War Story

"Doc, you gotta help me. I can't take it any more." 

In the midst of the assorted humdrum and the occasional catastrophe, that was the complaint I heard the most when I served in Vietnam. And mind you, compared to the grunts, I had it way good. I, and the people for whom I was a doctor, lived on a base, not in the jungle. It was up north a ways, not far from the DMZ, and 160 mm rockets thumped (when far away) and crashed (when close) their way across the base pretty much every night. "Oh, Rocket City," was what people said when I told them where I'd been assigned. Still, by some measures, you could call it cushy. And that's my point. War, even at its edges, ravages people. The threat of random rockets dropping through the roof of your barracks can lead to "I can't take it any more." Think of the guys on patrol in Iraq and what their job does to them.

A twenty-two year old Marine from my community -- he went to school in the district for which my wife has served on the school board for ten years -- is facing court martial for his actions when on patrol (his third tour) in Iraq. I read another article about him today in the local paper, and it pierced my heart. I can't speak to the details; nor would I excuse it if crimes are committed by troops. But I can understand. It's something you don't hear much, in conversations about this war or any other. Taking young people -- teenagers and barely beyond -- and teaching them to be killers, then putting them in the situation where that's exactly what they must do, where they see death all around them in the most horrible of ways, where they live with knowing it could end in a second; taking humans and telling them to stop being human for a while while expecting that they can turn it all back on at will and at once; plainly, that's not a realistic expectation. It's a grand delusion. How outraged are we who sent them there entitled to be when, under circumstances in which most of us have never been (obvious comment about our leadership omitted here), they react? (I was going to say "over-react." What, exactly, is over-reaction to being spattered with the brains of a friend? Slipping on your own blood or someone else's? I see guts all the time. Those kids hadn't until they tripped on them.)

When I arrived in Danang, I was horrified at the attitude of the GIs towards the South Vietnamese troops on our base. "Zips," they called them, and it was in the most derisive inflection. (I think the origin had to do with the garish flight suits, full of zippers all over the place.) These are the people we're here to help, I thought. In time, I'm sorry to say, I came to feel the same: base security under them was abysmal. Sapper attacks were frequent, barracks were regularly stripped of personal stuff -- all because the guards let bad guys sneak in. Worse, most of the rockets originated nightly from "friendly villages," meaning nearby locations into which the GIs couldn't go, by the rules of engagement, without permission from the locals. So in the morning we were told how many and from where, and in the evening the steel storks would deliver their babies.

It was a big base. Odds were, any given person would be OK. But not everyone was. I stuffed my shirt into a torrential wound one night in front of my barracks. The man lived long enough for the Huey to arrive, not much longer. As the only doc living on the flight line, which was very near our clinic, while the sirens of the night were still sobbing I had to don a flak vest and helmet and run down the often-muddy road to the tiny hospital, as helicopters diced the air overhead, hosing the jungle just over the fence. Tracers were only every sixtieth round; yet the bullets came at such a rate that it was like a searchlight. Each time I ran that road, hunched, I lagged behind myself, looking without entirely comprehending. What am I doing here? What's wrong with us humans? And who is that guy up there?

I used the math -- small rockets times big base -- to keep fear at subconscious level. I think most soldiers do. When my barracks got hit and I got hurt, I figured I'd had my time, and had lucked out. But I slept under my bed thereafter.

As a doctor, I've tried to help guys cope -- guys who, compared to the young man from my town, had a hell of a lot less with which they had to cope. In charge of Medevac for a while, I saw guys come through on their way home, handed Purple Hearts in exchange for their limbs. Legal tender. Overtly wounded or not, those guys won't be the same. You carry stuff around. Easy as I had it, I still hate the sound of helicopters.

My place in the war was far from the center, but I've been there and I've felt the effects and seen them in my patients, if only a little. I'm no pacifist. It'll be another million years of evolution before war is unnecessary, and I'd fight if I had to. But no matter what he did, I feel sorry as hell for that kid from my town. Whatever he did, something was done to him by us, in our name. Because our leaders deemed it necessary, his life is ruined. And I hate it -- I absolutely hate it -- when I hear hard-on holding TV pundits and chest-thumping politicos who haven't the slightest clue what war does to people getting all teary-eyed about "sacrifice" and square-jawed about bravery. Not to mention people who get shocked when a soldier living in that world goes off the deep end. It's what happens. When we send kids to war, sticking little magnets on our bumpers, putting down the remote long enough to give the finger to peaceniks; when we force our young to leave their humanity behind (while telling them not to and pretending it's possible), we ought to be damn sure -- we ought to be god damn sure there's absolutely no other choice. The only people for whom war is glorious are those who never were in one. It's tragedy of the most awful sort, and I wish more people would behave as if they knew it. Starting at the top.

