Breast cancer: some basics

Based on comments, I'd say readers of this blog are pretty sophisticated; so at the risk of boring some, and before flying off in various directions on the topic, let me establish a few basic breast cancer bits.

First, the most basic of all: what is cancer? Most all of the tissues in your body have a cycle of life and death, as cells die off and are replaced by new ones. This is especially true of surface cells, like skin and those that form inner linings: glands, guts, various tubes. Different cells have particular rates of division and reproduction, timed exactly to replace those that die off: dandruff is proof of the process, if you need any. For a few reasons, a cell may mutate in such a way that it loses the control of the replication rate, dividing more rapidly than needed to replace its cousins. The cells formed in that division process have the same misinformation, and the process continues, producing a cluster of cells: a tumor. If that tumor grows slowly and stays where it started, we call it "benign." If it grows more rapidly, and especially if it develops the ability to invade through local barriers and into blood and lymph vessels, by which process it can spread elsewhere, we call it "malignant" -- cancer (or "carcinoma.") Cancer carries the name of its organ of origin, no matter where it ends up: breast cancer means cancer that started in the breast. If it spreads to the liver, it's still breast cancer, not liver cancer. In the breast, there are two main cell origins: the ducts through which milk flows (from which arises the most common form: ductal cancer), and the glands (lobules) that produce milk (from which arises lobular cancer.) Behavior of the two is slightly different, but the treatment is essentially the same (lobular may grow a little more slowly, but has a greater tendency to occur in both breasts.) There are a couple of rare types; and there's the whole issue of cancer in its most early -- and theoretically 100% curable -- form, ductal carcinoma in-situ. (DCIS -- an entire treatise in itself. Maybe, at some point...)

The goals of breast cancer treatment, from a surgeon's point of view, are two. The first is to eradicate the cancer from the breast, and the second is to get information about how far it might have spread from the breast, mainly by removing some regional lymph nodes for analysis. Many changes have occurred in the achievement of each of those goals.

If a breast has a cancer in it, there's a significant chance some cancer cells exist elsewhere within that breast. If the only treatment were to remove the cancerous lump, many women would in fact be cured; but at least thirty or forty percent would have recurrence. Since there's no way to determine with certainty when a woman might be in the first category, the entire breast must receive treatment. (I've seen many a frail and very elderly woman for whom I felt it best simply to remove the lump -- often in my office under local anesthesia -- perhaps adding hormone treatments (more later on that subject), and following along, expecting another of life's end-games to play out before the cancer ever would. But those are very individual cases.) As I said in the previous post, until around thirty years ago, breast treatment meant removal, usually by radical mastectomy. Over time that most radical operation was modified (known now as the "modified radical mastectomy"), still involving removing the entire breast but leaving enough skin to close the incision, and leaving the muscles on the chest wall. It's significantly less disfiguring and disabling, but still is complete removal of the breast.

The other option is to remove the cancerous lump with a rim of healthy tissue around it, and to treat the remaining breast with radiation. As both surgical and radiation techniques have evolved, the cosmetic results are usually excellent (as opposed to my description in the previous post), and the local control (meaning absence of local recurrence) approaches (but does not quite match) that of mastectomy. There are a few situations that mitigate toward choosing mastectomy (multiple or very large tumors, mainly) but for most women, how the breast is treated is a matter of personal choice. Some readers might be surprised to learn that many women prefer breast removal to breast preservation. And like many other emotionally charged issues, the choice has become complicated by factors beyond such simple matters as cure and personal comfort.

"If your surgeon tells you you need to have your breast removed, find another surgeon," says the woman who's the subject of my previous post. Said, more properly. No longer says. Took her a little longer to get it. What's wrong with that recommendation is that, first, there are a couple of situations for which there really is no option but removal of the breast. I'll get to them eventually. Second, some women simply don't want the stress of worrying about what's going on in that remaining breast. Many women have had lots of lumps and lots of biopsies before developing cancer. Surgery and radiation can cause lumps and mammographic abnormalities which change over time and which may require biopsies to be sure what's going on. Some women simply don't care that much about that aspect of their appearance (I've always thought, paradoxically, that that was the most liberated view of all -- the opposite of the "women's movement" argument). Or they elect peace of mind over concern about some aspect of appearance. It can be a strange thing: when a woman chooses mastectomy, there's an assumption on the part of some folks that either her surgeon is an idiot or a pig, or that she's in some way falling short of her obligations to.... to whom, exactly? It complicates things, sometimes.

It's another paradox: much as it's a step forward in healthcare that people are taking more and more charge of their medical decisions (the days of the god-like doc telling a patient what will happen and expecting no questions are happily and long gone) there are times when choice ain't all it's cracked up to be: when faced with a deadly disease, many people want someone to take charge and tell them what to do. It's a copout, in my opinion, when a doc basically tells a person, well we could do A, B, C, or D. Let me know when you make up your mind.... I think it's a doc's obligation fully to inform, lay out the pros and cons of the various options, but also to state an opinion of which is the better choice, if that doc has such an opinion. For breast cancer, I'd get asked for my opinion very often; and in most cases I'd honestly say I thought the options were equal and that it really came down to which the person felt, at her core, would make her most comfortable. When there were specific reasons why I thought mastectomy was safer, I'd say so. And when I thought there were reasons why lumpectomy and radiation might produce a less than satisfactory cosmetic result, I'd say so; likewise, when I thought post treatment surveillance would be an issue. I ended up doing a fair number of mastectomies: whether that reflected an unconscious bias on my part, I can't say with certainty. Twenty years ago, when the data were young and the radiation treatments were less reproducible, I'd have to say yes. In recent times, I don't think so. I know I had no problem with women choosing preservation in the vast majority of cases. But if it were me, or my wife -- and as a male person I happen to be among those that deeply loves the female form, visually and tactilely -- I'd start with the idea mastectomy (for its lowest chance of local recurrence, for avoiding the hassles of radiation, for simplicity of followup) and work back from there. For a small tumor with favorable parameters (guess that's another thing we need to get around to, eventually) it would probably seem like overkill. That's just for the record, since this is a personal blog. It in no way means women who choose otherwise are making a poor choice; not one bit, whatsoever. And my wife would make up her own damn mind, thank you very much.

We still haven't talked about lymph node testing. That's next, among other things.

Breast Cancer; prologue

Driving to the hospital on a Saturday morning several years ago, I was listening to NPR, which happened to be airing a discussion about breast cancer. One of the panelists was a woman surgeon with whom I was vaguely familiar; in fact, it's possible she sewed me up once. While training in San Francisco, in an incident well-documented in a certain book I'll not specifically hype (just this once) I suffered an intra-operative cut to my finger, which necessitated a trip to the ER for stitches. At the time, some surgical residents training at Beth Israel in Boston spent time at our trauma center for the unique experience (their boss had trained at UCSF; plus it's well-known there're no training programs in Boston that compare with mine....) I've forgotten the name of woman who sewed me up (and did a fine job), but I know it was one of those residents. And I know that the NPR panelist had done time in that capacity while I was there. I'd been grateful for the repair work. What I heard on the radio pissed me off royally.

"The only reason mastectomy was invented," she proclaimed, "is that men like to mutilate women." I managed to maintain control of my vehicle while screaming at the radio. "You shameless bitch," I shouted. "If you really believe that, you're too stupid to be a surgeon. And if you don't, you're a unprincipled self-promoting whore. Ever hear of penectomy? Know how debilitating prostatectomy can be? The reason mastectomy was invented was that at the time, it was the only thing that had ever cured breast cancer. The reason we do those gross things is that gross is all we have. We're still Neanderthals. You unrepentant hack." Or something subtle like that. I heard her and her shtick several times in several venues over the next couple of years. It made her famous, and probably rich. To her credit, I'll acknowledge she used her fame and fortune to produce an excellent book on breast disease, and eventually dropped the man-hating drivel. I'd Love to tell you her name.

When it comes to cancer treatment, we are indeed Neanderthal, compared to the ideal, and to how it'll surely be in a few decades. It's because of two most major failings: first, we have no way of knowing, for a given individual, how much is enough to cure a cancer (and the converse: we can't tell which tumors aren't going to be cured -- even when they fall into a favorable catergory -- no matter what treatment we apply.) Second: we don't have the proverbial magic bullet -- a therapy that will kill every single cancer cell, and spare everything else. With rare exceptions, non-surgical treatments -- drug therapy and radiation therapy -- can't distinguish between healthy and deadly cells. They work in proportion to the rate of cell division; and cancer cells divide more rapidly than normal ones. But that's why they cause side effects: they kill good cells along with the bad. Just in smaller numbers. And surgery -- like radiation -- only goes where it's aimed, and we have no way of being accurate enough only to remove malignant cells while leaving everything else behind.

We have good data about responses of large numbers of people. But there's a spectrum, of course; which means that we can't avoid the fact that we will over-treat some people, giving them side effects they didn't need (or remove too much or too little), and will under treat others. Some would have been cured had we done less than protocols require: some will die no matter how favorable their situation appears. Before radical mastectomy was invented, by William Halstead in 1889, women who got breast cancer pretty much all died.

Simply stated, the idea of surgical treatment of any cancer, when aiming for cure (as opposed just to biopsy or palliation), is to remove the entire tumor with a rim of healthy tissue around it, allowing enough room to include possible locally migrating cells. And it also means taking adjacent lymph nodes from the region likely to include those to which the tumor might also have spread; hoping, of course, that the surgery is being done before spread has already happened beyond the limits of the operative field. In the time of William Halstead, there weren't mammograms, women didn't do self-exam, and decorum meant that a gentleman (doctor) didn't touch a woman's breasts for routine checkups. So by the time attention was actually given to a breast cancer, it was likely to be huge.

