain was very much improved. So he went for his operation. I'm waiting in my office with my grandma. Some time goes by and all of a sudden I hear code blue in the OR over the speakers. And I'm like, okay, grandma doesn't know what this means, you know? So I'm like, and then I hear it called again. And I'm like, all right, I can't just, I'm going to go down. So I walked down there. And I go in and, you know, there we are doing chest compressions, coding my grandpa. And it's quite an experience.
Dr. Randy Lehman (11:17):
It's a Sunday, you know, so that the regular hospital crew's not around. And the skeleton crew's sitting there coding grandpa. I tried to have you know i just kind of asked what can i do what uh and they said well you know what are his wishes, which I didn't really know. And so they said, you know, why don't you go tell your grandma what's going on and let's have a conversation. And I can't remember if I went there with my partner or just by myself or how it was, but basically we went and talked to my grandma and they continued to do the resuscitation. The reason why that happened, they were done with So that was converted to an open operation.
Dr. Randy Lehman (12:05):
And then there was, you know, it's just a terrible, you know, like a bomb went off in the gallbladder fossa and everything. And so a ton of operations over. Then the extubation occurred. After extubation, you know, you... There's lots of things you could say about the whole entire scenario and i don't want to say anything bad about anybody except for my own judgment right in in the scenario uh obviously anytime you have an m m there's probably there should be 10 or 12 things that you could say well i could have done this or that differently so that's always going to be true but anyway he coded then the re-intubation was performed and then chest compressions and chemical coding was done
Dr. Randy Lehman (12:48):
According to ACLS protocol. So I go back there and talk to my grandma and we call my uncle who my grandpa works with on a daily basis. And both of them are like, well, this isn't good because not only is he dead and they're coding him, but he never would have wanted this. And I'm like, okay. So, you know, and they say, well, every day he says, you know, if I die, you let me die and I don't want CPR. And if it's my time to go, it's my time to go. And I'm ready. And I don't want any, you know, mechanical support. And I basically want to be at DNR, although that wasn't communicated and put in place before the operation.
Dr. Randy Lehman (13:30):
So we kind of decided we don't think he would want that. And so I walked back over there. But by that time, they got him back. And so then we're like, OK, well, you know, let's carry on and see how this goes. Get him to the recovery area. So they took him to recovery. We go back and kind of talk again with my uncle. And all of a sudden I hear code blue in the recovery area over the speakers. Right. So then I go down there and. Uh we're talking again and we're like well we think he might want to be a dnr so but we'd still been like 100 we weren't completely on board that was a relatively short-lived code
Dr. Randy Lehman (14:07):
And then uh they got him back so we're still gathering the family and trying to you know communicate about things leave them there And then, but we're getting more clarity and we're like, we think he probably is going to want to be made a DNR. Meanwhile, I go back to my office. We talked to the doctor that the hospital has come in now that's going to be assuming the care of the patient. And he's a good friend of mine. We started the same year and he wanted to, you know, just be clear. Well, sure enough, we have a third code.
Dr. Randy Lehman (14:41):
And now in the middle of the third code, we kind of decided we really don't think that this is what grandpa would have wanted. And so we decided to stop the code. And so they stopped it and shut off all medication, shut off the IV, shut off the monitors, and they have them on the vent. And we decided to gather the family and essentially come pay our last respects to grandpa before we extubate him. And this is in the middle of COVID. There's like maybe three other patients admitted in the hospital. One of them's mine. And he gets admitted. We start calling and it's Sunday afternoon and everybody comes.
Dr. Randy Lehman (15:35):
And because it's Dr. Lehman's grandpa and the whole situation, the whole family comes in. We've got like 40 people. Okay. My grandparents had eight children. And there's, I think last count is it's above 60 in terms of my first cousins and the rest of the family all combined. And it just now it's just like blowing up the family because, of course, we're all having our own kids. It's a huge family. My grandma and grandpa on my dad's side actually became quite close with them. Always were but especially after my mom passed away and they'll often come to family events and so they even came to the hospital and were all gathered around
Dr. Randy Lehman (16:17):
Grandpa's bed um and he's just laying there with no medication unresponsive on the vent and it's kind of sad um but if you know my family they're They're hugging each other, supporting each other. They're in there singing songs. I hear from my patient that was admitted to the hospital the next day. Yeah, it was kind of chaotic over there. And I don't know what was going on, but we were hearing like singing and. Well, sure enough, about when we get a critical mass of all these people in the room. Grandpa opens his eyes and he starts looking around at all these people. And then he kind of half smiles, you know, with the tube and everything.