"My fellow Americans," the President ought to say in declaring war. "We are now a nation at war. People will die. Innocent people will die. Lives will be destroyed, because war does that. We hope our soldiers will not be indiscriminate, but we know some will. For in asking them to go to war, we are telling them to leave civilization behind, because war is its opposite. Of the soldiers we are sending to war, many will die. Of those that return home, many will be maimed for life, body and soul. Because we have asked this thing of them, we must also commit to nurturing those that return. They do not go to war alone. We must support them with more than words, and that means we must all bear the burden of this awful decision; it is our duty to our soldiers, it is our obligation forever. We will name them and learn of them, as we did with those at Virginia Tech and Columbine. We will see their coffins, hear the words of their loved ones. And we must pay for this war in every way, from its beginning and beyond its end. That means I will impose a tax surcharge to pay for the immediate costs and those of rebuilding ourselves afterwards, for as long as it takes. And because we ask sacrifice of our fighting men and women, I ask it of everyone. In going to war we have concluded there is no other way, that our very survival is at stake. It is the most important and terrible thing we do as a nation. So I will impose a draft on each and every American. Those that can't fight will build the machines of war. Those that can't build will do our work in their offices, their homes. War is cataclysm, and everything else is secondary, and thus it will remain until we have prevailed. That is what war is. That is what sacrifice is. May God forgive us."

I've Seen Ghosts

As a med student, I did a few circumcisions, in the free-hand style. Later, as an intern, on one occasion I had just finished a very well supervised hernia repair, along with which the adult patient had requested a circ. My attending couldn't have cared less about doing, helping with, or observing that part of the deal. "You can handle it, can't you?" Spoken through his back, and then through the door as he exited the OR, it wasn't really a question. Adult circumcision isn't the same, I discovered, as doing it on an infant. To my horror, I left the man's shaft looking on one side like a pink banana after some monkey had partly stripped back the first section of the peel. The feeling remained in the frontmost of my mind for the remainder of my training. When I helped, I stuck around.

A reader asks what I think about "ghost surgery." Complicated answer: depending on terminology, I'm ok with it. Simple answer: it's complicated.

First, the semantics. For one thing, I think the reader and I are not talking about the same thing: to me, "ghost surgery" implies deception and dishonesty. It means borderline, if not actual, criminal behavior. "Ghost surgery," as I've understood it, is the happily rare practice of a (usually less-than-competent) surgeon lining up patients for operations, telling them he'd be doing it, then having it done by others while he was somewhere else, collecting the money. (In a related arena is "sham surgery," wherein a patient is faked into thinking something was done when it actually wasn't. There was a time when such things were done hemi-demi-semi honestly, as a way of testing for the placebo effect of an operation. On the other hand, when I was in med school, there was a later-infamous "surgeon" who did so-called brain surgery at a nearby osteopathic hospital. Until they'd show up at our institution where xrays showed no skull entry under their scalp scars, they believed he'd done something in their brains. They'd paid for it; monetarily, and otherwise.)

As I infer it, by "ghost surgery" my reader meant something different: being operated on at teaching hospitals by surgeons-in-training; and there's an implication of failure fully to inform people of the extent to which such surgery will be done by the trainee instead of their presumptive surgeon. Whatever the proper term for such a thing is (the operative part, not the informing part), it's that of which I'm in favor. And which is complicated. Without it, I'd be nowhere.

Part of the question we can dispense with easily. There's no excuse for not letting a patient know a trainee will be doing all or parts of the surgery. Which is not to say it's always been clearly laid out, nor that in every instance in every location under all circumstances it now is. And whereas a patient ought to have the right to opt out, to demand that their surgeon will do every bit of their operation, I think a surgeon ought be free to tell his or her patients that in coming to a teaching institution, they must expect and accept that such supervised operating will take place and that if they want the knowledge of that surgeon and the support of that institution, they must agree to it or go elsewhere. In the best of worlds, that would be worked out well in advance of the patient showing up for surgery.