The fact is that radical mastectomy was the first procedure to come along that actually cured breast cancer. It was a huge deal: enormously disfiguring, and significantly debilitating. I'm old enough that I watched a few being done, and even did some. I always found it horrendous. One of the surgeons who taught me had a specially-made, highly polished oak plank with which he levered the patient's torso off the operating table, still asleep at the end of the operation, in order to wrap her round and round with compressive bandages, tightly tethering her arm to her chest in the process. After the wrap -- which by immobilizing the arm ensured a long hard rehab -- we'd lower the woman back down and slide the board out of the bandages. Later, we'd begin daily dressing changes and re-wraps, after inspecting the skin graft for viability and likely avoiding the stunned eyes of the patient. Yes. Skin graft. The operation entailed removing the entire breast along with all its skin, and the two pectoral muscles; and extensive removal of the lymph nodes under the arm. The edges of the wound were too widely separated to re-approximate, so a skin graft was fashioned from somewhere to cover the ribs, which were exposed from the dissection. The effect was indeed mutilating, and the loss of the pectoral muscles, along with the lymph node dissection ensured that the arm was weakened and swollen. But until around the 1970s, the only alternative was death. Rather than some sort of perverse vendetta against women, it was done because at the time of its invention, nothing but radical mastectomy had ever worked on the gross tumors that were typical at the time.

Big changes were occurring by the time I was learning my craft, inspired in large measure by the realization that breast cancers were being discovered smaller and earlier every decade. In France (of course, it would be France) preservation of the breast using radiation treatments was being tried. I saw a woman who'd been among the early subjects: her breast had been cooked hard and brown, and was like a piece of wood on her chest: as different from the other as a rock from a pillow. But she was happy with it -- compared to the alternative, it seemed a fair trade. Surgically, mastectomy was being modified to a less radical form: more skin was left, so it could be closed without a graft. And one or both of the pectoral muscles were being left in place: cosmetically it still left a flat chest, but it was a human one, with contour and function, as opposed to bare ribs. Lymphedema (swelling of the arm) was much less common (but hardly eradicated), as lymph had channels in those retained muscles through which to flow from the arm. With no chain of patients, no long experience with treatment failures, I could be open-minded. But my mentors were of the prior era; for years, they'd seen it as it had been. Big tumors. Local recurrence. One and only one way to treat it. Is it a wonder that they'd be skeptical? Or, more correctly, worried about doing lesser operations when the data were young: when the price of failure was losing someone who might have been saved by the "old ways?" In my transitional time, in my arrival on the scene as things were changing, I could see it their way, without malice. That lady on NPR, she was of my time. Why couldn't she see it, too? Why cast it in such venal terms? But heck with her. It's a complicated and interesting subject. Let's talk some more, later.

Interlude

While gathering thoughts on my planned series on breast cancer, allow me a brief interlude. I had reason recently to recall something of interest:

My wife is the oldest of nine kids, and all her siblings live within shouting distance. As a result, I've been to many a graduation of many a niece or nephew. Always I find myself not particularly looking forward to them, and always they turn out to contain pleasant surprises. Since it involved graduation from U Dub (as we like to call it), a huge university, I was particularly not happy about going to see my niece graduate, a couple of years ago, with her degree in marine biology. To my great relief, her group had their own ceremony, in a friendly little auditorium. And the speaker turned out to be Jonathan Raban, a British writer now living here, who's written novels and non-fiction about the sea. In his buttery British voice, ennobled by the accent of the erudite, he gave a wonderful talk on mankind's relation to the sea, as manifested in literature; beginning with the myth of Narcissus falling in love with his reflection, and ending with (natch) Moby Dick, he delivered an enrapturing talk. I spoke with him afterward, which only added to the joy of the day.

More recently, we watched a nephew graduate from high school. The speaker was the district superintendent who, we all knew, had only recently recovered from life-threatening illness. He spoke candidly about it, in gripping prose, to a silent and barely breathing audience, telling us what he remembered, and what he'd been told. Suffering a perforated colon from diverticulitis (a condition with which, as a general surgeon, I'm all too familiar) he'd gone on to multisystem failure, was on a ventilator in intensive care for weeks, had been given last rites, and his family had been advised to collect anyone who'd want to arrive for their final goodbyes. He told us of vague memories of conversations around him, about sensing and trying to make peace with his imminent death. And he closed with this (more or less): "I've been through something I hope none of you will have to endure. I've seen life in its frailty and death in its inevitability. I've learned things about myself, and about life itself, and I'm in a unique position now -- for which I'm eternally grateful -- to pass a lesson on to a group of wonderful eighteen year olds as they approach adulthood. This I tell you from a perspective most will never have. If there's one thing I would have you know -- one thing I hope with all my heart that you'll carry with you through your lives -- it's this......... EAT LOTS OF FIBER! Good luck, and congratulations."

Book report

Well, for anyone who's interested, the reading actually went pretty well, in that several (well, around a dozen) people showed up to my reading. And they all bought books, which tells me they liked what they heard. If I say so myself, I like performing (high school: Sir Joseph Porter, KCB in "HMS Pinafore; Judd Fry in "Oklahoma." College: Conrad Birdie in "Bye Bye Birdie.") and make it pretty entertaining. If it'd been advertised, one can only imagine an impressive bunch of sales. Oh well.

More importantly for this blog: I'm back home now, and after a day at work tomorrow, I plan to begin posting on a subject I've planned for some time: breast cancer. Numerically speaking, breast problems made for the largest part of my practice. There's a lot I have to say about it, I think. So stay tuned.

Beach bust?

I'm doing a reading of my book tonight at the Cannon Beach Gallery. It's been on the books, as it were, for a couple of months. Beach time: they never got around to running announcements in the paper or putting up any of the thirty posters I had the publisher send them. Can't say I blame them: the weather's been beautiful, the beach beckons at any time of day or night. Who'd want to take the time to arrange things, much less show up on a Saturday night of vacation? I'm thinking I'll be talking to pictures on the wall. Which reminds me of one of the more bizarre evenings I've spent: on a trip to Death Valley, having heard about her somewhere, we stopped at a small auditorium in the middle of nowhere, desert on all sides for miles, heat shimmering even toward night. There, a woman named Marta Beckett danced her ballet every night, to music played on an old phonograph on the front of the stage, and with an audience of kings and queens and their subjects, sitting in fancy balconies, painted on the walls. That night, Judy and I were the only breathing visitors, except Marta's husband, who'd painted the walls and lifted the arm of the phonograph onto the record. That's love. Judy'll be there tonight, absorbing some of the echos.

Heartfelt

Still at Cannon Beach, we've been driving into Portland frequently to visit my mom and my aunt. Yesterday my aunt told me a story I hadn't heard before, and it moved us all to tears.

She has a friend who had a heart transplant, nine years ago. He'd been an Olympic-class athlete, and now, with his new heart, he's again able to climb mountains, run marathons. In fact, he's participating this weekend in the annual and insane run from Mt. Hood to the Oregon Coast. A team event. But still...

Before his transplant, he'd come very close to the end. My aunt describes the two months he was hospitalized, awaiting a heart: she visited regularly and saw more machines and hoses than she imagined possible (I infer he was hooked to a ventricular assist device). All the while, the man maintained humor and optimism. When the heart arrived, it had come from a young college student, killed in an auto accident. It was a perfect match in all senses of the term.

My aunt's friend came to know the mother of his heart donor. They've become extremely close, and visit with one another regularly. He, my aunt says, is a big guy, six feet five or six. The mother is tiny, less than five feet. The three of them -- my aunt, the man, the mother of his heart -- spend time together frequently. My aunt says that when they meet, the mother -- whose ear is chest high to the man -- always leans to him, wraps her arms around him, ear to his chest, to hear the sounds of her son's heart, beating inside the man and giving him life.

Giants of the Jungle

In a previous post, I mentioned stopping on my way to Vietnam, to participate in jungle survival school, in the Philippines. I want to tell you more about it, even though it's not at all surgical.

Before heading off to the great war, I'd spent three months in San Antonio learning to be a doctor for fliers, at flight surgeons' school. Much of it was fun and interesting: I learned about the physiology of flight, about baro-trauma, about particular afflictions that affect one's ability to operate aircraft. Playing soldier, I learned to fire an M-16, went up in an altitude chamber (note: gas expands at altitude. Colon gas.) I found out what hypoxia (low oxygen levels in the blood) feels like; how you can be completely gorked out from lack of oxygen and believe you are functioning just fine. Showing how tough we were (or ought to have been) we went into chambers filled with tear gas wearing gas masks, and were made to take them off. Then, while choking and coughing and nearly blind, we rammed toothpaste-like tubes with needles at the end into our thighs, squeezing saline (in lieu of atropine) to practice saving ourselves. Over half the guys couldn't do it: push in a needle through dirty pants, no alcohol wipes? No way! Pussies. I was the only one headed to Vietnam: I had no problem. Later, we used parachute trainers, and fired and rode ejection seats up a Disneyland-like tower.

