Friday, September 29, 2006

Take Your Lumps


What to do with a patient referred for a finding that you can't interpret on a test you'd never have ordered? It's a tough one, and not as rare as you might think, especially in the area of breast lumps. As a topic for posting, the subject comes up in a roundabout way. A couple of other medical bloggers picked up on my mammorable patient" post, and a comment on Orac's site raised the issue of the morbidity of medical screening. It's a fruitful object of scrutiny: false positives, for example, (a finding that requires further evaluation, possibly invasively, that turns out to be nothing) add up on the other side of the ledger. If a person suffers harm -- or even death -- from investigation arising from some sort of routine screening (for whatever...), when the issue raised turns out to be harmless, well, that's not a good thing. There's lots to say about it. I won't, exactly, now. It's just that it reminded me of something that used to drive me crazy.

I could rant all day and into the night about evaluation of breast lumps and where I think the surgeon's role ought to begin. I had a sometimes friendly, sometimes antagonistic relationship with a number of radiologists over breast evaluation, and I tried over my whole career to educate (based on my own biases, of course) primary care docs in the matter of breast lumps. A dispassionate review would likely show I won the occasional battle, but lost the war.

In a nutshell, it comes down to this: when there's a lump you can feel, diagnostic imaging (Xrays, ultrasound, etc.) is a waste of time and money. OK, that's a bit over the top: you get needed information about the rest of the breast, and the other side, which will come into play at some point. But getting a bunch of studies -- particularly without the input of a surgeon -- as the initial step in working up a lump adds up to lots of unnecessary running around for the patient, distractions in the diagnostic process, and -- not rarely -- detours into side roads that never needed taking. Ain't nothing like a good physical exam by a person highly familiar with breast exams, followed, when indicated, by the quick poke of a needle. Don't get me wrong. I recognize that radiologists do good in this world. In fact, I'll admit that the occasional interventional radiologist has saved my bacon more than once, with a well-aimed drain into an abscess here or there. But as the evaluators of a palpable lump (emphasis: palpable. When you can't feel it, that's a whole different ball of wax), they either muddy or bloody the waters.

Mild to moderate disclaimer: ultrasound quality and interpretation is constantly improving. It probably has a role in the screening of breasts too dense for useful mammographic interpretation; and as specificity improves, it may become more reliable in the interpretation of solid lesions. But, basically, the value of ultrasound in the study of the breast is to determine if a thing is solid (which means a possible tumor in need of a biopsy, usually) or liquid (which means, almost always, a harmless cyst in need of no further investigation.) And when is it useful? When a thing shows on a mammogram, and when the thing can't be felt. Period. If you can feel the thing, poking a needle into it gives the same info and more; cheaper, quicker, and more definitive. If it's a cyst, the needle will produce fluid and can empty the cavity, which in most cases makes it go away permanently. So it's diagnostic and therapeutic. Or if the thing is solid, then with the knowledge of simple technique, a sample can be taken with the needle, smeared on a slide, and reviewed under the microscope; often giving a final answer. It makes me lunatic bonkers when the first stop for a woman with a lump is the radiologist's store.

She finds a lump in her breast: it's round, tender, and she's sure it wasn't there a month ago. Because it's the way things work, she sees her primary doc who -- because it's the way things work -- sends her for an ultrasound. Or, more likely, a mammogram and ultrasound. Or a mammogram, leading to an ultrasound which is hopefully done at the same time, but maybe requires a return visit. As expected, the finding is of a fluid-filled cavity consistent with a cyst. (Once in a while, the report will refer to some "debris" floating in the liquid, or some echoes that suggest some irregularity in the cyst wall, of uncertain significance. Now she's worried. My office gets a call: our patient is scared to death over her report. Can you work her in today? Even if there's not the fear element, she's coming to see me much later and lighter in the wallet than if I'd gotten a call about it in the first instance. So I see her, use my handy little needle, diagnose and disappear the cyst, talk to her about cystic breast problems. Depending on age, time since last one, I might have ordered a mammogram, if I'd seen her first. (There's another reason for holding off on it: why get a picture of a thing that'll be gone?)

But it gets more complicated: she gets her ultrasound, and it shows a simple harmless cyst, as expected. But of course the whole breast has been scanned, and wouldn't you know they saw a five millimeter (less than a quarter of an inch) something somewhere else, too small to characterize fully, can't rule out every bad thing on the planet. See, that's what I was talking about. What to do with something you can't interpret on a test you wouldn't have ordered, found in an area not even part of the original concern? Just to make it realistic -- and worse -- the radiologist who read the study has recommended ultrasound-guided biopsy of this tiny spot.

What I'd do is candidly tell the woman my feelings on the matter: that I think ultrasound is the least reliable and reproducible of the studies we do on a breast; that I'd not have ordered that test in this situation, and that whatever this incidental finding is, at that size it's most likely perfectly safe to leave it alone for now and repeat the test in a couple of months. And that based on my experience, if repeated in that time-frame, it's quite likely it will no longer be there. And, of course, I'd also explain that there's no way to be sure at this point and that if it'd drive her crazy to wait, we should arrange for a biopsy. (In several of such cases, the scheduled procedure was unsuccessful in finding the original lesion.)

In the case of large lumps in the breast, I've seen women sent for mammogram and then, per recommendation of the radiologist, undergo stereotactic biopsy. That procedure is intended for things seen on mammogram and not feelable: whether the recommendation was based on an unskilled exam or without an exam at all, it's an expensive and cumbersome way to handle tissue sampling when a simple office aspiration would have gotten the same info. I've seen infections from such biopsies which the radiologist feels uncomfortable in handling; so I see the patient ex post facto, having received an unnecessary procedure and now, salt in the wound, I'm to care for the complication.

What's the point here? Not, despite appearances, to say that radiologists are the enemy. Rather, it's to say that with breast problems more than any "surgical" problem I can think of, coordination of care makes for better care; more economical, more efficient, less stressful. At worst, it can be fragmented into disconnected pieces, where doctors see the problem through a narrow lens, applying tools at their disposal no matter the alternatives. At best, it can come together in a true breast care center, dedicated to comprehensive and complete care. In the best of all possible worlds, surgeons, radiologists, pathologists, and oncologists are under the same roof and consult freely before diagnostic and therapeutic decisions are made. Such centers exist. They're not widespread; and, sad to say, there are some bogus outfits out there. I know of so-called "women's breast care centers" that imply broad-based care but which in reality are drop-in centers that encourage women to show up without referral, to have a cursory exam, mammogram, and quite often an unnecessary ultrasound. The results, rather than explained and followed up upon, are handed to the woman with instructions to see her doctor. It's a rip-off, not run by legitimate radiologists with honorable intentions, but by guys out to make a buck; some aren't even fully certified radiologists.

In most communities, women with breast problems have to start with their primary doc, and then follow a circuitous path to diagnosis and treatment. The end result is going to be good care, but it's hardly the most efficient journey. It's a microcosm of American healthcare: limited by the absence of agreed-upon protocols, complicated by varying levels of expertise, sullied sometimes by docs guided by self-interest (or at least a limited view), marked by wide variations in efficiencies and cooperation. And it showcases a central unclarity: is the best care delivered via good ol' Doc Jones, who knows and cares for the whole patient, or by taking certain body parts containing certain problems to a specialty center right off the bat? I guess if every doc in every area of practice were perfect, and had skills and knowledge equal to every other doc in their field, the question would be moot.

Wednesday, September 27, 2006

Opportunity lost


I've seen people reject mainstream (read: rational) treatment for alternative therapies, despite my attempts to shed light. When they came back with their cancers or other chronic diseases advanced far beyond where we started, I've not said anything. I've listened patiently to recitations of the value of what I've known to be useless approaches. I've encouraged my patients who wanted to, to supplement their recommended treatments with whatever herbs and potions they liked, as long as it was not in lieu of standard therapies. When I had nothing left to offer, I've not tried to take away the last straw for grasping, if I thought they had their eyes wide enough open. And, of course, I've wondered how many of the purveyors of fraudulent care actually believe in what they're doing. But it's not often that I've lost a patient because of the success of mainstream therapy; which is why the case of Orchid bothers me so much.

She'd been having trouble getting food to go down and hadn't waited long to have it looked into. Cancer of the distal esophagus had been found, and it appeared wholly confined to within the esophagus: curable, best we could tell. I had a long visit with Orchid and her husband, during which I detailed the operation I proposed to do (described in previous posts: really, it's not the only operation I know): esophagogastrectomy. Removing the bottom half of the esophagus, the top half of the stomach, pulling the stomach into the chest and hooking the remaining ends together. And I recommended an appointment with an oncologist ahead of time, because I thought her chances of cure would be enhanced by pre-operative chemo-radiation. The two of them were appropriately serious and worried, particularly about the operation. Ironically, they were living temporarily in the US; they were natives of Japan, the country wherein probably more such operations are done -- and done very well -- per capita than anywhere on Earth. In fact, I felt the need to point this out, and to raise the possibility that when it came time to have the operation they might want to return home where there are several surgeons with enormous experience. No, they said, they were committed to staying here.

