Confessions of a Surgeon: A Deeper Cut

By Paul A. Ruggieri

As an active surgeon over the last thirty years, Dr. Paul A. Ruggieri has experienced and lived through the best and the worst of his profession. In his first book, Confessions of a Surgeon: The Good, the Bad, and the Complicated he pushed open the operating room doors to give the public a startling view of what really went on inside the operating room. In Confessions of a Surgeon: A Deeper Cut, Dr. Ruggieri blows the operating room doors right off their hinges. It cuts deeper into a profession, even more mysterious then ever before. He candidly shares his thoughts on the patients that have impacted his life the most. He also exposes how surgeons (including himself) and the surgical profession have dramatically changed since the first time he nervously picked up a scalpel blade as a naïve surgical intern. He explores how these changes have helped and hurt patients. He also explores how these changes will continue to have a direct affect on anyone about to enter an operating room.
Ultimately, Dr. Ruggieri’s passionate and candid account of his life inside a changing operating room will give his audience the power of transparency and truth.

• Language: English
• Publisher: Gatekeeper Press
• Release date: Mar 24, 2023
• ISBN: 9781662936104

Book preview

INTRODUCTION

Irealize it has been over a decade since I pushed open the operating doors, with the writing of Confessions of a Surgeon. Despite its raw and personal message, the memoir was a unique perspective on the complicated life of a surgeon. Many reacted viscerally to the graphic descriptions of my operating room experiences and unfiltered personal opinions. I was happy to see that.

Since the last time I tossed a malfunctioning surgical stapler against the operating room wall, much has changed with myself and my profession. Some of this change has improved surgical patient care. Some has been detrimental to it.

Change has made my job inside the operating room easier and more difficult at the same time. Throughout all that has unfolded over the last decade, there is one constant in what I do for a living. People continue to live, die, and experience everything in between. Life inside the operating room continues to remain complicated no matter how I cut it.

Since my last confession, my profession has dramatically modified the way it trains and treats its surgeons. I was born out of a different generation of surgeons, training in an era where instruments were thrown at walls without consequences, egos went unchecked, and fear was the prevailing feeling. It was a generation molded by mentors who consciously weeded out the weak.

There was no political or social correctness to how we were treated. No one apologized for the lack of sleep, sex, or family life. Naps and workplace hour restrictions existed as topics in academic papers. No congratulations for getting something right, just criticism for screwing up. Due to the lack of supervision, and chronic fatigue, human mistakes were part of the training process—all crucial in the making of a surgeon, despite the collateral damage to patients. Those of us who were fearless, thick-skinned, or had nowhere else to go kept moving forward. Those who could not deal with the unique stress of surgical training dropped out, were fired, or became radiologists.

Today’s making of a surgeon is a much kinder process. The training is less intense, the supervision almost too heavy-handed, and the learning expectations tempered, forcing surgeons to extend their training years.

Since my last confession, the practice environment in which surgeons have operated has also dramatically changed. Independent surgeons have been overshadowed by a corporate business model with little use for nonproductive surgeons, particularly those in the sunset of their careers. I am part of a disappearing breed of surgeons who worked for patients, not corporations, for most of their careers. I am part of a generation of surgeons who had complete control over their professional lives and the patients under their care. I am part of a unique generation respectively connecting the past era of open, big-scar surgery to the present era of minimally invasive, robotic surgery. I am the last of a generation to run away from the laptop computer and refuse to let it replace my stethoscope. I am part of a generation immensely proud of its illegible handwriting and the throwback black pager attached to my belt. I am the last of a generation swept into the ranks of the employed, surrendering to the changing political and financial winds blowing through my profession.

Since my last confession, the way in which surgeons have operated on patients has dramatically changed. Most of the operations I now perform are carried out through small incisions. Today most patients go home the same day after their operation and no longer linger in a hospital bed for days recovering. What was considered the standard of care for some operations decades ago might border on malpractice today. The medical devices I used on patients when I started are now antiquated and frankly, dangerous.