I got onto a Pan Am (note to young readers: it used to be an airline) plane at Travis AFB, dressed in my starchy khaki uniform replete with shiny silver bars on my collar. Cheery stewardesses smiled us all the way to Clark AFB, where I disembarked a couple of weeks before Christmas, onto a steamy-hot tarmac, trying to look like I knew what I was doing. After waiting in several lines, showing my orders to several people who actually did seem to know what they were doing, I found my way to a bed, with plans to begin survival school the next day. Went to the officers' club, where I heard a guy sing "I be home for Chreeesmiss..." After a mostly sleepless night and a ride in a beat-up bus with GIs of various services and rank, I stood in a group of men at the edge of dense tropical jungle. Within three days and two nights out there, we were to learn everything needed to forage and hide, escape and evade an enemy -- not to mention snakes and big bugs. Divided into groups of eight, we headed off in different directions, each with two instructors: an Air Force trainer, and a Negrito genius.

Legendary for the help they gave the Marines during WW II, the Negritos are a pygmy race who populate many of the Philippine Islands. Their chief, we were told, is the only person on the planet not in the US military who is officially entitled to wear the uniform of an Army general. After spending two nights in the jungle with one of their tribe, I have no difficulty whatever believing the several stories I heard of their military prowess. To wit: it's said that during a terribly bloody battle in which Marines where trying to take a strategic hill, they were pinned down for days and taking huge casualties inflicted by machine gunners dug into foxholes further up the hill. At some point the Marine leader was surprised by the arrival of a Negrito leader who offered the help of his men.

The Marine, skeptical but desperate, probably said something like, what the hell, do whatever you want. Next morning the Marines awoke to silence. They crept up the hill, encountering no resistance, eventually making it up to those foxholes, in which they found the enemy gunners, decapitated. On another occasion, a base commander was approached by a Negrito leader who offered to take over security: the base had had a huge problem with thievery and other crimes. The commander wasn't interested, but finally agreed to a challenge: if your men can keep my men off the base tonight, and away from the flight line, I'll forget it, the Negrito man offered. But if we manage to get there, you agree to hire us. Deal, said the commander. He doubled security that night. They heard a few noises, fired off a couple of shots, and kept the base quiet. Next morning the commander and the Negrito leader met. "Guess you lose," said the commander. "Not so fast. Check the shoes of your guards. Every one has a mark on it. Go down to the flight line. Each plane has an X painted on the side." And it was so. And I believe it.

I believe it because I watched my guide, four feet tall and so at one with the jungle that he practically disappeared into it before my eyes, produce fire and water like magic. I saw how he knew where to find food, how to move through the underbrush without leaving a trace; knew which plants stopped bleeding or cured headaches. With a homemade knife and a length of bamboo he produced fire in less than two minutes: slitting off a thick piece of bamboo and then a thin one, he made a bow and string. Another rod of bamboo was carved off and place in the bow in such a way that it spun like a drill as the bow sawed back and forth. The end of the rod was poked onto the remaining bamboo, on the surface of which the guide had carved up a bunch of curls, still attached, like the pubic hair of the Jolly Green Midget. Rowing the bow and spinning the rod, puffing breath onto the curls, he made smoke appear and then fire, in seconds. None of us came close to making a serviceable bow, let alone fire. Later, he showed us how to recognize a particular palm; how to lop it off about a foot above ground, and scoop out the center. Next morning, a gallon of fresh and filtered water filled the bowl. He dug taro root, chopped it up, put it and some water into a section of bamboo from which he'd cut off a trap door and re-attached it after filling the hole. Buried under the fire, it cooked into a (marginally) palatable meal.

Rustling sounds in the jungle kept me awake most of the night. Rats, we were told, were everywhere and had been known to gnaw on fingers. Who knows what else was out there?

Next morning was instruction in E and E (escape and evasion). Find a leafy branch to use as a broom, back your way into underbrush, sweeping away your tracks as you do so. Cover yourself with vines. Negrito kids were hired to find us: we had special dog tags that we had to give them when discovered, and they turned them in to exchange for food and candy. Eventually everyone in my group was found (we were told the kids never failed) but I was the last one. That, despite the humiliation of backing my way into underbrush, sweeping away my tracks like a pro, backing deeper and deeper until I'd showed my camouflaged ass, like a hippo in reverse, to a bunch of instructors smoking and chewing the fat by their jeeps on the road on the other side of the brush. Oops. See ya later.

There were no failing grades. They showed you stuff, you took it in and hoped you'd never use it for real. We were given radios and taught to guide a helicopter to our position in heavy jungle, unable to see it but hearing the sound. Talked them to our position, had them lower a "tree penetrator" (a cable with a heavy bullet-shaped device at the end.) Flaps folded down from it to make a sort of seat you slid under your thighs, then rode the thing up and out of the jungle into the chopper. Scary, but somehow reassuring when I managed to do the whole drill, scrambling into the pounding machine high above the trees.

On the final day, we learned what was known or surmised about POW camps. We saw devices. We read a letter that a prisoner had managed to get to his wife despite the censors: it said, "If he paints the house, tell old Roger to use real enamel." Not knowing anyone named Roger, she'd turned it over to the military, who recognized an acronym. Do you? Tales were told, pictures were shown. I guess the point was to make sure we took seriously the idea of avoiding getting caught. Pretty grim. Suffice it to say, I think surviving that environment isn't a matter of what you're taught: it's about who you are. I'm glad I didn't have to find out.

Dirty Sex and Soldiers

There. That ought to get a few new viewers. And here's a warning: grossness follows.

Medically speaking, my time in Thailand was boring. There were no attacks, no casualties of the sort I'd seen in Vietnam. Since guys weren't scared all the time, there was much less of the depression and jitters amongst the troops. We did get an occasional cobra bite, which could be exciting. The flying I did was also not as much fun: in Vietnam I mostly flew with a squadron of spy planes, low and slow. There were creepy guys in the back doing things I didn't have clearance to know about; but the flying was uninteresting to the pilots, so they were glad to turn the controls over to me. "Roger, rollout one-five-zero," I'd say, as I followed directions from the back. "Roger, climb to flight level eight thousand." Cool hardly describes what I was. Us pilots: shit-hot as we liked to say.

In Thailand, I flew on tankers. Converted Boeing 707s, flying gas tanks, militarily known as a KC-135. I did occasionally get to fly the things, but they were more complicated than the old Gooney Birds of Danang, and I was just kidding myself. Aware of the potential consequences of a gas tank with wings meeting a missile with fangs, I tried to sign on to missions well into the south.

Wrong information got me all the way to Haiphong harbor by Hanoi once, and when I heard the copilot call out "Bandits approaching 6 O'clock," I reached for my survival vest. (That's a story in itself: it contained such things as a hacksaw in a rubber casing, for insertion into one's rectum. It had a beautiful silk cloth with an American flag and a paragraph in sixteen local languages, saying "I am an American citizen. Misfortune has befallen me. ["misfortune." "befallen." Who wrote that stuff?] My government will reward you if you take me to safety." A six-shot .38 pistol was included. Those hot shot pilots, they added a bandoleer containing a couple hundred rounds. Me, I figured if I went down, I'd only need one.)

Once, I got to control the fuel nozzle. From the back of the plane protrudes a long maneuverable hose. It has little wings on it, and by manipulating controls you can make it move up, down, left, right. Lying on your belly, facing backwards and looking out a small window, wearing headphones so you knew when to expect them, your eyes would pop as a group of F-4 fighter planes would swing into view, in formation, just yards from the back of the tanker. One by one they'd fly into position, close enough that you could easily see the pilot, like he was across the dinner table from you. And you'd manipulate the nozzle -- sort of a team effort: you'd move it around a bit as the fighter jock nudged his way into it, and the nozzle would find its way into a receptacle on the nose of the plane. Then we'd fly together like dragonflies do, while I transferred fuel to the fighter.

The one time I did it, the pilot smiled at me (nice blue eyes) and held up a photograph. It showed a particular sex act that one might associate with the feat we'd just accomplished. Prodigious equipment.

Which gets me to the meat, as it were, of the post. Routine in most ways, my medical experience in Thailand was an occasional lesson in tropical medicine; in particular, venereal diseases of which I'd only heard most vaguely in medical school: syphillis, lymphogranuloma venereum, chancroid, and, of course the clap (gonorrhea.) We did see some malaria and plague. But today we're talking crotch. And hygiene, or the lack thereof.

"Hey doc, you treated me a month ago for the clap, and now it's back," he said. "So what do you have," I asked the airman, "the drip, or the burning, or what?" (Those of you who read my book have heard this one.) "The drip," he says. "OK, let's have a look." So he drops his pants to reveal a green stain of pus on his underwear, the size of a salad plate. "Wow," I say. "That's some drip!" "Yeah," he grin/grimaces. "And that's just since Thursday." It was Tuesday.

"Congratulations. You've got the clap," I tell another. "Why the hell don't you guys wear a rubber like I warned you?" I ask. (I'd descended into lecturing all newcomers about VD.) "I did, Doc. I really did." "Did you use it every time?" I ask. "Damn right, doc. Second time I just turned it inside out and used it again." And of course, every day ad nauseum I heard, "Shit doc, you wouldn't take a shower with a raincoat on, would ya?"

There was a persisting rumor about "The Black Clap," a variety so virulent and so resistant to treatment that anyone who got it was spirited away to an island off the coast, never to be heard of again. "Is it true, doc?" "Nah," I'd say. "I've been to the island, and you got nothing to worry about."

