It's Complicated: part one

One of the hardest things about being a surgeon is the inevitability of complications. It's true for any doctor; but with surgery, it's as if they are lit in neon and given a soundtrack. At least to me. Aiming for perfection (as do we all) and beating myself up (more than healthier people) when I miss the mark, I found bad outcomes of nearly any magnitude deeply disturbing. The big ones are there for lots of people to see: nurses on the surgical floor or ICU, operating room personnel when you have to re-operate. And of course, the patient. The family. My family, for that matter. Smaller problems might just be between me and the patient; but they still are painful. Carrying the responsibility for having done harm to people who gave me their trust can be nearly too much to bear. Thankfully rare, it's never been easy. Nor should it be.

I don't know the extent that I speak for other surgeons in this matter. I actually believe I took it too hard, and too personally; so what I say (which I'm sort of anxious to find out myself) may be fairly singular. But I got a specific request to tackle the subject, and I think it's an excellent one. So here goes.

There are two cardinal sins, in my estimation, for the general surgeon. The first, the sine qua non of a surgical screw-up, is injuring the common bile duct. Nailing the bowel with a suture while closing an abdominal incision is the other. Each tends to bespeak carelessness, and I'm sorry to say I've done both. Only once each, thank God, in what I'd conservatively estimate to have been around ten thousand operations (not all, of course, subject to those particular errors.) Actually the cardinal error -- more like the pope error -- of bile duct injury is to do it and not recognize it at the time. THAT, I've never done. Unrecognized bile duct injury can lead to a tragedy for the patient. If you're gonna ding it, at least see it at the time and fix it. That usually works out ok.

In the community of my first job as a surgeon, each newbie was subjected to a monitoring process in which every other surgeon in town was to scrub with him/her at least once at to render some sort of judgment. So the first time I was able to do a case unmonitored, I had the referring doc assisting me on a very routine gallbladder removal. It was the classic situation for injury: the easy case -- when the going is tough, you tend to have all the feelers out for problems. (I'd add, apropos a comment I received on my mini-gallbladder post implying it was the worst of all possible worlds, this was in the days of the big incision, and well before laparoscopic surgery.) My patient was a tiny woman, with tiny ducts. Her gallbladder had practically no length of duct connecting it to the main bile duct, so I thought I was dissecting the cystic duct (normally much longer, it's the tube that connects the gallbladder to the common duct), when in fact I was working my way down the common duct. Somewhere along the line, I discovered I'd cut it clean in half. As my heart sank and my hands got clammy with the realization, my forehead and armpits drenched themselves with sweat and I told the referring doc I'd be wanting to get my partner in to help at that point. He was only too happy to vacate. I repaired the duct -- among the smallest I've ever seen -- over a baby-sized T-tube, drained it, and closed up. And for the first time as a real doctor, I had to face my patient and tell her what happened.

It's excruciating. I hate everything about it. There is a very real temptation -- to which, even in this age of attorneys under every rock, some people still succumb-- to fudge it, not to tell it like it was, to protect oneself. In my case, I think, the urge is motivated less by fear of lawsuit than of confronting my own inadequacy. And the acute awareness that I'm telling a person things will not be as she expected; that her life could be very unpleasant for awhile. It's not what she signed up for, and it's my fault. Face to face. You're screwed. My fault.

I doubt I could successfully bullshit a person if I tried. My car got stolen when I was in med school. In the glove box was a small amount of what might be called an herbiferous stimulant (that it was small and had been in my glove box for months bespeaks the extremely limited use to which it was put.) For what may be the only time in the history of the local police, they found my car, and called me to pick it up at the station. Finding the glovebox contents strewn about the car, I noted it was all there; except for the one item. To the query if anything was missing, I said no. Couple of days later, there were two cops at my door, holding badges at eye level (narcotics boys) and asking for me. Had they just graduated from cop school, had they never seen a guilty person in their lives, they'd have known I was as guilt-ridden as if I were holding a bloody dagger. They displayed (holding it by a string: no fingerprints) the Alka-Seltzer bottle which held the offending material, and asked if I knew what it was. "Well," I said. "You guys being here and all, I suppose it's some sort of drug...." Fortunately, they also knew that the car had been stolen and there was no way to pin the contents on me. A stern warning was what I got, as my future career and my father's wrath passed before my forebrain: the one waning, the other waxing. I'm a lousy liar. (And since then [well, not too long after] a confirmed non-user.)

I told my patient truthfully what had happened, but I was not above trying to put it in the best light. Her anatomy was unusual, I explained, with her gallbladder so close to the bile duct that removing it left the duct damaged. True. But passively stated. To my retrospective regret (because it was less than entirely forthcoming), I glossed over the fact that I hadn't recognized the anatomy until I'd done the damage. I didn't lie. Yet I didn't resist the urge to sugar coat it. She was disturbed, but not beside herself: ultimately she had to put up with a capped-off tube with no drainage for three of months, after which it was gone and she had no further problems. (Being just out of training, I wrote to my professor to ask his advice about how long to leave the tube. In doing so, I said "I was recently called upon to repair a bile duct...." It was not untrue. I hoped he'd assume it was someone else's injury. He never said otherwise, but he was a very wise man.) It could have been much worse. As to the conversation I'd had with my patient, it's weighed on me ever since, and it was a long time ago. So many issues are at play in such a situation, it's hard to enumerate them, let alone fully understand them. I'll try.

The suture thing was quite different: the whole spectrum of terribleness, way worse for everyone. It had been a routine colon operation, and she'd gone home quickly, doing fine, only to come to the emergency a few days later, sick. My clamminess didn't take over right away, because my first instinct was to try to fool myself, to convince myself it wasn't what it was....

Local Hero

I said in a recent post that I liked doing office surgery, somewhat parenthetically implying as well that I could do a mean local anesthetic. It's true, of course. More than just lumps and bumps, I did lots of breast biopsies in my office under local, revised mastectomy skin flaps, took off a few humongous lipomas, excised gynecomastia; and I did more than a couple of simple mastectomies under local in frail ladies (not in the office.) (Also not in the office, I repaired many a hernia under local.)

Per a request from a commenter on that post, I hereby share some tricks of the trade. None, I'd say, is original; but I'm not sure that by the time one finishes training, all of these pearls -- if that's what they are -- have been assembled in the same part of every graduate's brain. Realizing it's the ultimate in surgical esoterica, I hope non-medical readers might also find it interesting, if in a useless sort of way.

"Vocal anesthesia" is the term for when a local isn't working out. "Hold still!!... It can't possibly hurt that much!!... I've never had to inject this much local!!..." That sort of thing. The aim is to avoid that scenario. And whereas it's not quantifiable or even supportable, I think step one is establishing some rapport and a measure of emotional comfort. No point dwelling on it, since it's probably condescending: but I really like light banter, joking when appropriate, taking the time to establish a little calm and relaxation. And, of course, letting people know what's going on every step of the way. (There are, strangely, some people in whom no amount of any kind of local seems to work. I've not seen articles about it -- I bet there are some -- but I've had a few patients in whom I simply couldn't get them to the point of adequate numbness, no matter what. Extremely uncommon; but real.)

