Sunday, July 30, 2006

Memorable patients: part four

I didn't know her name until it was over, much too late. What I knew was she was thirteen and that on this winter day someone in her family had been pulling her behind their car, on a sled. No doubt laughing and looking in the rear-view mirror, the person driving had whipsawed around a corner, and the young girl -- probably screaming (fear? delight?) -- held onto the sled as it careened off the road and into the side of a concrete culvert. The girl took the blow in the middle of her right side. Reportedly, as they helped her up, crying, she fainted. The family member did what a family member who'd pull someone behind a car on a sled would do: took her home and laid her on the couch. About forty-five minutes after that, when she was unarousable, 911 was called. Half an hour after that, she arrived in the ER, in full cardiac arrest, which was also the way the medics had found her.

There was still electrical activity in her heart. Her pupils were dilated, we couldn't measure any blood pressure. But she was thirteen. Several IVs were started, massive fluids infused, and she started to produce a pulse. Her belly was greatly swollen. We got her to the OR before the O-negative blood arrived (it can be given fairly safely to anyone, regardless of blood type), and continued the resuscitation until it seemed possible to anesthetize her and cut her open.

Blood had filled her abdomen. I scooped it out, mopped it out, suctioned it out. Her liver looked as if someone had inserted an M-80 firecracker into it and lit it off. As soon as I'd gotten in -- you can slash inside pretty rapidly when you need to, making a nick in the upper abdomen, inserting a couple of fingers, lifting up hard, sticking the scalpel between the fingers and zipping straight south in one motion -- I'd put a clamp across her abdominal aorta, just below the diaphragm, to limit the amount of blood that could enter and leak out; plus, it helps maintain blood pressure to the head and heart. I stuffed a few packs into the crater of her liver and pressed on them. Had I gotten to the point of trying to repair the damage, it would have been hard as hell.

Instead, my aim was just to control bleeding, enough to give the assembled group of nurses and anesthesia folk time to catch up on her fluid needs, push in pint after pint of blood; try to get her stable enough to see what would happen. Clamp on the aorta: done. Pack the liver: done. Pringle maneuver: did it. For a while, we observed a sustained blood pressure, so I made ready to see what I could do about the wreckage. Then her EKG complexes started to widen. Eventually, they became slower and slower, flattening out, resistant to all the drugs that were tried. I took turns with the assistant compressing her chest. And finally, when it was beyond obvious, we stopped. In-field CPR for half an hour before arrival, plus who knows how long in arrest before the medics arrived: too little, too late.

When you close an abdomen after a failed rescue, the OR is silent. No beeps from monitors, no sighs of the ventilator, no small talk. You use a large suture on a giant needle, taking big bites of tissue, making it quick. On a thirteen year old, with a baby's beautiful skin, healthy tissues giving more resistance to the needle than usual, perfect organs disappearing from view, you are sewing through tears. You feel the loss as if it were your own.

I went alone to the family area. I've done that walk a few times: If the earth were to open up and swallow me at that point, it'd be ok with me. The mom was there, maybe a few others. Seeing the look on my face, she stepped toward me, hand in a fist, pressed against her mouth. "I'm sorry," I said. "I couldn't save her." Without a pause, the mom began beating me on the chest, with both fists, hard, yelling and moaning, crying, "What do you mean you couldn't save her? Why? Why? How could you not?" "I'm so sorry," I said, again, finding none but the predictable words. "We tried everything, but there was too much damage." Letting her beat away without raising my hands, forcing back the obvious statement: had she been brought in immediately we'd have had a chance. "Oh my God. How could you not save her? Oh my God, oh my God, oh Amy, oh Amy."

So that was her name. Amy.

Saturday, July 29, 2006

Memorable patients: part three

She was a Korean woman, spoke passable English. We always exchanged pleasantries, and she called me "doctor" when I picked up my laundry. This time she was notably quiet, distant. I didn't figure it out until I got home and hung up my jacket, on the inside of which I noticed she'd pinned an envelope. It contained a photo I'd taken months ago, left and forgotten in one of my pockets. What it showed was a nude female torso, sixteen stabwounds up and down the left side -- chest, breast, abdomen -- with the handle of a 12-inch butcher's knife buried to the hilt, protruding a couple of inches below her left breast. (Shakespeare said it so beautifully: "Over thy wounds now do I prophesy,--- Which, like dumb mouths, do ope their ruby lips..") Self-inflicted, after killing her care-giver.

The police had been called to a trailer park, where neighbors had heard screams. A schizophrenic woman in her twenties, living with a man in his forties who cared for her, had been off her meds lately. In a rage over who-knows-what, she'd first stabbed the man multiple times, then herself. He died. She didn't. She was mumbling but cooperative in the emergency room. Her vital signs were remarkably stable, despite the impressive amount of blood covering her; maybe it wasn't all hers. The knife handle rocked gently with her respirations, and noticeably twinked, ever so slightly, with her heartbeat. In the OR, we prepped her from chin to pubis, figuring we might be going in everywhere.

A cop accompanied us to the OR. Worried that I could cause a catastrophe if I did it blindly, I hadn't removed the knife: the cop needed to maintain "chain of custody." (Link added 12/09, after a reader question.) I opened her belly first: with stabwounds to the lower chest, the most likely place of injury is within the abdomen. Indeed, the knife had passed through the left lateral part of her stomach, and its sharp edge rested along the surface of the spleen, kissing it gently. Holding the spleen out of the way with my left hand, I withdrew the knife with my right, and handed it off to the cop, feeling pretty cool: surgeon, calmly and professionally cutting the lady open in front of the cop, handing him the weapon like I did it every day. He tagged it and bagged it, like he did it every day.

Thoroughly searching the abdominal cavity revealed no additional injuries, so I closed the two holes in the stomach (one thing about penetrating injuries: you need to find even numbers of holes in things: entrance wound + exit wound. And you "run" the entire bowel, meaning spooling it carefully between your fingers, flipping it over and back to look at all surfaces. Since intestine slithers freely, a stab in the upper abdomen can easily have injured bowel now lying in the pelvis). About the time I finished, the anesthesiologist started rooting around on the other side of the drapes, then hollered for help. The patient was crashing.

