Doctors, Working Together

One of my more naked screw-ups during training occurred when I was Chief Resident, and in the blink of an eye (quite literally) it took me from feeling like God's gift to surgery to certainty that I was the village idiot. (Turns out that form of rapid decompression continues more or less weekly throughout the career of any busy surgeon. Nevertheless, this was as deflating as hearing "That all you got?" from Scarlett Johansson.)

I'd seen a man in the clinic who'd had several operations for fistula-in-ano, recurring within a short time on every occasion. Brilliant surgeon that I was, I considered the possibility that he was one of the less common victims, having a connection from skin to colon, well above the anal area from which fistulas most commonly arise. So I ordered a barium enema. Sure enough, I got a call from the radiologist telling me there was a fistula between skin and sigmoid colon. Hot damn! Not only could I demonstrate my acumen to my attending, I'd be doing a very cool case: sigmoid colectomy was then and remains now one of my favorite operations. Got the man all worked up and prepped and a few days later, there I was in the OR, making a nice little lower midline incision. Figuring on finding some inflammatory process in the colon, I expected a possibly tough operation, but I felt up to it. So I was surprised to see that the man's colon was soft and pink and normal as the day he was born. No fistula, no how. Ooops.

My attending, having confidence in me, had had me start the case unattended, so I called him into the room to convey the news. "Where are the XRays?" he asked. Well, er, for some reason they weren't in the OR. "Did you look at them yourself?" he asked, voice a little tighter and higher than with the first question. Like a goddamn idiot, for no reason that would ever hold water, I hadn't. I'd been so excited to hear the confirmation of my brilliant diagnosis that I didn't bother to go down to the XRay department and have a look myself. The arrival of the films in the OR was met with steely silence by my attending, and horror by me, as even I could tell the so-called fistula was an artifact: spilled barium from the procedure, masquerading in at least one view as a tract from colon to skin. Idiot radiology resident had made the wrong call; idiot surgery resident hadn't gone to check it out.

Lesson: confer with the radiologist. Look at all your films yourself, most especially when the situation is unusual. Sit down side by side with the radiopod and go over the details. I can tell you I NEVER failed to do that again. (Incidentally, the man had a "horseshoe fistula," which had never been properly unroofed and cleaned out. My attending took over: propped the man's legs up and back and carved away most of the skin of the man's hindmost, until his sorry little anus looked like a tiny island in the seas of Hades. I was numb-struck at the carnage, but damned if it didn't eventually completely heal, and fixed the problem. (It was, however, I'd say in retrospect, a bit more than the poor man needed; maybe my attending was too pissed at me to slow down.)

Which brings me to the point of the post: as I've said previously, the best outcomes occur when docs work collaboratively. And that implies, among other things, that the people involved 1) know what they're doing, 2) like the idea of collaboration, and 3) can do it in a collegial fashion. For example, when I ordered a radiology study (except in the most routine and simple of situations), I talked to the radiologist in advance, explained exactly what I was looking for, solicited suggestions if another study might be better and, when the study was done I got together with the radiopod and went over it with him/her. Love and kisses, right? Well, not always. It was not rare that, despite my ministrations, the study didn't get done when scheduled, the wrong study was done, and the doc to whom I'd spoken neither ended up being the one to do the study nor took the time to pass the info to the one who was. And despite having made clear my concerns and the levels of urgency, I'd not get a call when the study was done. Or I couldn't find the radiologist who did the study, or even the available one, to sit down with. Not to mention being able to find the films.

That last little frustration, thankfully, is becoming rarer, as nearly all studies can be and are digitized into a server right when done. So as long as the names and numbers have been inputted correctly, they're instantly available. But the others, well, nothing's perfect. And between my occasional less-than-charitable attitude over such missteps, and some radiologists' less-than-delighted willingness to drop what they're doing to sit down with me, sometimes the atmosphere was a bit sullen. Nevertheless, the fact remains: that sort of working together is the ideal. Especially when it actually works.

Then there's this: sort of like actual humans, doctors vary in their level of skill and commitment. I think that's a huge part of the variation in costs and outcomes among doctors, and it's something about which it's hard to see what the solutions might be -- or even if there are solutions. You've got your great mechanics, honest and reliable plumbers; artists of varying talent; lawyers who get OJ off, and lawyers that wouldn't have. It's just the way it is. But with doctors -- and especially those in high acuity fields -- the impact of variation is enormous. I think the example of interactions between surgeons and radiologists, pathologists, anesthesiologists is a microcosm which provides some insights, and I plan to say more about it.

[Addendum: several months after posting this, I received an email from a person rightly upset about something I wrote, namely: "It was, however, I'd say in retrospect, a bit more than the poor man needed; maybe my attending was too pissed at me to slow down." He was outraged not only that I'd screwed up but that an attending might have, in anger, over-done the extent of the operation. Looking back, I think I was saying that nowadays one might have been able to do less extensive debridement, and I sort of threw in the "anger" proposition, because I still feel bad when I think of it, and of how angry he was at me. Anyhow, the fact is the man got what he needed from my attending and healed completely, and permanently. And although it in no way justifies it, I learned a valuable lesson than stuck with me and helped me provide better care for my patients throughout my career. I don't blame the reader for being ticked off.]

A Little More Gas

The anesthesiologist is the surgeon's best friend. The only times when that's not true are the times when that's not true.

In thinking about the relationship (because Enrico asked me to), I've come to some conclusions, most of which are less than earth-shaking. As with most collegial relationships, the best are those in which there is mutual understanding and respect; and that, for the most part, comes from working together consistently. I had the luxury, for the better part of my career, of working with excellent anesthesiologists, and working with the same ones on a regular basis. So. What makes for an excellent anesthesiologist? Pretty simple: don't drive me crazy.

OAFAT (pronounced "Wah-fat"). It stands for "Obligatory Anesthesia Fucking Around Time." Surgeons -- me at least -- are just the teensiest bit impatient. If I've got a case to do, I want it to get going. Patient's in the pre-op holding area: I want to go in there, talk to him, explain everything, touch a little flesh, and then get him into the OR. Hell, I'll be there to push the gurney, move the patient from it onto the OR table. Now, I'll be the third or fourth to admit that surgeons vary widely in all things. I've already posted about the ones that are chronically late. Some seem constitutionally unable to arrange convergence of patient, lab data, history and physical (I always hand-carried lab and H and P myself, to the OR, the night before scheduled surgery.) Others take inexplicably long to do an operation that can be done in half the time; or they regularly spring surprises on the OR crew, changing the plan with no warning, announcing a need for critical instruments at the last minute (when I was doing a particularly big operation, I'd talk to OR personnel the night before to be sure everyone was on the same page.) There are surgeons that have limited understanding of how to prepare a patient for surgery. So far be it from me to suggest that anesthesia folk are unique in their deviation from standard. But diverge they do; they sure do. If I had long list of operations lined up, there were some gas-passers whose names I loved to see on the schedule. With others, I knew it'd be an annoying and frustrating day.

Let's put it this way: I know from observation over a large number of years that it's possible for an anesthesia person to examine and counsel a patient very thoroughly and sensitively, get them into the room and off to sleep safely, have them wake up smoothly and comfortable exactly when the operation is over, and do it consistently and predictably, all the while adding only a few minutes to each end of an operation. And repeat the process throughout the day. So why in HELL am I out here in the hall, pacing up and down, looking into the pre-op area, seeing that person STILL in there gabbing away with the patient? Or standing at the patient's side, observing her looking around the room nervously wondering why she isn't asleep yet, while watching the anesthetist tearing off tape, popping open vials, looking for tubes, sending the nurse out to get this or that, adjusting dials for FIFTEEN GODDAM MINUTES, when I know another person would have had all that stuff laid out in advance?? I'm just asking. Worse, why did the patient's blood pressure crash when anesthesia was induced? Or how come the whole crew had to stand around at the end of the case while the patient refused to breathe enough to be extubated or moved to the recovery room? And mainly, why do those scenarios always happen with some docs, and never with others? Or nurses, for that matter. Why, in short, can't they be more like me? (Cue Rex Harrison...)

OK, so it's about more than driving me crazy. And I know it's not a one-way street. Surgeons drive anesthesiologists crazy also. But when it works, it's a beautiful thing: and even when we know each other well, it takes a certain back and forth throughout the operation: me saying what I'm about to do, making it known if something is happening out of the routine, announcing when I'm nearly done.

A good anesthesiologist has an orderly mind, and a smart one. He or she needs to be expert in cardiopulmonary physiology, and the drugs that effect it. I think anesthesiologists are better scientists than surgeons. She or he needs to be able to think fast and to run logically through lists of possibilities and probabilities -- in that way, they are like surgeons. It's helpful if he or she can connect with patients positively and easily, since they rarely meet before the immediate pre-op commencement ceremonies. Like piloting a plane, giving an anesthetic is critical at takeoff and landing, and -- one would hope -- can be boring in between. So a good anesthesiologist must know how to turn pages without disturbing the surgeon. Be facile at text messaging. Have an iPod with good music and know how to hook it to the stereo in the OR. Laugh at the surgeon's jokes, and tell a few of his/her own.