Suffering very little of the possible side effects, Orchid went through her treatments without complaint, and noted quite early in the process that her symptoms were disappearing. By the time she returned to see me as planned, she was eating normally. Somewhat embarrassed, she said she didn't want to go through with the operation unless someone looked down her throat again to see if the tumor was still there. I pointed out the results wouldn't matter: even if visibly gone, the probability was high it wasn't fully eradicated by the treatments, and her high cure rate was predicated on going through the entire plan. She was insistent, respectfully. Her husband agreed, although he seemed less sure. So I contacted her original endoscopist, who repeated the study. Sure enough, there was no sign of the tumor.

As far as I was concerned, this was wonderful news and supported the optimism I had about her long-term outlook. I also, based on our conversations, knew it would make it nearly impossible to convince her to proceed. It was, in fact, completely impossible. She was convinced she was cured; and she was certain having the operation would be very difficult for her, with complications. It turns out she was well aware of the operation at home, and had heard stories.

No doctor wants to deceive a patient (no legitimate doctor). Much as I was convinced of her excellent prognosis, and confident as I was in my ability to do the operation well and with a very low likelihood of complications, I certainly could make no guarantees. "You'll be fine," I could have told her. "My patients do well and don't have problems," I might have said. "I know what it means to have a life in my hands, and I will do whatever it takes to cherish it. Please trust me. I can make it all right."

The most amazing thing about being a surgeon is that most people -- by far -- make that leap of faith without my having to say such things. (I don't -- I can't -- say them, of course.) I surely doubt it's because I'm overtly trustworthy. It's the situation: I hold all the cards, really. The patient hardly has a choice but to trust. As I've written elsewhere, "trust isn't given; it's taken." Is there, in part, an acting job in my encounters? Do I, or must I, behave deliberately in certain ways to engender confidence? At some level, I suppose the answer is yes. There is an extent to which I see myself doing a sort of performance. Yet it's not deceitful. I want to gain trust: it's essential, I think, to get the best result. And I believe in my ability. I would never falsely seek trust from a patient (I've sent people elsewhere when I think there's someone available with more experience in a particular area, even when I think I can do the procedure perfectly well.) Were there to be a complication, I'd have a hard time living with myself if I'd presented myself to the patient as equally qualified. Implicit in my "contract" with a patient is my belief that I can render the needed care as well as anyone. All surgeons feel that way, I guess. Perhaps you need to. But you also need to be reality-based. In the case of Orchid and her tumor, and the surgery necessary to deal with it, I felt fully able to speak with conviction.

I failed. I couldn't convince Orchid to have the operation; I couldn't overcome her fear of it, and neither could the other docs who'd been involved in her care. So away she went, husband in tow, looking back on his way out the door. Worried, he was. Unsure. Was he also disappointed in me, that I hadn't gotten her to say yes? He didn't say so. But they were both very respectful people. His silence felt incomplete, unconvincing. In an album he made, posthumously, containing her letters, photos, her artwork, the words of her friends, he spoke eloquently and voluminously. Her whole life, page after page, rendered in perfect strokes, Japanese calligraphy, English used sparingly. No need. He sent me a copy. It was heartbreaking.

It took about nine months for the cancer to recur, presenting as before with swallowing trouble. Scans showed no evidence of spread, and now she agreed to have the operation. My sense that we'd lost our chance didn't keep me from going ahead. The surgery was more difficult than usual: had it been done on schedule, the changes from radiation wouldn't have been as "set." (Scarring occurs, but not right away.) Worst of all, the tumor had perforated, causing a small abscess. I gave it wide berth, but anatomy (heart, diaphragm, big vessels) mitigate against the generous swath you might take in another location. None of the things she feared about the post-op recovery came to pass. Hospitalization was brief, she went home feeling strong; life, for a while -- until the invasion of her liver and spine -- was good. Her English was deeply accented, and halting, not easy. "Had I known....," she said with her lowered eyes. "Had I convinced you..." I said with mine.

Monday, September 25, 2006

Mammorable patient




It was so unusual that I wanted to write it up and send it to a journal for publication. But I didn't want to embarrass my colleague, who was a good guy. So I tell the story here for the first time.

When something shows up on a mammogram that warrants investigation, but can't be felt, you need to sample it using some form of Xray guidance. (If you can feel it, you can poke a needle into it in about two seconds, taking a sample for analysis. Or do a surgical biopsy. But when you can't feel it, there's no simple way to get at it in the office.) There are two main choices: wire localization, or sterotactic biopsy. In the former, the radiologist guides a wire to the area, and the surgeon then operates, following the wire to the target. In the latter, the radiologist does the whole procedure, with the woman lying prone, breast hanging down into a device which is aimed by Xray and then sends a biopsy-needle to the zone. There are, as usual, pros and cons of either method. Choosing one over the other depends on factors I might get around to some day. More and more, the stereotactic method is used; which is fine. In an ideal world, however, there'd be surgical input into the decision: coordinating diagnostic interventions in breast disease can eliminate a lot of unnecessary or duplicated testing. But I digress...

Marlene had had needle localization for a shadow on her mammogram. "Enormous" would be the word to describe the organ in which the shadow resided. The surgeon who did the procedure -- struggling, I'd imagine, in a very deep hole, following a flimsy wire into oblivion -- unfortunately cut the wire as he was working his way to the far end. As one might expect, gravity being what it is, the wire disappeared into the abyss. The surgeon spent a very long time trying to locate it and the target to which it pointed, and failed. He even transferred her from the surgicenter to the hospital across the street, where he used a mobile Xray machine (called a C-arm, for the shape of the business end which can be positioned to take live-action pictures on an operating table) without success. He gave up. Fully recovered and not a little pissed, Marlene came to see me for a second opinion.

Reviewing the Xrays led me to a couple of conclusions. First, uncomfortably: the shadow in question had, comparing mammograms taken regularly for several years, quite innocent characteristics (maybe fodder for another post, sometime) and -- more importantly -- had been unchanged for at least eight years. I, in other words, wouldn't have recommended biopsy in the first place. Second, the surgeon had given a pretty thorough effort to finding the wire, and I had no reason to think I'd be any more successful. We deliberately leave metal objects of all sorts in people; I didn't think the wire was in need of removal for its own sake. So I recommended watchful waiting, beginning with a repeat mammogram in a few months. If anything, Marlene seemed relieved. She's had enough plowing around in her breast for a while, thanks very much. She might have been a teensy bit annoyed at having undergone what may have been an unnecessary procedure, but we didn't dwell on that aspect. So when she reappeared in my office later, as planned, bearing the repeat Xray, we were both pleased to note that the shadow remained quite benign-appearing and absolutely stable. I was, however, a little puzzled to note that the wire was no longer there.

As usual, there are several types of wires from which to choose. Below is the kind I like:



It has a sharp backwards bend at the end, which discourages accidental dislodgment -- as can happen during the hubbub of transferring from the radiology area to the OR (not rarely involving a ride in a car) or during the operation itself. It also -- not relevant to the present tale, but giving credit to the inventor -- has a change in diameter near the end, which is helpful in pointing out that you're nearing the target as you dissect. It hadn't occurred to me until now (why would it have? It had never come up) that the characteristics of the hook could, with motion of the breast, allow for inching it forward. Guessing the wire had migrated itself to the periphery of the breast, outside the mammogram field, I ordered a regular chest Xray, and indeed it showed the wire. But not hardly where I'd expected it. Not hardly at all.

At the far edge of her right lung, is where it was. It had originally been in her left breast! And -- for you anatomists out there -- subsequent views showed it was definitely within the lung, not overlying it on the outside. Now, here's the hard part, because I'm not clever enough to be able to draw explanatory pictures and load them into this blog: the only way this could have happened is if the wire had humped itself directly down through the breast, through the chest wall, and into Marlene's heart: her right ventricle, to be precise, after which it was flushed out into the pulmonary artery and sent into the lung. The only other avenue was for the wire to have entered a vein in Marlene's breast -- or the big vein under her collarbone (the subclavian vein) and then gone to the heart. But the wire was at least two inches long. No way it could have made the twists and turns required of that circuit, starting its journey through a small vein.

"I've got some good news, and some bad news," I told Marlene. "The good news is that the shadow in your breast continues to look harmless, and safe to leave alone. The bad news is that the wire..... DRILLED A HOLE THROUGH YOUR FRIGGIN' HEART, PASSED RIGHT THROUGH IT AND STABBED ITSELF INTO YOUR LUNG. YOU'RE GONNA DIE!!!!!" OK, I didn't say that last part. But I figured that's what she'd hear, no matter what I said. Who wouldn't? I explained as mildly and as carefully as I could, drawing the sort of pictures I'd be doing now if I were clever enough, pointing out that if anything bad might happen, it'd already have occurred. I must have done alright, because Marlene remained seated calmly, as opposed to falling to the floor. I told her honestly that I'd neither seen nor heard of anything like it, and that I'd get consultations from cardiologists and chest surgeons; but that I thought the wire had done all the traveling it would ever do, and had come peacefully to rest where it would do no further harm. She liked that.