It's all in the wrist: making a really rapid (but controlled) flick with the back of the wrist is the way to make the first stick. Right through the skin and into the subcutaneous fat. Many times, after saying "OK, here comes a little poke," and flicking the needle in in a nanosecond, I hear "you mean that was it??" Save infiltrating the skin for the very last: once through the skin with that quick move, first fill the subcutaneous area. The idea is that if you get the nerves to the skin from below, when you finally inject the skin itself -- which is otherwise the most painful part -- it's barely felt. It's often helpful to pinch the skin before poking it: first, of course, telling people you are going to do it. A gently increasing pinch is a familiar sensation which isn't frightening; and it'll mask the poke. Pay special attention to dermatomes; that is, infiltrate the upstream subqu, innervationally speaking, before the target area. Like a mini-field block, essentially. And one thing that's important and which I don't recall hearing during training is the need to infiltrate separately around blood vessels before cutting them. Even when the area seems otherwise numb, people often feel pain on cutting a vessel. This is particularly true doing hernias under local; also with breast biopsies. In the breast, I came to do most dissection sharply, with a scalpel, finding it to be less uncomfortable than using scissors. I didn't like to use cautery on awake patients except when absolutely necessary. Because of the smell. Suture and ligate.

[Super-esoterica warning] There are classic articles about local anesthesia for hernia repair, and I can't improve on them other than to say the simple approach is simpler: I didn't find it necessary to try the regional block at the ilium. Do the skin and subcu as I already described. Pop below the fascia and fill that layer up before starting. Pay attention to blood vessels. Infiltrate the base of the sac when you see it. And that's about it. Except: I used long-acting anesthetic for the skin and muscle/fascia, and short-acting for the subcu and the sac. Partly to avoid nearing the limit, and partly, in the case of the sac, in case some local leeches to the femoral nerve: in which case, it's nice not to have a gimpy patient for twelve hours.

In medical school, I was allowed to remove a bunch of sebaceous cysts (plugged up oil glands in the skin). The people teaching me challenged me to remove the cyst intact, without disrupting its wall. It wasn't until many years later that I figured out that meant making a much larger and more noticeable incision than necessary. After a (perfect) local, make a little stab into the cyst, squeeze out the goop, and the cyst sac will follow it out. A little dissolving stitch or two, a steri-strip, and that's it.

Anyone who's bonked their head knows how well-vascularized the scalp is. Anything with that much blood is going to heal more or less no matter how you handle it. So with scalp cysts, I shaved little or not at all: taped hair out of the way, did my thing. People really appreciate not having to walk around looking like they were treated for ring-worm. And never put in a stitch that needs removing, unless you need it for hemostasis. Big pain in the rear to remove them amongst all the hair.

I hardly ever did the bicarb trick (mixing it with local anesthetics raises the pH and lessens the pain of infiltration, especially of the skin. Since I saved that part for last, I didn't think it made a difference.) I did find the thankfully rare patient in whom no flavor of local seemed to work, no matter what I tried. If I couldn't achieve comfort, I quit and scheduled for the surgery center.

Long run, as they say, for a short slide. Less here, maybe, than I thought. Guess you had to be there.

Mini Me

"Big surgeons make big incisions," said the visiting professor at our Saturday morning conference on deaths and complications. He could also have chosen to say "incisions heal side-to-side, not end-to-end," which was another aphorism professors liked to repeat, with the same implication: for safety's sake, the bigger the incision the better. In a training program -- especially in the ancient times in which I trained -- the point was made often. When open incisions were the only game in town, and when a young surgeon-in-training found him- or herself in difficulty, the first thing the attending was likely to do was to enlarge the cut. And, as I said in a post a while back, there's nothing quite like stepping up to the table and making a bold and generous incision; especially when carrying it through skin and fat and fascia in one glorious and heraldic (if medieval) stroke. By contrast, poking little holes in a belly for inserting scopes is like peeing sitting down.

So I grew up making big incisions, with no second thoughts. Until I thought third: you can indeed make them larger, so why not start small and -- assuming the ability to anticipate before causing a problem -- enlarge if necessary. Bigger wounds hurt more, and are more traumatic, requiring more energy to heal. More pain, more tiredness, slower recovery. Made sense to me. So I changed direction. Rather than go to extremes and start tiny, I simply began to make incisions for all the operations I was doing smaller and smaller over time, heading to an unknown end-point. And that's how I invented mini-cholecystectomy (cholecystectomy = gallbladder removal.)

Well, I suppose I can't claim I invented it. Like several good ideas I've had over the years (another post?), I've come up with a few things up with which others seem to have come as well. My kind of good ideas, evidently, aren't the kind to stop the world from turning: if I think of them, so do others. But there are a few things -- taking gallbladders out through tiny incisions among them -- that I just started doing before there were professors publishing articles about them. (You can read more about these things here.) In the case of "mini-cholecystectomy," it evolved in my practice simply by steadily decreasing the size of the cut from an initial eight inches or so, to six, to four, to three, to two and, eventually to one or one-and-a-half. Somewhere along the line, I had significantly to change techniques: for one thing, no OR light shines through my head into such a hole, so I started wearing a surgical headlight. For another, I ordered some very narrow bendable retractors, figured out different ways of inserting packs, used different methods of teasing the gallbladder away from the tissues that sometimes surround it. I figured out how to "walk" my way down the gallbladder with long instruments, exposing the important anatomy at its bottom end using a thin suction catheter. The patients recovered very rapidly: instead of the typical three to five day stay (when I trained, it was closer to a week), I was sending patients home happy in a day or two. Then one. Eventually (I admit it was only after the laparoscopists came along -- which happened a while after I'd perfected my version) nearly all of my patients went home the same day, and ultimately I did most of my gallbladder surgery at a free-standing surgery center.

I thought more than once that I should write it up. What kept me from doing so, mainly, was the realization that I'd evolved the technique gradually, going from a very wide view to a harrowingly narrow one over enough time to be confident in what I was doing. If someone tried it straight off, I feared, they'd booger the bile duct, lacerate the liver and generally trash the technique. Whatever else is true about it, it ain't exactly easy, especially when it's hard.