Giving an anesthetic is no easier now than it was decades ago, in part because we're able to do more complex things on sicker people. But it's safer. One of my mentors liked to say you're never safer than when you're under anesthesia: there's real-time monitoring of your most critical functions, and safeguards to detect changes in important parameters before they get anywhere near the levels required for notice a few years ago.

For anyone out there looking to make a career choice in medicine who thinks they like hanging out in ORs but who wants actually to have a life, consider anesthesia: the work is dramatic and intellectually rigorous, they get to hang out with surgeons, and when they work at night, they get the next day off. What could be better? If at times we drive each other crazy, well, who doesn't, really?

But when the shit is hitting the fan, when we're in there together -- me trying to stop bleeding, he squeezing blood in with both hands, when we pull off an amazing save of a desperately ill person because we've both done our jobs extremely well and when it couldn't have happened if either of us hadn't, when it's over and we're moving the patient to recovery and I say "thanks man, that was a great job," I really really really mean it.


[Update: 2/1/08. Sometimes I re-read an old post and think it was pretty good. Other times, I wonder what I was thinking. The tone of the first half of this one falls into the latter category, although the last couple of paragraphs aren't too bad. Judging by the comments, some anesthesia folk rightly took offense (and likely quit reading before the latter parts), and got what I hope is an erroneous impression of who I am. But one not unjustified by what I wrote. I can only say, and hope it's believed, that I actually had an excellent relationship with all but a couple of the many gas-passers with whom I worked. And hope that anyone else who reads this and takes umbrage will poke around at some of the other stuff here, before judging on this post alone.]

It Can Be a Gas

While assisting on a carotid endarterectomy (wherein the main artery to the brain is clamped off, opened up, and reamed out) one time during my surgical training, I noticed the anesthesiologist was rummaging around a bit more than usual: opening drawers, drawing up drugs, checking monitors. Finally he casually looked over the ether screen and said to the surgeon, "Jack, you might want to stop what you're doing for a while and push on the man's chest."

* * * * * *

Shortly after I'd arrived in town, the new guy on the block, I told the anesthesiologist assigned to my impending breast biopsy in a frail elderly woman that I'd be happy to inject a bunch of local anesthetic if he thought it would simplify his anesthetic. "I don't need some pipsqueak punk telling me how to do my job," he yelled.


* * * * * * *

In the middle of a big case during which the patient's heart had become erratic, the nurse anesthetist seemed a bit flustered. "Think you should call Dr X (the nurses always worked under the direct supervision of an MD anesthesiologist) to come in," I asked? "He's out on his boat," she replied.

* * * * * *

Debbie the Nurse gives the anesthesia quite frequently for the obesity surgery operations in which I participate of late. Those patients, being quite large and often having associated medical problems, present some unique intra-operative management issues, especially since most are scheduled to go home the same day. More than any of the other anesthetists, nurseoid or doctoroid, Debbie the Nurse can be counted on to have the patient awake and devoid of a breathing tube as the case finishes up.

* * * * * *

The patient is asleep, prepped, draped; the equipment is all ready; it's time to begin. I always ask the anesthesiologist, "OK to start?" before I make the cut, and when the reply is affirmative, I dig in. Sometimes the patient responds a bit, moving. Occasionally it's a pretty vigorous move. I hate it when that happens. (Note: I've never had a patient remember it or comment upon it.)

* * * * * *

During a major abdominal operation, open or laparoscopic, it's imperative that the patient is given muscle relaxants so the belly wall is nice and floppy; otherwise work is nearly impossible. Sometimes it's obvious they are tightening up: I say to the anesthesiologist, "He's getting tight." "I'm on it," is the response, usually. Better: with some docs, it never ever happens. Worse: "No way. Monitor says he's fully relaxed," comes the voice from above the patient's head. "Check the goddamn battery on your nerve stimulator, doc. He's tight as a drum."

* * * * * *

Tough case. Big operation, sick man. Septic, needing ventilatory support, on blood pressure drugs. I'm not sure what I'm going to find, or whether I can pull him through. The anesthesiologist says, "Right. Let's get in a few lines; I'll pop in an internal jug after you're started. Piece of cake." And he sets about his business, gets the man off to sleep without the bottom dropping out, keeps his tank full, making it smooth. What a huge comfort that is. The guy's a genius at what he does. The only tension is on my side of the screen, and it melts away as things progress. The man's gonna make it. I can breathe easier, even ask the anesthesiologist how his kid's doing in school. At the end I -- as usual with the guy -- thank him for a great job.

* * * * *

"The blood looks really dark," I say. "Everything OK up there, Ralph?...Ralph?" I look over the screen. Ralph isn't there. "Where the fuck is Ralph," I ask. "Tell him to get his ass back in here." That's what did it. That's when the rest of the docs in my clinic agreed with us surgeons that it was time to hire our own anesthesia team. Which we did. They're a phenomenal group who, unlike the other group when they were the only game in town, make a continuing effort to remain excellent. (The other group soon did, too. Ralph ain't with them anymore.)

* * * * * *

I'm struggling to see. It's late at night, there's a limited crew, no one extra to scrub in for a few minutes to hold a retractor. "Give it to me," John says. I position the handle of the retractor so he can grab it, layered behind the sterile drape; John gives a good yank and holds it while I finish my suturing, eyeing his monitors, doing the rest of his job at the same time. John spent a couple of years in surgical residency before he got wise and became an anesthesiologist. Nothing ever fazes him. He's sweet as can be to the patients ahead of time, gets scared kiddies to eat out of his hand; he's the one the others call when they can't get the tube in. Everything he does, he makes look easy. I love having him do my cases. Except that he's so handsome and ripped, the nurses are overtly gaga over him and sometimes I have to remind them to pay attention to me. He did my anesthetic when I broke my ankle; my son's when he tore his ACL. We named our new surgery center after him when he died of melanoma, leaving a wife and two young kids. He'd come to me for the biopsy that gave the bad news.

* * * * * *



In response to my post requesting suggestions, Enrico asked about the relationship between surgeons and anesthesiologists. It's a good subject. I'm working on it.

Big Joe

When I think of Big Joe, I see his overalls, and how he filled them. And how a couple of months after I operated on him, there was room for both of us in there. Big Joe: farmer, salt of the earth, tough, stoic. On the day I met him, if it'd been Halloween, I might have tried to stick a candle in him. That's how orange he was. My initial recommendation, while probably justified, damn near killed him.

Big Joe hadn't been sick a day in his life. Well, he was diabetic, but it hadn't been much of a problem. He worked his tractor every day; took a hell of a lot to slow him down. He'd been feeling a little poorly, less appetite than usual, no pain really. It was the white stools that worried him, along with the brown urine. His color, well, he was in the sun all day, so that hadn't seemed too strange to him, although his wife was starting to notice. So he saw his doc, who ordered a battery of blood tests, an ultrasound followed by a CT scan, and then shot him over my way. It looked bad.

Jaundice comes in two basic categories: obstructive, and non-obstructive. Surgeons see the first category. The second is usually from "medical" liver disease, like hepatitis. What makes people yellow with liver trouble is bile pigments getting in the bloodstream, either because the liver isn't processing the chemicals properly, or because the bile can't flow out of the liver into the intestine where it belongs. (The liver makes about a quart of bile a day, which flows through a tube called the bile duct, into the upper small intestine. It helps to digest fat. A main component is bilirubin, which is yellow.) Obstructed flow begs an operation of some sort to relieve it. Once again there are two general categories: gallstones, and tumors. (There are also things that scar down the ducts which are fairly rare and often present supreme surgical challenges.) Gallstones, formed in the gallbladder (future series of posts), can pass out of the gallbladder and get stuck in the main bile duct, plugging it up. Typically, because it happens fairly suddenly, it hurts like hell. Painless jaundice, a result of a slow squeezing of the duct, most often says something bad like cancer. Big Joe didn't have pain; he had an enlarged duct consistent with obstruction, no duct stones on sonogram or CT scan, and an ominous enlargement of the head of his pancreas. Just to frost this sour cake, a blood test had been done that showed very high levels of a certain protein, associated with cancer. Walks like a duck, quacks like a duck, and has feathers. A duck. Duct.

He did have stones in his gallbladder, but no evidence they'd moved out to cause the problem. I decided to send him to a gastroenterologist before I operated, to Xray the bile duct just to be sure it wasn't stones causing the blockage (duct stones are hard to see on sonogram or CT scan, but the GI doc can pass a scope through the stomach, into the duodenum, and inject dye directly, for an excellent picture. It's called ERCP, for "endoscopic retrograde cholangio-pancreatogram." Plus, as long as he's there, he can insert a tube to allow bile flow pass the obstruction which, it was felt, can improve hepatic function before surgery, making healing more propitious. The ERCP showed no duct stones; the stent was successfully placed, so by the time I operated on Big Joe, his bilirubin levels were falling. The operation would be a Whipple Procedure, which I've referred to previously. A complex operation, which I expected to be doubly tough in a five-foot-ten, 350 pound guy.