Dr. Randy Lehman (17:06):
And of course, the family just, you know, confused, looking around and like, what's going on? They ask me, you know, what's happening? And I was like, well, you know, we're all just gathered around here. Preparing ourselves to terminally extubate grandpa, you know, and they said, well, okay, well, what are we going to do now? I'm like, I mean, I don't know. And they said, well, well, what would you want? And I said, well, if it was me in his situation, I would want someone to ask me what I wanted. And they're like, oh, well, could you do that? And I said, yes, sure. This is literally, I just recall as clear as day. And I go up to him and I said,
Dr. Randy Lehman (17:50):
Grandpa, here's what happened. You had a heart attack after surgery. You coded. We had done three rounds of chest compressions and we thought you were dead and we thought that wasn't what you wanted. And so we... We shut everything off and we were previously preparing to pull this tube out and thought that you were going to be pronounced dead. If you want to be treated further to live, you need to go to a place where there's a cardiologist. You'll have to be transferred. It'll probably be an ICU for quite a while. It'll be a long recovery. Is that what you want? And he emphatically nods, yes, you know, with his whole upper body, basically, because he's still intubated. And I was like, okay.
Dr. Randy Lehman (18:40):
And, of course, I got my uncle, who's... Works with him and has to hear about it, like how I don't even want to drive in an ambulance if my life depended on it and all this stuff. And he's in the back corner and he goes, even if you have to drive on a bumpy road to get there? And my grandfather just, you know, of course, like he didn't respond to that. But, you know, when faced with the dire straits, you know. It feels different for the individual. So basically coordinated for the nurse to come in. And of course, the nurse asked him all the things. Would you want chest compressions? Yes.
Dr. Randy Lehman (19:15):
You know, would you want a longer term intubation? Yes. Would you basically full press, full court press, you know, is basically what he agreed to, which is totally different than what he's been saying for 30 years to the rest of the family, which makes it hard. And that's why you should have the discussion. With your family members. And certainly that has changed my discussion with some of my family members. And so we decide, okay, we're going to ship him. Well, now all of a sudden, they didn't want to take him now, intubated or something. I can't remember at the nearest referral center, which would have been in Lafayette, and they have a cardiac.
Dr. Randy Lehman (19:50):
On-call team and everything, and he seemed to be sort of stabilizing. So he gets some stuff, and there was going to be a hassle to sort of transport him intubated anyway. And so he was looking so good now that the decision was made to extubate him and stay the night and then go down there the next day. I can't remember all the details. In retrospect, obviously, it seems like a bad decision, but we were making decisions on the fly. And long story short, we extubate him. He's talking. He seems to be doing okay. They're kind of like lining things up, getting another set of labs and everything, and I'm in the room. And a couple minutes after extubation,
Dr. Randy Lehman (20:34):
I'm just sitting there watching and watching him. All of a sudden his eyes go real big and his mouth purses into an O and he's just real still and not breathing. And I said, grandpa, nothing, no response. I'm like, grandpa, can you hear me? Yes. He gives me a big body nod. I go, grandpa, are you in pain?
Dr. Randy Lehman (20:59):
Yes, he's nodding.
Dr. Randy Lehman (21:00):
I said, Grandpa, are you having chest pain? Yes, he's nodding again. I'm like, guys, pretty sure he's arresting again. So come back over. And yeah, he's not breathing. He's not. He's legit arresting. So you re-intubate him. And then he did not require. I don't think he required any more chest compressions at that moment. But of course, then the decision was made, we're going to fly him down. So they flew him down. And no, they didn't fly him down. I take that back. I think weather prevented flying. That was part of the problem. Uh so we put him in als ambulance and shipped him that was part of the problem sorry uh and
Dr. Randy Lehman (21:42):
So then i called my other buddy who's a physician in town and he was just coming back in from being out of town and he came in and sort of you know helped us all just mentally and and actually rode down in the ambulance with my grandpa as well as one of the nurse practitioners from the hospital um and this sort of thing again like this is this is a small town and the atmosphere. And then I chased the ambulance down there with the car. And by the time I got there, he'd been evaluated by cardiology. And he went for angiogram. And on angiogram, he had essentially 99% stenosis all over. They said his coronary arteries are a block of calcium.