Catheter-wielding cardiologists and scalpel-wielding heart surgeons agreed: leave the damn thing alone. More damage was possible from trying to get it out than it could conceivably cause left in place. Subsequent Xrays over the next year confirmed it was happy where it was, and so was she. I'm pleased to say I'd never cut and lost a wire in a breast; but after meeting Marlene, I was even more careful with them than I'd been.

Saturday, September 23, 2006

Memorable Patients: version seven point one.




Speaking of gastrectomy, as I was in the previous post, there's another patient I'd like you to know about. But first, a word regarding gastric surgery in general: it's fun. Unfortunately, it's much less common nowadays, because those doggone scientists have come up with excellent drugs to prevent and/or treat ulcers, which used to be by far the biggest reason for operating on stomachs. Too bad for me, good for you. Anyhow, there are several things that make stomach surgery fun, uncommonness being high on the list. Also, richly endowed with blood supply, the stomach tends to heal well, no matter what you do to it. And, depending on how much stomach is removed, there are lots of ways to put things back together, each with its own nuance and technical challenges. Plus, you get to say the very cool surgical name, Billroth, when talking about a couple of those reconnections.

Christian Albert Theodore Billroth (Teddy-boy to his friends) is one of the main inventors of abdominal surgery. Born in the 1820s, he was working with a clean slate: everything he tried was the first time it had been done. My mind can hardly encompass what that must have been like; and not only in terms of technique. He had at his disposal the most minimal of anesthesia, few (and often home-made) tools, no IV fluids, no antibiotics. Not to mention an uncovered voluminous beard. It's amazing. And whereas it's true that (as my mentor said) the patient, ultimately, takes all the risk, still men such as he had a kind of bravery that I find astounding; not to mention provocative of envy.

After removing a portion of stomach, it's necessary, of course, to reattach the remnant to the intestine. Among the choices shown in the above link, the amount of stomach remaining has much to do with selecting: the ideal is the Billroth 1,
because it is the most "natural," if you will. (I know I will.) But hooking to the duodenum is limited by the fact that it (the duodenum) is fairly-well fixed in place; so if the gastric remnant can't be pulled down there easily, you have to close off the duodenal stump and bring the closest bit of small intestine up to the stomach. That's a Billroth 2 operation:

It has more potential problems: duodenal stump leak, bile and pancreatic juices building up in the stump and/or periodically squirting too briskly into the stomach (bile and pancreatic juice drain into the first part of the duodenum, and the duct through which that happens is one reason the duodenum can't be moved much). If you take away the whole stomach, a whole lot of plumbing is necessary:


I get a kick out of that stuff. In fact, it's better than the illustration above: if you do it as shown, there's no reservoir for food. I like to bend the intestine around in the shape of a "P" (a backwards one) and sew the top of the P to the esophagus. The loop of the P (which involves, as you can imagine, an extra suture-line to connect the bottom of the loop to the vertical part) makes a nice holding tank, and allows people, more often than not, to eat quite satisfactorily. That's what I proposed to do for Arthur, and it totally freaked out his wife.

Already slight and small, Arthur had been diagnosed with stomach cancer, in a location that demanded total gastrectomy. He was a "whatever-you-say-Doc" sort of guy, but his wife was literally beside herself. Vibrating in such a way as to appear to be two people must be how the "beside herself" expression came to be. That's what she was doing. "How can he live like that? He'll starve to death!! Look at him!! How can I feed him? What can he eat? I can't cook like that. What'll I do? What'll I do?" It's certainly reasonable to be shocked at the idea of an absent stomach, but she was letting my words bounce off without sticking: I was telling her I thought he'd be able to eat whatever he wanted, maybe in smaller portions. There was no special diet. No instructions. He should eat whatever sounds good to him, and we can see how it all works out. Boing, boing, my words came back un-received. She was as refractory to input as a crashed hard-drive. But there wasn't much choice; and as our meetings continued, I managed -- calling upon my greatest communication skills -- to lower the vibratory amplitude. Calm, such as it was, prevailed.

The operation went fine, despite finding that the tumor had grown directly into the left lobe of the liver, requiring that I take the whole stomach and a pie-slice of liver as well. Arthur made an uneventful recovery, and was ready for discharge in a few days. I stopped by his room for a final goodbye, to find his wife -- who'd relaxed a bit until then -- wide-eyed and pale-faced, vibrating anew as a dietician instructed her on a "gastrectomy diet." WTF?? Who requested that consult? Delicately as possible, I invited the dietician to join me in the hall, where I explained that this what exactly what the woman did NOT need; I'd take care of the dietary management myself. Had anyone requested the visit? No, she said. She'd just noted that the man had had a gastrectomy, and had taken it upon herself -- per some protocol or other -- to make the connection. I explained the peculiarity of the situation, to which she smiled nicely, and returned to the room and took up where she'd left off, as Mrs. Arthur levitated to the ceiling.

It may not be a surprise to regular readers here that this event sat uncomfortably with me. For now, suffice it to say there were communications. It's my opinion that there are lots of very useful services provided by many professionals attached to a hospital. And they should be used. When invited.

Well, I managed figuratively to hose Mrs down. And how did Arthur do with his extensive cancer and large treatment? Two answers: first, about ten years later I took his gallbladder out. Second: around a year after the gastrectomy, my wife and I were eating at a local steak joint. Couple of tables away was Arthur chowing down on a nice New York strip (medium rare, I'd say) and a baked potato, as his wife, calm and cool, did likewise. They had dessert, too.

Thursday, September 21, 2006

Memorable Patients: Part seven


I'm certain that if I hadn't been just finishing a midnight appendectomy, Daphne would have died. Not fully balancing all the bad luck in her life, she fortuitously chose to exsanguinate when a surgeon and OR staff were immediately available. Nevertheless, vomiting all that blood, she damn near died before she got to the hospital.

Niceties like passing a scope to find the source go out the window when someone is bleeding to death from her stomach. When I'd gotten the call, I was writing orders for the previous patient. I let the OR know they'd be getting someone in a big hurry, flew down the stairs to the ER, and met Daphne, who wasn't in a position to be sociable. In shock, confused, continuing to vomit blood, she was also very obese and showed obvious signs of Cushing's syndrome: side effects of high dose steroids. Whatever I might find and do, healing would be severely limited by those drugs. And you can't stop them for surgery: it would cause general collapse. Daphne's husband had ridden along in the ambulance. Compared to her, he was a tiny wisp of a guy, looking appropriately worried. I told him -- no surprise -- that she needed immediate surgery, and we'd see what we'd find, and do what we could. It was a very critical situation, I said. Blood had been drawn for cross-match, and I ordered a bunch of O-negative blood, started a couple of big IVs, told the OR we were on our way, talked to the anesthesiologist, and drove the gurney myself, pointed the way to the waiting area for her husband.

One thing about operating on the hypercritically ill: when you start from zero, there's no downside: clearly, she's going to die unless I can do something. No decision there; and, at some level, no pressure, in a perverse sort of way. Which is not to say I'm cavalier about it: I know that I'm the only hope she has. But unless I make a horrible judgment, or a monster technical error, a bad outcome is the default situation: I can't make it worse. I think.

In the middle of the belly wall, the rectus muscles (the six-pack muscles, in the fine and fit) are separated by a fibrous band, called the linea alba, or "white line." It's pretty bloodless, and what you aim for in making a midline vertical incision. Off to either side, it can get bloody. But in the very fat, it can be hard to find rapidly. There's a trick, for those of you trying this at home: after cutting through the skin, if you and your assistant pull the edges away from each other, hard, the fat splits apart like the Red Sea (the yellow Red Sea), right down to the white line, fast and smack on. Then you can split the linea sharply, fastly, and get in there.

What you'd expect, based on the odds, is a bleeding duodenal ulcer, the surgical approach to which is generally quick and easy: make an incision through the pylorus, place a couple of well-aimed sutures, and it's all over but the closing. Cut a couple of vagus nerves for good measure (it reduces acid secretion). But Daphne was anything but routine: she had two enormous ulcers, huge, encompassing much of the middle of her stomach, front and back; one of which had eroded through the wall of the stomach and into the splenic artery. No wonder she was bleeding so massively: that's a really big one, and I'd never seen it be the source of gastric hemorrhage. Having eventually made a large incision in the front of the stomach, the next thing I did -- once I realized the source -- was to put my finger in the hole in the artery to stanch the flow and give the anesthesia team a chance to catch up on volume replacement. That took a few minutes, during which there was nothing for me to do but stand there, a warm-blooded cork. Several pints of blood and bags of saline later, I placed sutures on either side of my finger, and warily pulled it out of the hole. Dryness, welcome dryness. (A professor of mine once said, "You don't need to worry about bleeding, Doc, unless you can hear it." Ha ha. This bleeding, I actually had heard and it's scary as hell. A hiss, a jet, a roar, hauling life with it, like a raft in a river.)