Surgeons are made, not born. It's a long process. When I was applying for surgical training, one of the places I checked out -- which is now very highly regarded -- was on probation and in danger of losing accreditation from the American Board of Surgery, or College of Surgeons, or something, for failing properly to supervise residents doing surgery. (I figured if I couldn't get in anywhere else, surely I could there.) The place I chose (and which chose me) was quite the opposite -- and its approach is entirely the norm now: baby steps. Interns are allowed little bits of operating at first: close the skin, place a clamp here or there. When it's apparent they can handle a knife and fork without spilling food in their laps, they may get to do an "intern's case." A hernia repair, for example. The attendings are there, describing every step and, in fact, holding tissues in such a way that there's no possible misstep. Truth is, I "did" many hernias without a clue as to what was really going on, so carefully were the moves orchestrated. Which brings us to the complicated part. At some point, you have to have your umbilical cord cut.

My friend just soloed for the first time after a few months of flight training. Had he crashed, most likely he'd have only taken out himself. In surgical training, there does come a time when you operate without an attending in the room. He or she is close at hand; but there you are. It doesn't happen, however, until you've shown yourself to be ready, over a period of several years, and with many an attending signing off. Still, as opposed to flying for the first time, the danger is not to oneself.

I love to teach. In training, by the time I was Chief Resident I was the "supervisor" on many an operation done by a junior. I was, if I may say so, good at it. There were times when I called in an attending, but not often. And the cases, by definition, were not the biggest of the big; if they were, I'd be doing them myself, with an attending there much if not all of the time. (Most Chiefs relished doing as many big cases alone as they could. I figured it'd be soon enough that I was on my own and I wanted to pick the brains across the table for as long as possible.) In my private practice, the teaching I did was at the tail end, when I mentored newly-hired surgeons. In those cases it was their patients and I was providing pointers, sharing a few tricks. Letting them know how a four-hour total colectomy with J-pouch could be done in two. Had it been my patient, I'm not sure I could have let them actually do parts, given my need for speed. (Controlled speed, may I add!) More paradox.

Inevitably, there are classes of care. Time was, there were "charity patients" and "charity hospitals." One can argue the ethics, but it was understood that patients there were "teaching cases." Nowadays, there's still a difference between "private patients" -- meaning those with insurance and who've come specifically to see a particular surgeon and who are admitted to that person for surgery -- and "clinic" patients, meaning those that came to the hospital clinic and were seen there by residents, under the supervision of an attending. Mostly, those patients are uninsured or are on some form of assistance. At a teaching institution, whether private patients have residents doing parts of their operations depends on the attending. Some let residents assist only, never doing any part; others let trainees do parts, or even all of an operation. No private patient would have any surgery done without the attending there and breathing heavily down the neck of the resident. Clinic patients well might. It needs to be made clear; yet it needs to be.

Does care suffer in training institutions? No, mostly. Yes. Ironically, I'd say having a surgical resident participate in your surgery is the least likely arena in which problems occur. The supervision is eyeball to eyeball, hand on wrist. My most influential technical mentor (you can read all about him in "Cutting Remarks"), without exception let me, when I was Chief Resident, do every one of his operations, and he had some pretty hoidy-toidy patients. But he was literally at my side (as opposed to across from me like everyone else in the world), controlling and cajoling as if wired directly into my head.

In training, operations take longer, and time under anesthesia adds up to problems in a small percentage of patients. Still, it's in the hours outside the OR -- especially the wee ones -- that problems may occur. May I hasten to add, that applies equally -- more, in fact -- to the medical wards. Again, there's irony. In no community hospital are there as many doctors present around the clock as there are in teaching places. If I get run over by a truck, get me to a trauma center in a university setting. If there are a few people running around with minimal experience, so are there plenty with plenty. It's the humdrum stuff that's more likely to be delegated down, to people without the experience to recognize what's going on and who therefore fail to call for help.

Safeguards break down anywhere. In a community hospital, when there were problems with my patients, I was the one called, not an intern. That's better, as long as I got the call. It didn't always happen.