After a few years, papers began appearing, especially in England. Some even called it "mini-cholecystectomy," which is the term I'd begun using in my operative reports, having never heard it elsewhere. Since laparoscopic gallbladder removal had pretty much taken over the world, and since I steadfastly resisted it (I took the courses, I could do it easily and enjoyed it), I was pleased that these reports confirmed what I'd been saying to colleagues: mini was way cheaper than laparoscopy, and was otherwise the same in terms of patient discomfort and recovery. And mind you: these reports were defining "mini" as an incision less than eight centimeters. That's more than three inches!! With incisions half that size, my patients had less total incision than the lap patients with their four holes, and less pain. Still, I feared writing it up. (Interesting note: in at least one study comparing lap- and mini-chole, the patients were randomized after going to sleep, into one group or the other. Everyone received a bandage large enough to cover either a mini hole or the spread-out four holes, so neither the patient nor the nurses taking care of them knew from looking which they'd had. Same results in each, except for lower mini costs. Cool study! This was when patients were staying in the hospital, and had they had "my" operation, I'm guessing they'd have gone home sooner than the laps.)

At one point, I entertained the idea of hooking up a video camera to my headlight and recording the procedure, developing some sort of presentation to teach it. Hell, charge for seminars!! But I didn't. I did have some pictures taken, at the request of a couple of OR nurses, having been invited to give a talk about the procedure to a regional meeting of AORN, the association of operating room nurses. Had nice slides, the last one of which showed, for all to see, the incision covered by two half-inch steri-strips. They were impressed. The slides that got the most murmurs, however, were the ones that compared the nursing set-up: for the lap-chole, a table covered with tubes, trocars, all sorts of very expensive instruments. For mine, a couple of long clamps, two three-quarter inch retractors, a few of the usual surgical instruments used since the Red Sea parted, and a clip applier.

Is laparoscopy a step forward? Absolutely! For many operations, it's an unmitigated marvel. And the technology has advanced at light-speed. Is it over-hyped? Yep, in my opinion. When you can take out a gallbladder through a one-inch incision in twenty minutes or less, as an outpatient; when you can resect a colon through a three-inch incision in forty-five minutes or less and have the patients go home in two days, I can't think of a reason to do it laparoscopically for thousands of dollars more/pop. Clearly, however, I lost that battle a long time ago: there's billions of bucks behind the hype. The public thinks it's the only way, and surgeons would rather learn the cool stuff. Despite the opportunity to save a gazillion dollars a year, the chances of my approach taking hold are ze-fricking-ro. I'll say this, though: in my little corner of the world, as time went on I had patients coming to me because they'd heard what I was doing and preferred one small hole.

Foxy Me

(picture from yerf.com)


Hey, welcome to readers who drop by from the Fox News site! Just saw the article myself. I hope you'll wade into the archives to get a feel for the place. To make it easy, a couple of oldies but goodies are here, here,
here,
here,
and here.
I'm more than pleased to have been noticed, and welcome a look around. There's lots more. Some of it gory, some a bit raunchy, some, I'd like to think, informative.... and occasionally moving.

Taking my Lumps

One day when I was in college, when my hand was near my lower abdominal wall for reasons I don't entirely remember, I felt a lump. Off to the right, a little below my belly-button, and just under the skin, it was firm, smooth, and moveable, sort of ovoid in shape. Maybe a half-inch in size. It scared the crap out of me.

Mine was a very small college, just over a thousand in the entire student body, and all male, which narrowed the health care needs quite a bit. So the student health service -- such as it was -- was sort of a mom and pop operation, literally. A doc and his nurse wife, housed in a small one-story building, with a tiny lobby, couple of chairs and magazines, maybe two exam rooms. In the back was the infirmary: the size of some people's bedroom, it held about three beds, meant mostly for guys who didn't feel like going to class that day. No one very sick could stay there, if he planned to see the next sunrise. Mister Brown the doctor, is what we called him. Not known for medical acumen, he could splint a fracture from the athletic fields, look at sore throats, stick a thermometer in your mouth; none of it done with much enthusiasm. Whatever his practice had been before he settled in on campus, at this point he was clearly there to glide into his dotage.

But I had no choice. Lugging my lump, I went to the clinic figuring even Mister Brown would be able to tell I had cancer, and let me know if there was any point in studying for finals. I signed in, and sat for what seemed way too long, unregisteringly aiming my eyes at a magazine, clammily. When I was directed into his office, Mister Brown asked, without looking up from some papers, "so what's the problem?" Said in a tone that suggested, had I ever been there before, the question would have ended with "this time?"

"I found a lump," I said, as if it might be the last words I ever spoke.

"Show it to me," he ordered, in a way that would ordinarily accompany a heavily-burdened sigh.

I lifted up my shirt. Mister Brown leaned partly out of his chair, reached across his desk, and touched the lump with his index finger, rolled it around a little, and sat back down. Flipping over the paper he'd been reading, he said, "I don't know what it is, but don't worry about it." If the preceding details are embellished at all, the words are exact. I could never forget them, because I found them so stunning. Along with the fact that those were the only words he uttered before excusing himself. How, I wondered, could you reconcile the two thoughts: the doctor doesn't know what it is, but is telling me not to worry about it.

Forty years later I'm alive and I still have the lump, so I guess he was right. Given how frightened I'd been, and how completely unsatisfactory the encounter, I can't imagine why I didn't go somewhere else for another opinion. I guess that concept was just foreign in those days. But I remember how I felt, and it was important to me throughout my years in practice. In fact, I told the story many times, when seeing patients with clearly benign but not necessarily bedside-diagnosable lumps.

It's possible with the vast majority of lumps and bumps people get, to assure oneself by context and by exam that whatever it might be, it's not dangerous. Location, texture, shape, behavior all can add up to a safe clinical assessment that a thing is innocent: a lipoma, fibroma, cyst of one sort or another. Reassuring the owner, however, takes a little more than "don't worry about it." You'd think even a guy like Mister Brown would know that. He probably did, but at that point in his career was beyond caring.

Removing little lumps and bumps in the office is something I always enjoyed. It's recreational: simple, non-threatening, a way to show off my skills with local anesthesia and gabbing with a patient while puttering around. Prior to doing it, I'd always have tried to reassure the person that this thing was harmless, and I rarely failed. Removal nearly always was because the lump in question bugged him or her, rather than frightened them. Reassurance is easy: tell them the characteristics on the basis of which you are sure it's ok; list the possible causes of a lump; say why you're confident it's safe to leave it, and offer to remove it if they prefer. Taking only a few moments more than Mister Brown had, maybe with a little eye-contact as well, knowing that these things are frightening to people.

I'm pretty sure I didn't need that personal experience to have had the sensitivity and ethic of treating patients as I'd want to be treated. But it gave me a cute story to tell people when I didn't have an exact name for their lump, yet was sure it was no big deal.

Speaking of Grand Rounds...

... during training, Grand Rounds were a big deal. Whereas our weekly conference on deaths and complications that had occurred throughout the surgical services was the most informative -- and entertaining -- Grand Rounds were the stately and intellectual reminder that we were at a major academic institution. Held monthly and theoretically directed at the whole spectrum of people in the institution, they'd usually involve a presentation by one of the honcho/professors, speaking about some cutting-edge (as opposed to cutting-error) research. More often than not, the lecturer had briefly emerged into the light, from the medical or PhD side of the mysterious and removed laboratory wing, behind the hospital. Kinetics of messenger RNA. Membrane potentials in sciatic nerves of thymectomized rats. Conflated uranian hopflotsch in HLA reduced amoflatric cell tramiphones. I didn't go on a regular basis.