Even when it's necessary, operating on someone in shock is not a good thing: it unavoidably adds to the trauma, even as it seeks to reverse it. The least you can do is the best you can do. Get in, get out. But Daphne was in a hell of a fix: these ulcers of hers took up over half her stomach; plus, I'd probably just killed her spleen. I actually tried to save some of her stomach, not wanting to do a total gastrectomy for myriad reasons, but it was clear the remnant wouldn't survive. So, despite everything that would be ideal in a dire emergency, I removed her entire stomach and her spleen, and fashioned a sort of stomach-substitute reservoir out of intestine, and stapled it to the end of her esophagus. Too much surgery, really, for such a sick and medically depleted lady.

In a book I could tell you about if you were interested, I mentioned the generally competitive and uncooperative relationship between surgeons and medical docs in training. In practice, happily, it's the opposite. I worked with a sensational group of intensive care specialists, and between the two of us we pulled a few people out of the fires over the years. Daphne was one. In fact, I picked up her chart in the ICU one day to see a note from her primary doc -- pretty much out of the picture at this point -- saying, "I stand in awe of the excellent cared being rendered to my patient by Drs Schwab and OConnor." Never saw anything like that at San Francisco General Hospital.

Despite my having told the family to expect, at best, a long and complicated stay in intensive care, Daphne actually recovered on a semi-straight path. (Secret to caring for surgical patients on high-dose steroids: lower the dose as much as possible, give supplemental oxygen, intravenous multi-vitamins and extra vitamin C.) Her life was tough: she lived in a half-hovel, to which I made many house-calls over the years. Her kids -- whom she'd named after cartoon characters -- struggled in school; her husband rarely worked. Unlike most patients with a total gastrectomy, she had a hard time nutritionally (other than a need for injected vitamin B12 on a monthly basis, many actually eat fairly normally and do well.) It had, in part, to do with the mysterious disease for which she'd been put on steroids in the first place: she sort of wasted away over the next several years. But every Christmas I got a card from her, thanking me for another year of life she'd not have had, had we not met. Once in a while she'd call with some concern or another and, since it was hard for her to get around, I'd go see her and do what I could.

Several years later, she underwent a total cystectomy for a chronic bladder infection: an ill-advisedly (in my opinion) big semi-elective operation for a woman in her shape, and once again she damn near died. This time, it was from MRSA. Not directly involved, but feeling responsible, I visited her in the ICU and painted a pretty grim picture to her family. Yeah yeah, they seemed to say. Heard it all before. She'll be fine. And darned if she didn't make it, again. She had healing problems this time around, and I became the default home-health aide, debriding her wound for months at her sorry little home. I guess I didn't want those Christmas cards to stop. They did, eventually, but not for a few more years.

Tuesday, September 19, 2006

Tales From the Right Lower Quadrant, Part four


I used to have certain prejudices, one of which was that people who'd attended college were smart. I'd managed to hold onto that one for several years, until I met George, in the emergency room. He'd been sick a few days, getting more feverish, vomiting, suffering increasing pain in his right lower belly, putting up with it long enough for his appendix to rupture and form a quite impressive abscess, easily detectable on exam. That's not the un-smart part; I'll get to that eventually.

There are several ways to handle an appendiceal abscess, most of which don't involve removing the appendix right away. Since the body has, in forming the abscess, managed to keep the infection from spreading all over the place, it's generally a good thing to keep the barriers in place; rooting around within the abscess cavity in order to find and remove the appendix can tear down the wall (Mr Gorbachev) and spread infection around. So quite often, treatment consists of draining the abscess, surgically or by placing drainage catheters into it with Xray guidance. Typically this leads to rapid resolution of the immediate problem, but leaves on the table the question of how -- or whether -- to deal with the offending appendix in the future. But before we get to that, let's talk a bit about draining that abscess.

Mainly risking incredulity and recommending finding another surgeon by the patients' friends, I've on a couple of occasions treated small abscesses only with antibiotics. When a person comes into the office complaining of a month's worth of somewhat annoying illness, and the workup shows mostly swelling in the appendix's homeland with only a small fluid collection, it's seemed reasonable to take a pretty conservative approach. But in most cases, the patient is sicker than that, and the abscess is bigger, so drainage is best. Of course, I've always leaned toward the surgical approach, because it's the most definitive: especially for a large and loculated collection. You can get big drains in there, wiggle your finger around in the hole to break down the septations, and get it done all at once. Radiologists are getting better and braver at approaching intra-abdominal fluid collections, and it's become the preferred approach in lots of situations. The one area that until fairly recently many of them like to avoid, however, is a deep pelvic abscess. I liked it, if the anatomy was just right, because even in busy operating rooms, it seems I could always surprise a person or two with how I did it. Guess it must be an old-timer thing.

When the appendix is long and low-lying, and its tip sits way down in the pelvis, it's not rare for it to rupture by the time its particular form of appendicitis is figured out. That's in large measure because it tends to present with diarrhea, as opposed to most cases, in which bowel shut-down is the norm. The abscess that forms sits on the front of the rectum and bulges inward into it. You can put the victim up in stirrups, spread open the anus, confirm you can reach the abscess, poke a little needle through the rectal wall to prove the pus is there, and then, grossly, ram a clamp through the same point, through the entire thickness of the rectal wall and into the cavity. Pus ensues; fragrant, copious, gratifying pus. Guide a rubber drain into the area, and you're done: no skin incision, no consequences. You'd think poking a hole through the rectal wall into the abdominal cavity would lead to disaster; but it's well walled-off, it drains, it heals, and everyone is happy. The drain falls out in short order.

I drained silly George, and he got well promptly. He followed up as suggested, in the office, and I told him (as I had in the hospital) that I recommended he have his appendix removed after an appropriate amount of time had passed for healing. It's become controversial -- more now than a few years ago. The concern is that left in there, appendicitis will eventually happen again, and it's one of those things passed down from generation to generation of surgeons. It's only quite recently that studies have been done that raise questions about the need (these are all "retrospective" studies, meaning analyses of existing data, rather than "prospective" studies, meaning randomizing current patient to groups who'd have it done and who'd not have it done, and seeing what happens. Prospective studies are better. None have been done; but the papers have, rightly, gotten the attention of surgeons.)

Trained in the dark ages, I've done quite a few "interval appendectomies," and it's interesting how they have varied: in some cases it's as if the person had never had appendicitis. Everything normal, easy as pie. In others, the worm has been plastered to various entrails and exceedingly difficult to remove. Once or twice, it had been so fried by the original infection that there was nothing left but a thread; clearly incapable of causing further trouble. One time the pathology report came back "acute appendicitis with rupture," months after the actual event. But the need for the surgery was not what troubled George. He was worried about having his appendix removed, fearing the loss of it would lead to some sort of future health consequences.

That's not an unreasonable concern, and it's been addressed in many ways. I liked to refer to a study done by the Mayo Clinic (can't find it now. Didn't try real hard.) that compared around 4000 people who'd had appendectomy with the same number of ones that hadn't, similar in all other ways, and found no difference in incidence of health problems over many years of observation. But George brought an article, published in a journal of alternative medicine. It had actual photomicrographs of the appendix, showing lymphoid tissue (well-known.) The article pointed out the appendix's location between the small and large intestine (close enough) and stated that given the location and the lymphoid tissue, it clearly had an immune-surveillance function. There were no data, no studies. Just a conclusion out of thin air. Now this is not really a big deal, and I don't mean to hijack my own post. But it was the first time I'd seen an educated person show a complete lack of ability to judge data. Pretty picture, shiny paper = conclusion must be correct. Imagine. George rejecting reams of scientific and peer-reviewed data in favor of pseudo-data that served his purposes...

I'll finish this series (for now) with another prejudice, for the heck of it: I'm not a big lover of laparoscopic appendectomy. I think laparoscopy is a fabulous innovation, and there are several operations for which the laparoscopic approach is clearly superior to the open one. Appy, in my opinion, ain't one of them. Why? Properly done, an open appy takes fifteen or twenty minutes, uses a small incision that isn't very painful (much less so than the original disease was!) and from which the patient recovers rapidly; often in the hospital only a day or so postop. Admittedly, this isn't always so: appendectomy can be an extremely difficult operation. But we're talking typical, here. Come in to do an appy in the middle of the night, get a crew not so familiar with all the laparoscopic tools of the trade, and you've turned a simple thing into a time- and money-consuming circus. But tool-makers are very talented at marketing (there are some great technologies out there, just waiting for a disease.) High profile, big-ticket lasers gather dust in OR hallways as we speak. But that's for another post, another time.