When I was in training, I believed evangelically that the best surgical care anyone could get was right there, not despite but because of all of us trainees and attendings in the mix. After a couple of years in practice in a community hospital, devoid of students at any level, I came to feel the exact opposite (meaning the best care was in that community), and I still do, except for certain highly special situations. It's a hell of a paradox. If my reader has made it through my ping-ponging thoughts to this point, I imagine she's more concerned than when she asked the original question. Scary, huh?

Plumbing the Depths

Our shower has been acting up lately. It's happened before, but this behavior was different. Not wishing to hijack my own post, suffice it to say I came up with a clever solution. These little domestic victories, when they occur, find parallels in my mind with surgery. Finding solutions to unusual problems is very often what it's all about. Every once in a while I allow myself an inward smile, and tell myself I have a brain with certain kinds of software -- and feel surprise that I found my way to being a surgeon. It was, in the subject sense at least (and in others, not so much), a good fit. I'm able to figure certain kinds of things out with efficiency, and I think it's a talent not given to everyone. Not even every surgeon.

It's not unique, of course, and I'm truly not trying to boast. It's just that I'm sometimes amazed at having wandered into surgery from a series of serendipitous situations, discovering after the fact that I can actually do it, that my thought processes are suited to it. Given the body's amazing ability to heal itself and to withstand various insults, I'd say most people who don't faint at the sight of blood could be taught to do a large portion of what surgeons do. Nor is the talent, or whatever it is, to which I refer unique to people who do surgery. Artisans of all sorts surely have it. What I'm trying to describe is the ability to find ways out of unfamiliar situations. You can be taught how to use certain tools, how to accomplish a particular job. It's when encountering problems for which there's no road map that a certain (probably indefinable) way of looking at things is a great help. The body continually surprises; or, as I used to say, there's a lizard under every rock.

"We're bogging down, boys," was a thing I frequently uttered during a difficult operation. When working through a tough bit of anatomy, distorted by scar tissue or tumors or infection, if I sensed progress wasn't swift enough, I'd find a different avenue. That's in no way unique, of course. But it's critical that you get that vibe before crossing a line into tiger country. Likewise, there's some sort of spatial sense that allows some people to look at a surgical field and see what the perfect tool is; or to be able to position a needle in a needle-holder at exactly the best angle in a deep hole before trying it another way and having to change. Letting the scrub nurse know what you'll next be using, especially if it's not going to be something typical, far enough ahead that she'll be able to get it ready, is something not everyone does easily. When assisting, it frequently happened that I'd see where the surgeon was headed and assume a certain approach would ensue, a particular instrument would be called for, only to be surprised. And often, after watching futile diddling, finally see (or suggest) that other approach.

Only so much can be taught; only so much can be assimilated later. To some degree, it's about pre-existing wiring. I hope the reader will accept that when I say I think I had it, it's not for self-tooting. It's in abject amazement, because I had no reason to suspect it before I chose to be a surgeon, or even while I was in the early stages of learning. It's a "who knew?" sort of thing. (While in training, I first heard the quote from an unknown [to me] author, describing the necessary attributes of a surgeon: The eye of an eagle, the heart of a lion, the hands of a woman. I used to describe myself has having the eye of a needle, the heart of an artichoke, and the hands of a clock.)

For the life of me, I can't paint or draw anything that looks like something. I couldn't sculpt my way out of a canvas bag. Building a glob of clay into a recognizable work is a talent entirely out of my ken. Even more mysterious is the ability to hack a chunk of marble until it's the Pieta. (Who was it that said "I just cut away everything that doesn't look like a duck" -- or something similar? Might have been big Mike himself.) Given the choice, I'd absolutely, in a heartbeat! opt for that kind of art -- which is truly a gift -- over some sort of ability (real or imagined) to smooth out some surgical rough patches. But there have been times when I was glad to settle.

Update: the shower is acting up again.

Holes

OK, so surgeons in New York pulled a lady's gallbladder out her vagina. There's a punch line in there somewhere. Anyhow, whereas that particular route is new, the concept of "natural orifice transluminal endoscopic surgery" (NOTES) is not. Or at least not as new. One has to wonder what is the motivation. According to those that advocate such things as pulling an appendix out a person's mouth or anus, the aim is to reduce pain and scarring for patients. I call bullshit. I think the motivation is "Hey, look at me!"