In the emergency room, I'd placed a chest tube on the left side, because the lady had caused herself a pneumothorax, so I knew at minimum she'd punctured a lung. Now I thought she might have nicked her heart as well, causing cardiac tamponade. With her blood pressure dropping rapidly to zero, there was no time for a tidy entry into her chest, so I did it down and dirty (for a nice description of this technique, see page 180 of my book).(And yes, I know it's shameless, but it's my blog...) Had it been tamponade, her pericardium would have been purple and swollen from underlying blood, but there was no such thing. Here's where my memory (several years ago) is cloudy: I can't remember if I actually saw the air bubbles in her coronary arteries, which would mean I probably opened the pericardium -- which I might not have, absent obvious tamponade -- or if I just presumed it as a process of elimination. Nevertheless, it's a thing that can happen when the lung has been cut, especially in the setting of positive-pressure ventilation, as happens during anesthesia. A cut lung allows potential entry of air into the pulmonary arterioles, which then returns to the left ventricle of the heart, from which it gets pumped out to the body. First point of departure from the aorta are the openings to the coronary arteries; an air bubble in them acts no differently from a blood clot, with the potential of causing a heart attack. Next points of departure lead right to the brain.

Following a protocol of which I was vaguely aware but had never used, I clamped the aorta downstream from the head vessels, had the anesthesiologist tilt the OR table as head-down as possible (routine for low blood pressure, but in this case also to keep any more bubbles from getting to her head), and asked him to give our patient drugs to raise her blood pressure as high as safely possible, and to run 100% oxygen (in addition to protecting ischemic tissues, it speeds up absorption of air). The idea of the high blood pressure is to force the bubbles through before doing permanent damage. Clamping the aorta that close to the heart raises blood pressure as well. It's potentially a dangerous combination of maneuvers, but as they say about desperate times...

At this point (if I hadn't already) I opened the pericardium, and sure enough, there were little bubbles in the coronary arteries.(See, I can't remember exactly when I saw the bubbles, but I clearly remember seeing them... This blog is gonna be an honest one, dammit.) As the pressure rose, I could actually see them moving along. And when her pressure began to get dangerously high, I incrementally released the aortic clamp, and amazingly enough, she was able to maintain her pressure, as she hadn't before. This, ladies and gentlemen, had been a very precarious situation, which turned out amazingly well. She woke up without obvious signs of brain injury, and her cardiogram returned pretty rapidly to normal. Sixteen stabwounds, seriously delivered; not a single after-effect. Dead caregiver.

Being young, and still occasionally allowing myself the misconception of surgeon as god, I figured that, having rummaged around quite considerably in her entrails and having held her heart in my hand, I of all people should be able to get through to this lady; certainly she'd express admiring gratitude. Well, of course, no. And not that it relates to the previous thought, but the psychiatrist I asked to see her -- it is my distinct recollection -- concluded she didn't need psychiatric hospitalization and could go straight to jail. Which she did, eventually, still mumbling. In retrospect, taking the picture served no useful purpose at all. I'd thought I might use it in some lecture or other, or a paper, and I'd taken it before all the excitement. But I never did. I kept taking my laundry to the Korean lady, and our conversations reverted to normal.

Thursday, July 27, 2006

Wednesday, July 26, 2006

Memorable patients: part two

"Musta been the ham sandwich," he said as he leaned onto the operating table and belched a couple of times. We were half-way through a thyroid operation and Doug, my partner, didn't look all that good. I'd been in practice for all of a year, and Doug, ten years my senior, was my guardian angel, my guide through the vagaries of the world of private practice, and the best surgeon I'd ever seen. Suddenly, he was definitely off his game.

We managed to get through the operation. Doug had an appendectomy teed up to follow, but instead of showing up to get it going, he'd gone to the ER, from which I got a call telling me Doug was down there being evaluated, and requesting that I do his case. Introducing myself to the patient, explaining the strange situation, convincing the man that this shiny-faced kid (a 33 year-old kid, but still...) was a satisfactory stand-in, I had more on my mind than the operation at hand. But the patient was fine with it, and I finished removing the appendix in time to take another ER call: Doug needed a surgical consult, and was requesting me.

Stone-faced, stiffly trying not to writhe, Doug was clearly in a lot of pain. Xrays didn't show much. Lab work showed a very mild elevation of amylase, a digestive enzyme produced mostly in the pancreas (and salivary glands); high levels most often signal pancreatitis. Alcoholism and gallstones are by far the most common causes of pancreatitis, and Doug wasn't a victim of either. His abdomen was pretty tender in the upper portion, which is where pancreatitis pain usually shows, but it wasn't rigid (as you know from the previous post, rigid ain't good.) For now, I'm thinking it's his pancreas, for one of the less common causes. I didn't think operation was indicated, and admitted him to the floor. Before that, Doug said to me, "Look, I know it's not easy taking care of a partner, and if you want to get someone else, I'll understand. But there's no one I'd rather have care for me than you." That's the thing: Doug and I had an amazing relationship: in the OR we clicked like we'd been doing it forever. I loved him as an assistant; he loved me. We were perfect together.

Proudly referring to himself as a "closet hick," Doug usually wore jeans, had a few acres, occasionally skipped town to buy a cow. He was tall and thin, taciturn, had an Adam's apple from which you could make an entire pie. Mostly serious, he had an occasional but fine sense of humor, was very respectful of and engaged with his patients, but less than empathetic: tough it out, he seemed to say. Now he was trying to do it himself.

Over the next few hours, Doug's pain persisted. He threw up a couple of times, so I put in a stomach tube (did it myself). Amylase levels remained only slightly up, repeat films remained non-specific, but his white blood cell count was rising. Having no clear idea what was going on, I called another surgeon for moral support, and scheduled surgery.