Sunday, September 17, 2006

Tales From the Right Lower Quadrant, Part three


She was among the sickest kids I've ever seen: as close to death as any who eventually made it. And I never figured out if her parents were just incredibly clueless, or criminally negligent. When I saw her in the ER, her pulse was thready, barely palpable, and slow -- as in nearly agonal. Undoubtedly, a day or two ago it had been rapid, a desperate staccato plea for help. She moaned a little to deep stimulation, but her eyes -- like a doll's, like a pathetic imitation of some cliched cartoon -- were rolled up with only the whites showing. Instead of flushed and hot, as would be consistent with the rigid abdomen that told me her likely diagnosis, she was dusky and cool. Temperature below normal, heart slowing down. Jesus Christ!!! This little girl is dying of a ruptured appendix. I was as shocked and angry as I was scared I couldn't save her.

It had started over a week ago, her parents said: upset stomach, vomiting, fever. They put her to bed, figuring, they said, it was the flu. They just planned on waiting it out, as she got more and more lethargic. OK, yeah, kids get sick, they get a bug; don't call the doc for every sniffle. But vomiting for a week, becoming unresponsive: this is cult-worshipping craziness. You have to be nuts, or a committed conspiracy theorist -- a believer that doctors plot to make people sick, a snake-oil consumer -- to ignore all that for so long. Their daughter was no more than hours from death.

Cleverly called "the policeman of the abdomen," the omentum is there for a reason: it hangs down in front of the intestines like an apron, sliding around looking for trouble. If it finds it, in the form of an infection or inflammation, it sticks to the area, sealing it off with its layer of fat, richly endowed with lymphocytes and fibroblasts. Plug holes, send in the repel and repair crews. It works quite well when it works quite well. I mentioned previously that rupture leads either to pus all over the place, or to an abscess. Which one, depends largely on the omentum. If it finds the appendix early in the process and sticks to it -- and if in the process the nearby intestines close in as well -- the area gets effectively walled off. In kids, the omentum is thin and can be small. In the case of this little girl, for whatever reason it didn't do the job: she had a belly as full of pus as I've ever seen. And see it I did.

With warm IV fluids, heating blankets, and having given broad-spectrum antibiotics and medications to improve heart function, we got her in shape to handle an operation. I made an incision in her pretty little belly, up and down, in the middle. It would be there as long as she'd be there. I never cared too much about putting a belly-scar on an adult: whatever the indication, they'd know it was worth it. But cutting into a child's belly always bothered me a lot, no matter the reason. The bigger the cut, the worse I felt. The thrill of being the cavalry, riding to the rescue, was and is absent. That perfect skin, the vulnerable little child.

It was as if someone had taken a gallon jug of ugly gruel and poured it in: her insides were literally afloat in it. Raw and red, her intestines bobbed in pus. Her liver and spleen, surrounded. Sickly consistent, the same soup in her pelvis, the lateral gutters (that's the term for the area to the right of the ascending colon, and to the left of the descending. Never more appropriate), under her diaphragms. I sucked it out with catheters, and irrigated and irrigated, flooded her over and over again with liter after liter of warm and clean saline. Lastly, with antiseptic-laden solution. Assuring an un-cosmetic scar, of necessity I left the edges of her skin apart, lest she get infection in her wound.

Oxygen has antibiotic powers, and I kept her on it postop, to the (only slight) consternation of the pediatrician, since her measured oxygen levels were fine without it. The irrigations, the antibiotics and oxygen, her youth and who-knows-what other factors combined to give her a remarkably easy recovery. I was even able to tape her skin edges together, and her scar wasn't, as these things go, too bad after all.

Miracle? Not to me. The miracle would have been giving her parents who'd not let it happen in the first place.

Speaking of God, at the opposite end of the spectrum of parental involvement was a girl of similar age I was asked to see after she'd been in the hospital for three or four days with abdominal pain and not much else. No fever, no vomiting, no abnormal blood tests (the white blood cell count, a reflector of infection under usual circumstances, is nearly always elevated in appendicitis), Xrays, tea-leaves all OK. Was an operation indicated, I was asked? Look around, see if it's her appendix or something else surgical? I reviewed all the data, examined the child, and was as certain as I've ever been that it was neither appendicitis nor any other surgical situation. "That's what they told us about my other daughter, in Colorado," her mother said. "And she had a ruptured appendix and nearly died." I told her I understood how scary it was, that I couldn't comment on how that situation might have differed from this, but I was as sure as I could be that her daughter didn't have appendicitis, and I didn't think surgery would be of value. I told her I'd keep seeing her daughter every few hours to be sure, and moved toward the door. At which point the mom took that other daughter by the arm, and they both knelt and prayed at the child's bedside.

I was young then. I don't know if it was wise or not, but then and there I decided the little girl would never be really well -- never free of her mom's fear -- until her appendix was removed. So I did. When I told the mom I'd go ahead, her relief filled the room like fresh air; she looked as if she'd sprout wings and fly. And here's the amazing thing: in the face of my certainty, the normal lab work, the Xrays, the repeated exams, when I got in there it was as obvious as could be: her appendix, that mysterious little worm, that innocent little stripe-cum-killer, was.... entirely, amazingly, completely..... normal and pure as the first snow.

I've got a few more of 'em....

Saturday, September 16, 2006

Tales From the Right Lower Quadrant: appendixes I have known. Part two.


"Get a crew ready!! Guy coming in with a ruptured splenic artery aneurysm!! Order blood and a cutdown tray, be there in the ER. He's arriving by medevac in five minutes!!!"

Wow! This was a big deal. The only intern on the vascular surgery service, I was already swamped with work, but this was going to be an amazing case. As I sort-of knew, the splenic artery is a pretty big one, heading from a take-off point on the upper part of the abdominal aorta, across to the left behind the stomach and on the upper edge of the pancreas, to the spleen, which lies in the left upper abdomen. (Since I now have a search box on this blog, and since I'm sure you've read all my previous posts, in which I've mentioned those organs now and then, I'll assume you don't need hot-links to all of them. Gets a little showy, I suppose.) Splenic artery aneurysms are pretty uncommon: once in a blue moon you'll see an ovoid rim of calcification in the right spot on an Xray that clues you in that a person has one. In most cases, they're silent unless they burst. When that happens, you'd expect sudden onset of pain in the mid or leftish upper abdomen, and, most likely, the rapid descent into shock: clammy, rapid pulse, low blood pressure, mentally out of it.

Which is exactly the story behind this man's arrival: he'd been ambulanced to an ER across the Bay, where an Xray had shown the typical calcification pattern, and he'd been fired off to us, one of the pre-eminent vascular surgery departments in the country. Dr. Wylie himself, chief of service and famous, who rarely came in for emergencies, was on his way. (He was pretty much the guy who'd invented repair of abdominal aneurysms, and pioneered much of the modern world of vascular surgery. He didn't have to take call!) We got the man well-resuscitated and into the OR in short order. Bags of blood at the ready (strangely, he didn't show signs of much blood loss, although he definitely was in shock...), extra anesthesia personnel in the room to help if he crashed further, with the patient shaved from stem to stern, special vascular clamps shiny and in easy reach of the scrub nurse's hand, Wylie got the nod from the north end of the ether screen and opened the man up with his usual dexterity, despite lacking the tip of his index finger (boating accident.) Expecting to find blood filling the lesser sac, everyone was more than a little surprised to find the cecum rotated up to and plastered on top of the stomach and spleen, forming the front wall of an abscess cavity, central in which was a ruptured appendix. "I'll be goddammed," said Dr. Wylie as he walked out of the OR, leaving the disposition to the resident team. The shock, it turns out, had been due to sepsis, not blood loss.

Malrotation of the gut is moderately uncommon, and usually presents with obstruction of the bowel due to twisting on itself. That can be very serious; in fact a case of it early in my practice was my virgin entre' into the medico-legal system (sounds like a fruitful subject of a future post!) Presenting as a dislocated case of appendicitis is not common; especially when also associated with a previously-undiagnosed splenic artery aneurysm -- which the man did indeed have. The patient did fine. Dr. Wylie had to take some gleeful guff at weekly complication conference for an error in diagnosis and for venturing out of vascular surgery into general surgery.

It wasn't the only time in my experience that a floppy cecum fooled me: I once operated on a man with a diagnosis of strangulated left inguinal hernia. (Yes. Left!) He had a hernia, all right. But what was contained in it was not dead bowel but his appendix: infected and ruptured. He also did just fine, thanks. But it's one more instance in which I remembered that Dr. Dunphy (previous post) was a wise man. And hardly the only time I was impressed by the power of the appendix....

Friday, September 15, 2006

Tales From the Right Lower Quadrant: appendixes I have known. Part one.


Dr. Dunphy (J. Englebert "Bert" Dunphy, Chairman of the Surgery Dep't, UCSF, RIP) used to tell us: when evaluating abdominal pain, never have appendicitis lower than second on your differential. It's a good thought to keep close: whereas classic appendicitis is most often a fairly straightforward bedside-makeable diagnosis, it can do pretty strange things, and be a major diagnostic challenge. Not to mention being the cause of a few good stories.