See, we're already at a point where most operations done laparoscopically require holes around a quarter inch in size, with maybe one more, 'bout half an inch. Cosmetically, not a major problem. Pain-wise, pretty minimal, most of the time. So we're talking, according to the rationale, about lessening something already pretty minimal. Moreover, since it's literally impossible completely to sterilize the mouth, rectum, or vagina, any procedure done through them will necessarily introduce organisms into the abdominal cavity. A small number may not always be significant. Still, it's of concern. And the hole that's made needs to be sealed back up safely, especially one in the stomach or colon. Finally there's this: these procedures take longer and afford a less-good view of the target area, unless at least one or two holes are made in the abdomen anyway. That's what was done in the vaginal operation.

It's a tough world out there: find a way to do something that no one else is doing, convince people they need it, and maybe you'll make an extra buck. Or at least get some good pub. To me, it's time to apply a little reason to the field: when the benefit is vanishingly small and the costs (and, until we know otherwise, the risks) are higher, a little stepping away from the scalpel for a moment of thought is in order. There are actually devices that allow an entire hand to be inserted into an abdomen through a special sort of air-lock (laparoscopy requires the belly to be filled and distended with gas) to accomplish "hand-assisted laparoscopy." Say what? The hole that's made is large enough that many people could do the whole operation through it, avoiding all the extra operative time and costs of the scope procedure. But there it is.

The only surgery in which I'm now involved is laparoscopic. I like it. It's fun. I enjoy learning new techniques, and I'm constantly impressed with the latest engineering marvel up with which some brilliant geek has come. But this NOTES stuff: from what I've seen so far, it's an irrational ego-trip which -- because it adds extra risk of infection or leakage, and because unless at least a few holes are made in the abdominal wall it affords a less-good view of the work -- will make a big splash, convince a few people to try it, and then retreat in hiding. I could be wrong. For now, I think the answer to the question "Why do this?" is the same as to why a dog licks his balls.

Booboo?

Some would say I was asking for trouble.

In my office practice, on any given day the plurality of patients were women with breast problems. Conservatively, fifteen hundred to two thousand a year. With a receptionist or two out front, in the work area it was only me and my medical assistant. She was a wonder of efficiency (me too!), but had lots to do: scheduling surgery and followup visits, talking to insurance companies, fielding calls from patients. Plus getting patients in and out of rooms. I helped: when necessary, cleaning rooms, bringing patients from the waiting room to the exam rooms, getting them settled and properly attired. There simply was no way Trish would have had time to chaperone while I did breast exams. So, with rare exceptions, I did it alone.

We used to have nice cloth garments: like a mini-poncho, they'd slip over a woman's head and were, I think, comfortable. When it became cheaper to use disposable items (yes, I contributed to trash, too. Were it up to me, I'd have kept the cotton. The clinic overlords demanded otherwise) we had to switch to scratchy paper vests. "Undress from the waist up and put this miserable thing on," I'd tell them, on my way out of the room. "So it opens in front, like a vest." About one out of six, I'd find on re-entry, had put it on backwards. Since the paper wasn't particularly pliable, it was hard to maneuver under them that way, so I'd ask patients to switch them around, while I discreetly turned away. Some didn't care if I turned away or not: "You're going to see it all anyway."

With the rest of their clothing on, and with the vests being large enough to provide good coverage, I think most women felt as if they were still dressed while we talked. They sat on the exam table; I sat in a chair, lower than their eyes. Maybe that helped to get things going in a non-threatening way. Sometimes there were vibes: the bra hadn't been removed; eye contact was lacking; various non-verbal clues. So I'd either ask if they'd like my assistant to be present during the exam, or just invite her in without asking. That happened less than once a month. Mostly, after talking, I'd do the exam. Life being as it is, it amazes me that I never got any complaints, any claims of indiscretion. Mind you, there was none. But there are crazies out there, and we were generally alone.

My standard breast exam was four ways. I'd examine initially while the woman lay down, first with her arms above her head, then by her side. And then I'd have her sit up, and I'd re-examine, again with arms up and then down. While sitting, it was bi-manual; that is, my left hand would elevate the breast, and the right would palpate, like a human mammogram. That maneuver struck me as both intimate and mechanical: intimate because it was unexpected, since most women hadn't been examined that way and may not have know what to make of it; mechanical because it was done in the most matter-of-fact way. It also often led to the most detailed findings.