Robots have now infiltrated every hospital throughout the country. Over twenty years ago, they started arriving in operating rooms like alien pods. In the 1970s, a robot was a character on the television show Lost in Space. Danger, Will Robinson. In the 1990s, robots were gifts for children during the holidays. Ten years ago, robots were busy vacuuming and cleaning floors while you were out having dinner. Today robots are your surgeons removing gallbladders, prostate glands, and uteruses and repairing hernias. Their presence is crucial to the survival of operating rooms, along with the professional identity of all newly trained surgeons.

Since my last confession, operating rooms have morphed into high-tech revenue bastions, crucial to the economy of any hospital system. Many have unique personalities, their own names, staff, and revenue streams. They no longer belong to your surgeon. Along with changes in the operating room, the entire health-care business model has morphed into a corporate monster with a veracious appetite for revenue and cutting costs. As a result, key aspects of your health care are secretly being outsourced to physicians in different zip and country codes. Physicians you will never meet are making decisions that will drastically affect your health care. Your future operation is being handed over to a surgeon you barely know anything about. As a result, the relationship between surgeon and patient has dramatically regressed.

Everyone in the health-care industry is being pressured to do more with less, or just do more with nothing. Throughout all these changes, hospital systems in this country are under intense pressure to survive. Most have circled the wagons, in an attempt to capture every dollar at the expense of patient and practitioner choice. On top of all this, I can’t even begin to tell you how a pandemic has permanently changed the way health care is now delivered in this country.

Since my last confession, surgeons have also changed. I still remain the quiet, confident, imperfect surgeon who will do whatever it takes to improve the quality of life of my patients. However, I am now cognizant of my own aging skills. Keenly aware of my own limitations. I am at peace with the overall quality of care I have provided over the course of my career. Every muscle in my upper body aches longer each time I leave the operating room. After experiencing two major operations myself in the last ten years, I now have a deeper appreciation for the vulnerable situation in which I place my patients every day.

Despite all the changes that have occurred in health care over the last thirty years, surgeons continue to remain highly disciplined, incredibly underpaid specialists. Yes, underpaid. The impact a good, or bad, surgeon has on a patient’s life and their family cannot begin to be measured in any tangible currency. It is often measured in time (and lives) lost or gained, depending upon the skills, experience, and diligence of the ­surgeon.

Since the corporate world has taken over medicine, most surgeons don’t even know who signs their paychecks. I have no idea who signs mine. FMLA, PTO, HIPPA, and sick days are part of my vocabulary now. Compliance videos on fires inside the operating room, active shooter scenarios, financial conflicts of interest, burnout, and workplace harassment are now included in my job description. Renewing internet passwords continues to be a constant nuisance. Patient satisfaction surveys, internet reviews, and monthly production reports are part of my evaluation as a surgeon. Ironically, monthly quality reports on my complications and outcomes are not.

Despite all the distractions, surgeons are still a unique breed, whether our employer thinks so or not. We continue to go where no other physicians dare to go. We continue to work when the rest of the world sleeps. My generation has always worked for a higher authority other than ourselves. However, money has complicated that relationship more so than ever before. Today most surgeons are being forced to adjust to the distance the current health-care business model has placed between them and their patients.

Surgeons will continue to sacrifice the best years of their, and their family’s lives, for the operating room. Most will continue to give up time, their children’s soccer games, and holidays for their patients without blinking an eye. Most will continue to give up their physical bodies inside the operating room until the pain in their neck, back, or shoulders becomes part of daily life. It is a choice we make willingly from the first day of internship. Young and old, surgeons in active practice will also continue to evolve and learn from their experiences.

After I am long gone, the surgeons who follow will continue to be called upon to address intestinal obstructions, cancerous thyroid glands, gangrenous gallbladders, and life-threatening bleeding. They will continue to drain pockets of pus. Surgeons drain a lot of pus. The next generation of surgeons will continue to remove perforated organs or extract objects from dark body cavities. They will continue to be on the front lines of treating cancer. Surgeons will continue to be the bearer of good and bad news. This is what general surgeons have always done. This is what we will continue to do.