It may seem paradoxical for such a huge operation, but there are times when we proceed on the assumption that it's for cancer, without trying to confirm the actual cancer: biopsy of the pancreas can be dangerous, and even if a biopsy doesn't show cancer, it can't rule it out. So we check certain adjacent areas to be sure there aren't signs of spread, and plow ahead. Plus, there are certain points beyond which bridges are burned, so you can't go back. In the case of Big Joe, the bridges were burned by the time I divided his bile duct. At which point a couple of large gallstones rolled out. Shit. Hardly an "Oh Well" situation; putting someone through a huge operation when a small thing would have sufficed is sickening. On the other hand, there was the mass in his pancreas, and there was that cancer blood test. The gallstones could have been incidental, and the pathologist might still find pancreatic cancer. They weren't, and he didn't.

The operation was surprisingly easy despite Big Joe's girth and fat upon internal fat, and everything looked great when I was done. I'd have felt pretty good, but for the fact that within eight hours, Big Joe was nearly dead.

Septic shock, happening so fast it couldn't be from surgical infection or leakage. This was infected bile, "cholangitis," undoubtedly a result of having the stent in for a few days ahead of time. Turns out, as with other medical ideas, placing a stent before a Whipple -- which was thought to make sense (it did to me, and was written about in journals) -- on further review was found to be associated with a high incidence of perioperative sepsis.

For about forty eight hours, he was as close to death as you can get and make it back. Drugs supporting blood pressure, maximum ventilatory assistance, kidneys not working, pathological bleeding ("DIC"). I spent lots of time at his bedside, sweating alongside my trusty angel, the intensivist; and consoling Big Joe's wife. Worse, at the absolute nadir is when the pathology report came back: no cancer.

You can't get that sick after a big operation and heal normally. He leaked pancreatic juices, his incision fell apart. Fortunately, per my routine, I'd put a feeding tube into his intestine during the operation, so we could feed him easily. He finally turned the corner and, after a long hospitalization and having passed many crises so severe I thought we'd lost him, he made it home. I saw him constantly for months, tending wounds, dealing with drainage, watching him get smaller and smaller. He always wore those overalls, as if to remind me what he was going through. But that wasn't Big Joe. Neither he nor his wife ever suggested I'd screwed up. They were glad for my constant care and, over time, he eventually dried up, healed up, had repair of his incisional hernia, climbed back on his tractor.

Big Joe: living proof of our fallibility. Useful tests, wrong answers. Procedures aimed toward helping, making things worse. Every time I saw him, I felt bad; really bad. Until he finally came in to the office, bulging out of his overalls, like the day I met him. Only pink.

Request?

As I look ahead, bloggingly, it occurs to me that it would be fun to hear from readers about subjects they'd like to see addressed. Anything you'd like to hear a surgeon (this one, anyway) talk about? Because I just might.

The Rupture; End Times

Someone once said that a pediatric surgeon is one that thinks a hernia repair is a big deal. Personally, I think that's quite off the mark; especially when you think of the really big deal operations they do for any number of severe congenital defects, and since it was a pediatric surgeon who taught me how to turn a pedi-hernia repair into a piece of cake. I have watched a couple, on the other hand, who made it seem like building a Swiss timepiece.

As I mentioned in my initial post in this series, most groin hernias result from incompletion of a process that begins and should end in utero. When groin hernias present in kids, in most cases it's much simpler to fix than in an adult: if you remove the sac that didn't regress, and since the kid still has growing to do, the muscles around the hole will tend to slam shut as they should have; so closing that hole, either with stitches or with placing mesh, isn't necessary. And that makes it quick and close to painless to fix. Which isn't the way I was first taught.

In doing an open inguinal hernia repair one typically makes an incision parallel to the inguinal ligament, carries it down to the fascia that overlies the spermatic cord (or round ligament), removes (or tucks in) the hernia sac, fixes the muscle defect in one way or another, and then sews up the fascia. WIth a little kiddie, you can do the whole thing through a quite tiny incision, never touching the muscle or fascia: all you need to do is tease that sac away from the cord, remove it, and let it all fall back into place. On a good day, it takes less than ten minutes, and the babe is cooing happily soon thereafter. The whole trick is being able to run your finger back and forth just above and lateral to the pubic tubercle, and to feel the cord roping around under your finger, which allows you to know where to make your tiny cut. Then, using a pair of fine forceps, you can tease your way through the cord, find the sac, peel it away (look out! That's the thread-size vas), suture ligate it, put it a little more local anesthetic (the kid's asleep, but putting in local at the beginning and at the end makes the general anesthetic simpler and makes the kid wake up happy), one tiny dissolving stitch under the skin, a steri-strip, and you're done. Tell Mom to check the diaper a little more often than usual, sponge bathe for a couple of days, then forget about the whole thing. Fun.

Did you know that if your baby is born with a belly-button (umbilical) hernia, you can tape a fifty-cent piece over it and it most likely will go away? It's absolutely true.

It's rare indeed that we'd fix an umbilical hernia in an infant, because around 90% will go away on their own, unless they're really huge. It upsets some parents to be told to leave it alone, because it can be unpleasant to look at. Even in an adult, the mere presence of such a hernia isn't reason per se for repair. Many are asymptomatic. And if the reason to fix a hernia is to relieve discomfort or to prevent problems, the fact is that the belly-button hernias tend to be pre-corked with a glob of fat, preventing anything very important from getting in there. When making the decision to repair one, it's nice to try to hide the incision within the umbilicus, where it becomes virtually invisible. I've seen a number that have been fixed via quite large incisions above, below, or around the belly-button. Rarely necessary.
Uh, well, sure. That's one of them, all right.

I did discover somewhere along the line that no matter what technique is used, adult umbilical hernias have an unacceptably high rate of recurrence if you don't put mesh in there, almost no matter the size of the defect. I came to abandon trying to close the hole altogether, sliding a piece of mesh deep to the muscle, and loosely tacking it it place. Keeps it pretty pain-free, and virtually eliminates recurrence. As with several changes I've made in the way I do things, compared to how I was taught, I never wrote it up and eventually -- a few years after I'd started doing it that way (to the bemusement of my partners) -- saw a few papers showing the value.

I know that sounds like self-promotion (far be it from me to self-promote), and I'm quite sure that most surgeons have similarly come with ideas that made sense, but since it was never a matter of seeking fame or fortune, it did however give me some silent satisfaction to see that ideas I came up with on my own were also at some time, in some place, thunk up by smart guys who wrote about them. Among them: properitoneal placement of mesh in the anterior approach to inguinal hernia; the triple-test; mini-cholecystectomy; using long-acting local anesthetic in every incision I made. Mind you: I neither claim to be the inventor, nor that the acceptance of those ideas emanated from my very hands. Just that, with my head into my own practice, a few things bubbled up that worked, and were good enough that other people came up with them too.

Here's the best of them all: when I was in high school in Portland Oregon, my calculus teacher gave us each the assignment of coming up with an original pun. Mine went like this: A Russian couple, Rudolph and Nathasha lived in a cabin in the woods. One morning Rudolph got up, opened the shades and says "It's raining." Natasha, still in bed, says "From here, it looks like snow." "No, it's rain," says Rudolph. "But it really seems like snow," she repeats. "Look," he says. "Rudolph the Red knows rain, dear." Twenty five years later, driving through Portland listening to some local show, I heard the DJ tell that very pun. Had it bounced around Portland since I gave birth to it? Had someone else come up with it later? Had I heard it before I made it up, and not remembered? And why am I ending the post in this way?

The Rupture, part three

Hernia repair is surgical bread and butter. It's so much so that "hernia equivalent" has been used to measure surgical work: how does the difficulty of an operation compare to that of a hernia; how many "hernia equivalents" does the average surgeon do in a week; how many should she? And when attempts have been made to quantify surgical difficulty in terms of relative reimbursement, hernia repair is often the base unit. If a hernia is worth "X" bucks, then a colon resection is worth 2.3 "X" bucks. Or something scientific like that. Repairing hernias, evidently, is the essence, the mother's milk, the calling card of the general surgeon. Ridding the world of ruptures is what separates the surgical sheep from the surgical goats. Is that why it's an intern's case?