Dr. Randy Lehman (22:23):
And there was no... Stent that could even be placed, no minimally invasive intervention that could be performed. The only answer would be a bypass operation. And that couldn't happen right now because he's basically too sick and he would die from the operation anyway. And so, All we can do is supportive care in the cardiac ICU. So they put him in the cardiac ICU and they, you know, started whatever antiplatelet and the best cardiac treatment. And then my buddy and I went to IHOP and I just felt like the weirdest sensation. Like my life was just buzzing around me and I went home and I was pretty sure that he's going to die from all this.
Dr. Randy Lehman (23:10):
I kind of felt, first off, in the middle of it, like I was personally responsible for my own grandpa dying. I mean, he was in pretty dire straits, but I was involved. And then we just waited. And it was day after day. And he's kind of stabilized in the cardiac ICU. And he got better. And then eventually he left the cardiac ICU and he went to cardiac rehab. And he spent, I don't know how long, but... Well over a month in the hospital. And then he was able to discharge home. And that was in 2020. And we're in 2025, coming up on a five-year anniversary. And he's still kicking back to
Dr. Randy Lehman (23:47):
His baseline using the same wheelchair to get around his house. And all he's kind of left with is an incisional hernia, which we're just going to watch and never fix. And of course, he refused cardiac bypass surgery. After he was out of the window and it was offered to him. And so basically, you know, he's back to his usual state of health, which, you know, according to this idiot, is healthy and takes no medications. Thank goodness he didn't die. And thank goodness it was my grandpa and not some other patient in my community, because I can tell you that story now. It's not painful so much. I mean, it's not a great story, but because of the outcome, it worked out.
Dr. Randy Lehman (24:30):
And I hope that you, especially if you're a resident or a junior attending, can just kind of imagine yourself in my situation. And then when we talk about resource limitations, a single CRNA practice, right? A hospital with no cardiology, hospital with no dialysis, hospital with no nephrologist, you know, there's things that we don't have. And the risk stratification of these patients ultimately comes down to the responsibility of the surgeon. And you're trying to have an educated conversation. A lot of these patients, they do not understand or do not believe in modern medicine to begin with. And they're untreated, they have untreated diseases, and it is our responsibility to
Dr. Randy Lehman (25:18):
Work them up appropriately before surgery and to be aware of the medical things that are going on. And that's why a lot of us went into general surgery, at least I did, is because the general surgeon of all doctors is the doctor that's still is the surgeon that's still the doctor, we'll put it that way. And if we, you know, I like to be a technician, I like to do the technical work, I like to be efficient, I like to crank cases out, but we need to have some sort of process to evaluate the medical fitness of these patients, especially the ones that we're putting to sleep, and to really understand on the inside what
Dr. Randy Lehman (25:56):
Their cardiac condition specifically, as well as pulmonary, what effect that has on their overall risk for surgery. So that's the case that changed me. I would say of all the cases that I've done, and it wasn't even my case, but it made it really personal. And it also makes it very easy for me to relate to my patients and to think about how they're going to feel. Uh if they're confused about end-of-life care for their patient how they're going to feel in terms of stranded when the patient is having a bad outcome it's actually i mean i've had almost no situations like that in my practice largely i would say because of that experience because
Dr. Randy Lehman (26:36):
I'm not a cowboy i'm you know discretion is the greatest part of valor like i'm i use a lot of discretion and a lot of pre-operative cardiac consultations and testing and optimization and turn people down when when it's not the right thing to do it's not a black or white thing but you can try to develop some protocols and guidelines for yourself. And I'd encourage you to talk to your anesthesiologist about that and have just basically check boxes for when you're going to say no and why, whether that's weight, comorbidities. And it's a balance because I don't want to not offer something to my community. And I understand the burden of travel on these patients.