After any office visit, I dictated the note immediately. For breast exams, I never failed to use the phrase, "She was examined erect and recumbent, arms up and arms down." Our stenographers were headed by a highly, uh, extroverted woman. On the occasions when I'd wander into the steno room -- usually to share a joke or two with the boss lady and catch up on office gossip -- she'd announce, "Ladies, Dr. Schwab is here." At which point they'd stand in unison, throw their arms into the air, whip them to their sides, then sit and do it again.

Nice

I suppose there's no point in mentioning it, since you're already reading this and therefore don't need enticements. Nevertheless, there's a nice little blurb about this here blog at OneBlogADay. And pay no attention to the picture. Not having one of myself, I gave them one of my elderly and slovenly great-grandfather.

Dirty Laundry

Sharing many characteristics of humans, doctors can be assholes. Petty, venal, vengeful. Excessively political, and narrow-minded. I don't exclude myself. Here's how some of it goes. Went.

In training there was a tradition of oil/water incompatibility between surgeons and medical types. It was reflexive, legendary, cultivated, part of the air we breathed. But also superficial: we said bad stuff about each other, yet -- no choice, of course -- interacted to the benefit of all. Like your embarrassing uncle: talk behind his back, but get along at family gatherings. In private practice, it's a different game: the animosities, it turns out, are real and impactful. It's not just surgeon - medical doc hostility: it's any doc on doc. Join the wrong clan, expect open hostility; damn the party-favor pretensions. It's real and serious, and deadly unpleasant. Pocketbook precludes pleasantry.

When I arrived in town, young and naive, ready to become everyone's favorite surgeon, I walked down the halls of the hospital (often lost!) smiling at everyone I saw, uttering expectant greetings. Didn't take long to notice: some doctors not only failed to return the salutation, they literally looked away. Not a word. Knowing nothing about me other than that I was the new guy at the Clinic, they had no hesitation: I was one of THEM, and deserved not the slightest notice. Well, OK. To some extent I understood, once I understood: the Clinic had just opened its first satellite office, and had recently signed an exclusive contract with a health insurer. The non-Clinic docs felt threatened, saw the Clinic as actively trying to put everyone else out of business (not only was that not true, but as time went on and the Clinic continued to grow with the community, the non-Clinic docs increased in number and thrived as well. Still, I didn't entirely blame them.) So I was branded. Some of those docs wouldn't have referred a patient to me if I started raising people from the dead. (Well, as time went on, some referred themselves when they needed surgery -- just never a patient.) In my infancy, I operated on the mother-in-law of the son of a prominent family doc whom I happened to use occasionally as an assistant -- an older guy who did lots of surgery himself, not particularly well, but knew his way around the other side of the table. During an operation he told me how much the woman had appreciated my care, and said he was impressed as well. He went on to explain that I surely must understand that, as a Clinic doc, he'd never send me a patient. He, and many others. Quality was not the overriding issue: it was where you parked your car.

The emergency room, which disrupted our lives and saddled us with cases we'd rather not take, at times we didn't like using time we didn't have, was the petrie dish in which, like familiar pathogens, much of the interpersonal enmity grew. As a reader of many fabulous ER blogs (this, this and this, to name but a few), I'm now ashamed to admit it: I wasn't always above dancing on the fine print of the staff bylaws to stay in bed at night. The on-call rules were arcane here, fluffy there, and made for many a midnight merengue. And when it involved a pirouette across political lines in the sand, grit got in the tutu.

"No-doc" call, meaning being designated to accept patients who showed up in the ER with no doctor of their own, was assigned among each of the specialties. There was no refusing a no-doc patient if you were the one on call, but it got trickier when the receiving doc called another specialist. Politics being what they were, generally the doctor who took the patient called people in his/her own political sphere to consult. And in fact the rules were that once a doctor accepted a patient, that patient was no longer "no doc." So other rules applied. I have no obligation (other than pragmatic ones) to agree to a consult request from a fellow (non-ER) physician. And after a few years of being shunned by those on the other side of the aisle, there were few things that annoyed me more than getting a call from some doctor who'd never refer to me, to be surgeon to his no-doc patient, when the only times it occurred were for a patient with a particularly unpleasant problem, and with no insurance. Otherwise, they'd have called their pal. So when it happened, I'd mostly say no. More often than not, I'd also say why. Until they'd be informed later that I was within my rights, the jilted physician would usually threaten me with some sort of medical staff censure. Such were the realities of politics, and of being tired at two a.m. It nearly got me into big trouble once, when a surgical competitor tried to screw me. In the political sense of the word.