About a year after he'd finished training, one of the stellar medical chief residents was invited back to present Grand Rounds. He was an extraordinary guy, blessed with a non-academic practicality, a sense of humor, brilliance, and -- based on my encounters with him -- an absence of the typical training-time disdain of non-medical types (which was, of course, echoed exactly in the surgical types vis a vis the medicals.) Out of curiosity and admiration, I showed up. And was delighted to hear about his subject. "Ladies and gentlemen," he began, "the topic of today's Grand Rounds is the condition with which, having been in practice now for about one year, I am most commonly faced. This, it turns out, is the main work of an internist, the chief complaint with which I most regularly deal. Today's subject is........ tiredness." He went on: " 'Doc, I'm just tired all the time' is what I hear over and over in my office, every day."

I guess I don't remember much about what else he said (although it's more than I remember about any other Grand Rounds). But it did give a new perspective on what we were doing, and reinforced a maxim I'd learned in med school: "Rare things are rare; common things are common." It takes a while, after spending several years in ultra-academe, to re-aim your focus on the doughnut, instead of on the hole. One forgets, in the tertiary care centers of the world, that most of the patients originally presented with some sort of mundane complaint. Flu-like symptoms are most often from a flu-like illness. Those local docs, derisively referred to by us as "LMDs," who seemed so obviously to have blown the diagnosis weeks ago, had probably treated a dozen upset stomachs before the Crohn's disease patient showed up that same day.

Not every thing about having been drafted out of my internship into the Vietnam War was bad. Among other things (seeing venereal diseases I'd never even heard of, treating cobra bites, experiencing the seminal event of my generation, feeling cool at the controls of airplanes), before returning to finishing my training I'd gotten a couple of years of being a general doc. I developed an appreciation (I suppose some might have a hard time believing it, reading a couple of my prior posts) for the difficulties of primary care. For most physicians coming out of a highly academic training program, it's a good thing to be aware of in advance.

There's another side to the coin, of course. In private practice, local staff meetings take on an entirely different tone. Gone are the open and frank discussions of morbidity and mortality. Those conferences, which in training taught me far more than any others -- about what to do and what not to do in myriad situations, and about personal responsibility -- became an instant and permanent thing of the past. No private doc, I found, even with identification disguised, likes to have his dirty laundry aired out in a venue filled with his competitors. I tried several times, as chairman of the Surgical Quality Assessment Committee (appropriately referred to by its acronym "Squawk"), to set up such a conference. No dice. Not ever.

Rounding Off

I was in a fraternity in college. (Where I went to college, housing depended on fraternities: there weren't anywhere near enough dorms to handle it on their own. Also, there were rules such that everyone who wanted to be in one, was guaranteed to do so. I say this because people who know me might not consider me a frat-guy.) It was a national fraternity, but on our campus the rules and mumbo-jumbo went out the window. Literally, in some cases. Anyhow, we'd occasionally get visits from some grownups in the national organization. Among other things, it struck me as an entirely useless job: an organization whose purpose was to promote the organization. A self-perpetuating loop of meaninglessness. Which brings me to Grand Rounds.

I'm getting a little annoyed over here. In the last few weeks, the whole raison d'etre seems to have changed. Instead of being a collation of the medblogosphere's current writings, it's become a theme-park at the direction of the current host. Maybe that's fine. Until recently, I'd thought of it (wrongly?) as an assortment of posts chosen from those things the bloggers themselves felt like writing about. Now, it seems to be a high-class meme; a writing challenge of sorts. I like writing challenges: I've participated in a few. (And I ignore memes, which may explain a lot.) But Grand Themes is an entirely different kettle of fish. I blog, in theory at least, because I have things I want to say. Sometimes a subject evolves from a comment or suggestion I get, which is great: it means my blog is stimulating (or so I'd like to think.) I assume that's what motivates most of us. To turn Grand Rounds into a theme dictated by the host is entirely different and, in my opinion, wrong. Want people to write about a subject you find interesting? Excellent idea! Post a request for submissions and call it whatever you want. Just don't call it Grand Rounds.

All politics, they say, is local. The reason I'm annoyed, of course, is personal. I've had a few posts of which I'm sort of proud lately, and which I'd intended to submit for Grand Rounds consideration. But for the past few weeks, in checking out the host site, I find a bunch of rules, criteria, demands. So, rather than write what I want to write, I'm to write what I'm told to write (within an admittedly broad band.) So I don't submit. Or, in one case, evidently, am rejected for non-compliance (can't say for sure: never got a response to an inquiry.) Again: I don't object to the concept; I just object to it as a modus operandi for GR. On the other hand, it's not my gig, and isn't up to me. Plus, I'm still a newbie. It doesn't matter, in the grand order of things, if I stop submitting -- it only hurts me, I guess, to the extent that GR brings readers to my site. But I don't go quietly. I go. But I thought I'd say why. Just in case anyone cares.

How does the above relate to the fraternity analogy? Sketchily, I suppose: a fraternity is for the people in it. The guys at the national level are no longer doing the fraternity thing; they're doing a thing about the fraternity thing. Grand Rounds are about bloggers. Themed Grand Rounds are about hosts.

The preceding is an opinion. It is not a call for action, even if I were in a position to do so. Grand Rounds should be what people want it to be, and if this is where it's going, so be it. I liked sending stuff in, and was pleased when it appeared. I'll get over it. And for any reader who came here looking for something other than medblog esoterica, my apologies. We now return you to your regular program...

Give Peace a Chance

"Peace of mind." In the previous post, that's exactly (as a commenter pointed out) what the ad is all about: trying to create peace of mind as a new reason for having a defibrillator implanted. Get people to dread Sudden Cardiac Arrest, maybe they'll try to talk their doctors into the procedure, even as the typical cardiac indications don't exist. And, when you think about it, it could happen: Doc, if you don't give me one, and I die of cardiac arrest (don't we all, eventually?), I'll see to it that my family sues you for everything you have....

These ads, and many like them, are about creating a cure for a problem that doesn't exist -- at least not to the degree that the makers would like you to believe. Haven't heard much about "social anxiety disorder" for a while? Maybe it's because it turned out the acronym was already taken. (OK, I'm no psychiatrist: I'm sure the condition exists, or could well exist. But the ads clearly were trying to convince a big swath of the population that they have it. Hell, I may have it... Got a drug?)

Getting back to where I began: peace of mind is not a specious goal. Certainly, it's part of what physicians aim for in treating their patients: reassurance, satisfaction that a risk or disease is under control or being attended to properly. The concept comes up in my field in the form of "prophylactic surgery." Breast cancer is a case in point.