For some reason, it fell to the Flight Surgeon's office to control the spread of VD; that included, among other things, making inspections of all the bars and their "staff." Once a week we'd make the rounds, nurses doing pelvic exams and testing for gonorrhea. To whom that ever made sense I was never made aware. I was not among them. We were, of course, offered various incentives to certify the ladies. Despite our efforts -- pathetic as they were -- the attack rate for the GIs who partook was around 90% if they didn't use condoms, and still above 30% if they did: not surprising, given the above examples...

So I did a little experiment with my staff of medics, who were not inclined toward abstinence. I gave them little tubes of neomycin ointment. "You didn't hear it from me," I said as I passed the little saviors out. "But you might want to see what happens if you take a leak and then squirt some of this up your urethra right after sex." "Doc, you're a genius," I heard more than once. In around seventy-five "exposures," there wasn't a single case of the clap. Of course I was loathe to write it up, and never did. And, in retrospect, I was damn lucky none got a contact reaction to the stuff: such things are not unheard of, and in the urethra, one can only imagine what might happen. So don't try it yourself, and don't tell anyone what I did.

Shrinking from duty?

I know I have at least one psychiatrist reader who passes by these parts. So Dr W, this is for you:

As I mentioned a post or two ago, when I was in Vietnam, part of my job was that of a humdrum office doc, when we weren't being rocketed or, rarely, shot at. While humdrum, being in Rocket City wasn't exactly your normal existence, and it was not infrequent that a GI came to see me with the complaint, "Doc, I can't take it anymore."

For most of these poor guys, there really wasn't a hell of a lot to do: sympathy, the occasional specific suggestion, once in a while a kick in the pants. Except in rare circumstances, there was no choice but to send them back to duty. On one or two occasions, I'd give a guy a break, and bed him down in our small inpatient facility for a day or two.

There were lots of backaches, headaches, sore this or that which begged a duty excuse (and I must say that during the time I had to lift my right arm to the desk using my left arm, I got fewer requests for duty excuses); once again, for most it was some sort of analgesic a pat on the back, and return to work. (There was in our pharmacopeia a great drug, called Parafon Forte. I don't know if it's still around or not. It was supposed to be an analgesic, touted in particular for back pain. It was my distinct impression that it was no more effective than aspirin, maybe less. But it was HUGE! And HEXAGONAL! And GREEN! Give a guy a horse-pill like that, and he just knew it was a killer drug; gonna work like a charm. I'd write for a few and add "NO REFILL" in big letters on the prescription. I wasn't above snake oil when it was called for.)

So it happened that among the ebb and flow of unhappy guys in various states of depression, I encountered one who was borderline de-compensating. I decided I needed help, and tried to contact a military psychiatrist in Saigon. It took about three days of calling, leaving messages, radioing, and cursing. Finally I caught up to the man. "Look," he said. "I'm the only military shrink in all of Southeast Asia. I can't deal with guys who are depressed or neurotic, or I'd be swamped. If he's not out-and-out psychotic, you're just gonna have to figure it out yourself." Click.

Well, I thought, I suppose that's reasonable. Poor guy must be overwhelmed, alone as he is; although it did occur to me that Saigon was pretty plush duty. I'd been there. It's a beautiful city, with canals, classic Asian architecture, and at that time was perfectly safe and quiet. Buzzing with commerce, women in traditional garb, men zipping around on scooters, smells of food, noisy markets. No rockets, no sappers (individual sneak attackers -- we had a few). And between drinks and girlfriends, GIs assigned to Saigon picked up the same combat pay that the rest of us did. But heck, he was alone in theater. Whacha gonna do?

I can't recall what exactly I did, but somehow or other I managed my patient and got him back to duty. Time passed. GIs trooped in and out of my office, rockets landed at night, life went on. And then one day I was made aware of a man who'd had a bona fide psychotic episode, and who remained fully delusional and unfit for duty. I gave him a bed and a guard, and began the frustrating process of tracking down the Shrink of Saigon. Messages left, calls placed and re-placed, swear-words issued profusely.

And after another three days or so, during which I worried that I had no idea how to manage the man beyond restraints and a few drugs, the doc got back to me. I described the situation. "Well," he said. "That man is psychotic. Nothing I can do for him here. Send him back to the States."

Beach to beach, cont'd

I figured out right away what had happened: a rocket had, by pure chance, hit my barracks -- slammed into the revetment protecting the bottom floor of the two-story building. It turns out there was far less damage than you'd conclude from the crash and the subsequent chaotic yelling. My mental inventory made note of a pretty painful shoulder, and some blood dripping into my right eye. Dripping, not flowing: I was ok. I got up and out, checked the hall and, seeing no obvious carnage, headed downstairs. The building was dark, and it was nighttime outside. In front of the door lay a guy familiar to me but unknown by name. He was rocking slowly and moaning. "Get a flashlight!" I said to an onlooker. "Get an ambulance here!" I said to another. Meantime, I could see blood on the man's shirt, by his left shoulder. Tearing open his shirt by the neck, I saw that part of his shoulder was missing; when the flashlight arrived, it was apparent that it was bleeding pretty briskly. I took off my shirt and shoved it into the wound, applying firm pressure. That was it. Nothing more I could do until the ambulance showed up, which it did in a few more minutes. I rode with the man to the clinic, helped unload him and get him inside. After clamping and ligating a couple of vessels, and exchanging my shirt for some disinfectant-soaked gauze, I wrapped the shoulder as tightly as possible while a medic got a couple of IVs in. Meanwhile, someone was calling for a chopper. A quick check-over revealed a few more shrapnel wounds, on his buttock and belly. Given our lack of facilities, and his stability at this point, I just documented what I found for the docs at the evac hospital and sent him on his way.

There were a few other casualties; wounds needing cleansing and suturing, taking up a couple of hours. Finally, as the dust was fully settled, I began to pay attention to the fact that my own shoulder hurt like hell. Broken clavicle, as it turned out. Poor timing, given that in a few days I was scheduled for a week's leave in Hong Kong, with my wife scheduled to meet me there. Well, where there's a will, as they say, there's a way...

I called the Army hospital next day to find out how the man was doing. The news shocked me: he'd died in surgery to repair internal abdominal injuries from the shrapnel. I wasn't able to track down the surgeon; the nurse with whom I spoke didn't know the whole story. Even now, I can't imagine what it could have been, given how stable he'd been while at our base. As I said in the previous post, I had it better than most in Vietnam, and didn't handle many major injuries, at least not initially (I was in charge of the medevac flights to Japan, and saw lots of injured in that role, but they'd been stabilized enough to make the flight.) So that man's death bothered me a lot; and again when I saw his name on the subsequent casualty list. And today, miles and years away, I can't remember his name at all.

I only had one GI die in front of me, and I can't remember his name either. It was toward the end of my tour of duty. Because the US was bugging out, we'd had to leave Danang in rather a hurry, as the North Vietnamese made their way relentlessly south, though our base and not long thereafter, to Saigon. We ended up in Thailand, at a hastily re-opened air base in a little town called Takhli, the downtown of which went from one or two bars to fifty literally overnight. With that, of course, came rampant venereal disease. We'd arrived at the base before much in the way of equipment (can you believe it? The military sending undersupplied soldiers to a place?) so we set up shop using cots for exam tables, empty boxes for chairs and desks. We had plenty of penicillin, a few other drugs, virtually no machinery. So when a poor soul developed anaphylaxis (severe allergic reaction, prominent in which is airway constriction), we (and he) were up a creek. We did have a laryngoscope (for passing a breathing tube into the airway) and I managed to intubate his trachea and start squeezing oxygen into him, but it was increasingly difficult as his bronchioles (the smallest airway branches) shut down one by one. Ten by ten. Thousand by thousand. Epinephrine was given to open the airways; at some point I stabbed it directly into his heart (like in Pulp Fiction). But he clearly wasn't responding. We had no heart monitor, no defibrillator, but it became obvious that he was heading toward cardiac arrest. I looked around the empty and echoing room, and in desperation grabbed a lamp and ripped out the electrical cord. Not being much of an electrophysiologist, thinking maybe it would give his heart a jolt, I peeled the wires, plugged in the plug, and touched the raw ends to opposite sides of his left chest. Made his pectoral muscle jump, not much else. And then it was over. How, I wondered as I looked at him lying there, his underwear showing the green stain of his gonorrheal discharge, would we inform his family back in the world?

At this point, I feel I should say something: I think my beach-blogging isn't up to whatever standards I might have had, blogging from home. I don't want to wear out my wifi welcome by taking the time to provide links to words or ideas; so I'm saving the "deeper" posts for later. My war stories aren't as glamorous as some, but I have a few more that might be instructive. Hope you'll understand. And keep coming back anyway; it'll get better, at least in my view, after I return home.

Beach to beach

Beach blogging is harder than I thought: prying surgical stories out of my surf-soaked brain ain't easy. Here comes the best I could do, taking a circuitous route from the sands of the Oregon coast to the gentle breakers of China Beach, in Danang, Vietnam, and then beyond. A major difference between Cannon Beach and China Beach is that at the moment there aren't helicopters patrolling the beach, gunners dangling their feet out the doors, making it safe for us to swim. Plus this water is way too cold to attract me. And there are no Army nurses peeling off their camos to get to their bikinis. Attention span shortened as it is by the lure of walking on the beach, I might have to tell these stories bit by bit.