As you read this, you may wonder why I am writing the unofficial sequel to Confessions of a Surgeon, given the nerve it struck with the public and my colleagues. Why would I want to continue to expose the public to the candor of what I do as a surgeon? It has been over a decade since my last confession. Ten years is a long time in surgeon years. I want to give the public one last perspective on a changing profession. One with so much influence on the lives of everyday people, yet with so little transparency.

In addition to being a surgeon, patient, husband, father, dog owner, scotch drinker, and grandfather, advancing age has been both a blessing and a curse for me as a surgeon. The major operations I had no problem performing ten years ago, I no longer do now. The one beautiful aspect of aging gracefully, it gives you the camouflage to drop all inhibitions. I am at a point in my career where I can express my opinion and not worry about whom it might offend.

As an aging surgeon, I have much more to say about the good, the bad, and the complicated in my profession. I have much more to say about how the surgeons coming out of training today are neatly molded to fit into their future employer’s business model. I have much more to say about how the corporate mentality has influenced the entire spectrum of surgical care. I have much more to say about the continuing lack of transparency in my profession in regard to surgeon competence and hospital performance. I emphatically have much more to say about the patients I have had the privilege of caring for over the years. The vast majority have enriched my own life in ways they will never understand. Others have frankly been pains in the asses, literally and figuratively.

It is time for me to close the operating room door on a unique way of life. When I completed my training over thirty years ago, I was on the cutting edge of minimally invasive surgery. At the time of my first job, my older partners were the ones behind the times, eager for my skills. Now, as I enter the operating room for the last time, my older partners are long retired, and my own surgical techniques bordering on obsolete. For me, the circle of my surgical life has now closed. It is time to step aside and let the new generation of surgeons, along with their robots, do the cutting. It is time for me to gladly remove my name from the call schedule. It is time for the worrying and second-guessing to stop. Time for me to be around my wife, children, and grandchildren on weekends and holidays. It is time to place the last stitch, close the last abdomen. It is time for Confessions of a Surgeon: A Deeper Cut.

CHAPTER 1

TIME TO STEP ASIDE

W e have to get you to the operating room now, or you’ll die. I could hear my voice rising, filled with the frustration of trying to convince Mr. Woodford not to sign out against medical advice (leaving the hospital against a doctor’s advice). But he was adamant about leaving. He had to go back to his apartment—and take care of some business, as he put it. I was certain he knew he might never make it back. I could sense the uneasiness in the nurses circulating the periphery as the sound of my increasingly loud voice began to reach them. Normally, I don’t make it a habit to shout at patients, especially when they are trying to die on an ER gurney. Screaming to get a point across is not a feature of my bedside manner. Until tonight. Sure, over the years, I had thought about yelling at a few of my patients. What surgeon hadn’t? Mr. Woodford’s situation was different. I was beyond worrying about the consequences of my behavior. Way beyond listening to the politically ­correct voice of the surgeon telling me to show some compassion.

There was just no time to finesse this patient. Any professional gatekeeping mechanisms fortified over my experience as a surgeon over the last thirty years were completely blown off their hinges. Sure, I knew I was screaming at a critically ill man, but the clock was ticking. The longer I argued, the higher the chances were of him going into cardiac arrest from septic shock before I could get inside his abdomen. Sepsis is a life-threatening condition that occurs when the body’s response to an infection damages its own tissues. It can lead to septic shock and death. Now, it was very eleven o’clock at night, and the time for arguing was over.

Shit, that hurts! He recoiled almost off the bed as I gently placed my hands on his distended abdomen.

Sir, I need to operate on you now. I glared at him. Both our pulses were racing—his from going into septic shock and mine from anger. You have peritonitis from poison leaking out of a hole in your intestine.