For women with a high-risk family history of breast cancer, and/or who carry one of the breast cancer genes, prophylactic mastectomy is a recognized option. And it's more than peace of mind: clearly in this context, it's cancer prevention. I've done it in several women, most often after a long relationship and a few biopsies, counseling about the options of careful followup and stating the degree to which, in an individual case, I'd be comfortable with it; and without reservations. But I wasn't sure what to do when Jane Doe requested it.

Jane was also a long-time patient. She had no significant family history, but her breasts were moderately lumpy and she had some fibrocystic changes. I'd done a few interventions over the years: open or needle biopsies, mainly. One day, she'd had enough. I knew it was very hard for her; she was frequently beside herself when she came to see me, whether it was for a routine checkup, or because of a lump she'd found. Yet as these things go, hers were far from the most difficult-to-examine breasts among my patients. I'd never felt uncomfortable in my ability to follow her along; in fact, as with many of my patients, I frequently avoided open biopsy when a lump felt benign to me, and a needle sample and mammogram were also bland. But Jane was a wreck much of the time, and on one visit she said she just wanted to be rid of her breasts: she couldn't sleep, she cried a lot, she worried about her kids. Her risk was not significantly elevated, I reassured her, and told her I felt we were on solid ground in the followup plan we'd established. It made no difference: she'd simply hit the wall. Peace of mind is what she craved, and bilateral mastectomy was the only way, she implored, she'd ever have it. Absent specific risk, was that a good enough reason?

I told her I wasn't entirely comfortable. In the back of my mind, thoughts flickered about being party to some form of self-abuse, of Munchausen syndrome, who knows? Again, I'm no shrink; I didn't have a name for it. But it was a concern -- facilitating a really big deal for the wrong reasons. Delicately, I told her before considering such a thing, I'd like to refer her for counseling: to see if there were other ways to deal with her anxieties (and, unspoken, seeking an answer to whether her concerns were due to some sort of thought disorder, or whatever a shrink might call it.) She wasn't delighted, but agreed.

The upshot was that the psychologist found Jane to be a generally well-grounded person, and felt there was no specific reason not to do the surgery, felt it was, in fact, reasonable. I was sympathetic to my patient, and after more meetings between us, I agreed to do the surgery. For peace of mind.

Well, it wasn't so easy: cancer-phobia is a recognized entity and has, I believe, its own diagnostic code. Trouble is, it's not on anybody's list of indications for mastectomy. Jane, and I, and my nurse all spent considerable time on the phone with her insurer. I wrote letters to their medical director, assuring him, among other things, that this was not an operation I undertook lightly; I'd not done it before for this reason. But Jane Doe was a special case, whose life had become miserable. I reviewed with him the psych evaluation. No sale; they resolutely refused to pay for it.

We worked it out: reduced fee, payment plan, doing the operation (bilateral simple mastectomy) as an outpatient to minimize cost. She recovered rapidly; soared, really. Neither she nor I ever regretted it. Still, I doubt everyone would agree I did the right thing.

Ads Up

OK, it's official: what little is left of my mind is now totally blown. In today's New York Times is a full page ad for ICDs (implantable cardiac defibrillator), and it's aimed straight at the consumer. I've gotten used to the ubiquitous ads for every prescription medication in the book; which is not to say they don't annoy me anymore. It's just that I've descended into a sort of overload that allows me to ignore them. Plus, in my bailiwick of the medical barnyard, it's rare to have a patient request a particular medication (other than the "this pain medicine yer givin me ain't fer shit" trope.) But this, this really is something.

"532 Candlelight Dinners; 4,354 Blissful Moments; 687 Walks in the Rain," it lists. Never mind that it sounds like a pathetic ad in the personals section of a book review mag (not that I read them.) It goes on to say "...ICD can give you more time to do the things you love with the people you love. You see ( getting very close and sensitive, maybe trying to whisper in your ear), an ICD is the most effective way to protect you from Sudden Cardiac Arrest (Capitalized!)" It goes on to give a handy website for more information, and suggests (how could you not, after all that?) "then talk to your doctor."

Sudden Death!! Gol' Dang, what 'er we waiting fer?? Maggie! Fire up the ol' buggy, we're headin' to town to talk to Doc Andy and get us one of them things. Got no time fer no website, even if'n we had onenna them 'puters.

Well, I suppose they're aiming higher: they put it in the NYT, after all.

The hell of it is, it must work: it certainly seems to with drug ads. But a heart operation? We're not talking Viagra here (if your heart-shock lasts more than four hours, seek immediate medical attention.) Hard-hearted?

I suppose the thought is that not everyone who's had a heart attack is being advised to get an ICD, and the reason must be that doctors are circumspect enough that they need jogging from their patients. "You mean you don't care if I ever walk on a beach at sunset, Doc? No more nookie, and you don't care?" Damn the odds and indications! We can sell these things if we just get people to want them. Like surround sound. "Just because" is a reason, if properly fortified with scare tactics. It's a huge insult to physicians, for one thing. And to the target audience, whose emotions, they figure, are pretty easily manipulated.

But what really bugs me is that I never thought of it myself:

House Doc (Not "House, Doc")

I received a request recently to share my thoughts about the future of surgery; specifically, I was asked about the concept of the "acute care specialist." About the future, as I've implied in some earlier posts, I have concerns. Despite my occasional wistful posts about the good old days, my worries are less about the people choosing to enter the field (I've indeed expressed concerns about how various factors are converging to select people with different expectations and perhaps a lower commitment level -- not entirely negative, in terms of a surgeon's self-preservation) than about the milieu in which they'll be practicing. I've also said here and elsewhere that whereas surgeons may have brass balls, they don't have crystal ones. So my predictive powers are diminutive at best. Nevertheless, because I see a continuing trend toward needing to work more to receive less, and an undeniable trend toward making the choice of surgery less appealing which is already manifesting itself in the numbers and kinds of people choosing it, I think the concept of the "acute care specialist" has a definite future. (Whew; long sentences!) And as it happens, I have personal experience on which to base that conclusion.

For a while after I bugged out of my full-time practice, the clinic at which I worked used me as a mentor of sorts for the surgeons they hired to replace me. (It took three.) Later, when one of the surgeons (the female, as I recall) got pregnant, they approached me to assume her practice during her maternity leave. I demurred, but proposed an alternative: becoming a surgical hospitalist (i.e. an acute-care specialist), working daytime only but taking care of all the acute consults, and urgent operations that came up during my shift. They agreed; and it turns out that it helped the (comparatively) over-worked surgeons far more than if I'd re-joined the practice. And it was a hell of a lot of fun.