I got drafted during Vietnam war, at the end of my surgical internship. After three months in San Antonio learning to be a flight surgeon, and a brief stop in the Philippines to take a course in jungle survival and escape and evasion, I found myself in Danang, near the northern end of South Vietnam, just below the ironically named Demilitarized Zone. Danang was otherwise known as Rocket City, and it wasn't because it was where rockets were made or fired. It was where they landed, pretty much every night.

I was at the Air Force base. The big army hospital was across town; may as well have been across a canyon, because driving there was unsafe. We choppered the injured or the really sick to the hospital. On our side of the chasm, we had a clinic with a few inpatient beds. Compared to the grunts, I had it pretty easy. I never slogged through a jungle or slept in a foxhole. I never fired a gun except in training. Arcing up toward me on many a night flight as we took off and landed on surveillance missions, I often saw tracer bullets come close but none made a dent. The rockets, well, they tended to make life a little uncertain, and constantly reminded us that we weren't in Kansas. Like the ones you've been hearing about in the Middle East, they really weren't aimed precisely. In fact, it was said they often were launched from makeshift bamboo cradles. (Typically, in our daily security briefing, we'd be told how many to expect that night: eight, a dozen, sixteen. They saw them being assembled; couldn't go into the villages where they were without permission of the village chief, who'd be killed by the Viet Cong if he gave it. "Friendly villages" they'd been designated.) But they always landed somewhere on base, in clusters. You could hear the whoompf somewhere in the distance, and then several more, one at a time, a few seconds apart, seeming to walk their way closer and closer. The nearby landings were more of a crack -- like close lightning -- than a whoompf. Injuries were random. We thought the rockets were mostly aimed at the flight line, toward the planes. As opposed to the rest of the doctors and nurses, who lived in the center of the base, I lived with the pilots, alongside the airstrip, so we got more than our share. We counted on and took comfort in the odds: lots of acreage, only a few rockets.

As a flight surgeon I was required to log a certain amount of flying time, which is why I was on those missions I mentioned (more in another post?). Otherwise, during the day I was mostly office-bound. "Doc, I can't take it any more" was a common complaint. So were drug problems: detoxing guys who found the practically pure heroin over there more than they'd been used to. Saw a few cases of bubonic plague, believe it or not. (Rats. Plenty of them.) Syphilis. Cerebral malaria, hepatitis, granuloma inguinale. I also gave intake lectures to the newly arrived about snake bites. Cobras, I'd tell them, contrary to popular belief, can't lunge very far; only one third of their total length. 'Course some of them are eighteen feet long...

Being closest to the clinic, when the nighttime rockets began landing, I had to run a few hundred yards to the clinic, ready to receive victims. My sleep pattern was not unlike that of my internship: somnus interruptus. As I ran, ridiculously useless helmet flittering around my head, somewhat more functional flak jacket on my torso, I'd usually see Cobra helicopters firing into the jungle. Sixty rounds a second, many of them tracers, making like a spotlight. Who the hell am I and what am I doing here, I'd think. But I kept running.

On one occasion, I saw four guys nearly stuporous with barely receding fear: a rocket had crashed through the ceiling of their hootch, pronging through the card table at which they were playing poker, drilling itself into the floor without exploding. Guess they all held winning hands that time. And I think they needed a laundry more than they needed me. On another night a rocket hit my barracks, and that one didn't misfire. I was asleep at the time, and wound up in a heap on the floor. I awoke to yelling and screaming....

Beach blog

I'm blogging from the beach. Cannon Beach, Oregon, in particular, hitchhiking on wifi in a just-opened bakery/coffee shop, "Waves of Grain." My family has had a home here for several decades; my folks retired to that home about twenty years ago, after which my dad became mayor for a while. One of his crowning achievements was negotiating getting the cars off the beach. The local business folk feared that the attraction of being able to drive on the beach was what brought folks here. Hardly. It has become one of the best beaches in the world.

Not wanting to push my luck with the proprietors of the bakery, who offer free wifi with a purchase (how much is time is appropriate for good coffee and a tasty cinnamon roll?), I'm loath to spend the extra time needed to provide my usual litany of informative or witty or annoying links. I may not even get around to topics surgical today.

Before my parents bought this house, we came here every summer since I was a toddler, renting a house not far from the one we now own; so my roots here run deep. I feel core pleasure whenever we get back. When the tide is out, you can walk for endless miles on a wide and white sandy beach, and once you're a mile or so south of Haystack Rock, even in the height of the tourist season, you'll be amazed at how few people you see. Rocks (many of them huge monoliths several stories tall) scattered up and down the coast amongst the breakers at high tide with some stranded in the sand at low ebb provide caves and tide pools rife with life: anemones, sea stars, hermit crabs, krilly-fish. The baby gulls and puffins we saw last time we were here, huddling high and wind-blown along the tops of huge rock formations, are now mostly fledged and flying. Just when I'm warmed into the rhythm of walking and listening to the surf, my wife has to stop and check out the birds with her binocs. Or pick up the occasional perfect sand-nickel. The reach of the tidal flow between high and low is unique among the beaches I've seen -- California, Florida, Maine, Massachusetts, Hawaii. In six hours the tide line will have receded -- or encroached -- by a distance of a hundred yards; more in some places. Beware on your walks. If you go beyond any of the several points of land that scallop the shoreline, you may not be able to get back till the next tide.

In winter the sea is rough, the wind howls, and the beach is smaller and rockier. But it's worth bundling up and getting to the surfline. Marking a place on a rock formation (one has a hole in it the size of a basketball, with some lucky green and feathery anemones in it), you can see that the level of the entire beach -- miles of it -- rises and falls several feet in a year. In winter the hole is eye level. Today it's three inches above the sand.

The family home is right on the beach, on a low bluff just steps from the sand, about a mile and a half south of Haystack. The living room is graced by a stone fireplace, mantled with a huge piece of Douglas Fir, about six inches thick, bark outward, on top of which are a couple dozen wooden candlesticks of various twists and turns, all with partially burned candles, placed there over the years by my mom who by now is barely able to remember the place, much less make the trek to see it. Four little bedrooms upstairs, separated by thin walls comprised of a simple layer of wood slats, through the gaps in which my son and I used to pass notes when he was single-digits old, sleeping in the room next to ours. He triumphed over many of the rocks, scrambling up the steepest sides to sit on the tops, face into the wind and sea spray, years ago.

On my computer at home there's a photo of the weather vane out front; if it was on my laptop, I'd post it for you. Judy and I made it around thirty years ago, while I was still a surgical resident in San Francisco. It's taken glue and brackets to keep it intact against the sea weather all these years, but it still points into the wind. One end is a fanciful sun-shape with a face; the other is an arm and hand, finger pointing, carved after tracing around Judy's arm/hand/finger. She's held up pretty well, too. No brackets yet.

So the place is full of memories. We don't get here enough. And, in not too long, the fates have seen to it that we probably won't get here at all.

Memorable patients: part six

"You can't just let me bleed like this, Doc. I need to get out of here." So said John, a man in his seventies, with kidney cancer spread to his Ampulla of Vater. Renal cell cancer is among those that sometimes behave in very strange ways. John had had his removed, along with his left kidney, about nine months earlier. At the time, it was thought likely to be a curative procedure. Now, he'd been admitted anemic, weak, with evidence of blood in his stools. Workup, including endoscopy, had shown a friable bloody tumor right at the ampulla, and biopsy had shown it to be the kidney cancer, now spread to this ultra-highly unusual place. It didn't seem to be anywhere else. He wasn't bleeding much, as these things go: about a pint a day. Easy to keep up with; hard to send him home.

Ordinarily, the operation for a tumor at this location is a choice between two options: local excision (done by opening the duodenum and carving the tumor out), or a Whipple procedure -- the biggest of the bigs. For a diminutive tumor, the former may suffice. Its main limitation is that you can't carve very deep without getting into the pancreas or going through the back wall of the duodenum. So it's pretty much reserved for those small tumors, preferably mild-mannered ones. If you're serious about cure, you go for the Whipple. I talked about a Whipple in my book: it's every surgical resident's dream: the full-meal deal, the three-ring circus, the Superbowl of surgery. It involves about every trick up the sleeve of a general surgeon: removing some stomach, some bowel, some bile duct, some pancreas, the gallbladder. Hooking things back together using -- because the organs are so structurally different -- every type of sewing technique you know. As challenging and fun as it is, it's also risky for the patient (mostly because of the possibility of leak of digestive enzymes from where you sew the pancreas to bowel, which begins a process of auto-digestion...) So doing it on a patient with metastatic -- and therefore statistically incurable -- cancer just aint' hardly done.

What a nice guy John was. Big, gregarious, talkative and congenitally humorous. Recently retired, he and his wife had bought a motor home and made plans. No way he was gonna spend his precious time in a hospital. Other than his need for a bag o' blood a day, he appeared healthy as a horse. The decision to operate was a no-brainer. And the obvious choice was a trans-duodenal local excision. Which I did, pushing the limit of the possible and, far as I could tell, leaving no obvious tumor behind. John recovered fast, and beat a path to home, no longer bleeding.

Not very surprisingly, he was back in about four months, bleeding in the same way, from the same place. This time, according to the CT scan, the tumor was infiltrated into the head of the pancreas. And, as before, there was no sign of it anywhere beyond that spot, in his belly or elsewhere. "Here we go again, Doc. Whacha gonna do? I feel fine, I really do." So now what? Send him home with arrangements for a daily transfusion? Made sense in many ways. But not to him. Or to me, really. So, despite what would seem on paper -- and probably to a review committee, were he to have problems -- to be contraindicated for metastatic cancer, I talked to him about a Whipple and signed on.