First, some background: the appendix -- its spanking name is appendix vermiformis, which means wormlike thingy -- looks, in its normal state, like a little worm, 'bout half a night-crawler. Doing nothing that any (reliable) research has ever identified, it hangs down from the cecum like a sad little rat-tail in the right lower part of your belly. Most people never have any reason to know it's there. When they do, in by far the most of cases, it's because it becomes infected: infection of the appendix is called appendicitis.

Your mom may have told you if you swallow cherry pits you'll get appendicits. I know your mom: she wasn't wrong often, but this is one of the times. That rumor may have gotten started because of an item called an appendicolith, which means a stone in the appendix. ("I gave my love a cherry, without a stone... I gave my love a chicken...." etc.) The other, less impressive, name is fecalith. What it is is a piece of stool that got stuck in there and become so inspissated it's like stone. This is one presumed cause of appendicitis; it also can lead to a rare situation of recurring appendicits (more, later.) But the fact is, in most cases there's not an identifiable reason when it happens; and in the vast majority of instances, it's a one-time deal. (I always made a point of telling kids with appendicitis, and their parents, that it's no one's fault: it's nothing they ate, nothing they did. It just happened.)

The gut doesn't have a large trick-bag; meaning, it only has a few ways it can respond to illness, and it doesn't have the sort of pain nerves that allow localization. If I pinch you on your skin, you'd know exactly where, with your eyes closed. Pinch a spot on your intestines, and you'd likely only muster a "yuck." So the early signs of infection or inflammation of one part of the gut have a way of sounding like and feeling like those in another. When appendicitis starts, therefore, it's usually with a vague yucky feeling, loss of appetite, nausea. Pain is hard to put a finger on, at first. It's only when the inflammation progresses to the point that it involves surrounding tissues -- specifically, the parietal peritoneum, which has LOTS of nerves, of the kind the brain can pinpoint -- that the pain begins to localize where the appendix is (or is supposed to "is"), in the right lower abdomen. Typically it takes a half a day or a day for the symptoms to localize. Appendicitis can happen at any age, but is significantly more common in kids (around five years old to teenage, and there's another spike of frequency in us senior citizens.) Luckily, it's rare in babies, which is good: it's hard as hell to diagnose early in them.

As the infection evolves, the appendix gets red and swollen, going from worm-size to -- sometimes -- finger-size. And left to its own devices, the infection eventually rots away all or part of the appendix (gangrenous appendicitis) and it falls apart, allowing the pus inside to leak out. Ruptured appendix, as you've no doubt heard. When that happens, things generally go in one of two ways, depending on several factors, including the location of the tip-end of the appendix: either pus flows all over the place, causing generalized peritonitis, or it gets walled off into an abscess. In the former case, you'll get sick as hell; in the latter, you won't feel great but it's possible to limp along without disaster.

The cecum is always the starting point, anatomically, of the appendix, and the cecum is nearly always situated in the right lower part of the abdomen. But the tip of the appendix can be in a lot of places, depending on its length, and resting place. Some far ends of the thing are way down in the pelvis; some are across to the left, or aiming north. Quite a few take off from the cecum and run backwards behind it, and can go as high as the liver in that "retro cecal" orientation. Major bummer for the victim and his/her surgeon.

OK. So now, assuming you didn't already, you have a background for a few stories I'm going to tell.

Thursday, September 14, 2006

The memo, at last


THE BOARD OF TRUSTEES IS PLEASED TO ANNOUNCE
A NO-HOST BARBECUE TO CELEBRATE THE OPENING OF OUR NEW BURN UNIT
ALL STAFF INVITED. BRING YOUR OWN BUNS

We are delighted to announce the immediate opening of the Catherine O'Leary Burn Unit. As this project may not have been well-known to all, there follow herein some details, in a question-and-answer format, designed to show our sensitivity and desire for thorough -- albeit ex post facto input.

Q: Burn Unit?? Where the hell is it going to be?
A: Patients will be housed on the surgical floors.

Q: Aren't those floors already at capacity?
A: Data have shown that on weekends, there are quite often available beds, and it is on weekends that people typically ignite.

Q: Who will be taking care of the patients?
A: The plastic surgeons.

Q: Uh, what do they say about it?
A: What possible difference does that make???

Q: Aren't there only two of them?
A:Yes. And that's the beauty of it: there's nothing they can do about it.

Q: Well, what facilities have been put in place to deal with the patients?
A: As we speak, finishing touches are being put on a large sign that says "Burn Unit," to be placed at the entrance to the ER.

Q: Isn't there a world-class burn unit just a few miles away with lots of experience and excellent results? Why on earth would we want to open one here?
A: Listen, you smart-ass son of a...... Sorry. Excellent question. It's why we do everything, It's about the effort we are making on behalf of the hospital. It's our new mission: Market Share.

Q: Burn patients require a great deal of nursing care. Will more nurses be hired, and will they be experienced?
A: You can be sure we have looked into it. And while we're on the subject, let us remind you that most nurses are women, and women have plenty of experience scraping crust off of burned toast. In life, things overlap.

Q: I have a bad feeling about this. If our patients do badly, what shall we tell their families?
A: Tell them "Nobody Cares More."



That's it. I think the original was longer, but as usual I can't find it. This is pretty close.


Followup number one: the hospital is still designated at level three for trauma care.

Followup number two: the hospital now, several years later, has a cardiac surgery program consistently ranked in the country's top 100, and the hospital has been so ranked as well. It's building a whole new plant. Actual "state of the art." Go there with confidence. Times change. Sometimes -- who knows why? -- for the better.

Wednesday, September 13, 2006

Hospital politics: the infamous memo. Part three


Where was I? Something about trauma centers....

So this Level Two thing was occurring at a time when the hospital was in a major funk. Nurses, as I said, were feeling lousy. Care was spotty, despite the presence of a bunch of the best nurses I'd known: they were overwhelmed with work, frustrated by lack of support. And despite this, because of the combination of sustained growth in our area, and the recent converting of many of the beds in the former competition to long-term care, the hospital was jam-packed much of the time. Having made commitments to using those beds across town for other purposes, and still running deficits, locked into an old building, the options for increasing bed space were few. And weren't happening. The ER (soon to become a high-level joint, evidently) was not rarely on "diversion," meaning the medics were told not to bring in new patients because there were no beds in which to put them. Elective operations were occasionally cancelled. Postoperative patients were sometimes kept in the recovery room for hours or overnight because there was no place to send them. Patients who might have otherwise gone to the ICU (intensive care unit) were kept there as well, for the same reasons. So among the least important issues for administration was attracting more patients. Patients, they had up the wazoo.

One more piece of the puzzle: trauma is, mostly, a money-loser for hospitals. Following a rule mentioned in a book I recommend, trauma happens to people who are asking for it (more of a county hospital rule, actually, but still...), meaning they have no insurance and governments don't pay well for them. Off the top of the head, it wouldn't seem like a desirable thing for a hospital already hurting financially. And this: whereas trauma is the lifeblood of surgical training, and something people in surgical training love, for most surgeons in busy practice (which describes all the town docs, clinic or not), it's not always welcome. If it happens in the night, it means you face the next day's schedule tired; if during the day, it throws already-busy schedules into chaos. Because unlike training (as described in a particular book), where the trauma service hangs around waiting to receive the next case, in practice you have a million other things to do. So the idea of doing more trauma, and having, on the days you were the designated trauma doc, basically to write off the whole day so as to be available by the rules of Level Two, was received -- let's see -- unenthusiastically. The anesthesia docs were similarly hypo-ebullient. Unlike any other issue including what time it was, on this everyone agreed, across all party lines.

Seeing danger down the road if its reputation didn't improve (several smaller hospitals line the periphery of the area, and they were salivating), the hospital embarked on an all-out effort to...... market itself. Not address care issues (OK, it's not as if they were totally unaware or making no attempts at all: but cost-cutting was the ne plus ultra, so not much was becoming apparent.) Marketing was where it was at.

I'm guessing the person who came up with it didn't last long in the advertising game, but the new slogan up with which the hospital came was "Nobody Cares More." Banners and posters appeared all over the hospital, and, of course, in TV and newspaper ads. I suppose you can guess how the hospital ones were defaced, in short order (not by me, I'd add: too mundane): Either the "More" was crossed out, or "Any" was added between Cares and More. Among the staff, it was a running joke. And it bears remembering, for later on.

I may have exaggerated when I said the move toward a Level Two Trauma Center united the medical staff. Fact is, since it didn't affect a lot of docs one way or the other, they didn't care. But those most affected -- surgeons of many specialties, and anesthesiologists -- were horrified at the prospect, and were of one voice in expressing their displeasure. And truly, it wasn't just about the work-load. It was very, very much also about concern over the hospital's ability to provide the resources to do it right, and the fact that the best around was within shouting distance. I wasn't the only one who'd had experiences like the one I described. But of this "one voice" it must be said that one vocal chord was paralyzed. That's because half of the docs in town, as mentioned earlier, were in bed with the hospital. So much so that if the hospital CEO had gotten the clap, they'd all have had to take penicillin. So much so that when they walked into the hospital, they were handed tubes of KY jelly. So -- and don't doubt that administration didn't know this very well -- when the hospital did something that the medical staff didn't like, half the staff kept their mouths shut. And the medical staff officers pretty much spent their time sending out memos telling us what plans the hospital had, with no input and no feedback. Puppet government? Puppet something: government seems a little generous.