Closed loop bowel obstruction has a typical xray appearance; but if the case were typical, it wouldn't be memorable, now, would it? I opened Doug up and found about an twelve-inch segment of small intestine twisted around a single band-like adhesion (cf: previous post). Adhesions by far most commonly occur as a result of prior operations; they're rare in virgin abdomens, like Doug's. They can be congenital, result from a prior infection, or who the hell knows? Doug had one, and only one, and it killed a piece of bowel -- or close enough to make me afraid to leave it in. It took one quick snip to release the adhesion, but the bowel remained pretty black and motionless, so I cut it out and sewed the ends together. Piece of cake, routine stuff.

When doing his own operations, Doug had a thing about closing the mesentery after bowel resection. He sewed up both sides, instead of just one. Sewing it prevents a hole through which other intestine could slip, causing obstruction. Sewing both sides cuts down on the raw surface to which bowel could adhere, or so Doug believed. Nevertheless, most surgeons, myself included, don't take the time and don't think it makes much difference because the surface heals to smooth pretty fast. But I figured Doug'd be pleased; so I did both sides, and used his favorite suture, the old-fashioned "chromic" suture" (click the link and check out the contraindications) instead of the newer style I liked.

Doug woke up with a smile on his face. "You cured me," he said. His pain was gone; tough as nails, he was walking around, impatient to get the hell out of there, within hours. Until he started to vomit a couple of days later.

For brevity let me just say it was hell on earth. I was miserable: Doug wasn't getting better, I didn't know why, and the other surgeons in town hardly wanted to look at me in the doctors' lounge. They knew what I was going through; and if any of them was too dense to know, I was broadcasting it at 50,000 watts with every bone and muscle of my body. I couldn't sleep. I couldn't think. I got second opinions. Then Doug started to go nuts.

It's not all that rare: the combined effects of altered sleep, drugs, whatever, mean a certain number of patients will develop postop psychosis. Unlike some who go really crazy (it always clears up, by the way), Doug was just mildly paranoid. He started coming up with bizarre diagnoses, eventually became convinced he had horrible infection inside, and began to accuse me of deliberately withholding reoperation. Miserable ain't the half of it.

Early postop bowel obstruction happens sometimes, and it's one of the situations (cf: previous post) in which there's good reason not to reoperate very soon: more often than not, it clears on its own. I hung in there as long as I could stand to, with Doug getting more and more dour and accusatory, and finally I decided to re-operate. The surgeon I asked to assist didn't agree, but I thought I was right, for psychological as well as physical reasons.

Doug, it turns out, is allergic as hell to chromic suture. No reason for him to have known, since he only handled it with rubber gloves. Everywhere I'd placed it, in his honor, he'd reacted by swelling and hardening the tissues containing it. His bowel anastomosis had been puckered into a tight kink, in a way I'd never seen before, nor have since. "Well," the assistant said, "I guess you were right. This never would have opened up." So I re-did it, with my kind of suture. And before he woke up, because I feared he might not be able to eat for several more days, I inserted a special IV catheter into a vein below Doug's collar bone, to allow high-calorie intravenous feedings.

It took a few more days, during which I was pretty much a total wreck. But Doug started eating, doing well. One night I removed the IV, planning discharge for the next morning. "OK, Doug, looks like we made it," I said that morning, feeling elated in ways not felt for seemingly eons. And there it was: his right arm was swollen like a dead pig. Blood clot in the subclavian (below the clavicle) vein, no doubt from the IV I'd inserted.

Sometimes it's hard as hell, placing a subclavian IV: poking in and out, hitting the artery, causing bruising and pain. Doug's had gone in easily, first shot, like driving a scooter into a tunnel. So which is it, I thought? Push Doug out the window, or jump myself? Now he needed anticoagulation (not entirely clear, but majority position says so); of course, as a result he'd bleed somewhere, probably into his head. Or get a post-phlebitic syndrome-- uncommon as hell in the arm -- never operate again. Somebody kill me, please. Insurance doesn't cover suicide.

Well, he got better. No arm problems, no bowel problems. He brought me a bottle of wine or something one day; we never talked about his accusations. I did ask him if he thought the experience would change his attitude toward patients with problems. "Nope," he said. "Let's get to work."

Tuesday, July 25, 2006

Memorable patients: part one

I got the call from the ER because I was the "no-doc" surgeon, meaning I was the guy to call when a patient showed up needing a surgeon, and who had no primary care doc to direct the referral. Usually it meant trouble. A drunk who smashed his car and himself, possibly others. Stab-wound, gun-shot. People who don't have their own doctors include more than those down on their luck; not all of them are nice. So when the ER doc calls and starts with "You're the no-doc surgeon, right?" it raises hackles.

"Got an acute abdomen down here. Older lady, goes to Seattle for her care, comes in looking real bad." Jesus, I'm thinking. We're not good enough here for her elective care, but when the shit hits the fan, she takes a shot at anyone? Little did I know. About the shit, I mean.

Gotta admit, it's annoying. Turns out this lady had had innumberable orthopedic operations for horrible arthritis. New joints, fusions. Infections, removal of joints. So why not call her docs in Seattle, if they're so great? Such were my thoughts, having to leave an office full of patients and head to the hospital.

She was, indeed, sick as hell. Low blood pressure, rapid pulse, flushed, feverish, not entirely coherent. And her belly felt like stone: a rigid abdomen is pretty much a sine qua non of something real bad going on. No need for a lot of fancy xrays: check her cardiogram, blood work, call the OR, fill her back up with lots of IV fluids, cover her with antibiotics, get her upstairs. At her side, holding her hand, looking worried, her husband turned to me and asked "Is she going to be ok, Doc?" What an interesting thing: they chose their doctors carefully, so it would seem, bypassing us for those in Seattle. But now I'm "Doc" and instantly trusted to save her life. But that's not my point. It is interesting, however.