I've planned a number of Whipple procedures and more than once, despite the high quality of modern imaging, have been disappointed when I made the incision and went through the usual assessments to be sure it's really operable. In John's case, amazingly enough, everything was as advertised: not a sign of tumor anywhere else but in his pancreatic head. I gave him a nice job. There were no postop problems and he went home, as was his habit, on the fast-track. I saw him for a couple of routine office visits, and he disappeared back into his life.

As often happens, for magical reasons I guess, within a week or so of wondering whatever happened to ol' John, about a year and a half after the operation, he was back in my office. With a hernia. (Not -- I hasten to add -- in his incision. It was a garden-variety groin hernia.) "Damn thing bugs the hell out of me when I'm driving the motor home, Doc. Fix me up, willya? Oh, and Doc?"
"Yessir?"
"Knock Knock."
"Who's there?"
"Hernia."
"Hernia who?"
"Hernia good jokes lately?"

He was, of course, back on the road in a few days.

Once again I lost track of John for a couple of years. Then one day I ran into his urologist, the one who'd done the original kidney removal. "Guess who I just operated on," he asked. "Your friend John. He showed up with his left testis big and sore. Turns out he had another metastasis, this time to his nut." The urologist had checked him out and found, per usual, no tumor elsewhere; he'd removed the testis and sent John back to his motor home. Last I heard, he'd moved to a nearby town and was still going strong. I have no doubt that at some point (if it hasn't already) the cancer will reappear and will sometime get the best of travelin' John. But in the meantime, he remains unique among my Whipple patients. I've done my share of them, nearly always for primary cancer of the pancreas. It's the only cure for that disease, but the results have been pretty dismal no matter who does it, and mine are no exception. Good surgery, bad outcome, sooner or later. But there goes John, in a situation that should have killed him years ago, guzzling gas, probably sideswiping Volkswagens, having a hell of a good time barreling down the road in his motor home, thumbing his nose at the odds. I must say this has almost nothing to do with me, and everything to do with the curious equilibrium between John and his tumor. Good for him!

Baby Killer

The potential to do dramatic good, as is the case with surgery, means that sitting and staring back at you at the other end of the see-saw is a grinning dysmorphic ogre. He keeps his eyes locked on yours, staring with the smug certainty that you can't toss him off, up when you're down; down when you're up. The ugly little sonovabitch never goes away. It's an issue for every healthcare provider. Were it front and center at all times, it'd be paralyzing. But if it's completely out of mind, you'd become dangerous, or careless at the least.

So there's craziness: much as I find doing surgery exhilarating and fun, and much as I'm amazed at and grateful for the willingness of people to turn their bodies -- with their most intimate secrets -- over to me, in the entryway to the back of my mind resides the awareness that it's a dangerous thing I do. Thin ice. There's a lizard under every rock. Sometimes the realization comes upon me like a bucket of ice-water. (I should acknowledge that -- maybe unique in the "dangerous" professions -- in my case the danger is the patients'. A mentor of mine said, "The patient takes all the risk, Dockie." I don't minimize that. But to harm another is, in many ways, worse than harming yourself.)

Imagine being the parents of a perfect baby. All the fears of pregnancy and expectations of birth have resulted in a beautiful boy, thriving. Looks like his dad. Other than being tired all the time, you're ecstatic with the love you have for this little thing. He coos, he looks lovingly back at you as you feed him. And now he's six weeks old, and you're being told he needs an operation.

Having fed quite normally for the first month or more, the baby is now vomitting, more and more forcefully, until it seems he's keeping nothing down, and isn't gaining weight. Hypertrophic pyloric stenosis, the surgeon says, speaking Greek, or Martian. Like a raw doughnut tossed into the fryer, the circular muscle at the bottom of the stomach has grown, and it's preventing food from leaving the stomach. The treatment is surgery.

As operations go, it's quite simple. Many years ago, part of the stomach was removed: in starving kids, that's a big deal, and lots of them didn't do well. The modern operation is quick and comparatively trauma-free, and works great. You make a small incision on the baby's belly, find the enlarged muscle, and slice into it, splitting the muscle fibers (it looks strange: instead of the healthy pink, the muscle looks like the meat of a white peach) and spreading them apart.

Imagine a tight ring over a glove on a finger. You want to cut the ring, but not the glove. You want to see the glove fabric bulge up into the cut you made, indicating it's free. But if you cut the fabric, you've done a bad thing. The glove is the inner lining of the stomach: the mucosa. A hole in it means leakage of stomach contents. Making it tricky, it sort of folds over on itself exactly at the bottom end of the muscle. You need to cut the entire muscle or the operation won't be effective; but if you go too far, you make a hole. Doing so isn't the worst thing in the world: if you recognize it, you sew it up and there's no problem. The danger is puncturing the mucosa and not noticing. That can be deadly.

So you explain all this to the parents. You tell them about the possible problem, but say that prevention is what we're all about in doing the operation. You say that the kid might still vomit a bit for a few hours, but in all likelihood, he'll be home in a day or two, doing fine. Like magic. They agree, of course.

There's something completely wrong about a tiny baby on a big table in a huge OR. I could cover the entire person with my two hands. All the machinery, the tools, the drapes, the surrounding team seem terrifyingly outsized. It's like a joke. We're playing dolls. Except it's real and the stakes are high. It's one of those times when I ignore the reality and just focus on the job at hand. Tiny hole, tiny instruments, fine little sutures at the end. It goes fine.

"Shit," I say, as the phone rings at two a.m. It's my usual response, whatever the call. This time the nurse tells me the baby has a fever of 103 and his abdomen is rigid. "I'll be right there," I tell her, the words finding great resistance, barely squeezing out through my suddenly constricted throat.

It's easy to describe how I felt, because I feel that way again whenever I think about it. Had my wife awakened, she'd have seen me appear ghost-white, I'm certain. My stomach was hollow; my hands were ice. I could barely tie my shoes; my hands were shaking, and not following commands. It felt as if a cold hand were gripping my neck; I could hardly swallow. I splashed water on my face, made it to my car, raced to the hospital. As I drove, hands so tighly on the wheel that they were getting numb, I was thinking I'd do whatever was in my power to save the kid, do whatever it takes. Never leave him until it was over. And then I'd never, never, ever, ever do a pyloromyotomy again. And if he did poorly, I'd never operate again. This was a baby. Someone's precious baby.

As I headed to the pediatric floor and entered the baby's room, saw the nurse standing by, I felt as if a million eyes were on me, accusing and hateful. (They weren't. But that's how I felt.) And there he was. Fussy face flushed with fever, but moving around like a baby, looking not so bad. His belly was soft as, well, a baby's bottom. An xray looked fine (before surgery, to make the diagnosis, he'd been made to swallow some dye. It still showed up, some in his stomach, some happily in his intestine, and none at all outside the proper confines.)

Who knows what it was? The kid did fine and went home, as promised, in a day or so.

I drove home nearly limp, still shaking, barely able to control the car, wrung out like a wet sock. I lay on the bed exhausted; relieved, but absolutely spent. An hour or so later, I dragged myself to work. And next time a pediatrician called for a consult for a kid with pyloric stenosis, I took a deep breath, considered it carefully, and said... "I'll be right there."

When Nurses Attack

Maybe six months after I arrived in town, I was referred a patient with cancer of the distal esophagus. The perversity of being a surgeon is that despite the terribleness of the disease, it's hard not to be excited about the prospect of doing the operation to (hopefully) cure it. If you like doing general surgery, esophagogastrectomy pretty much has it all: the blue-plate special. First, you lay the patient on his back, and open his belly. Then you cut loose the stomach from all its attachments, tying off many many vessels, peeling it off the pancreas, separating it from the liver the colon, until it's hanging like a hammock in the breeze, suspended between the duodenum and the esophageal hiatus. You may or may not remove the spleen. If you're smart, you'll insert a feeding tube into the intestine (in case there are post op swallowing or other difficulties). I always did a very short pyloroplasty (slightly controversial: it's to prevent food from backing up in the partially defunctionalized stomach. If you make it too big, there can be a "dumping syndrome." Never saw it with a minimalist cut.)Then you sew up the abdomen and roll the patient onto his left side, after which you slash open the right chest, between the ribs. After entering the chest cavity and loosening up the lung, you dissect free the lower half of the esophagus, up to the azygous vein; then you pull the free stomach into the chest. Including the tumor in the middle, you remove the lower portion of the esophagus along with the upper portion of the stomach, and drop the sizeable chunk of tissue into a bucket for the pathologist. Then you attach the remaining esophagus to the remaining stomach and fashion a sort of collar of stomach around the anastomosis, to prevent reflux. Leaving a couple of chest tubes, you reapproximate the ribs and sew everything up.

The man was in his early 50s; a smoker (aren't they all?) but otherwise quite healthy. I explained the situation, and he agreed. What choice did he have, really?

The operation went perfectly; in fact, I think everyone in the OR was impressed. New kid in town, tackling a big operation with aplomb and dispatch. In the recovery room, the patient was stable as could be. But a two-cavity (as we like to say) operation takes a lot out of a person (no pun) and many postop difficulties are possible. Fluid shifts, heart and lung problems, pain management. I admitted him to the ICU, where I hung around for awhile, then went home assured he was doing great. My sleep was untroubled.