Any group of surgeons (it's true of all genera of doctors) rotate on-call responsibilities. Details may differ, but in general when one is on call, one is responsible for all the emergent issues that arise; and since it's rarely practical to empty one's schedule on call days, being on call means frequently disrupting the office or operative schedule. Which has a domino effect on many people, including the surgeon; especially if, like me, that surgeon hates -- REALLY HATES -- to be late or make others late. For me, call days were corrosive. On my gastric lining. And, vis a vis the milieu referenced above, since surgeons (and all docs) are of necessity trying to shoehorn more and more patients into a fixed number of hours in a day, disruptions are, well, disruptive.

Enter the hospitalist. During the hours I worked (7 am to 5+ pm), the on-call doc knew he'd not have to interrupt his schedule. Huge relief, reflected in oh so many ways. As for me, I was having the time of my life: 100% of my time was dedicated being an actual surgeon. No distractions, no business crap, no politics, no paperwork beyond the usual charting requirements. Expecting a fairly mundane practice consisting mainly of appendectomies, I was surprised to find myself doing colon resections (for bleeding, for perforations, for toxic megacolon), acute gallbladders, gastric cases. And, of course, bowel obstructions, incarcerated hernias and appys. Couple of wound dehiscences (not mine!) Tracheostomies for the ICU patients. Trauma, too, but not a whole lot: around here, most bad things happen at night. Being readily available for consults, I was able to provide better surgical care than some patients might otherwise have gotten: instant response to requests for a visit. The medical hospitalists were delighted: rather than having to receive excuses and invective from a frazzled surgeon trying to juggle several things at once, they had quick access. The upshot was more timely requests for surgical input: pancreatitis, bowel obstruction, undiagnosed abdominal pain -- often previously suffering from late call to a surgeon -- were attended to in a timely manner. ER docs were happy, too, for the same reasons.

Nothing is perfect. By definition, each patient I encountered was someone with whom I'd had no chance to establish a prior relationship; and they were all pretty sick. Every operation I did had to be insinuated into an already full schedule. (Actually, the OR folk were delighted: lots of surgeons try to schedule urgent but not emergent cases at the end of their office hours. I was happy to squeeze in anywhere, meaning the pile-up of cases in the evening was reduced.) I didn't have the long-term relationships that I'd treasured in my office-based practice. (I did have office hours a half-day a week for followups, but it wasn't the same.) But it was, in a new way, highly satisfying: rather than being a threat, an imposition, urgent cases and consults were welcome. Clearly, I was providing a very useful service to patients and the nurses caring for them, to my fellow surgeons, to the medical and ER docs. Nor was it anything less than wonderful that I was never working at night -- other than hanging around to do a case I'd had to schedule after my "shift" was over. (In fact, I'd negotiated the option to punt such cases to the on-call surgeon, who took over at the end of the day. Rarely did I take advantage of the possibility.) (Also: hospitalists in many situations work at night as well. It's just that I didn't, because that's the deal I arranged.)

I gather, from reading other opinions, that the concept is not universally embraced by all surgeons. Some, I infer, think it cuts into their gig. In situations where the acute-care specialist might be hired by the hospital, it threatens those in private practice on many levels. In my case, I was hired by the clinic, and served only my own former group. My presence allowed a busy group to ply their wares uninterrupted -- if trends continue, that will be increasingly valued.

Guts. Glory.

I've said it before: I love sewing bowel. Nothing, it seems to me, represents what the general surgeon does more than that. It makes me feel connected to and a part of the chain of daring and innovative people who braved the terrain and blazed the path for us all, a century and a half ago; done right, it can be beautiful. Yes, guts: beautiful. Done wrong, it can kill.

Even unopened, intestine has a faintly unpleasant odor. Not repellant; certainly easy to ignore. In fact, the smell is like a musty greeting, of sorts: here we are now, in the belly, what's next? In a virgin abdomen, where they are free to slither and slide unbound by scars of previous surgery or from disease, grabbed by a hand gloved in latex, the bowels are slippery and smooth, and the sensation of holding them is like warm pudding flowing. When you need to push them out of the way, to expose a particular area, they stream around either side of your hand, slurpily wanting back in.

The classic method of sewing together two open ends of bowel demands everything of a surgeon: delicacy, accuracy, knowledge of anatomy; boldness, caution. Meticulous technique. To apprehend beauty where not all might see it, while admittedly dispensable, is to elevate the process to the level of art. Hidden, transitory, and unseen except by a few -- particularly not including the beneficiary; even unappreciated. But art, nonetheless. Like Andy Goldsworthy's.




And here's the thing: the newest crop of surgeons may never have the pleasure. Substituting staplers for sutures -- except when staples allow a hookup that's otherwise impossible or unnecessarily difficult -- is like handing Michaelangelo an eight-inch brush and asking him to whitewash your fence. Damn near criminal. But that's what they prefer, every time. In fact, they're barely taught the old way.

Any sort of stapled anastomosis uses at least a couple of machines, tossed away at the end, costing a couple hundred bucks a pop. If they save time (depends) and are easier to do, less exacting, they add cost, distort the anatomy (not functionally significant, but ugly) and deprive the operator of quite specific satisfaction. Whap, whap. K'chunk. Squeeze the stapler, leave the bowel not end-to-end but overlapping, like broken bones. Even kinked backwards on itself, like a frightened U-turn. How different from a hand-wrought creation! Properly sutured, as the ends are made lovingly to appose, the cut edges will roll inward, making a smooth juxtaposition held in place by perfectly spaced stitches. (That's no distortion of nature: like a perfectly laid-out vineyard, it's an honor to the land.) It's that rolling, precipitated by pulling just right on the suture as it's tied, that looks so beautiful, like two waves flowing into one, like something meant to be exactly as it is. Leaving it looking as if, in time, no one will be able to tell you were there. I've had GI docs say they can always tell my patients when they scope them in followup: they can't find the anastomosis. Surgery. As it used to be.

[Lest I be considered a Luddite, let me state for the record: I admire and use staplers. They've allowed me to avoid colostomy by hooking colon back up deep in the pelvis; they work great for certain esophageal anastomoses. Cleverly designed and steadily improving, they are fun to use, and I like doing so. It's just that in the situations where they offer no advantage, gimme the old fashioned way every time: I love everything about it.]

Self-Service

I never wore a white coat. Sleeves rolled up, open collared is how I dressed in my office. (Well, early on, I not only wore a [non-white] coat, for some reason I presented myself with a collection of the most garish ties imaginable. "Oh yeah," people would say when I was mentioned. "The guy with the ties." Somewhere along the line, I got tired of it, and opted for comfortable. Meanwhile, I developed a small lipoma on my left arm, which never bothered me but which, as time went on, I realized people were noticing. I'd be sitting in front of a patient, gesturing this way and that as I explained (beautifully and patiently, I might add) some surgical subject or other, and I'd notice a distracted glance at my arm. Surgeon with some sort of growth, a tumor, not the guy for me....