Dr. Randy Lehman (27:23):
And the purpose of my existence is to provide care in the hometown. Of these patients to help support the hospital so that it can stay open for both emergency and elective indications. But when a patient dies in a small town, except for maybe coming in and the patient's already known to be end of life and, you know, we facilitate a... A comfortable death for them. Those kind of scenarios are a little different, but especially if you have elective case that goes bad and then there's a death, the community and the people, they don't look at it the same. I'm thinking OB as well, like they don't look at it the same because it's like it's okay for the patient
Dr. Randy Lehman (28:03):
To go to the big city and die in the big city. But when it happens in the small town, it's not okay. And honestly, I don't want to have my patients dying anyway. And for me, the practice that I have, which is a largely elective, patients largely do well. They're generally not Whipples. They're not esophagectomies. They're not liver resections. They're not big operations that patients are going to really have a large physiologic insult from. In some ways, my practice is kind of like a... It's like a dermatology practice for a surgeon. I mean, I'm doing real surgery, you know, colons and hiatal hernias and breast surgery and abdominal surgery, hernias and gallbladders, appendectomies, and hysterectomies,
Dr. Randy Lehman (28:42):
But then lots of lumps and bumps and carpal tunnels and, you know, lipomas and trigger fingers and things like that. So it's a nice practice to have all ages. Both men and women, all throughout the body. It's like everything you would want from surgical oncology specialty and also from a pediatric surgery specialty. That's why people like to go into those. One reason why people like to go into those specialties, I think, is because they operate on the whole entire body. But at the same time, it's like all the positives of an elective outpatient dermatology practice because most patients do well and you can kind of...
Dr. Randy Lehman (29:16):
Sleep a lot of nights uninterrupted. And at the same time, you're providing such a service to your community by keeping the care local. So it's this fine line, like I said, between not offering the thing, going down that rabbit hole of cancelectomies and saying no to people, and also like never wanting to be unprepared. Never wanting to be a cowboy in the rural scenario. And there's also rural surgery is different because as we've talked to people from rural Canada on this podcast, you know, the rural mountainous West is a little different than rural Indiana where I'm at. And I do have a hospital with cardiology 45 minutes up and down the interstate, either direction, 45 minutes to an hour.
Dr. Randy Lehman (30:02):
Um, so that's a little different helicopter ride, maybe 20 minutes. And what I'm doing maybe is not realistic everywhere, but those are the thoughts that I sat there for five years in residency, knowing where I was going to go, well, like four years, I would say. Sign my contract with maybe three and a half, four years to go. And every case I did, I imagined I'm going to be in this austere rural environment how am i going to do the case differently i remember being on vascular surgery talking to dr cholera and we're doing a triple a and i said okay this comes in to my
Dr. Randy Lehman (30:36):
Hospital what am i doing how am i doing it you know step by step just like i do how i do it here on the podcast and uh you can do that all you want in training but That case made it real for me. And it made me really understand other things that I didn't quite get, like all of the pre-op testing, all of the anesthesia, PAME clinic that we had in residency, what was actually being done. If you're a resident, I would encourage you to go spend a day or two on a PAME clinic and really talk about things. And maybe before you start practice crystallize or early on in practice crystallize.
Dr. Randy Lehman (31:15):
Here's what I'm going to do with these conditions and how they all affect the risk. And look at the risk models that anesthesia is using and cardiology is using to determine surgery risk in terms of the level of the case and the level of the anesthesia risk as well. So I hope that you gained something from this. Crazy experience that I had. If anything good can come out of it by some other patient having, you know, just a thoughtful surgeon considering perioperative risks. And, you know, there's so many other options besides what was done. You know, we totally could have done a percutaneous cholecystostomy tube, transfer the patient to ICU, percutaneous cholecystostomy tube probably never would have coded.