Other than removing various lumps and bumps, fixing a hernia is generally the first crack an intern gets at "doing" an operation. It's a good example of how it works: a good teacher can take you through an operation -- sometimes even making you feel as if you actually did it -- without your having the slightest understanding of what you've just done. I could pick up some tissue with a forceps in each hand, holding it in such a way that there's no place you can cut other than what I'm showing you. I can use my fingers or a retractor or two to expose an area -- and only that area -- in such a way that you'd know the next move if you hadn't the faintest idea on your own. Cutting the hernia sac away from the rest of the spermatic cord can, with a large hernia, get sort of confusing: dissecting off the blood vessels to the testicle, and the vas deferens, one can get a little lost if one isn't very experienced. But by holding this, peeling away that, the knowledgeable assistant can keep everyone above water. Plus, basic as it is, there are a few tricks of surgical technique that can be imparted which have crossover to other kinds of dissection. It's a thrill at each end of the knife. As an intern, just using the tools and gaining experience in handling various tissues -- how to turn the needle holder as you place a suture, how tight to tie, millions of little things that need learning -- is exhilarating even as it's frightening. Don't want to look like an idiot, don't want my hands to be shaking, do want to be able to answer the inevitable questions about groin anatomy. (Hint to would-be surgeons: forget about the so-called "conjoined tendon:" you really don't understand hernia repair until you understand the transversalis fascia.) As a teacher, imparting the pearls of wisdom, and realizing that you understand it well enough to teach it is a thrill of its own. (It's possible, of course, to learn an inferior method, based on incomplete understanding, and to teach the same ad infinitum. Sadly, it happens.)

"Hernia equivalent" sounds so pejorative. To a young surgeon looking ahead, the hope is to have a practice more exciting than one consisting primarily of hernia repairs. Myself included. But I always found them pleasing to do: each is a little different from the last -- some quite challenging. And except for the emergencies -- the strangulations -- most hernia repairs are low-key, done in a surgery center, with the stresses of the day insulated and few. Time to talk casually with the crew, or with the patient when when done under local. Tidy, fun, clear-cut, appreciated. Nothing wrong with that. And with time, I evolved my own way of doing them, using a little common sense, maybe some creativity, which afforded me the satisfaction of predictably happy patients. There were days when I did six or more at a time, in my four-hour block of time at my favorite surgery center. Nice days, those.

I'd guess that if you were about to have an operation, you'd like to think that everything about it has already been figured out: that there's no need for improvement; that you've entered the operating room in the jet age, and not as the cousin of a Wright brother. Maybe it's like buying a stereo, or an HDTV. Next year's version will always be better. There was a time when a bottle of whiskey and a leather strap was state-of-the-art for anesthesia. Likewise, there are many operations that in my lifetime as a surgeon have changed so much as to be nearly unrecognizable. Hernia repair is certainly among them. My apologies to those people who needed repair a couple of decades ago. Sorry about the recurrence, or the extra time off work. On the other hand, contrary to the perception of some that surgeons are a bunch of tight-ass, my-way-or-the-highway sort of people, it does show that, like actual human beings, we are constantly in search of better ways. After all, we get hernias, too.

The Rupture, part two

Well, OK, I'm no good at suspense. Plus, I guess my hints were too obvious anyway. It (new reader: refer to previous "rupture" post!) was indeed a uterus, a teensy one, complete with a couple of sort-of-ovaries, smaller than BBs. (For the record I've also, as suggested by commenters, seen several appendices in hernias, some requiring a little maneuvering to get it out. One case of acute appendicitis in a hernia.) It was as if Ken had read "Surgery for Dummies," and operated on Barbie, dropping the pathology specimen on his way to the lab. It's not my intent to make this a post about hermaphrodites (I'd have to look it up, anyway); but the first thing that came to my mind (second thing, I suppose, after the WTF moment) was the question: what do I tell the man, and his family? "He's doing fine. Operation went great. You'll be able to see him in about an hour." And, while walking out the door, turning back, "Oh, and by the way, he's a girl, sort of. See ya."

Turns out his kids were adopted; he'd never been able to impregnate his wife. It fit. Nor would there be any familial implications, if any of them were to worry. Rightly or wrongly, I decided not to mention it. The "cover your ass" thing, I'm sure, would have been simply to lay it out. I figured, he'd been living his life for seventy-plus years, with his family, as is. There seemed no good to come of the revelation.

But the point of these couple of posts was hernia. So let's get back to it.



Yikes. I've never seen one quite that large in the flesh, but I have had some doozies. It's amazing how much up with which some people will put. Allowing a hernia to get that big takes a long time -- several years. What would finally motivate a person to seek attention after that long? "I'm getting old, doc," was one answer I got. "I just decided it's time to be able to enjoy life without messing with this thing." Imagine keeping the area clean!

In the groin, repairing a hernia requires -- among other things -- closing a hole in an area wherein the surrounding muscles are pretty flimsy. And on the lower side of the area to be closed, there's hardly any muscle at all. Originally, the methods to accomplish this were several, and that's a bad sign: when there are a bunch of methods to accomplish a thing, it suggests that none is perfect. Hernia repair is a good example of how things have changed in surgery, and how attitudes get fixed for no good reason. When I was a resident, the two most common types of inguinal hernia repair were the "Bassini" and the "McVay," named, of course, after the guys that invented them. There are variations of each, little tricks here and there to relieve the tension on those flimsy muscles that you've pulled together. Thing called a "relaxing incision," for example. In none of the repairs back then was any artificial material (other than sutures) used. Surgical mesh -- a polypropylene cloth that looks a bit like very fine screen door material -- became available a few decades ago, but using it for a hernia repair was considered very uncool. Never use it, we were told in no uncertain terms, except for a recurrent hernia -- of which we saw plenty. The recurrence rate for the usual repair was somewhere around ten or twenty percent. Even so, those who deigned to use mesh generally did so after the second or third or fourth recurrence. ("Why do you beat your head against the wall?" "Because it feels so good when I stop.")

Giant groin hernias present two main problems: first, after you let that much of your guts live outside the belly, there isn't room easily to return them: things take over the space, the space shrinks. Squatter's rights. Second, the huge hole, now bounded by even flabbier muscle, is nearly impossible to close in anything approaching a permanent way without using mesh. The main concern about mesh -- and the reason it was accepted with some reluctance -- is the possibility of it becoming infected. Like everything else, the earliest ways of using it, namely laying it on top of the muscles close to the surface, have given way to better methods; namely, burying it below the muscles whereby infection is much less likely. So giant hernias were among the first for which initial repair with mesh was done; and it worked so well that nowadays practically everyone doing hernia repair is using mesh of some size or other, placed in some layer or other, by one method or another. In addition to dropping the recurrence rate dramatically, it lessens post op pain, by avoiding the need to pull muscles tightly together.

In fairness, I should say that there are a couple of herniologists who still repair without mesh and get very good results. There are several clinics that do nothing but hernia repairs. They get pretty skilled at it. Which is nice, because the surgeons who gravitate to those places (some aren't in fact fully trained surgeons -- which may not be important, because they learn the one thing very well) may have done so because the rest of surgery was too hard for them. And in the name of full disclosure, I'd have to admit that I repaired a lot of hernias in training before I really understood what I was doing. The anatomy isn't as easy as it seems as an intern, when someone is talking you through the whole thing. And like snowflakes, no two hernias are really alike: it can require quite a bit of creativity. Even more so when it's the third or fourth time around. I think I've got more to say, unless you're bored to death.

An "Ah-Ha" moment

Allow me a brief diversion, not intended to delay the return to hernias. In my recent post, "Taking Trust," in which I tried to describe an aspect of the mysterious relationship between surgeon and patient -- being allowed, given the privelege, to reach inside another person -- my words "creeped out" a few people. Of course, that makes me feel bad, in that I'd like as a writer to be able to express my thoughts clearly enough that they aren't misinterpreted, and in that as a surgeon my relation to my patients is and was anything but creepy. In my ruminations and recriminations over the post, something just occurred to me: something I of course assumed, but which not everyone who read the post may know. Us older surgeons, who trained before CAT scans and laparoscopy, were taught (required!) to "explore" the abdomen as part of any abdominal surgery. Before attending to the problem at hand, in a systematic and thorough way, we felt every organ in order to be sure no other pathology was present, and to (in the case of cancers) look for signs of spread (you may be surprised to know that most intestinal cancers can, for instance, spread to ovaries). The exploration was expected to be done, and the results included in the reported operative findings. Far from "taking liberties," it was as important a part of the procedure as sewing up at the end. It didn't occur to me until now that my description of that -- poetic or not -- without explaining why I was doing it could be part of what some people found weird. Or not.

Awaiting the Rupture

I'd have to say he was a typical grandfather: grey, bald, with the usual crescent of remaining hair. His skin was, perhaps, a little more vibrant than you'd expect, and he had a pleasant peachy sweetness of face that I didn't attend to in any particular way. I was more concerned with his groin, in which there resided the typical tender mass of an incarcerated inguinal hernia. It had been that way for several hours, and he was feeling nauseous and quite uncomfortable. He had earned a round-trip ticket to the operating room, on the express route. His family was there with him: wife, couple of kids, grandchild or two. Nice guy.