So I took it off. Laid out all the stuff I'd need, sat on a chair resting my arm on the bed in one of my exam rooms, painted it up (my arm, not the bed) with betadine, stuck on a sterile drape, injected local, made a little cut, squeezed out the lipoma, taped up the wound. My medical assistant had asked if I wanted her there to help, and I'd told her no, just listen for the sound of me hitting the floor, in which case she was authorized entry. Turned out fine:

There are lots of stories of surgeons operating on themselves: setting up mirrors, taking out their own appendix under spinal anesthesia. And of course there's the recent saga of the young hiker who cut off his own arm to escape being trapped between rocks. The latter is understandable and more than admirable, if barely imaginable. The former is some sort of showboating, or the mistaken belief that no one could care for oneself as skillfully as oneself. In my case, I think -- being a rather small deal -- it was just wanting to avoid a fuss. I've had a couple of patients who've wanted to watch their operation. In the case of hernia repair under local, I've accommodated the request (properly angling a mirror for viewing while lying flat -- sitting up would have made the surgery impossible). I enjoyed describing what I was doing, hold up this or that structure in the process. Never had anyone faint or otherwise bail out ex post facto.

In the Air Force I worked with a medic who told me a surgeon he'd known had attempted his own vasectomy. As had I, he'd set up all the stuff and excused everyone from the room. Unlike me, he materialized in the hall a while later, unsuccessfully holding his bleeding scrotum, staggered around a few steps before passing out, unceremoniously, in front of the crowd of nurses and medics that had gathered awaiting just such an outcome.

If alone on an island with my Swiss Army knife, I guess I'd take a stab, as it were, at my appendix if I felt I had no other choice. Don't think I'd have tried the vasectomy.

Rationale

I've written in this blog, and in a certain book I've been known to hype, about the pleasures of doing an operation when it all comes together. I've compared it to music: the transcendent feeling that derives from the sense that the team is flowing together, from being able to ply the craft with no distractions. No need to wait for an instrument, to ask for something you always use; having people assembled who know you, and what your intent is and who can nearly wordlessly join the orchestration of effort, uplifted by the knowledge that you have been invited into the essence of another human being. Because, for many reasons, it's rare to work with the same team over and over, achieving that kind of soaring synergy is uncommon -- when it happens it's invigorating beyond words. When it doesn't, the lack is ruefully noted at best; deeply disturbing at worst. That an operation is carried out by a team is an understatement, which brings me to the off-the-wall point of this post. As much as I love it when able to do surgery in a way that I consider some sort of artistry, and as much as I realize that being able to do so is the result of the efforts of nearly countless people, there are times when I've had a moment of disconnection (or is it clarity perhaps?) and have wondered if it's all insanity.

For an operation of anything more than the most minimal magnitude, the team consists of at least five people -- and often more: anesthetist, surgeon, assistant, scrub nurse or tech, and circulator (meaning the person who runs around getting stuff, more or less) but it's always in fact way more than that: anesthesia tech, people in the sterile core, in the pre-op holding area, admitting, in the recovery room. Central supply techs, assistants to set up and turn the rooms over between cases. Schedulers, people at the front desk keeping the day in synch. And these are just some of the folks surrounding the operation itself. One-on-one or one-on-two nursing in the intensive care unit, around the clock. Nurses, aides, assistants on the surgical floor; physical therapists, social workers, unit managers and clerks. Pharmacists, lab techs. The number of people involved in supporting an operation on any individual is staggering. Clearly, for the patient and his/her family, it seems worth it. But is it crazy to wonder if it makes sense, economically? Or even, given limited resources, ethically? Thinking of so many people involved in the care of a single individual makes me wonder, sometimes, if societies would be better off if that effort and treasure were directed in ways that would benefit more people. Is surgery an example of our fundamental instincts to help one another; or a sign of misguided priorities? Do we allow such lop-sided economics because, at bottom, we want that effort when it's our turn, damn the cost? I'm no philosopher, nor an economist. I don't suppose societies ought to behave only on the basis of cost-effectiveness: some values are reflected in ways that don't fit bottom-line thinking. Still, there are times when I look at all the effort involved in supporting what I do, and it gives me pause. Funny thing is, I've never regarded any patient -- famous or infamous, wealthy or destitute, brilliant or slow -- as unworthy of that effort. It's only when I think of myself lying on an OR table, and of all the people called upon to do whatever they'd be doing to accomplish whatever operation I'd be getting, that I think of it as somehow unseemly. But that's just me, I guess.

* * * * * *

Well now, as luck would have it, while I'm putting the finishing touches on this post, there appears an article in the local paper about an eight-year-old boy receiving an intestinal transplant. So maybe it's destiny that this becomes about something larger (as I implied in a recent post, we're not in charge of our thoughts anyway.) The pictures show it: he's a really cute kid, and he's looking forward to being able to eat. It's heartwarming; it really is. And yet. The operations that gave me pause above are in the most minor of leagues compared to this sort of thing. Dozens of OR personnel, people involved in the harvesting, the maintenance of the organ; lab folks. The immediate post-operative care is highly labor-intensive; the drugs, the after-care. And oh, the dollars.

I recall watching Ronald Reagan many years ago, as he made a very public show of donating to the fund for a liver transplant for some cute little kid, during a time in his presidency when he'd been loudly decrying the costs of health care. There's a huge disconnect: who isn't moved by this beautiful child, who would admit to begrudging him whatever it takes? And who, if in a darkened room away from prying eyes and ears, if not given the particulars of any individual, if crunching numbers trying to balance budgets, would argue for paying a million bucks or more for a procedure whose long-term survival is discussed in terms of three-year alloquots? But if it were their child...?

It seems inevitable that at some point the US will join the rest of the western world and provide some form of universal healthcare. I wonder when, in the process of discussing it, the R-word will finally be raised and addressed head on? Unless there's agreement that healthcare is the sort of priority that gets all the money it takes to provide all the care possible to everyone in need no matter the details, sooner or later "RATIONING" (call it whatever you prefer) has to be part of the mix. Somewhere along the line, we will have to say THIS is how much or our federal budget we're willing to spend on healthcare; THESE are the things we're willing to pay for; and HERE is how we'll pay it. It's way too important to leave to the insurance companies, and it's way too difficult to think politicians would tackle it seriously, let alone with an eye to finding actual solutions. (They're all too busy electing themselves and playing power games -- and have been for several years.) If anyone asks me, I'll tell them we need to convene a dedicated group of economists, health-care experts, maybe toss in a politician or two if any can be found willing to out-stick their necks, business folk, consumers. Maybe lock 'em in a room with hardtack and water, don't let them out until they come up with a plan and a price; maybe a couple of them. And then let everyone think about it for awhile, and put it to a vote. It's long overdue. Meanwhile, out of concern for your money, I promise not to have an intestinal transplant.