The chronic tinnitus ringing in my head was getting louder along with my voice. Stress and fatigue are not friends of chronic tinnitus. Both were front and center tonight. This insidious, untreatable condition had appeared spontaneously in my brain one morning several years ago. Tinnitus is often a result of hearing loss, sound trauma, or aging. There is no medical treatment for it. After all the testing, my doctor chalked it up to age. The continuous, high-pitched sound of tinnitus can mess with your mood. If it becomes chronic, tinnitus is a frustrating condition that can hold your mind hostage if you allow it. Every day it reminds me I could someday wake up with something much, much worse.

But, Dr. Ruggieri, I just need a few hours. I promise I will come back. He winced in agony as the hole in his intestine released more poison into his already-contaminated abdomen. It was hurting him to speak, move, or breathe. I could only imagine the pain he was in.

Somehow, I had to convince him to stay, even if that meant using physical restraints. The conversation had already gone on too long. I was tired, his blood pressure was dropping, and mine was rising. Whatever he had to take care of at his apartment could wait.

Please, he said, grabbing hold of his gut, I need to go back to my apartment. I need to take care of something important. Another wave of intestinal poison caused him to recoil, his face contorted with worsening pain.

What the hell is more damn important than your life? I asked.

He winced again. I can’t leave my dog alone. His body sank into the bed. She was a rescue, he paused, and she’s the only good thing in my life. Right now, she is alone. I don’t have anyone to look after her.

His words hit me like a brain freeze after eating ice cream too fast. "This is about a dog?"

His sincerity was evident in his desperate, pleading eyes. He was willing to risk his own life for his dog. I knew exactly where this was coming from. I am a dog lover too, so I could empathize with his devotion to an animal friend, even when his own life was on the precipice. For a second, I felt guilty for yelling at him. I originally thought he wanted to go home to hide some drugs or cover up something in his immediate past. For a few minutes, I had allowed the cynicism from my thirty years of experience to blind me.

Yes, I was deeply moved, but tonight I only had enough compassion for one sick human being. And even that well was running low. The dog would have to wait her turn. I knew if I let him sign out, he would probably die on the floor of his apartment while his loyal companion stood guard like a sentinel, licking his face as his defibrillating heart came to a halt in cardiac arrest.

You are not going anywhere but the operating room, I said as I gently eased my face closer to his left ear.

Mr. Ronald Woodford was a sixty-five-year-old wrinkled, unshaven man whom life seemed to have abandoned years earlier. He lived alone in a one-bedroom apartment, on a dimly lit side street in a suspect neighborhood on the city limits. One sunny morning several years ago before, his wife of thirty-five years had packed up and left him for another man in another state a thousand miles away. Maybe he deserved it; maybe he didn’t. I didn’t care to know the specifics. Besides a broken heart and an empty bank account, his ex-wife’s departure left him with a spunky five-year-old mixed-breed Westie named Mary. To Mr. Woodford, Mary was the only good thing left in his one-bedroom world.

He had been experiencing some vague abdominal pains over the last several days but ignored them, like many do, hoping the pain would go away. For Mr. Woodford, the emergency room was the last place on earth he wanted to be. As the pains increased in intensity throughout the day, his brain could no longer ignore them. After checking into the emergency room, he had blood drawn and a CT scan of his abdomen to investigate the problem. The abdominal-pelvic CT scan is one of the most frequently ordered imaging studies today on patients who show up in the ER with abdominal pain. I refer to it as the fishing study because most doctors who order it are fishing for some pathology inside a patient’s abdomen. Unfortunately for Mr. Woodford, his fishing CT scan caught something big, bad, and foul-smelling—from a hole in his small intestine. Free air and intestinal contents were contaminating his abdominal cavity. The ongoing infection was beginning to seep into the rest of his body, as evident by his dropping blood pressure and high heart rate. He was getting septic, and soon his heart, kidneys, and lungs would shut down.

Doctor, I can’t leave Mary alone. I just can’t. Tears were forming in his eyes as he slumped back in his bed. I tried my best to