In the simplest of terms, a hernia means there's a hole somewhere with something poking through it. Those holes, for the most part, are ones that we're born with but which, for some reason, have become enlarged, allowing protrusion though it of something that doesn't belong in the hole. By far the most common of the "natural" (my word) hernias (herniae, if you grok Latin) are those in the groin. There, a bunch of holes exist, in locations subject to gravity, or the pressure of straining. But whereas those factors (straining, lifting, etc) may have a role in the timing of the development of a hernia, I think that to get one, you also have to have had some imperfection in the development of the area. Here, in words, is how I liked to demonstrate, in action, the development of the most common form of inguinal hernia. Put a kleenex (which is what I used) in the palm of your hand, and turn your palm down. The hand represents the muscles of the abdominal wall; the kleenex is the shiny saran-wrap inner layer of those muscles called the peritoneum (come to think of it, why not just use saran wrap? I didn't have any in my office.) Now make an "OK" circle with your thumb and index finger. Use the index finger of the other hand to push the kleenex up through the "OK" hole you made. That's the testicle (in the male) or the round ligament of the uterus (in the female) traveling out of the abdomen, through the abdominal wall and toward the scrotum (in the male) or the pubic bone (in the female.)

That's what happens before birth: in each sex there's a sac of peritoneum protruding though a hole in the abdominal wall, in the groin. A hernia, in other words, is always present before birth. That protruding sac in most cases withers away before or shortly after birth. But not always; in which case, the remnant can be the genesis of a future hernia. Its presence keeps the muscles from cinching up properly around the spermatic cord (in the male: the blood vessels to and from the testicle, and the vas deferens) or the round ligament of the uterus (in the female.) So you have a wider than normal hole with a bit of a sac protruding through. Presto, change-o! With time, something inside starts sticking out.

Whether a hernia needs fixing or not depends on various things: sometimes it's a bit of a bulge but causes no discomfort. No urgency; but the odds are it'll get bigger with time. Sometimes as the herniating organ (in the groin, usually intestine) pops in and out, it hurts. Fix it, at some point in the near future. And on occasion (much in the minority, in terms of reasons for fixing) the intestine gets stuck in the "out" position. When stuck, it may start to swell, get tighter, swell more, get tighter still, and eventually begin to cut off blood supply. A stuck hernia is referred to as "incarcerated." When the stuck stuff starts to die, that's what we call "strangulated." That's serious, and an emergency.

(For the record, in my opinion the choices for hernia management are live with it or fix it. A "truss" simply doesn't work. It's nearly impossible to get one to fit in such a way as to keep the hernia "in" at all times. So don't bother.)

Meanwhile, while I've been gabbing away, my nice old guy is heading to the OR, and by now he's asleep. My attention is directed to the slightly red lump in his right groin. I can't resist giving it a slight nudge: if it can't be (gently!) returned to its normal size after he's asleep, it makes more likely the finding of dead whatever in there. In his case, there isn't much of a change. So I forge ahead. For the most part it's simply routine: a loop of small intestine caught in the act, swollen, a little hemorrhagic, but clearly alive and well. I return it to the abdomen whence it came, and set about getting rid of the sac, getting it out of the way in order to close the hernia-hole back down snugly around the spermatic cord. Having opened the sac to inspect the bowel and slip it back in, it's necessary to remove the protruding part and the suture the remnant before turning it inward. But what the heck? Usually it's the simplest part of the whole operation. Something, however, is in the way, stuck to the side of the sac. There are several maneuvers to deal with such a thing: depending on the size of the sac, the most common organ to be involved with the sac wall is the urinary bladder. But this is... what the heck is it? I bend down for a closer look, feel it, look at it again. Son of a bitch! Wait a damn minute! No way!! Is it really what I think it is?? If so, it's definitely one for the blogs! In fact, I think I'll give you a little time to guess. It's not like I haven't given a hint....

Oops

One of my mentors (in my book, I referred to him as Ken Rockford, and described him as a "goddamn grenade") used to go crazy if anyone said "Oops" in the OR. It was a ticket to the exit door, quite unceremoniously. Indeed, it makes sense: "oops" is not exactly the thing an awake patient would want to hear from the other side of the ether screen, knowing people were taking liberties with his various parts. But, when you think about it, the term is as common as an itch: saying it, in most cases, is no more conscious or important than scratching your head. The word is quite loosely tossed around, at the least of opportunities.

I was thinking about it as, for the millionth time, I let an "oops" pass my lips this morning in the OR. The occasion: placing a simple stitch in the skin, closing the small stab incision I described a couple of posts ago. One end of the suture slipped through my fingers as I tied it, leading to exactly zero problem, and taking an extra two seconds as I picked it up and finished the knot. But "Ken Rockford's" voice shouted in my head as loud as if he'd been in the room. The patient was asleep; no harm, no foul.

Hernia repair -- about which I plan to put up a few posts in the near future -- is an operation I liked to do under local anesthesia; in fact, in training we used to make a big show of having our patients get up off the OR table and walk to the recovery room. And of course, I did lots of minor office procedures, and some less-than-minor things (breast biopsies in particular) in my office, on people who had reason to be nervous. Yet I never was able entirely to rid myself of the ooperative. Moreover, I tended to gab away at or with my awake patients; joking, telling them what I was doing, talking baseball, kids. So the sudden interjection of an oops tended to be a show-stopper. "What was that, doc? What's going on?"

In truth, I can't think of a time I actually got a question like that, because -- unable as I was to expunge the expression from my lexicon -- I was sensitive to it the minute it passed my lips, and I always managed to follow it with "sorry, sponge on the floor," or whatever truthful explanation there was. And then I'd often tell the patient about Dr. Rockford. Most people never seemed at all bothered. On the occasion when something of significance had happened, I'd likely say "oh, look at that. Got a little bleeding here, so I'm going to shut up while I fix it." Evidently, it would be said with enough calm that there'd be no headward panic. No emptying of bladder or bowels.

Given that in most ORs the default situation is a sleeping patient, it's not a rarity for someone to pop in and start talking, occasionally about things better left unsaid at that moment. I'm quite good at pantomiming "The patient is awake," even with a mask on. If anyone writes a book with that title, and I get it in a game of charades, I'm gonna kick butt.

I'm told -- I'd prefer to think it's a suburban legend -- that somewhere, sometime, some patient brought suit against his surgeon because during a procedure he heard the surgeon say "Oops." Convinced that it meant something bad had happened, he sued -- either for pain and suffering from the fright, or because there must have been a coverup. It's a good story. I think of that, right after the image of Ken Rockford tossing me out of the room way back then, whenever the word slips out. I wish I'd get over it.

Not Lately...

My aunt tells me this: (I have no recollection, but it makes some sense, considering.) My dad, she says, was taking me and my brother to a baseball game one day, when I must have been around five. Excited at the prospect, I ran up the street to tell my friend, instead of heading to the car; engine likely already running. My dad was many good things, but patience was not an attribute. As he drove off without me, I ran after them, crying; then stopped and stood there, crushed.

I really hate being late.

Throughout my career, the only schedule more sacrosanct than my office was that of the operating room. I was close to insane about it. For reasons I could never understand, some surgeons are never on time, routinely showing up at least a half-hour after their scheduled start time. It is, in my opinion, the height of rudeness: start your case list late, and the effect dominoes through the day and into the night, screwing up the plans of patients, OR personnel, other surgeons. I know: things happen. Even I arrived tardy once in a great while. But I know from 25 years' experience: on time can be done. Most often, I arrived in the OR at least a half-hour before my scheduled time. I never wanted to be the cause of a late start -- and late starts drove me crazy.

Making it worse, I always felt that a start time is a cut time: at 7 a.m. I expected to drop the knife, not see the patient rolling down the hall on a gurney. In fact, most ORs came not only to expect and appreciate it, there were a few that loved to see if we could get the first bandage on by the scheduled start time (especially likely if the first case were a pediatric hernia.) And when I had several cases lined up, I'd help move the patient on and off the table, get stuff for the nurses, help set up equipment. As a result, I got great turnover times (the time between cases): the whole crew would get into it. Which made me feel good, because if I delayed the surgeon scheduled after me, I felt like a criminal. It almost never happened, whether I had one case on the list, or six. Besides, I had patients to see in the office, and it's even worse to make yourSELF late!

Which brings up another point: when I told the OR scheduler that a case would take twenty minutes, or an hour, or three, I meant it. Orthopedic hours, as far as I can tell, have somewhere between 90 and 120 minutes in them. Plaster, I guess, affects the space-time continuum. Once again: things happen. A twenty-minute appendectomy can take a couple of hours; the belly can hold surprises. But I know it's possible to be pretty predictable, because I was.

I took call at least every third day/night, often more. My practice was no less busy than anyone else's. Yet I managed to run my office like a damn train schedule (the non-Amtrak kind, of the days of yore). My nurse would schedule a patient at 10:05, and tell her "That means ten oh five!" Got lots of incredulous compliments. Both of us did.

There are no mysteries here. I don't have any special secrets other than to be thoughtful when scheduling, and to be fanatical to the point of insanity. It's a good thing for everyone, with the possible exception of oneself.

Oh yeah. One more thing. I'm writing this in the surgery lounge, waiting for the surgeon I'm supposed to assist to show up. So far, we're an hour late. And counting. Counting. Counting.

On the Other Hand...