Until around three a.m., when the phone rang. Without any preliminary pleasantries, the nurse on the other end said "Mr. D's CVP is zero." I waited a beat, assuming there might be more info forthcoming. None. So I asked "How's his blood pressure?"
"120 over 80." (Note: perfect.) Pause, silence.
"What's his pulse?"
"76, regular." (Note: perfect.) Pause. Silence.
"OK, how much urine is he making?"
"50 - 60 cc an hour." (Note: perfect.) Pause. Silence.
"Does he have a fever?"
"No."
"So, how's his mental status?"
"He's reading a magazine."
"Well, uh, how's his oxygenation?"
"Last blood gas was fine." (Didn't have continuous oxygen monitoring in those days.) Pause. Silence.
"Gee, it sounds like he's doing great," I said. "
"A CVP of zero isn't normal," I was informed.
"Yeah, but it's really a relative number. Sounds like his volume is just fine." This was also before continuous readouts of CVP: to measure it, the patient was laid flat, a tube was filled with saline, held vertically (by eyeball) at a (hopefully) previously marked point on the neck, and the fluid was allowed to run into the patient. The point at which it stopped, in terms of centimeters above the marked point, was considered the CVP.
"You mean you're not going to do anything about it?"
"Well, really, it seems to me......" At that point I was talking to a dial tone.

What the hell just happened? The guy's fine. It's not like I'd been told his blood pressure was sixty and I'd said to give him an aspirin. Was it that her experience told her esophagogastrectomy patients don't do that well? (The surgeon in town who did most of them was, well, a bit brutal.) Was it just that she didn't know me? Was I guilty of operating a knife while young? Going back to sleep was impossible but I sure as hell wasn't going to go in to see a patient doing perfectly. I showed up, as usual, at 6 a.m.

A nurse I'd never seen before strode up to me quite purposefully. "Are you Dr Schwab," she asked (accused, really.) "Yes," I said, " and I'd like to talk......" The sentence trailed off as she turned and huffed out the door, as if I'd flashed her, or used the worst insult in my lexicon. Meanwhile, the only way in which my patient's status had changed is that he was now reading the morning newspaper. I sought out the head nurse. She seemed already to know what had gone on. "Geez," I said. "It's not like I ignored the guy. Look at him -- he looks like a damn visitor." The head nurse looked me in the eye and said, slowly, deliberately, with pained forbearance: "Our EVERETT physicians would have DONE something about a CVP of zero."

I was the ventriloquist's dummy, hand up my rear, mouth moving, no words forthcoming. I was the car on the side of the road, transmission splattered on the asphalt. I was a clubbed fish, a wet finger in a socket. I was so beyond speechless, I was prehistoric. Australopithecus, Neanderthal. Homo incredulous. The head nurse, having emptied her quiver, retreated to more important matters. Trembling with a mixture of anger and befuddlement, I reached for the patient's chart and wrote orders to transfer him the hell out of the ICU. The hospitals in town have since combined, but at that time there were two. I resolved never to admit a patient again to that one if it was likely he'd need intensive care. And I didn't for some time. Eventually we got to know each other, and things smoothed out. The patient, I might add, continued on his trajectory and was discharged in record time.

In my opinion, ICU nurses are among the finest there are, and I've always gotten along with them -- more than got along: most were buddies. Their job is a really tough one, and a good ICU nurse is thing to be cherished, nurtured: nay, worshipped. Which, in general, I did. They came to me when they or their family needed surgery. But not that night nurse. Never saw her again. And my colleagues, whenever the opportunity presented itself, loved to regale me with "Our EVERETT physicians...."

Memorable patients: part five

Sturdy and thickly-built, long since widowed, cheery in a sardonic sort of way, tough and opinionated, Flora's European roots ran deep; she'd been an Italian farm girl, and she'd rather be in her garden than anywhere else. The only reason she agreed to come inside and go to the doctor was that her bowel movements had finally gotten too painful, and too bloody to ignore. Which she had been doing, for quite some time. Still, she made it clear seeing me was pretty low on her list of things she'd like to do. I liked her right off the bat: she said exactly what was on her mind, she treated me with no deference, but with an expectation of straight talk right back at her.

Wishing not to turn away readers, suffice it to say everything that was visible and feelable about her anus had been taken over by an angry, florid and unprecedentedly (in my experience) large cancer. She wasn't surprised when I told her what I thought was going on; she wasn't happy with what I told her would be needed to take care of it.

There are two main types of ano-rectal cancer: squamous cell cancer derives from the skin cells at the anal opening, while adenocarcinoma arises within the lining of the bowel itself. In some cases, the former can be treated by radiation alone, which --although not free of side effects -- is a generally nice thing for the patient. With adenocarcinoma, surgery is mandatory, with or without accompanying radiation and/or chemotherapy. In Flora's case, it almost didn't matter which kind it was, in terms of surgical decision: as large as it was, surgery was going to be needed at some point. It was easy enough to biopsy it: I just pinched off a clump with my fingers and sent it to the lab. Meanwhile, I told her about colostomy.

In the majority of cases of cancer involving the colon, surgery can easily be done, and it typically involves removing the segment of bowel containing the tumor and sewing the ends back together; effect on bowel function is generally zero. Most people can have normal bowel movements even if over half the colon is removed; for the typical cancer operation, way less than that is taken. But after you've removed the cancerous part along with enough healthy bowel to assure complete removal, you need something downstream to sew to. When the cancer is in the anorectum, ain't nothing left but the outside world.

The operation is called abdominoperineal resection, and it's a pretty big deal. You must divide the colon somewhere above the pelvic portion, then follow and free up the distal segment all the way through the pelvis, down to the deepest part. And at some point, with the patient's legs up in stirrups, you cut an ellipse of skin around the anal opening and work back up to the pelvic part of the dissection. If tidiness is desirable in surgery, this is the antithesis. Working deep into the pelvis is physically hard: the bony hole through which you are working is unforgiving. I may be suited for surgery in other ways, but my hands are too damn big. In the pelvis, they cramp up. And direct visualization is difficult.

Much of the work is done by feel, and using long instruments, the ends of which are sometimes out of view. Running along the sacrum is a plexus of fat veins which, because they adhere to the bone like a starfish on a rock, are extremely dangerous if they get to bleeding: you can't encircle them with suture without the risk of causing more bleeding. But we didn't get into all that yet. The main message is that the end of the colon comes out to the skin, permanently. Colostomy. And her case, it was going to be essential to have radiation and chemotherapy ahead of time. Healing of the perineum after AP resection is a worry under the best of circumstances. In a heavy lady, radiated before surgery, it was pretty much a guaranteed problem.

Flora was not happy. Her anger was intense but polite and controlled. "Doctor," she said. "I'm going to die sooner or later, and it's not going to be with a bag full of shit on my belly and a hole in my ass." She started assembling her belongings and aiming toward the door. "Mrs. So-and-so, " I said. "I know this is a lousy deal. But let's talk about it and think about it some more. Believe it or not, a colostomy isn't is bad as people think. You can do anything you want to do, and it won't interfere. I promise." There's a lot we talked about, and it took more than one session; I actually looked forward to our meetings. They were testy but clear-headed and eye to eye.

Our mutual respect grew with each encounter; at some level it felt like a game, the outcome of which was predetermined but which needed full playing out -- assurance that each party knew the rules. Eventually she agreed to see the radiation and medical oncologists. I also arranged a visit with the colostomy nurse (enterostomal therapist). Our hospital had a really good one: she had an ostomy herself.

With cajoling and commiserating, she ultimately went for it. I saw her a few times during her pre-op treatments; she'd grouse about this and that, complain that no one but me listened to her, sighed and swore. But she kept on keeping on. And that enormous and ugly tumor, which I've studiously refrained from describing in vivid detail, regressed very impressively. So we scheduled surgery, after giving some time for the reaction to simmer down. (The dose of pre-op radiation is less than if it were given postop; and combining it with chemo has an additive effect, so you may see quite good shrinkage with a relatively small dose.)

Nothing, evidently, kept Flora from her enjoyment of food. She was no tinier when I operated than when I first met her. Getting a colostomy out though a thick abdominal wall isn't easy. Fat in the pelvis makes the work no less tough, either. This happens to be one of the very few operations for which I order blood to be available. One and only one time in my career did I get into those veins, and it was a very close thing. In fact, I did something sort of unheard of: rather than trying to suture the veins and tear them further, I had the nurses scrounge some thumbtacks, (note the date of the article -- I did this ten years earlier) cook them in the sterilizer; after which I threaded them through clot-promoting material like peppers on a shishkebab, and poked them through the veins into the sacral bone. Worked amazingly well. I say that to impress you: it didn't happen to be Flora.

You just couldn't keep Flora down. She wanted up. She wanted out of there. She walked and coughed and cooperated and did everything necessary to make a quick exit from the hospital; and she did just that. Like most patients, she made peace with her colostomy, figured out how to irrigate it (give an enema through the opening) so it emptied when she told it to, damn it. And went back to gardening in very short order. When she came in for visits, she'd bring a bag of green beans, or peas. Sometimes a perfect tomato (better than the best, Dr Charles). Always with a complaint about something, never letting whatever it was keep her from doing what she wanted.

Long past the time I usually followed routine cancer patients (I figure they had plenty of docs and appointments, and made followup optional, after a time), she kept coming, year after year, at least once. She'd call and complain about life to my nurse; she'd ask for a call from me. And she'd always come in, too. I'd poke at her perineum, check her colostomy, feel her belly, get a couple of blood tests, and tell her she looked good for another year. Listen to her gripes, accept her bag of veggies.