A simple abdominal xray had already been done, and it showed "fee air," meaning air in the belly outside of the confines of the stomach or intestine, where it ought to have been. Perforation, of something. Usually, there's no point in trying in advance to figure out the source: surgery is needed, no matter what. Sometimes there are clues from the history or physical exam: history of heartburn, indigestion, taking antacids, more tenderness in the upper abdomen, all suggest ulcer, for example. Nothing of that sort here. Because of chronic pain from her arthritis and many failed operations, she took high doses of narcotics, and was always constipated. Hadn't had a bowel movement in several days. Well, actually, she had; it's just that it all went inside.

The adult colon, if stretched out, is usually four or five feet long. In situ,which sounds, appropriately enough, like "inside you," it's like an inverted horseshoe, starting in the right lower abdomen at the end of the small intestine, heading up the right side toward the liver, turning to your left and crossing under the stomach, making a U-turn at the spleen, then heading south along the left side toward the pelvis, where it makes a corkscrew shape into the rectum. It can be pretty capacious, as Sally's most certainly had been, until it emptied itself.

Pretty rare and highly deadly as a cause of colon rupture is a thing called stercoral perforation. It means a hard piece of feces has rubbed its way right through the bowel (nearly always at the south end of the colon); a seriously bad thing. Opening Sally's abdomen, I encountered more stool than I could ever have imagined, spread everywhere: there were several enormous (what else is there to call them, really) turds, hard as rock, maybe a dozen. Swimming in no less than a gallon of liquid stool. Owners of motor homes who've had accidents with sewer hoses may have a vague idea...

The smell was astounding. The entire crew in the OR was bug-eyed. No one had ever seen anything like it, nor sensed it with pretty much all five. I filled a couple of big pans as I scooped out the solid stuff with my hands, then suctioned quarts more. (Despite the gloves, and vigorous washing many times after, my hands smelled like stool for days.) This was really bad: a huge bacterial load in an older woman who'd been in shock, portends a grim outcome. But she was hanging in there, having been properly resuscitated and maintained. Fast surgery is not always best per se, but sometimes it matters: the less anesthesia the better when a person is really sick. It's impossible safely to close such a hole; a colostomy is mandatory, getting the damaged colon out of the abdomen, letting bowel movements happen into a bag until such time as the patient is recovered and suitable for reoperation to hook things back up. So that's what I did, after irrigating the belly with about 10 liters of saline, followed by a diluted solution of bacteriocidal agent (povidone, if you care.) And closing with big "retention sutures," big and widely-spaced: not pretty, but protecting against the wound falling apart which is highly likely in such circumstances as these. Closing the skin would be asking for major infection.

The family was gathered in the waiting area, and listened silently and tearfully as I told them what I'd found and what we were up against. The odds were greatly against us, but there were no signs that we couldn't win, and we'd be doing everything we could. Expect a long stay in intensive care, under the best of circumstances.

Sally, it turns out, is an amazing woman, and became one of my favorites and a life-long patient. She never, as we like to say, turned a hair. (Where-ever the hell that comes from, it's an expression all doctors use for someone who makes an entirely unexpectedly smooth recovery.) At minimum, I'd told the family, expect several reoperations or procedures to drain abscesses, to tidy the wound. Plan on respiratory failure, maybe liver or kidney failure. Pneumonia. And this was the best-case scenario. Nada. She sailed. She was walking around on her kneeless legs in a day or two. I'm gonna take some credit here: thorough cleansing, quick operation, good postop management. But Sally, she's incredible. Nothing holds her back. A will of the hardest diamond.

Her belly is another story, or maybe the same one: it hardened, too. After six months or so, when I figured it'd be safe to go back in to close her colostomy, I encountered adhesions like I'd never seen. She hated her colostomy, and really wanted to get rid of it. As I struggled my way through, I thought a dozen times that keeping the colostomy would be better than suffering the complications of injuring the rest of her bowel to get there. But I managed to unravel the mystery without great harm and hooked her back up. She was delighted.

Surgically speaking, her life wasn't easy before she met me, and the struggle continued after. She had innumerable bowel obstructions, as she formed adhesions like they were money. Some went away without operating; some didn't. Each time I operated on her, I thought it was the worst obstruction I'd ever dealt with; the hardest to unravel, the most dangerous to tackle. Finally, there was the ultimate, and I thought I might have killed her.

Sally had come in with another obstruction (we're talking many years after we first met, by now.) As usual, I'd dragged my feet well beyond what I was taught in training ("never let the sun rise or set on a bowel obstruction," is what they told us. The worry is that whatever is kinking off the bowel could be compromising circulation, leading eventually to perforation. But there are times for clinical judgment.) After a few days of sucking on a stomach tube and high-calorie IV feeding, she hadn't improved, and had developed a low-grade fever. Drag the feet no more, doc. And as usual, it was hell in there. Just entering the abdominal cavity was a nightmare: bowel stuck everywhere, no recognizable separation planes. It's one of the most challenging and frightening things a general surgeon does.

Long story short. After spending hours moving my way into and through the abdominal cavity, and having nicked into the bowel several times ("inadvertent enterotomy," we used to call that in training, at D and C conference ((by all means, read my book to find out more)). My professor hated the term "inadvertent." Have a suction device where you're working: it means you expected it, he'd say. Good one.), I finally encountered the bowel that wouldn't budge. A loop of small intestine was plastered into her pelvis, fat as a salami, but thin and fragile as the wet toilet paper she'd have used the day I met her, if things had been different. Having switched all her care to my clinic, she had a new doc (excellent guy. My own doc) who had her on a new regimen for her constipation. Unfortunately, all the fiber she'd eaten for the past days had congealed in that one loop of small bowel, and it was going nowhere. I simply didn't think I could get it out of there without irreparably damaging the bowel, and, if I did so without the ability to work my way beyond it, and given the general immobility of the rest of her swollen and thin and surgically damaged intestine, I could imagine an insoluble (like the fiber!) problem. So I bailed. I found a loop of small intestine above the blockage that was barely mobile enough to bring out, and made a loop ileostomy, hoping it was downstream enough (no way to tell, given the tanglements and adhesions) that it wouldn't be a high-flow faucet. I told her husband in the waiting room that I wasn't sure it would work, I thought she might leak from everywhere, and she might or might not be able to eat again. Having operated on her several times, by now he never questioned a thing I told him.