The thing about laparoscopy is that it's so impersonal. If open surgery is intimate, as I tried to convey in my previous post, laparoscopy is insulated, stripped of sensation; performed, in essence, outside of and separate from the patient. I like it. Don't love it.

I'm no Luddite; not a troglodyte. I'm enlivened by the innovations that are a part of surgery, and I think it'd make an interesting post at some point to enumerate the ways in which things are different now in the care of the surgical patient, compared to the ice age in which I trained. Unlike some of my fellow elders -- unschooled in video games -- I found the transition to laparoscopy technically easy: the ability to do three-dimensional things while looking up at a two-dimensional screen is not intuitive for everyone. From the outset, for the most part, I could get a skinny instrument to where I aimed, and make it do what I Nintended. It isn't hard to see that certain operations done laparoscopically are better in all ways for the patient. And yet.

In that previous post, I tried to describe what it's like to stand before a person and cut deeply; to reach in and hold and touch. I suppose there's no reason why a procedure has to encompass that kind of drama, nor why a surgeon ought to or needs to have that sense of awe. Still, it's my reality. And it's entirely missing in laparoscopy, which happens to be all I do nowadays, in the OR.

To begin an open operation, you step to the patient's side, receive the scalpel, and go to work. WIth laparoscopy, you screw around with half a dozen hoses and cables -- these go here, those go there. Hook things up, white-balance the camera, adjust the screens. Make sure the settings are correct; there's gas in the tank. Then finally, pick up a pathetic toad-stabber of a knife, and make a little poke. A silly, baby-step of a puncture; like you ought to say "s'cuse me." Then, as enough time has passed already to be half-way through some operations, you fffffffffffill the belly with gassssssssssss, and wait some more, watching as the abdominal wall -- rather than submitting and opening itself to you -- distends like yesterday's roadkill.

Sorry. It's not that bad, really. But there's surely something missing. If you do what you do by watching on a TV, you're almost not there. The patient can't be sensed; it's remote and cold. And it's not just rhetorical: you get information from the feel, the warmth, the tissue resistance, the smell when you are open. Via the scope and its tools, it's transmitted; just pixels. You are in a real sense divorced from it. As with a jigsaw puzzle, or putting together the Christmas toys, it's engaging in another sense. It's the delivery of a skill, the application of rapidly evolving technology, using beautifully engineered tools. As I said, I like it, but in a way very different from open surgery. And whereas it's being used for a number of operations where it really is no better than well-managed open surgery (no safer, more expensive, no shorter recovery), it is a very positive innovation and a huge step forward in many important ways. Nissen fundoplication (to cure esophageal reflux) is clearly one of them.There's something fun about it, in a laboratorical way: placing a suture, cutting and tying it while observing your actions on a screen (despite the annoying time-wasting of constantly sliding instruments in and out of trochar ) is a rewarding challenge, the development of the skill for which is quite satisfying. Still, it would never happen in open surgery, as it does occasionally in laparoscopy, that when you and your assistant are manipulating the same sort of instruments, staring at the TV screen, you ask "Is that me, or you?"

Isn't there something to be said for intimacy? Is there no way in which a meeting is better than a video conference? Will we not have a more important bond if I've really touched you? Truth is, I don't know. Without doubt, the surgeon's relationship is different, in some ways, with laparoscopy. In the long run: probably doesn't matter. Even if it does, we ain't going back. If it did matter, I suppose there'd be surgeons and their patients wandering aimlessly around surgical wards like duckings that failed to imprint on their mothers. And I admit it: other than writing about it with the afterglow of my previous post still warm in my mind, I think laparoscopy is, in fact, a very good thing. Mostly. Much of the time. Usually. If well-chosen.

Taking Trust

When Tiger Woods addresses the ball, he's focused like a cat that heard a rustle in the leaves. He takes a few practice swings, moves up to position, adjusts his feet, steadies his shoulders, locks his eyes onto the target. He waits until there's absolute silence, brings his breathing under control, funnels all his energy into the impending swing; takes the club back, and explodes in an immensely balletic movement. It stops the breath of an onlooker, ripples the air in a wave that goes forever. Making a surgical incision is nothing like that.

But it almost is; and it should be.

Having held the patient's hand as she goes to sleep, having whispered "We'll take good care of you" as his eyes flutter to stillness, the personal remnant is still very much there as I begin, even as the person is covered in sterile green paper, exposing only the belly. It's the midline incision, especially the one in the upper belly, from breastbone to navel, that's the most intimate. To me, anyway. It's so direct, so frontal, so against the rules of personal space. Maybe even sexual. Because it's right into the middle of who she is -- the thrust aimed where anyone -- even a friend -- would hunch away to protect himself; yet, here I am, purposefully slicing deep into his core, willing and able, allowed, invited, trusted, observed. Going through the skin, the initial cut -- that's the cataclysm, the breaking of the barrier, the crossing of the line. It's the leap of her faith, the breaching of the wall, the stepping into space. Within moments, it's routine, nearly generic: his insides look like mine, yours. Been there. But the primal cut, the slice through that first and last line of protection, his skin, her freckles, the fine little hairs, the vulnerable innocence: I feel the intrusion, the awfulness, the promise made and broken simultaneously. After all these years, I never lost the wonder, the momentary look inward, the catch of breath, the faint crescendo of pulse. Primum non nocere!




These young guys: they like to cut only part-way through the dermis and put down their knife, finish off the skin with electrocautery; cook their way through the fat, smoke rising, stops and starts, pissily branding each little bleeder. I think they don't know -- really know -- what an incision is. No wonder their love for it is less personal, more abstract, more easily stolen. Take the knife in your hand, sister, and don't put it down. Watch me: take a clean and deep stroke through skin, fat, right down to fascia.. Have the courage of your convictions; make good on your promise and carry that same cut through the white line, the linea alba; let's see that little layer of fat that covers the peritoneum, let it show on the first swing. The patient deserves your best shot, your most bold. Honor your covenant to address him with all of your conviction and purpose. Swaddle the wound with pads, the bleeding isn't much and can wait.

I will reach in gently and caress the liver, the stomach and spleen. Slide over the top, into the recesses, curl the fingers enough to sense the texture, the fullness. The bowels move away and under, and over the top as I direct my hand. I can describe your kidneys now, I've circled the top of your rectum, held your uterus, measured your ovaries between my fingers. Part of you is gone at the moment, but I'm here, I know you now. You trusted and let me in, you opened your belly to me, and I entered with force. I'll stay until it's right. It's what I must do. You think you'll never touch me so intimately as I've touched you. But you have. You have.

Almost famous

I was nearly famous. Coming this close to being on the PBS News Hour, I was fully prepared to receive love notes and hate mail, and probably would have. The subject was outpatient mastectomy, and I was for it. My patient made it on; I didn't.

Let's get this part out of the way right off the bat: there's no way I would EVER advocate that mastectomy should be considered an outpatient procedure in the sense that insurance companies would urge or require it. The default mode (as we computer-literate folk would say) is and ought always to be that it's done in the hospital. As with many things, I think that when there are options, women having the right to choose is a good thing. Having done many outpatient mastectomies, I can say with complete confidence that it's safe, amazingly well-tolerated, and, for some women, is better in all ways than being in the hospital. Especially in a hospital where the nurses are made to care for too many patients, or to rotate to specialty areas with which they aren't familiar.

First, some housekeeping basics. Clearly, for the woman having immediate reconstruction, outpatient mastectomy is not appropriate. Maybe in the near future I'll say why I have a mild bias in favor of deferring reconstruction ("mild" being the operative word -- it's a complicated matter which I don't want to get into now, but, as I think more about it, will definitely do so later.) And I'm painfully aware of how devastating the idea of mastectomy can be: even mentioning outpatient surgery as an option is something I've done very selectively. It's not for everyone. But physiologically speaking -- referring here to the impact on the body -- there are several operations that I'd consider more "severe," and which are quite often done as outpatient procedures: gallbladder surgery, gastric banding for obesity, various gynecological procedures.

Poking around inside the abdominal cavity has bigger implications than what is essentially a skin operation. OK: "skin operation" is a little glib. But really, the breast is a modified sweat gland. That lovely form, the symbol of femininity and the object of admiration by men and women alike, that most desirable (here I speak as a heterosexual male person and not as a physician!), soft and warm living poetry stinks like a locker room when you cut into it with an electrocautery device. And when you remove it, the operation is mainly on and under skin, leaving muscle -- where most of the pain comes from -- pretty much alone. The old days of removing the pectoralis major and/or minor, along with swaddling the patient in enormous restrictive dressings, are long gone. So, thankfully, are significant blood loss and hours of anesthesia.

Properly done, mastectomy ought not require blood use, and can be thoroughly carried out in well under an hour. My patients almost always woke up with no pain at all, because I had a way of injecting a long-acting local anesthetic into the field. But even when it wore off, most women were quite surprised at how comfortable they felt. (Nothing in medicine is 100%!) Of those that were hospitalized, the greatest number went home on the first day postop.