Maybe five years later, Flora told me she was having trouble working in her garden. Her hip hurt too damn much. Damned if there wasn't a single metastatic nodule in her pelvis. An orthopedist carved it out (I had to convince him it made sense -- that he wasn't administering futile care), filled the hole with glue and a prosthetic cup; she had more chemo and radiation and went about her business. Kept coming in year after year, bearing veggies and gripes. A woman of the soil.

To which she eventually returned, a few years after that. My nurse missed her calls, and I missed her stolid presence, grousing about this and that, always with just enough of a smile to let you know she loved her life.

My (Nearly) Short Career

First time I laid a scalpel on a patient as a fully-trained practicing surgeon, he nearly died.

Well, actually, I never laid a knife on him. Having moved to Oregon and set up shop after seven years of grueling training, including a couple of military years, fully competent to handle the most major of major operations, my first case was the in-office removal of a cyst on a young man's face. The man, in his twenties as I recall, lay comfortably on my operating table; my nurse -- a throwback, in her starchy white dress and perfectly-placed nurse's cap -- was standing attentively by while I prepared to begin a simple five-minute job. I'd explained to the man that this was a plugged up oil gland (sebaceous cyst), given him the pros and cons of removal, and the routine game-plan.

He'd seemed perfectly comfortable. Already having prepped the area with a germ-killer and draped some sterile material onto the field, I began a gentle injection of local anesthetic, using a very small needle. I prided myself on gentle locals. Midway through the injection, the man announced that he felt like he might faint, at which point I realized I had no idea how to adjust the table into head-down position -- the first reaction for a vaso-vagal episode. In seconds, the man stopped breathing, turned bluish, and had a grand-mal seizure. Where's the crash cart, where's the oxygen, do we even have oxygen?

Greenhorn surgeon kills first patient in office,
 the headlines read in tall letters in my mind. Looking stricken, my nurse raced around the room and came up with a mask and an oxygen tank, from where I couldn't tell. I managed to find the pedal that controlled tilt. My patient began to blink, looked around, asked what happened. You're fine, I told him. You fainted, but you're fine. Yeah, he said. I tend to do that. Having had quite enough for the day, I told the man that he'd also had a seizure and that while such a thing wasn't necessarily a sign of anything, I wanted him to see his doctor and have a checkup before we tried again.

Not long thereafter I was doing a vasectomy on another young man, once again in my office OR. (I'd done a lot of vasectomies -- in Vietnam, many soldiers seem to have figured that since they weren't getting any, it was a good time to take care of business. I was halfway through the procedure, with the guy's vas looped out of his scrotum, pinched between my fingers. I think I'm going to faint, he croaked (bad choice of words. May have to edit that.) Like lightning, hard and fast, I stomped on the tilt pedal, enough so the table went nearly vertical.

As the man slid off the table like a frozen fish, I followed him down, trying futilely to maintain a grip on his vas (losing it could mean a tough time relocating the exact spot on which I'd been working.) He ended up with head and torso on the floor, feet and legs still on the table, pointing to heaven (perfect position for recovery, actually.) He woke quickly, wondering what happened. Oh nothing, I said, maintaining my shaky grip on the south parts of his manhood. You just fainted so I laid you down.

After a somewhat clumsy re-mounting of the table, during which I, of necessity, loosened my scrotal death-grip, we made it through the operation eventually; I was left sweating bullets, while he was left shooting blanks.

Hard not to wonder what I was doing wrong. Was I so young that people didn't trust me? Were my patient communication skills lacking? Were the gods against me? Was it too late to apply to law school? I'll be fine. I know how to talk to people, I'll get some grey hair; sooner rather than later, evidently.

At this stage I wasn't getting many referrals for major cases. So I was pleased one day within shouting distance of the previous events to see my office schedule included a lady with gallstones. Working though the patients preceding her -- lumps and bumps -- I looked forward to the upcoming visit. She was still sitting in my waiting room when, according to the receptionist, she began slowly to lean forward and rolled onto the carpet, dead. As the EMTs wheeled the body away, I thought I could see lettering on their backs: Stay away from Schwab....Stay away from Schwab....Stay away from Schwab.

It occurred to me later it could have been worse. The lady had had a workup before she was referred: a healthy 70 year-old. I might well have scheduled her operation and watched the event occur in the OR. Fragile as I was, it could have been the last straw. The gods, I decided, didn't have it in for me after all: they let me go on with my career. But I'm not sure how they felt about that poor lady.

When Surgery SUCs

Several years ago, when I was chairman of the Surgical Quality Assurance Committee, the hospital medical director came to one of our meetings. We have a problem, he said. The Joint Commission on Accreditation of Hospitals had, on its recent inspection, given our hospital a list of criticisms, one of which involved unnecessary surgery. That, of course, got my attention, even though I've often said unnecessary surgery gets a bad rap: it's easier than the needed kind (nothing like disease to complicate things), and healthy patients generally do better than sick ones. NOTE: kidding.

The problem, it turns out, was not that they'd uncovered instances. It was that there was no requirement that surgeons include surgical indications (the reasons for doing a given operation) in the operative reports. We had six months to implement a solution: they'd be back to recheck at that time. OK, I said, we'll do it. Forget that it's stupid. Because if a surgeon is willfully going to do an operation he knows is unnecessary, he certainly'd have no compunction about lying into the record. Moreover, times had long since changed: if people see something fishy in the OR, they talk, they report, they get things changed. Nurses ain't stupid; and not only do they no longer stand up when the doctor walks into the room, they (rightfully) see themselves as advocates for patients. Not that doctors don't, of course.

So, no problem. There are published lists of indications for any given operation. Surgeons can dictate into the record why they're doing a thing, people in medical records can compare their reasons to those lists. Everybody's happy. (Being the passive aggressive type I'd often say things like: "operation: appendectomy; indication: appendicitis." Some operations pretty much go without saying. Or so one might believe.) We got the word to the surgeons, everyone complied. As stupid hospital rules go, this one was pretty benign, and even sensible, more or less.

Time: six months later. Place: SQAC (pronounced squawk) committee meeting. Speaker: the medical director, again. Saying, guys, they came back, and they don't like your system. It doesn't work. What do you mean, I ask. It's not working, he repeats. It's not finding unnecessary surgery. Long pause. VERY long pause. Dick, I say (it was his name, not a declaration). Does it occur to you that the reason we're not finding unnecessary surgery is that we're not DOING unnecessary surgery? C'mon, says Dick.

The rest of the meeting is somewhat of a blur in my memory. The minutes of the meeting, assembled by the staff secretary, were tastefully discreet. Something like "discussion ensued." It's possible there was one less serviceable chair in the room at the end than there was at the beginning. There may have been suggestions made that, even for a surgeon, were anatomically impossible. Had they been, the minutes of the meeting, and the report of the inspectors would likely have required decontamination before handling again. I guess it boils down to this: regarding the suggestion that we come up with a better plan, I demurred.

What I did was, I formed a new committee. The Surgical Utilization Committee, or SUC. You know how it's pronounced. It never actually met, and it pretty much had a membership of one. But it did produce a memo, distributed to every doc on the medical staff. Copies are no longer extant, but the following is a pretty good rendition:

TO: Combined Medical Staff
FROM: Surgical Utilization Committee (SUC)
RE: Unnecessary Surgery

A recent hospital inspection has found a deficit amongst our staff regarding finding and identifying unnecessary surgery, and the SUC committee has been charged with correcting the problem. In order to comply, we are going to have to find ways to produce more unnecessary surgery in our community, and your input is requested

Preliminarily, we offer the following possible solutions:

1) One surgeon in the community will be assigned to do nothing but unnecessary surgery. The designated surgeon could be chosen by lottery, or on the basis of case-load. Logically, it would seem best to select the surgeon doing the fewest cases.

2) The task of performing unnecessary surgery will be rotated evenly among all surgeons, on a monthly basis.

3) Certain operations will be designated as always unnecessary. Left inguinal hernia, for example.

4) If non-surgeons are interested in helping, they would be welcome. While not always unnecessary, operations done by them would not be done well, and that might suffice, for inspection purposes.


In order to help understand the scope of the problem, we are asking that the following questionnaire be filled out. Signatures are preferred, but anonymous forms will be accepted.

I currently do unnecessary surgery _____ times per week.

I prefer to do unnecessary surgery:
___ in my office
___ at the surgery center
___ in Seattle

I would be willing to do unnecessary surgery
___ exclusively
___ occasionally
___ never (NOTE: this may not be an option, given the current situation, but, as with all staff decisions, your input will be filed somewhere.

Thank you for your support of our medical staff. Please return completed form to the staff secretary.






The staff mailboxes were on a wall in the doctors' lounge. I got there early, and took a seat and a cup of coffee. As docs trickled in and checked their mail, I observed this: the medical docs, seeing something referring to surgery near the top of the page, tossed it in the garbage without looking at it. The surgical types read it and had a good laugh. One of the family docs read it with increasing agitation, and finally spun around, shaking, and saying, they can't do this! They can't do this!! This is terrible!!!

I don't suppose it accomplished much in the greater order of things. But I never changed the indications monitoring system, and I never heard any more about it. Sometime, if I get brave enough, I'll tell you about the notice I distributed similarly, and which was mysteriously pulled from all the mailboxes by five in the morning...