Longer story short. She couldn't eat without flowing out her stoma like a river. I installed a special IV feeding line, and arranged for her to hook up at home, at night, so she could be up and around during the day. We waited for months. Eventually I took an xray by squirting dye through the south side of the loop: the fibrous obstruction had auto-digested, and the pipes were clear. Could I close the ileostomy? Was it possible to cut it loose from the abdominal wall, mobilize enough inches to work with, and safely close it and drop it inside? Would I try? Should I?

Yes yes, yes, and yes.

Sally called frequently over the next many years, came in often. Always wearing shorts, showing her scarred and stiff legs. Always trusting, always pleasant, often just wanting a laying on of the hands and a reassuring word. I knew and cared for her for years, until her recent death for unrelated reasons. Her husband was always with her, always telling me how they'd never have gotten along without me. No doc. What a day that was.

Sunday, July 23, 2006

On the bandwagon

Other than during training, when we were investigating a weight-loss operation now abandoned, my experience with bariatric (weight-loss) surgery has come during my recent semi-retirement. As mentioned in my last post, I'm exclusively assisting on laparoscopic surgery, and it happens to be with a group of bariatric surgeons. By osmosis, I've become more knowledgeable in the field than I was in my own practice. And I'm here to tell you: I've become a believer in the value of bariatric surgery in the right circumstances, and if I were to have it myself or recommend it to another, I'd unequivocally recommend the laparoscopic adjustable gastric band ("lap-band.")

For the sake of brevity, and my previously admitted laziness (as well as a so-far less than easy relationship with the intricasies of this blogging stuff) I won't get into the indications or the "morality" issue of weight-loss surgery. Let's just talk about mechanics.

Although there are a few variations, two main options are out there: gastric bypass and lap-band. Both are typically done laparoscopically, meaning via several very small incisions through which a camera and very cool instruments are passed. The former involves stapling off a big chunk of the stomach, re-plumbing a segment of intestine, and attaching that segment to the small gastric pouch created by the stapling. It works by restricting intake by way of the small pouch, and by creating some degree of malabsorption (reducing the intestine's ability to absorb food) by short-circuiting a portion of the bowel. The latter works by restricting intake only, by means of squeezing off the top of the stomach so there's only room for a small amount at a time.

Hormones are at work, as well. Recently discovered, it's now known that the stomach produces at least one and probably more hormones that send a signal to the brain when it's full. In fact, bariatric surgeons may end up on the streets selling pencils if the pharmacology of those guys gets fully worked out and becomes manipulatable by drugs. Interestingly, messing with the stomach in either of the bariatric procedures may invoke hormone production that tells the brain the stomach is full when it's not. Neat-o!

So why the band over the bypass? (Coincidentally "band over bypass" is an operation we do not rarely: meaning banding a patient who's failed to lose weight or to maintain weight-loss after bypass.) Simply this: it's faster, cheaper, safer, and equally as effective. The weight-loss is slower, which some people see as good, others as bad. But at a couple of years it's the same. And the malabsorption of bypass means that many patients need forever to take various supplements; bandees don't, because they can eat and absorb pretty much all foods, just less of them. To me, the main thing is complications: no operation is free of them, and in obese people there are certain irreducible -- if generally predictable and therefore manageable and usually preventable -- risks, especially as relate to anesthesia. But surgically speaking -- which is what I purport to do -- the complications of bypass are far greater, if they occur. When you cut and staple bowel and stomach, the big worry is leakage. A bad thing when it occurs. Using a band, nothing is cut or stapled, so leakage is really extremely remote. Band complications are pretty rare, and generally not life-threatening, and are easy to fix. And -- at least where I work -- the band procedure can be done as an outpatient operation. Quicker recovery, significant cost savings. Admittedly, it takes excellent anesthesia management, which I witness every time I'm there at the practice. Hard for a surgeon to wax laudatory about mere anesthesiologists, but there it is: they're great.

Doing justice to the subject would take a post much longer than most people would like to read, is my guess. But let me finish with this interesting revelation: I used to voluntarily post medical answers on a couple of online forums. On one, I ventured into this subject, trying to give useful information to people interested in all forms of weight-loss surgery. In some context or other I made the prediction that in a few years, bypass would be a thing of the past, because of what seem to be obvious advantages of banding. Yikes! You'd think I'd advocated baby-killing. Turns out, it's like religion out there. If you've had one procedure, it's like being a Yankee to another's Red Sox. You'd think I'd have learned a lesson.

There's an article in today's (7/24) New York Times about the high rate of complications of bariatric surgery. As usual in such articles, no distinction is made among the various forms of surgery. But it's pretty easy, in reading the article, to see that they are talking almost exclusively about bypass surgery. Res ipsa loquitur. As the Stones once sang, "Ti-i-e-imes is on my side, yes it is..."

Wednesday, July 19, 2006

Global warming: an inoperable truth

Here it is: It came to me yesterday, in the operating room. Surgeons are the cause of global warming.

My practice now consists entirely of helping with laparoscopic surgery, in which operations are carried out via very small incisions in the abdomen, through which long thin instruments are inserted, along with a camera with a tiny lens. In order to see what we do, the abomen is inflated with gas, which separates the abominal wall from the organs it covers. And the gas we use? Carbon dioxide, released into the air during and after the operation.

Is it coincidence that global warming is accelerating at exactly the time that such surgery is growing at expodential rates? I don't think so. In fact, I might just publish a paper on it. As Orac has shown us, there are medical journals out there that'll print it up for me.

Amazingly enough, I had the solution during the peak years of my practice, but no one listened. If I were a better marketer (buy my book, by the way) I could have saved the world.