So I was elected. The surgery department of the medical staff consisted of all surgeons in town, regardless of affiliation. Everyone knew I'd speak out and would say what was on all their minds, while allowing the rest to sit mute and enjoy deniability. "Sid, go talk to the CEO, and tell him why it's a bad idea," they all said, to man. And a couple of women. Give 'em hell, while we lube up. A meeting was scheduled with me, the CEO, and the hospital medical director. Armed with a well-prepared list of questions and issues that needed addressing, I spoke my piece, and was surprised by the candor of the response. "It's about market share, doctor. Our business plan is to be the referral center for the area, and being a level two trauma center will impress people, convince them we're the real deal." Or words to that effect. "Market share" is a verbatim quote. Providing service to the community was never mentioned, per se. What arguments did I have to counter "market share?"

The one thing they had done is to spiff up the ER a little: made it bigger, bought a couple of cool monitors. New paint. Being the second busiest ER in the whole state, it needed it, trauma center or no. What they hadn't done is make any effort to get the surgeons, et al, on board; no need, really. They held the cards, in terms of doling out staff privileges, and they had the other guys by the balls, and by whatever parts were available on the feminine side of the equation.

As I was talking with the rest of the surgical department and considering how to deal with the inevitable, what steps could be taken at least to ensure the best care possible, the hospital started running ads in the newspapers, when the paint was dry in the new ER. Here's an exact quote: "State of the art in every way, the ER is backed by an acute care hospital... We all hope that life-threatening traumas and illnesses never befall us or our loved ones. But if the unthinkable happens, isn't it nice to know that the very best help is available, right here at home." Let's be clear: "state of the art" does not mean Xray facilities five hallways away from the ER and which may or not be available, lack of onsite lab, or absence of clear protocols for handling given situations. The ad also listed the services available at the hospital. On the list was the term: Trauma Center. I suppose I can be self-righteous. I'm a surgeon, after all. But this really struck me as awful. To call the facility a trauma center, and to claim it was state of the art and that the very best help was available was, in my opinion, fraudulent. Premature at the very, VERY least. So I wrote a letter to the medical staff president and his executive committee. I included a copy of the offending ad, and said I thought it was time for the medical staff to step up and take a stand. Going ahead with a trauma center was a decision that seemed to have been made; but there was no reason we should be silent in the face of false advertising. I got a letter back. You shouldn't write letters like that, was the gist of it. My within-the-system wad was shot, I figured. I'd gone to meetings, I'd written letters, I'd talked formally and informally to administrators, physician officers. I felt the hospital was behaving as if all it had to do to be a trauma center was to hang up a sign in front of the ER. I'd lost the war.

So I distributed a memo to all of the doctors at the hospital. Put it in their mailboxes. From which it got pulled so fast hardly anyone saw it....

Tuesday, September 12, 2006

Hospital politics: the infamous memo. Part two


In offices all over town, doctors were busy trying to survive. The clinic, of course, had a significant advantage in many ways: we had excellent management, and we were getting large enough that we could throw our weight around. In a move that sent shockwaves across the entire US -- since it had never been done -- we'd actually fired an insurance company (ironically, the one with which we'd a few years earlier signed that exclusive contract): having had enough of the annual cuts in reimbursement, and having figured out that we were actually losing money on their patients (Old joke: how do you survive when you're losing money on each widget? Anwer: you make it up in volume) we told the insurer that that was it, sent letters to all our patients covered by them, offering help in hooking up with a new insurer. Set up a special phone line. Set a date. The insurance company caved. Of the bad new days, those were the good old days.

As private docs and small groups got into more financial trouble, some of them joined us. A few closed up shop. And the hospital, deciding that the clinic represented some sort of threat, began first a primary care network, and then a cadre of specialists as well. I can't say, from one point of view, that I blame them: they felt if the clinic became the only game in town, they'd have no leverage. (There was a time when all the rage was pre-paid healthcare, wherein the insurer paid a given amount to the docs to manage a patient, and the doc assumed the risk for overspending. The clinic bought into the idea, and went so far as to assume risk for hospital costs as well, which meant trying to negotiate daily rates with the hospital. More irony: the data for this concept looked great for a few years, and we thought we were better than anyone on the planet at controlling cost. Turns out it was an obvious accounting peculiarity: sign up a bunch of people, and for a few years it looks great. Then they start getting sick. That model is pretty well dead throughout the country now.) So on one level, I understand the hospital's thinking. On another, I thought it stupid for them to be underwriting practices all over the country with money that would be much better spent on improving their product. They were the only game in town. All they had to do was be excellent, and they'd be fine. And the clinic, believe it or not, didn't WANT to be the only game in town. We thought competition was good for everyone. As I recall.

Among other things, the effect of having the hospital support virtually every doc in town but us was to heighten the already great tensions between the doctor groups, and between the clinic and the hospital. To me, it began to feel like enemy territory whenever I walked into the place. Making matters worse, the hospital gave an enormous payoff to the specialist group, by paying them an outrageous amount of money to "manage" their outpatient operating room, a place at which I frequently worked. Scheduling time there suddenly became more difficult, on the one hand, and more unpleasant on the other. (Full disclosure: we eventually opened our own outpatient surgical center and, as one of its prime planners, I consider it one of my great accomplishments. As I wrote to them when I retired, "You are an island of excellence in a sea of despair.")

So that's pretty much the soil in which this story is growing: things are going to hell in a handbasket in town. Docs aren't talking to one another, everyone is paranoid and doing whatever they can -- even when it makes bad policy -- to survive. Insurance companies are loving it: trying to undercut the other, each party is willing to take less and less in payment. For a while, I used to imagine board meetings in top floors of skyscrapers, the air filled with cigar smoke and the self-satisfied farting of large and wealthy men, saying, "I was in their town yesterday, talking to such and such group. I offered them so and so in reimbursement. And guess what! They TOOK IT!!!!" High fives, yuks, and farts all around.

And then, improbably, the hospital made a move that united all the docs in town.

"Ladies and gentlemen, we're going to become a level two trauma center," said the CEO at a staff meeting, to the gasps of nearly everyone there assembled. Looks were exchanged, of the "they can't be serious" kind. If it weren't for the fact that trauma care was so lousy, making the act potentially fatal, people would have fallen out of their chairs. OK, I was wrong: I need to till the soil a bit more to have it all make sense.

First: the state had recently adopted a system of trauma-center designations. (Coincidentally, the main promoter of such systems was a good friend and mentor, from my training days: Don Trunkey. Yes, a character in my book -- here I am selling it again.) Level one was basically a world-class center with dedicated ORs and crew standing ready at all time, and having surgeons and anesthesiologists in house around the clock. Level two was nearly the same in terms of systems and facilities, but with the docs available within twenty minutes, 24/7, under pain of water-boarding and dismemberment. Level three was, more or less, where we were: take care of stuff pretty well, usually. If things fell into place. There was a level four as well, and, I think, a level five. Hard to imagine what those would be. Significance of trauma-level is that, among other things, medics in the field are required to triage a given level of injury to a given level of center, bypassing lesser facilities in most cases. Second important fact: twelve minutes away by readily available medic helicopter, and about twenty-five minutes by ambulance with lights flashing, was one of the best trauma centers in the world, level-frickin'-one, and then some.

I used to say that if I were run over by a truck, or shot in the belly at the entrance to our hospital, I'd want to be choppered to that trauma center down the road. And I meant it. Oh, if the stars aligned properly -- namely if a person had their major surgical emergency at 6 am, when the crews were all there but the day's patients weren't yet in the OR -- we could do as good a job (in terms of conduct of an operation) as anyone around. Not a couple of hours later, when the ORs were likely full, or in the middle of the night, when crews had to be called in. And not necessarily if the patient needed complex Xrays right away, or -- God forbid -- more than a couple of pints of blood. Not long before this jaw-dropping announcement, I'd had one of the worst experiences of my surgical life: called in to the ER at around midnight to care for a man gravely injured in an auto accident, clearly bleeding internally and massively. Because the OR had just finished some case or other, the crew was there. We got him ready in short order. I called ahead to get blood and emergency instruments available. I opened him up, unzipping his belly in a maneuver well-described in a certain book. (Note to reader: despite what you think, I suggest you take a second and click those book links. It's not what you think.) It was obvious he had a monstrous liver injury. I called for an aortic clamp, which, it turned out, wasn't in the pack supposed to contain it. In a cost-cutting move, the hospital had recently decided that having a bunch of instruments all cooked up and ready to go outside the rooms was expensive: they wanted everything centralized in the basement; and a lot of it -- believe it or not -- in a suburb a few miles away. So there was -- as there had been before the new idea -- no extra clamp on the OR. A call to the basement got this reponse: none. NO ONE ANSWERED THE GODDAM PHONE! Meanwhile, I'd sent word to the blood bank to send ten more units of O-negative blood (generally able to be given to anyone, without taking the time to crossmatch.) "You need to send us another clot," was the reply from the lab. (That's what you need to do a crossmatch.) Understand, I was in the process of losing the patient, and feeling very, very unsupported, to say the least. The list of things wrong is so long that I won't take up your time. Suffice it to say, the hospital at that time was clueless about what it would really take to upgrade to a level two. And not really in a position to do much about it. Did that matter? You'll see.