You get an idea when you see them: some women would rather not be in the hospital for any of a number of reasons. Privacy. Self-control. Whatever. And there was a time -- which is only marginally better today -- when nurses were so overworked and understaffed that patients didn't always get the sort of care they needed. Drains. Drove me crazy. Leave a drain or two in the area after mastectomy, expect them to be operated properly; otherwise, blood will build up (a "hematoma") and be a source of problems. I wanted them checked frequently and emptied properly; depending on the experience and workload of a given nurse, it might or might not happen. At home, with proper instruction, there was never a problem. So I did more than a few outpatient mastectomies, and neither I nor the women involved had reason to regret them.

In Connecticut, I think it was, a health insurance company is said to have announced it had designated mastectomy as an outpatient procedure. No reason it needed hospitalization; wouldn't pay for it in the hospital unless specifically excepted. People were, justifiably, outraged. There's some controversy as to whether it's actually true that the insurance company made the decision. But it's unquestioned that there has been an uproar, and that Congress has (huzzah) gotten involved, proposing legislation. "Drive-thru mastectomy" is what it came to be called, and it was a rallying cry for many advocacy groups. And, as happens when things get politicized, the truth got sort of swept away.

Once again, I'll say I fully agree: mastectomy has no place on the list of operations mandated as outpatient procedures. (Nor, in my opinion, does the one thing that is generally so mandated, and which is the most egregiously inappropriate: hemorrhoidectomy. Another topic, sometime.) But it absolutely can be done that way.

So, for some reason PBS got wind of it and of all places, it was in the Seattle area that they planned to do a segment on it, on the News Hour. And as luck would have it, the director of the surgery center at which I did most of my outpatient operations was contacted to see if she knew of anyone doing outpatient mastectomy. She gave them my name. I got a call and had a nice conversation with a producer of the show. Great, I thought. I could explain the realities; I made it clear to him that I thought it was very appropriate when the woman preferred it, but in no way should it be required. And, I figured, I'd get a chance to put in a plug for nurses: tell the country what the effect on quality care had been of the steady cuts in hospital reimbursement.

The man seemed quite sympathetic. What he wanted was to follow a woman through the whole thing: show a bit of the operation, film her at home. He needed someone within a fairly short time-frame, and although I saw several women with breast cancer -- as usual -- in the next couple of weeks, none was a candidate. I let the producer know, and asked if he'd like to talk to a patient who'd had it. He would. I contacted a couple of my patients and they were happy to offer themselves. If the piece was produced, I was assured, and if they included my patient, they'd schedule an interview with me, as well.

Time passed, silently vis a vis word from PBS. Until one day I got a call from someone telling me Mr. Producer wanted to let me know the show would be on tonight. What? No me? What about my three minutes of fame? My subsequent offers from Hollywood, the surge in my practice? Well, she said, it's on tonight.

It started well enough. The first patient profiled was mine, who said, among other things, that she'd had dental work that was a bigger deal. Her kids fought over who could empty her drain. She'd do it again in a heartbeat. Best decision she'd made. Like that. Then there were a couple of surgeons saying why it couldn't or shouldn't be done. Patients could never manage the bandages; things could happen that would lead to problems. It's a horrible and insensitive idea. Dangerous. And a couple of patients tearfully saying how they'd been hustled out of the hospital before they were ready. Had I been on, too, I suppose I'd have looked like an idiot. These docs were professors; I was just some country schmoe. And yet, they'd started with my patient saying what a breeze it was. Who, indeed, was the schmoe? If your patients can't handle a bandage, I thought, either you aren't instructing them well, or your bandages are too damn complicated. Bad things happen? Sure they do. But so they can with any outpatient procedure, or with brushing your teeth.

Surgeons -- myself included -- accept change with glacial speed. The things we were taught were pounded in with heavy hammers, and deviation was met with fire and spittle. To consider change is to face a nearly physical reaction and to hear your teachers shouting you down from the grave. It takes a conscious act -- an act of rebellion, really -- to consider the things you do and the instructions you give patients and to examine where they came from and the extent to which they actually make sense. "Don't lift more than ten pounds." Anyone do a study: this group, you lift five pounds; that group, you lift fifteen?

When I was in training there were a couple of old docs still practicing who'd been trained in the days when any person who'd had major abdominal surgery was required to stay in bed for two weeks. Pneumonia, pulmonary embolus -- they were just part of the deal. Get up, your guts'll fall out. Likewise, women who'd undergone mastectomy were told not to reach, not to lift, not to shower. Why, exactly? I was told -- very strenuously -- as a resident that everyone who underwent splenectomy needed a stomach tube for three days. Why? Because otherwise their stomach would dilate and pop the sutures off the short gastric veins. So that's what I did. Until I thought: wait a minute. I can tie a suture so it doesn't pop off. Do you suppose that it happened to one of his patients (or one of his teacher's -- or his teacher's teacher's) and led to a stone-carved rule?

My instructions to mastectomy patients -- no matter where they found themselves postop -- was to avoid things that hurt, and otherwise to do whatever they wanted. That simple. And, because I used a very small bandage covered in plastic, they could shower whenever they wanted. Yes, there was a drainage tube, connected to a bulb-like collection device. Hang it around your neck in the shower, like soap-on-a-rope, I'd say. And although I've seen the occasional hematoma develop in a hospitalized patient whose drain was ignored, it never happened in my outpatient people.

So what can we learn from all this? First, not everyone who speaks with confidence knows what the hell he/she is talking about. (This, of course, could just as well apply to me.) Second, health insurance companies -- no matter how soothing the music is in their TV ads -- are interested in the bottom line above all else and make decisions that are not necessarily in the interest of their subscribers. Third, doctors do lots of things because they were taught to do so and which have never been subjected to meaningful analysis to see if they actually make sense. Fourth, changing those things is incredibly difficult for lots of complicated reasons. Fifth, if -- and I hope you never are -- you are faced with the need for mastectomy and hate the idea of having to stay in the hospital, and your surgeon offers to do it as an outpatient, feel free!

Almost famous

I was nearly famous. Coming this close to being on the PBS News Hour, I was fully prepared to receive love notes and hate mail, and probably would have. The subject was outpatient mastectomy, and I was for it. My patient made it on. I didn't.

Let's get this part out of the way right off the bat: there's no way I would EVER advocate that mastectomy should be considered an outpatient procedure in the sense that insurance companies would urge or require it. The default mode (as we computer-literate folk would say) is and ought always to be that it's done in the hospital. As with many things, I think that when there are options, women having the right to choose is a good thing. Having done many outpatient mastectomies, I can say with complete confidence that it's safe, amazingly well-tolerated, and, for some women, is better in all ways than being in the hospital. Especially in a hospital where the nurses are made to care for too many patients, or to rotate to specialty areas with which they aren't familiar.

First, some housekeeping basics. Clearly, for the woman having immediate reconstruction, outpatient mastectomy is not appropriate. Maybe in the near future I'll say why I have a mild bias in favor of deferring reconstruction ("mild" being the operative word -- it's a complicated matter which I don't want to get into now, but, as I think more about it, will definitely do so later.) And I'm painfully aware of how devastating the idea of mastectomy can be: even mentioning outpatient surgery as an option is something I've done very selectively. It's not for everyone. But physiologically speaking -- referring here to the impact on the body -- there are several operations that I'd consider more "severe," and which are quite often done as outpatient procedures: gallbladder surgery, gastric banding for obesity, various gynecological procedures.

Poking around inside the abdominal cavity has bigger implications than what is essentially a skin operation. OK: "skin operation" is a little glib. But really, the breast is a modified sweat gland. That lovely form, the symbol of femininity and the object of admiration by men and women alike, that most desirable (here I speak as a heterosexual male person and not as a physician!), soft and warm living poetry stinks like a locker room when you cut into it with an electrocautery device. And when you remove it, the operation is mainly on and under skin, leaving muscle -- where most of the pain comes from -- pretty much alone. The old days of removing the pectoralis major and/or minor, along with swaddling the patient in enormous restrictive dressings, are long gone. So, thankfully, are significant blood loss and hours of anesthesia.

Properly done, mastectomy ought not require blood use, and can be thoroughly carried out in well under an hour. My patients almost always woke up with no pain at all, because I had a way of injecting a long-acting local anesthetic into the field. But even when it wore off, most women were quite surprised at how comfortable they felt. (Nothing in medicine is 100%!) Of those that were hospitalized, the greatest number went home on the first day postop.

You get an idea when you see them: some women would rather not be in the hospital for any of a number of reasons. Privacy. Self-control. Whatever. And there was a time -- which is only marginally better today -- when nurses were so overworked and understaffed that patients didn't always get the sort of care they needed. Drains. Drove me crazy. Leave a drain or two in the area after mastectomy, expect them to be operated properly; otherwise, blood will build up (a "hematoma") and be a source of problems. I wanted them checked frequently and emptied properly; depending on the experience and workload of a given nurse, it might or might not happen. At home, with proper instruction, there was never a problem. So I did more than a few outpatient mastectomies, and neither I nor the women involved had reason to regret them.