Dr. Randy Lehman (32:00):
You know, get yourself to cardiac workup ahead of time, angiography ahead of time, stress testing, cardiac interventions, and then an elective operation. It might not have had to go open then, you know, or whatever. There's lots of different ways that that could have been. Handled versus destination chole tube. But the thing is when you're sitting there and it's your grandpa in front of you and you know how much he's going to hate having that drainage tube stuck out and you think, well, we just get it out, you know. But once you choose surgery, like I tell all my patients, you can't take it back. You're just trying to make a wise decision. And also the more that you can just involve the patient,
Dr. Randy Lehman (32:44):
You can take the time to really explain what the risks actually are. The patient will make the right decision for themselves. And that's definitely where we've moved to with, I would say, medicine in general. Is not that paternalistic. I'm gonna tell you this is what's gotta be done, but rather let me explain to you as best I can. I mean, I can't take the last 20 years of my life and boil it down, but I can do a pretty good job and get you. On the right track. It could go this way or this way or this way. And you know, I had an 85-year-old
Dr. Randy Lehman (33:14):
Patient recently who we decided to do like a two-PEG-tube gastropexy technique to manage a large paraesophageal hernia. So just... Tilted her heavy bed up, drug the stomach down with the scope as best as I could, put two PEG tubes in just as an anchor, and that's it. No repair of the hernia. She obviously did great with that low-risk procedure, low-anesthesia-risk procedure. And I didn't know how much it would help her symptoms, but it definitely anchors her stomach down there. And so the risk of torsion is pretty much gone. And actually, her symptoms are much better. And she made that decision. And we had several
Dr. Randy Lehman (33:46):
Conversations about it. And she made the right decision for herself. But I mean, I wasn't opposed to fixing the hernia laparoscopically. And in the right person, if she said, no, like, I don't want to do that. I really want to drag the whole thing down if I'd really educated her correctly. On the risks and she made the decision then we can live with with the outcomes and it might have worked fine but she wanted to go with the lower risk lower morbidity um sort of lesser operation and i really think that was a great decision in that scenario so best of luck to you i just want to encourage you the practice that you have
Dr. Randy Lehman (34:21):
In rural america you are making a difference you are changing your communities for the better you're a role model in your community, you're bringing jobs to your community, you're helping patients directly, but even more than that, the people that see you, that are around you, they're going to feed off of your energy and that, that dedication and drive that it takes to get to the point of being a you know, a rural surgeon, that independence and strength that it requires to go to a place with less resources and be a surgeon in that environment. Keep up the good work. I appreciate you. I appreciate you listening to this podcast. If you're finding any value, the one thing that
Dr. Randy Lehman (35:00):
You could do for me is... Like us on Facebook, YouTube, on whatever podcast app you're listening. Please give us an honest review. And please share, maybe on your Facebook. Maybe you share through any other ways with people that are interested in rural surgery. Because I'm just a voice crying out into the wilderness here about a topic that I'm passionate about. But I'm having a lot of fun with it. And we just want to reach the right people and the right audience. Thank you again for being with us. And I will meet you guys next time on the next episode of the Rural American Surgeon.
Timecode:
00:06 Show Introduction
00:43 The Case That Changed Me
01:30 Four Months Out of Residency
02:12 Grandma's Call
03:00 Racing to Grandpa's House
03:45 Getting Him to the Hospital
04:25 Severe Sepsis and Acute Cholecystitis
05:11 Calling the On-Call Surgeon
05:51 The Blind Spot: “Healthy, Takes No Medications”
07:11 Untreated Disease and Functional Status
07:52 Initial Improvement After Resuscitation
08:32 The Goals-of-Care Discussion We Missed
10:29 Surgery the Next Morning
11:17 The First Code Blue
12:48 Learning Grandpa's Actual Wishes
13:30 A Second Code
14:41 The Third Code and Stopping Resuscitation
16:17 Grandpa Wakes Up
17:50 Asking Grandpa What He Wants
19:15 Choosing Full Treatment
20:34 Another Arrest After Extubation
21:42 Transfer to the Cardiac Center
22:23 Angiography Reveals Severe Coronary Disease
23:10 Recovery Against the Odds
24:30 Lessons About Rural Resource Limitations
25:56 How This Case Changed My Practice
27:23 When Bad Outcomes Happen in a Small Town
29:16 Balancing Local Access With Safety
30:36 Training for an Austere Rural Environment
31:15 Building a Preoperative Risk Process
32:00 Other Ways This Case Could Have Been Managed
32:44 Shared Decision-Making Matters
33:14 A Lower-Risk Gastropexy Example
34:21 Encouragement for Rural Surgeons
35:00 Closing