Cholecystectomy ("chole" = bile; "cyst" = bag; "ectomy" means removal. So we're talking removal of the gallbladder) is among the -- if not at the top of the list of -- most common operations. Must be at least a million a year done on the planet. During my years in training, cholecystectomy was done through very large incisions. Over the years in practice, I began making smaller and smaller incisions, until I was able to remove most gallbladders through a single one-inch (ok, occasionally one and a half; rarely two) incision. It was around the time I got that small (surgically speaking) that laparoscopic surgery came around, and revolutionized the operating room. I'm the first (well, the fify-thousandth) to admit it's been a good thing and that many operations are much better when done laparoscopically. Cholecystectomy, in my less than humble opinion, ain't one of them. Assuming all the surgeons doing it could be equally well taught to do it "mini" instead. In brief, mini-cholecystectomy, the way I did it, achieves the same results in terms of pain, time of discharge, and return to work. I did the extreme majority as outpatient procedures. The main difference: cost. To the tune of a couple of grand per.

There was a great study done a few years back in England. Natch. In it, neither the patient nor the surgeon knew ahead of time whether the operation would be a "lap chole" or a "mini chole." After the patient was asleep, he/she was randomized to get one or the other; a large bandage was slapped on everyone, hiding whether there was one mini-incision, or the four or five port-holes of laparoscopy. Not the patient, the recovery room nurses, or the floor nurses knew which had been done. The patient was given ad-lib pain medication, and ad-lib discharge, ad-lib return to work. No difference. Except in cost, signigicantly favoring mini-surgery. And get this: the typical "mini" incision over there, for the study, was 5-7 centimeters (2-3 inches), as opposed to my smaller ones. (Actually I'm pretty sure it was 7-10 cm, but I'm too lazy to look it up. In any case, the incisions were bigger than mine, which means if my patients had been in the study, maybe [can't say] the pain scores would have actually favored the mini.)

For a variety of reasons, I lost the war. Surgeons don't want to learn the mini-operation (it's harder than lap-chole). Outside of my area and a couple of others, patients don't hear about it, while lots of companies make wonderfully engineered equipment and make lots of bucks selling it for laparoscopy. It's beautiful stuff, no doubt about it, even if it costs a bucketload and gets to the landfill after use. So of the half-million or more gallbladder operations done every year in the US, nearly all are done with the scope. And carbon dioxide. Leaking into the atmosphere.

The list of abdominal operations done laparoscopically grows: hernias, appendectomy, colon resection, pancreas surgery, etc, etc. The jury, as it were, is still out on whether it's actually an improvement in many of those instances. My opinion: it's clearly better for hiatal hernia repair and for gastric banding for weight-loss. For the others, it depends on whom you read, and on how skillful the surgeons are at the non-laparoscopic alternatives. Don't quote me, but I'd say many operations are done laparoscopically for the same reason a dog licks his privates. But do it they do; more and more and more....

Meanwhile, gas escapes, in nearly every hospital, round the clock, round the world. The planet warms. And it's clearly the fault of me and my fellow surgeons. Sorry about that.

Monday, July 17, 2006

Ding ding

We doctors have come a bit late to the accountability game. There are lots of reasons, I suppose, not the least of which is that it's very hard to come up with meaningful parameters. And comparing one case to another is fraught with difficulties: no two are exactly alike. Nevertheless, it's laudable that attempts are being made. And yet...

The WSMA (Washington State Medical Association) Newsletter arrived today. In it was an announcement of a new program for quality improvement. Primary care docs (another reason I'm glad I'm not one) will be receiving "registries" which will contain patient names, conditions, treatments, and those treatments will be compared to "best practice" guidlines. Sounds good? Sort of. It's a good concept. Fact is, at the end of my book (hawk, hawk) I bloviate about things needed to fix healthcare, and one of them is figuring out why some docs get better results, and spreading the word. But there's a catch. It's the old "garbage in, garbage out" thing. I note from the Newsletter that the guy running the program is a former partner of mine. Think I'm going to email him with this story:

A few years ago, in preparation for a visit to the hospital by the accrediting folks, our medical director had records reviewed for "dingable" items: such things as untimely dictations of op notes, histories, discharge summaries, etc. Delayed discharges because of failure to order tests on time. Now I happen to be among the most compulsive people on Earth when it comes to such things. My desk is a mess, my shirts (what few I have) are wrinkled, but my charting is perfect. I go to the record room every Monday to sign my charts; I dictate everything exactly when it occurs. I make rounds so often the nurses get sick of seeing me; when things need doing, I get them done. So I figured the data accumulated in this little pre-inspection test run would show me in a most shining light.

Most of the staff had zero or one ding. A few had two. I was among only a couple with four fouls. Mortified, horrified, I tracked down the medical director and demanded to see the charts (there were no specifics in the report, only the number of transgressions.) Calm down, he said. It's only a dry run. No one will see it. Oh yeah? I growled. Someone typed the damn thing. At least a few people in medical records think I'm a bad guy. I want to see the charts.

He hemmed and humpfed. He said the data were good. Each chart had been looked at by three people. If I had dings, they were real, and they were mine. He said.

If you knew me well, you'd not be surprised at how upset I was. It took me days to harass the director into ordering the record room to cough up the charts. In doing so, he again said I was being ridiculous, and that I'd find it was accurate. Any guesses?

Every single one of the instances involved a trauma patient I'd admitted (the general surgeon is the captain of the trauma team: guy breaks his ankle and nothing else, he might go straight to ortho. Breaks his ankle and has a pimple, it's a trauma team thing, and the surgeon gets called.) In each case, as per protocol, I'd eventually signed off when the patient was stable and down to a pure ortho problem, and the chart issues were ortho's. But I was listed as the admitting doc so the strikes went to me, and none of the three reviewers had noticed.

Not a big deal; not even a great example, perhaps. But the point is this: hospitals get nailed because of mortality rates. Docs get nailed because of failure to do this or that. It's all based on data collected ex-post facto from charts. And it's frequently wrong.