In Connecticut, I think it was, a health insurance company is said to have announced it had designated mastectomy as an outpatient procedure. No reason it needed hospitalization; wouldn't pay for it in the hospital unless specifically excepted. People were, justifiably, outraged. There's some controversy as to whether it's actually true that the insurance company made the decision. But it's unquestioned that there has been an uproar, and that Congress has (huzzah) gotten involved, proposing legislation. "Drive-thru mastectomy" is what it came to be called, and it was a rallying cry for many advocacy groups. And, as happens when things get politicized, the truth got sort of swept away.

Once again, I'll say I fully agree: mastectomy has no place on the list of operations mandated as outpatient procedures. (Nor, in my opinion, does the one thing that is generally so mandated, and which is the most egregiously inappropriate: hemorrhoidectomy. Another topic, sometime.) But it absolutely can be done that way.

So, for some reason PBS got wind of it and of all places, it was in the Seattle area that they planned to do a segment on it, on the News Hour. And as luck would have it, the director of the surgery center at which I did most of my outpatient operations was contacted to see if she knew of anyone doing outpatient mastectomy. She gave them my name. I got a call and had a nice conversation with a producer of the show. Great, I thought. I could explain the realities; I made it clear to him that I thought it was very appropriate when the woman preferred it, but in no way should it be required. And, I figured, I'd get a chance to put in a plug for nurses: tell the country what the effect on quality care had been of the steady cuts in hospital reimbursement.

The man seemed quite sympathetic. What he wanted was to follow a woman through the whole thing: show a bit of the operation, film her at home. He needed someone within a fairly short time-frame, and although I saw several women with breast cancer -- as usual -- in the next couple of weeks, none was a candidate. I let the producer know, and asked if he'd like to talk to a patient who'd had it. He would. I contacted a couple of my patients and they were happy to offer themselves. If the piece was produced, I was assured, and if they included my patient, they'd schedule an interview with me, as well.

Time passed, silently vis a vis word from PBS. Until one day I got a call from someone telling me Mr. Producer wanted to let me know the show would be on tonight. What? No me? What about my three minutes of fame? My subsequent offers from Hollywood, the surge in my practice? Well, she said, it's on tonight.

It started well enough. The first patient profiled was mine, who said, among other things, that she'd had dental work that was a bigger deal. Her kids fought over who could empty her drain. She'd do it again in a heartbeat. Best decision she'd made. Like that. Then there were a couple of surgeons saying why it couldn't or shouldn't be done. Patients could never manage the bandages; things could happen that would lead to problems. It's a horrible and insensitive idea. Dangerous. And a couple of patients tearfully saying how they'd been hustled out of the hospital before they were ready. Had I been on, too, I suppose I'd have looked like an idiot. These docs were professors; I was just some country schmoe. And yet, they'd started with my patient saying what a breeze it was. Who, indeed, was the schmoe? If your patients can't handle a bandage, I thought, either you aren't instructing them well, or your bandages are too damn complicated. Bad things happen? Sure they do. But so they can with any outpatient procedure, or with brushing your teeth.

Surgeons -- myself included -- accept change with glacial speed. The things we were taught were pounded in with heavy hammers, and deviation was met with fire and spittle. To consider change is to face a nearly physical reaction and to hear your teachers shouting you down from the grave. It takes a conscious act -- an act of rebellion, really -- to consider the things you do and the instructions you give patients and to examine where they came from and the extent to which they actually make sense. "Don't lift more than ten pounds." Anyone do a study: this group, you lift five pounds; that group, you lift fifteen?

When I was in training there were a couple of old docs still practicing who'd been trained in the days when any person who'd had major abdominal surgery was required to stay in bed for two weeks. Pneumonia, pulmonary embolus -- they were just part of the deal. Get up, your guts'll fall out. Likewise, women who'd undergone mastectomy were told not to reach, not to lift, not to shower. Why, exactly? I was told -- very strenuously -- as a resident that everyone who underwent splenectomy needed a stomach tube for three days. Why? Because otherwise their stomach would dilate and pop the sutures off the short gastric veins. So that's what I did. Until I thought: wait a minute. I can tie a suture so it doesn't pop off. Do you suppose that it happened to one of his patients (or one of his teacher's -- or his teacher's teacher's) and led to a stone-carved rule?

My instructions to mastectomy patients -- no matter where they found themselves postop -- was to avoid things that hurt, and otherwise to do whatever they wanted. That simple. And, because I used a very small bandage covered in plastic, they could shower whenever they wanted. Yes, there was a drainage tube, connected to a bulb-like collection device. Hang it around your neck in the shower, like soap-on-a-rope, I'd say. And although I've seen the occasional hematoma develop in a hospitalized patient whose drain was ignored, it never happened in my outpatient people.

So what can we learn from all this? First, not everyone who speaks with confidence knows what the hell he/she is talking about. (This, of course, could just as well apply to me.) Second, health insurance companies -- no matter how soothing the music is in their TV ads -- are interested in the bottom line above all else and make decisions that are not necessarily in the interest of their subscribers. Third, doctors do lots of things because they were taught to do so and which have never been subjected to meaningful analysis to see if they actually make sense. Fourth, changing those things is incredibly difficult for lots of complicated reasons. Fifth, if -- and I hope you never are -- you are faced with the need for mastectomy and hate the idea of having to stay in the hospital, and your surgeon offers to do it as an outpatient, feel free!

Quick to the Cut

The following is from my book. It might lead to some posts on trauma issues. Meanwhile, it's a passage I like, and it's handy:

Real men open chests in the emergency room. Every surgical resident wants to do it; it’s exciting, dramatic, life-saving, and a little bit showy. We’d do it for any of several reasons, especially when there’s massive bleeding in the belly: getting a clamp on the aorta via the chest can slow the leak of blood into the abdomen, without getting into a mess before you’re in the operating room. Opening a belly in the emergency room for any reason—but especially for bleeding—would be disastrous. Because the belly wall compresses bleeding to some extent, pressure drops precipitously when you open and take away that compression, and you need all the resources of an OR to handle it. More exciting, chests also get cracked for heart massage. When the heart is empty from exsanguination, pushing on the chest from the outside does no good, so we’d open chests directly to squeeze the heart until we could get the tank filled back up with blood and IV fluids. The desire to do it could be hard to resist. I stood watching, on one occasion, as the team was tuning up a
victim of multiple gunshot wounds. He was semi-conscious, struggling and mumbling, fighting back reflexively at the efforts to help. Just after I turned away to call the OR and the attending, the patient hollered out in pain. Having heard the nurse announce the blood pressure had dropped to zero, the ER resident had started a slash in the chest.
“Holy shit!” I shouted as I turned back to the scene. “What are you doing?”
“Zero blood pressure. Gotta open the chest,” he said, getting pumped up for the glory.
“Jesus Christ, man, the guy is awake!”
Reaching across the gurney, I fended off the attack before the scapel made it all the way in, leaving the resident to his own thoughts as we took the victim upstairs. No pulse, no blood pressure— the combination was often a ticket into the chest. But, c’mon, not in someone still talking and moving around! After a routine save in the operating room, stopping some bleeding, closing some holes, the man recovered without a problem. A couple of days after the surgery I casually asked him what he recalled about his time in the ER. Nothing.


There’s a trick to emergency thoracotomy (opening the chest): ribs spread apart with difficulty, even in the OR. In an emergency, you cut between the ribs and toward the front, then turn the knife upward, making the shape of a hockey stick. To the side of the sternum, the ribs are all cartilage and cut easily. Slicing vertically through three or four cartilages makes an ugly scar, but it works: you can flip up the front of the chest like a trapdoor and get where you want to go. The most dramatic reason for thoracotomy in the ER, which we all wanted like a notch on a gun, is a stab wound to the heart (gunshots were rarely salvageable). It may not happen right away: a small stab allows blood to leak into the pericardium beat by beat, and as the pressure builds up it compresses the heart gradually (tamponade, as you’ve learned). Showing the typical sign of bulging neck veins as the blood backs up into the vena cava, the patient might fade away slowly. There could be time to get to the OR before opening the chest, maybe by sucking some blood out of the pericardium with a needle stuck in through the chest wall. With no time, you open in the ER.


If surgeons have a God-complex, this could be why: split open a chest, slice into the pericardium, stick your finger into a hole in the heart, and the patient may wake up with your hand buried in him half-way to the elbow. I did that once. The patient gave a thumbs-up to his friends as we wheeled him to the OR, the hole in his heart sucking on my finger like a hungry baby. At SFGH there were no cardiac surgeons, no pump techs. But it was self-selecting: a heart injury that might need bypass would have never made it to the OR. The ones that did could be fixed directly, by us. Holding the heart in your hand, compressing the hole with your thumb, enough also to dampen the beats as you place sutures on either side, timing your moves with the beating, aiming to avoid the coronary arteries—that’s pretty cool. (Could it be cooler than scooping stool out of an abdomen?) When you place sutures into the heart muscle, it fires off a string of crazed beats, trying to jump out of your hand, not knowing you’re there to help.