Monday, September 11, 2006

Hospital politics: the infamous memo. Part one.


In an earlier post, I made reference to a memo I once distributed to the medical staff which was so inflammatory it disappeared from every doctor's mailbox before most ever caught wind of it. Although there might have been suspicions, I don't think it was ever known who did it. I'm ready to let the cat out of the bag. It might take a couple of posts to explain the whole scenario. Done well, it ought to shed light on many aspects of what has been wrong in medical practice in recent years. Done poorly, it could bore you to death. But first, a disclaimer:

Let me say in all sincerity that this occurred some time ago, when medical relationships were at their nadir in our town. And the hospital in question has turned things around in remarkable fashion, so much so that it's as if I'm talking about another place. So understand this: although it's all true, without question, categorically, undeniably it is not a reflection of the current situation. Politics have improved, and the quality of hospital care and commitment to it are exemplary and award-winning. The hospital is now one of the best there is. Really.

Once upon a time, when hospitals were not under the sort of financial pressure that exists today, they could focus on their mission (providing care to the sick, in case anyone's forgotten) without much concern about the competition. And doctors, maybe a little too fat in their wallets, worried more about their patients than about their financial survival. But as those who pay for medical care (governments, health insurers and, to a lesser extent, consumers) began -- rightly -- to seek ways to control costs, they -- wrongly -- focused only on payments to hospitals and doctors. Squeezing pretty much all of the blood out of the turnip, they went -- in the opinion of me and many others -- well beyond what was reasonable, and set medical finances upon its collective ear. And whereas I'm among the first to admit that there was a time when many doctors were overpaid, and that hospitals should have long ago looked more closely at efficiencies in the delivery of care, the result has been chaotic and frustrating, and damaging. Among other things, it has set doctor upon doctor, hospital upon hospital, and every combination within: collegiality has been replaced by competitiveness and divisiveness. Our community has been a microcosm of all that, a laboratory study of how it works.

Guy wakes up one morning and hears a voice in his head: "Sell your house, your business, take your money, and go to Las Vegas." He ignores it. Next day, he hears it again, and again, until he hears it pretty much all the time. He decides he must believe it; sells his house, his business, takes the money and goes to Las Vegas. On arrival at the airport, the voice tells him "Go to Caesar's Palace." He goes. Entering the lobby, he hears the voice tell him "Go to the roulette wheel." He goes. "Take your money," the voice says, "and put it all on red 36." He does. The wheel spins, the ball stops on black 15. The voice says, "Shit."

The above had nothing to do with anything; I just thought things were getting a little heavy.

There's been a huge political divide in our medical community, between the docs in a large clinic (including me), and everyone else. Things got a lot worse about the time I arrived in town, just before which the clinic had opened a satellite office in a nearby town, and had signed an exclusive contract with one of the local health insurance companies. So I'd walk down the hospital hallways, smiling happily at the docs I'd see, oblivious to it all, young and optimistic; and they'd literally turn away without speaking. Unless they were in the clinic, in which case they probably wondered why I wasn't in the office cranking out patients. The other guys figured we were aiming to take over the town, running them all out of business. That was not the case, of course, and it never happened. Even though the clinic is nearly ten times as large as when I joined, the town nicely accommodates everyone. But it wasn't so clear, then. A major effect of payment reduction has been to cause everyone in healthcare to focus on their bottom line, to behave in ways they never thought they'd have to: competing for dollars, forming alliances, signing contracts they don't like. Up to a point, it wasn't entirely undeserved. But it's turned docs away from what they loved in the first place, which was providing care, and it's made them love it less. That's, I suppose, fodder for a whole other series of posts. But maybe not: it's too depressing.

Meanwhile, the hospitals were in trouble. There were two for many years, one private, one public. Having lived together in a measure of peace earlier, as reimbursement decreased each felt the need to grab patients from the other. Duplication of services, generally not a great idea when there are fewer patients than beds, actually increased as each hospital strove to attract clients. (Yeah, they started calling them "clients." What BS. It's like I told my son when he was tiny and asked if he could call me Sid. "Everyone in the world can call me Sid," I said. "You're the only one who can call me Dad." Likewise, everyone is someone's client. Only doctors and nurses have patients.) Long, longer and longest story short, the public hospital (the better one, in my opinion) started to fail and despite such draconian measures as firing all the senior nurses and relying more and more on less expensive locums nurses, eventually it sold out to the private hospital, and they merged. There followed a very dark time, and sadness descended upon the medical community, most especially the nurses. Though many of the public hospital nurses were retained, everyone had to get used to new people, new systems, and to try to forget the old days, when there were enough nurses to provide what they knew was excellent care. At some point, administration literally told the nurses to shut up and stop with the suggestions, or find another job.

The level of care unquestionably descended. The surgical floor at the old public hospital had been, not long ago, the best I'd ever known. Highly experienced, highly dedicated nurses with a team approach, were assigned to that floor and nowhere else. I love having confidence that my patients will be getting top-notch care, and that when something goes awry, the nurses will find it and understand it right away. That all slipped away, as the few remaining nurses were surrounded by a different crew every day; in fact, it became the mantra that all nurses should be able to work anywhere. Specialization was rationalized away, because it was cheaper to believe it didn't matter. Doctors were getting extremely frustrated; some of us began to consider admitting our patients, inconveniently, to hospitals in neighboring communities.

So what would you think they'd do, as morale fell, quality suffered, and word began to grow in the community that maybe you should think about going elsewhere when you got sick? Trade in the pig for a quarterhorse? Focus like a laser on improving care? Nope: think again. You put lipstick on the pig. Stay tuned.

Saturday, September 09, 2006

Breast Cancer Women



Something you may not know, and won't get by looking at most renditions of them, is that the legendary Amazon warrior women are said to have cut off their breasts. One, more accurately. In order to shoot their arrows with their bows, the left breast (assuming right-handedness) was removed. (The linked article above has it wrong, I think.) Pantomime it on yourself: the left breast would be in the way, particularly if bare-breasted, as they were, so it is said. And here's the kicker: it's in the name. Amazon. A (for absent); Mazon (same root as mastectomy: referring to the breast.) Of course, none of this is confirmable, but it is an accurate account of the legend. And so I told it to Gloria and her husband, competitive archers.

Women are tougher than men, no doubt in my mind, having operated on both more than a few times. The fact emerged first in medical school, when a fellow (male) student fainted dead away as we heard a lecture on blood types. A lecture, not even a lab! And about types; not even the gooey stuff itself! The prof was unsurprised: "Happens all the time," he said. "Always the men. Ladies live with blood. It's no big deal to them." Bunch 'a wimps, we.

Don't get me wrong: I'm well aware how devastating the idea of cancer can be, and how mutilating many operations are -- mentally as well as physically. And yet it's been a source of inspiration over the years to witness how well most women are able to adjust to mastectomy: with bravery, with calm, with humor. I learned many years ago, when inspecting a surgical wound, not to say "beautiful," no matter the operative type. And yet I've heard lots of patients, when they looked at their mastectomy scar, say "gee, that's not as bad as I expected." And many, for various reasons, chose not to have reconstruction later, when they'd initially figured they would.

This is not a treatise on the benignancy of mastectomy, nor a suggestion that women who have a hard time with it are somehow deficient. I'm just saying -- because it's been a source of amazement to me -- that for some women, it turns out to be ok. More ok than they'd expected it to be. On the day of her surgery, I pulled back the covers on one lady to discover that she'd crocheted a quite impressive nipple/areola in brown and pink yarn and placed it on her chest; delighting in my surprise.

So, back to Gloria. A very athletic woman, tall and muscular, she and her husband sat in my office hearing the results of her biopsy. In addition to all the usual fears, they were concerned about their archery careers. They competed at a very high level, and had tournaments coming up. How soon, they wanted to know, would she be able to pull a bow? That was as high on their list as any other issue, and I was glad to hear it: desire to get back into life is important, whatever the operation. I hadn't known about this avocation of theirs, and it gave me my one and only chance to tell the Amazon story. And yes, it was her left breast, and she was right-handed. She loved it. There was no question in her mind which option to choose: it was mastectomy for her, and she recovered like the athlete she was, proudly arching (or whatever they call it) and telling the legend to her competitors in short order. As I recall, her husband got her some sort of Xena paraphernalia to wear, as well. Sometimes, things have a way of working out.