Some docs are better than others. It stands to reason, and it's true. But getting a real handle on it -- establishing meaningful, useful, helpful, reproducible parameters by which to judge -- that's not easy. So we've settled, so far, on pretty mundane things. For surgeons, it's whether pre-operative antibiotics were given on time; things like that. Not insignificant, but hardly as important as choosing the right operation, doing it at the right time, and preparing for it and carrying it out properly. So despite a crying need for real quality monitoring, docs will be increasingly subject to very specific data-gathering which will inevitably contain lots of fallacious data and which will widely miss the mark, where the aim is not to harass but to lead to improved care.

It's a start. It's needed. But (another reference to my book) we need to keep our eye on the doughnut and not the hole. It'll take people smarter than me to find the right methods. As it is now, it's like judging your skills as a car owner and driver by whether you keep the tires properly inflated. Not irrelevant; hardly comprehensive.

But if they want to know how to take out a colon in 45 minutes and get the patient home in two days feeling fine, they only need to ask.

Saturday, July 08, 2006

Hard case

"I just want you to know," she said, "I hate surgeons. Surgeons have mutilated me. I don't want to be here." This was before I had a chance even to say hello. I'd flipped through her chart (Darlene G., her name was) before entering the exam room, opened the exam-room door, and walked in as usual, hand extended to introduce myself. This took me aback abit. Thought one: turn around leave, let the referring doc know, and move on to the next patient. Thought two: I'm not the usual surgeon. Rapport R Us. I can overcome this and hear what she's really saying. So I stayed.

Darlene G. was a mammogram referral, one of many I saw every day. She'd had a regular followup study for her previous breast cancer, treated elsewhere by lumpectomy and radiation, along with hormone therapy. Her initial cancer had been detected on mammogram, by the finding of small calcium deposits: the way mammography is most useful and life-saving. That's the good news. The bad news is that lots of things can cause small calcifications in a breast, and by far the majority of them are harmless. So deciding which deposits look suspicious is the key thing.

Calcifications show up as tiny white spots on a mammogram. They come in a wide variety of shapes, sizes, and patterns. Some can be quite confidently recogized as harmless: round little dots, for example -- almost certainly insignificant cysts. Others raise major alarms: clusters of variegated shapes and sizes, irregular. The former can, under most circumstances, safely be ignored, but the latter need investigation. And there is a broad range of "indeterminant" patterns: not highly suspicious, but not clearly innocent. Unfortunately, those represent a big chunk of the types we see. Since most of these things are not associated with a feelable lump (which is why, in part, when malignant they are associated with highly curable stages of cancer), sampling them for microscopic investigation requires the help of a radiologist, in one of two ways. Using xray guidance, a radiologist can place a thin wire with its tip at the area of concern, which the surgeon can then use to lead him to the target, doing an open (surgical) biopsy. Or the radiologist can do the whole thing herself (I'm switching "him" and "her" here randomly, to be sexually neutral -- making no insulting assumptions of who joins what profession...), using a quite clever stereotactic setup which three-dimensionally lines up the target area and fires into it a broad hollow-cored needle, taking a sample in the process. Choosing one over the other technique is a matter of several factors. Maybe later...

The radiologist who read my patient's current xray reported that there was a cluster of indeterminant calcifications in the previously treated breast which, in comparison to a prior xray, had increased in number. Biopsy, according to the radiologist, was recommended.

There are about a dozen difficulties here, not counting the verbal assault I'd received. First of all, I hate it when a radiologist recommends therapy. It boxes me in. I want a reading, an interpretation, a diagnosis when possible. Leave the surgical decisions to me. I've had many a go-around with individual and grouped radiologists over this. Suffice it to say, there's disagreement. As to the rest of the difficulties: a breast that's been injured, whether by surgery, radiation, or other trauma is prone to forming calcifications. It's what happens, quite often, within damaged tissue: part of the injury response leads to calcium deposition. In some areas of the body -- bone, mainly -- that's nice. In the breast, not so much. So seeing calcifications in a post-treatment breast is hardly a rarity, which is exactly the problem. This lady had three reasons to have increasing amounts of calcification: surgery (she'd had to have several, which is the "mutilation" issue); radiation; and, of course, a history of cancer.

After listening to her villification of her previous surgeon, and trying my best to establish a level of trust, I showed the xrays to Ms G. Indeed there was a cluster of calcifications, and whereas they were not highly worrisome to my eye, we had the report that they had increased in number. Making matters worse, the old films, to which they'd been compared, had already been returned by our xray department to the out-of-town hospital whence they came. The lady was infuriated by that news, and directed her fury at me -- who'd had nothing to do with it. I told her we could certainly retrieve the films; but meanwhile, the operative (to coin a phrase) issue was the report that there'd been an increase in the number of calcifications. And, I told her, it seemed that that was an objective enough finding that we could rely on it, despite being able to confirm it ourselves. That, it can be said with clarity, did not assuage her.

I went on to tell her that given her history of cancer which had been associated with calcifications, and given an increase in number currently, the option of observation would be a hard choice: one can safely observe in many situations. But what one is observing is stability. When the area is not stable, observation stops making sense. So, I told her, I felt under the circumstances a biopsy is what I'd recommend. Having the radiologist's recommendation of biopsy further mitigated against a non-surgical approach. Absent that, and given the relatively innocent nature of the spots, I might have considered a repeat exam in three months or so. The lady's anger made things worse: was she going to hate me more for falling into her view of surgeons -- namely a thoughtless cutter -- or if, unlikely as it might be, the area turned out to be cancer after we delayed a diagnosis.

Next question, she asked: could a stereotactic biopsy (the above-mentioned core needle) be done. I doubt it, I said: her breasts were quite small, the operated one distorted, and the area was close to the chest wall, which makes that technique difficult and often impossible. Well, if the wire-guided technique, could it be done under local? I frequently do them that way, I said. I've even done them, when I had reason to be very confident about the ease of wire placement (a poorly placed wire can make for a very difficult operation. There've been times when I sent the woman back to xray for a re-do, rather than risk missing the target), in my office.) But, I told her, in her case I'd want to do it with an anesthesiologist available, because placement might be more difficult due to her scar tissue; and scar tissue can sometimes make filling the area with satisfactory levels of local anesthetic. None of this was what she wanted to hear.