Spike

Among life's insignificant but grating annoyances are certain celebrations by athletes when they do whatever it is they were supposed to do. Linebacker sacks the quarterback, gets up and struts around, flexing his muscles, shaking his head, looking to me like an idiot. Guy dunks the basketball over another, gets in his face, prances in front of the audience beating his chest. C'mon man: you didn't just cure cancer. You put a ball in a hole. On the other hand (there's always another hand), I can relate. Some operations become so hard that when they're successfully over, I feel like there ought to be a gallery watching, doing the wave. In fact, I've done a couple of celebrations myself.

I've not hid the fact that I'm sort of an old-timer. Many operations I used to do regularly have all but disappeared. Common duct exploration, poking around in the tube that carries bile from the liver to the gut -- usually to extract a stone that's passed into it from the gallbladder and gotten stuck -- has been co-opted by the gastroenterologists with their scopes. Since the operation can be frustratingly difficult, and because it adds morbidity to what might have been a simple gallbladder operation, most surgeons (I'd guess) aren't all that unhappy to be relieved of the task, and it's mostly a good thing for the patient. But exploring the duct, when successful, is satisfying and beneficial.

It used to go like this: approaching a gallbladder operation (I'm still planning to get around to posting about it) you may or may not know the patient also has duct stones. In the day, we routinely took intra-operative Xrays to be sure, and if stones were seen in the duct, we went about various maneuvers to retrieve them. (The Xray in the link shows an unrelated anatomic abnormality, but it's a nice picture.) Sometimes it's easy as hell: open the duct and the stone floats right out. In the stone age (heh) there were pretty blunt and traumatic instruments available: scoops, spoons, scrapers, which you could bend into various shapes to try to fit them in. Later came scopes: first rigid ones, then flexible ones, allowing the surgeon (theoretically) to see what s/he was doing, and to guide an instrument under direct vision. Sounds good; not always easy, because -- among other things -- the scopes don't fit all the way down the duct. There are also catheters with balloons on the end: pass them beyond the stone (by feel or by luck), blow up the balloon, withdraw the catheter and the stone pops back and out. Or not. It can be frustrating and alarming, particularly in the days before the GI docs and their scopes: inadvertently leaving a stone in a duct could subject a patient to another operation, possibly preceded by getting pretty sick.

And so it was, one day, when I was gamely trying to get a single stone, strongly stuck snickeringly south, out of a smallish duct, that I flailed my way toward imminent failure. As the minutes ticked away, I ran the the entire gamut of instruments and maneuvers. Time was passing with no success, other members of the team were shifting their feet and figuratively looking at their watches, while the nurse manager occasionally stuck her head into the room, wondering when the hell I'd be done, what to tell the surgeon whose following case was on hold till I finished. Then, from somewhere in my badly burning brain there bubbled up a vaguely-remembered tidbit I'd read somewhere: take a red rubber catheter, snip off the small end, trim the big end, stick the small end on a syringe, slide the big end down the duct and when it's far as it'll go (hopefully stuck against the stone), apply suction on the syringe and pull it back. I'd never tried it, and no one in the OR had heard of it. With only some major surgical interventions remaining as options, I tried the trick. And drew back the catheter with a nice yellow stone stuck in its trumpet end. I couldn't help myself: I fist-pumped my way around the OR to the cheers of the assembled staff. Another time, I came this close to spiking a gallbladder on the operating room floor.

Pretty easy more often than not, taking out a gallbladder can sometimes be frighteningly difficult: bleeding from the liver, anatomy distorted by infection and scar tissue, stuck tight to surrounding tissues, just beyond which lies the possibility of causing great harm. It can be sphincter-puckering. It was after completing one such removal that I held the gallbladder over my head, swung my arm rapidly toward the floor, stopping in time daintily to drop the organ into the waiting pan on the back table. I'm pretty sure if I'd yielded to temptation, I'd have been in big trouble. Plus, I doubt a gallbladder would bounce. Wish I were a football-player.

Revelation (or, Why Surgeons Shouldn't Think)

Let's see if I can explain something I no longer understand. I'll preface by saying there are about three things I recall from studying neurosciences in med school. First, one neuroanatomist could draw perfect slices of the brain using both hands at once, holding more than one colored chalk in each. Second, studying I-don't-remember-what, a patient was presented who'd had a stroke which left him with a sort of aphasia. The professor held up some keys and asked the man what they were. The man said, "well, you know, you open doors...." "What's it called?" the professor asked. "It's, uh, it's what you use to start the car... It's..." Finally, after the same sort of back and forth, the prof tossed the keys to the man. As soon as he caught them, he said "Keys!" The story has no relevance to this post: it's just that it made an impression. It's the third vaguely remembered -- and no longer understood -- concept that I want to mention, because at the time it was a sort of metaphysical (and decidedly non-surgical) revelation.

Our brains, of course, are all about electricity: neurons connected in myriad ways to others, firing off little charges rolling down their axons and affecting whatever they're connected to in energetic little ways. (Making sense so far? It's the best I can do.) Simply put, what's involved is pumping ions across the membranes of the nerve cells, and maintaining different concentrations of those ions inside the cell, compared to the outside. When the permeability of the membrane is altered to allow a flow of ions across it, that flow is the firing of the nerve, resulting in the release of chemicals ("neurotransmitters") at the end of the nerve cell, which then affect the membrane permeability of those cells to which it's attached. So. You have zillions of interconnected cells, each having an influence on the membrane permeability of others, adding to or subtracting from it. Imagine holding hands with people on each side of you. And say that if your right hand is squeezed to a certain pressure, you'll yelp and squeeze your other partner with your left hand. Further imagine several people squeezing your right hand, and a few more massaging it to make it feel better. Getting to the point of yelping and squeezing your left amounts to the additive and subtractive sums of all those other people who are hanging on to your right. That, multiplied by a few trillion, is what's going on in our heads. Modifying cell membranes are all the sensations we own: our skin has a gazillion receptor nerves, responding to temperature, touch, moisture, etc. Our ears, eyes, noses are sending little packages of ion-flow altering messages to cells all over our brains, which are doing the same to others. At some level, all our thoughts and actions have correlations in electrical brain activity.

Oh wow, it occurred to me one day in a stuffy lecture hall: it's all connected. Everything going on in my brain is affected by everything going on around me. Were the room temperature different, the electrical milieu would be different. Likewise if the guy three people down weren't whispering to his neighbor, if there weren't a plane flying overhead, if someone was wearing different perfume, if the walls were red. What would I be thinking if the person in front of me had on a different shirt? And, of course, the ambient temperature is a result of the weather, the people in the room, the building -- what happened yesterday affects that as well. On and on it goes, to the proverbial butterfly beating its wings. Not to mention some person on the other side of the planet laughing or shooting a gun. The cosmic rays, the gravity of the sun. The book I read yesterday. George Washington sneezing in 1776. And, by golly, just imagine the warmth in which your brain would be bathing if you weren't reading this.