I can't do justice to the tension in the room. I'd asked my nurse to be present during the exam (for reasons of efficiency, and certainly against the advice of any attorney or insurance agent, I didn't always do so. Only when alarms went off. Never had reason -- dumb luck probably, infallible judgment maybe -- to regret that modus operandi.) Now my nurse was long gone. I'd have melted, if Darlene G's eye-beams were generating heat. She stormed out of the room, huffed past my nurse, glared her way through the waiting room, and was gone. Next I heard from her was in the form of a complaint filed with the local medical board. Unnecessary surgery, she claimed, along with an unnecessary anesthetic. The fact that I'd only offered an opinion didn't dissuade her from filing her complaint, nor, of course, did it stop the board from initiating a (short-lived) investigation.

In my practice, it was typical to see ten women a day with breast issues -- couple of thousand a year, for around 20 years. I saw countless lumps, xray abnormalities, vague and dire situations. I was comfortable choosing observation over operation in more situations than the average surgeon, by a long shot. Because I was scrupulous with followup, and with data-gathering to justify the approach. And I made sure patients were totally comfortable with whatever approach we chose, and I emphasized that no plan was carved in stone. If a woman went home comfortable and woke up worried, she should let me know immediately. In all those years, and in all those cases, that was the only failure of communication, the only complaint. It was a number of years ago.

And it still bugs the hell out of me.

Monday, July 03, 2006

Love Note to a Scrub Nurse

What better way to begin the surgery part of my surgical blog than with a love note to a scrub nurse? A scrub nurse is one who participates directly in the operation, setting things up, passing instruments, and, with luck, adding her (usually its a "her") thoughts to the proceedings. She can make a huge difference in the flow of things, raising it to an art-form. So here's an excerpt from my book, in which I try to make that point very clear. It begins as I find myself on the neurosurgery rotation, early in my training:

Esoteric and tedious, neurosurgery impressed but didn’t attract me. Charlie Wilson, however, amazed me. Chairman of the department, he radiated enough energy to power the place had the lights gone out. A marathon runner before it became widespread, he spent the rest of his time at the hospital, all hours, day and night. He was a superb operator, tackling brain tumors others refused, getting results far better than expected. He looked you right in the eye, drilling the truth in deep, exuding understated confidence. Patients came from all over the world, handing him their brains.

One of the neurosurgeons looked like an alien, come to Earth to help us, if allowed to breathe methane. He did all his cases with a self-designed, fully enclosed mask, dangling two exhaust hoses over his shoulders and down his back. As he meticulously
attended to bleeding, one corpuscle at a time, his operations took hours longer than anyone else’s. But they said he’d never had a post-op hematoma (blood collection), never an infection. Of course not: any bacterium that wandered into the wound would
have died of boredom or starved to death.

In a world where looks matter, kids with craniofacial abnormalities are screwed. When their facial bones and sections of skull fuse prematurely, or grow in the wrong direction, some are so disfigured you want to look away. A French surgeon, Paul Tessier, had developed a spectacular and wondrous approach to such problems, doing operations that lasted twelve hours and longer— unroofing the entire top of the skull, cutting out cubes of bone containing the eyeballs, moving them outward, rearranging entire sections of facial aberration that formerly had been set in stone. One of the neurosurgeons at UC had gone to Paris to study with Tessier and brought him back to San Francisco to put on a clinic. I didn’t have the time to watch an entire operation, but what I saw has stayed with me.

Dr. Tessier brought his team with him: an anesthetist, a tech, and a scrub nurse. It was the pas de deux performed by Tessier and his nurse that opened my eyes and dropped my jaw. As he sat, focused like a cat on his work, he’d raise a hand wordlessly and his nurse would give him an instrument, which he’d bring to the field, work for a moment, then pass it back and receive another one. Never a hesitation, never a wrong move, it flowed like a ballet, musically, the noblest art humans can create among themselves. Still clumsy, I could nevertheless recognize perfection. That, I thought, is what it can be, what it must be to do surgery. It’s a rarity. Few surgeons get to do the same thing over and over, in the same place, with the same team. Instead, it’s night shift, day shift, one hospital, two or three. You try to find the rhythm, to get a flow going, with you, your assistant, your scrub nurse all knowing what’s coming, facilitating, cooperating. In a tough spot, you want to maintain focus, not moving your head, keeping the area you’ve just exposed perfectly in view. Hand out, wanting the right tool slapped in smartly, you don’t want to fumble for it, nor lose sight, nor have to reposition the instrument; boring in, you try to keep it going, saying, “I’ll be using a long Allis next.” But instead of getting it you hear, “Sue, can you get me a long Allis from central supply?” “Geez! This is a low pelvic case. I always use a long Allis.” “Sorry doctor. I usually scrub ortho.” Screech. Nureyev drops Fonteyn on her ass.

I’ll divert to the present long enough to say that in my practice I got close. My clinic hired away the hospital’s best scrub nurse, Joanie Thompson, and I worked with her on most of my cases. When I did, we were a hell of a team. She knew. She always had what I needed. When I’d want an instrument different from what I typically used, Joanie had it before I asked. “I’ll need a longer needle holder, and mount it backwards.” Whack, into my hand, the suture perfectly placed in the jaws. “And make it snappy,” I’d say, after the fact. The pleasure from an operation allowed to flow, where every step follows logically from the last, where each move is fluid without stops and diversions, is transcendent. It restores the soul. It makes you want to sing, which I often did. Joanie told me the best thing I ever heard as a surgeon: “You make this look so easy,” she said. She became an RNFA (Registered Nurse First Assistant)—in fact, she’s a national force in making that occupation a reality; she’s just as good an assistant as she was a scrub. But I always missed having Joanie pop an instrument into my hand, the right one, at the right time, making music.