Russian sailor shows up in the ER right after his ship docks in port. Story is he'd been sick for several weeks, with no way off the boat. He had a history of vomiting, abdominal pain, and bloating. No fever, no evidence of infection; vital signs OK, abdomen soft and not tender. The initial call from the ER doc went to the no-doc gastroenterologist, who'd ordered some lab work and a CAT scan, choosing not to see the guy until the results were in. The scan showed nothing specific except for fluid in the abdomen. "Call the no-doc surgeon," sez he. "Thanks, but no thanks," sez I. "Free fluid in the abdomen is a surgical emergency," sez the ER doc. "Not in a guy who's stable, got a soft belly, no signs of infection. What about ascites?" queries I. The ER doc, a new one whom I'd never met nor even heard of, quickly implies I'm derelict in my duties, in the most unpleasant terms. I reply that since Dr. GI accepted responsibility for the patient by ordering and evaluating tests, the man was now his patient, and I had no obligation to see him. The GI doc, of course, had never referred me a patient in his life.

What I actually said was I'd be happy to see the sailor as a consultant if after appropriate evaluation it was determined he had a surgical problem, and if, in the light of day, Dr. GI still wanted me to be his surgical consultant. I stated it did not sound like a surgical problem, and certainly not an emergency, at that time. There were a couple more calls. The ER doc, I realize, was stuck in the middle; on the other hand, he'd been exceedingly rude to me when I'd simply pointed out a medical and a political truisim. As far as he was concerned, I was criminally negligent, and said so rather gracelessly.

By rule, the only person who was actually derelict was the GI doc, who, having initially ordered tests, refused any further care. He managed, after I was temporarily out of the loop, to punt the case to the on-call family doc who generously admitted the man, and arranged for another GI consultant in the morning, who in turn asked me to see the man, which, of course, I did, and my exam confirmed my impression that he was not a "surgical" patient. He never became one, either, and shipped back to Russia a few days later.

As this post threatens to get too long, I'll skip ahead to when I'm sitting in the hospital medical director's office, having been called in to respond to a letter she'd received from the original GI doc, claiming I'd refused care of this patient and that it was a well-known pattern on my part. "Acts like he's the alpha-surgeon," was a nicely-turned phrase in the letter. I pointed out that the man's course proved I was right in concluding he was not a surgical patient, and that since Dr GI had de facto accepted the patient, I had no obligation even if he'd needed a surgeon; I then asked if she'd found any instances where I'd refused to come in to see a surgical patient, or if there were any prior complaints from ER folk about my responsiveness or my care. There were none. Quite, in fact, the opposite. And she agreed, after checking it out (like that ER doc, she was new in town), that I was right about the laws of succession. But, of course, the letter went into "my file."

I don't know what happened to that ER doc; I never saw him again. I sent a letter to all the GI docs in town (they'd recently actually worked out community call-sharing across political lines) saying that I would refuse ever to respond to a consult request from Dr. GI and they should either arrange their call schedule accordingly, or expect to need to refer surgical patients elsewhere if we were on call together. I even explained why: the letter. A certain amount of fecal matter on a few ventilation devices ensued, and as luck would have it, not long thereafter the two of us found ourselves together in an otherwise empty elevator. "That was a pretty strange episode," I said. "Especially the alpha surgeon part. We've never worked together. Where did you come up with that one?" Sheepishly, he offered, "Well, you're right. And you were right then. Actually, [surgical colleague of his, competitor of mine] was the one who said it was a well-known pattern. He encouraged me to write the letter. I wish I hadn't." "Me too," I said. "I guess I could give it a shot, forget about it, work together if it ever comes up." "Me too," he said.

And with that, hell froze over.

On Death. Three.

Before there was hospice, there were house calls. As ought to be obvious, I'm old enough that I've practiced surgery through many changes. Early on, when I could, I had to be my own hospice, sort of. Having observed families dealing with death, both in my practice and in my personal life, I came to believe that there was great benefit from keeping a patient at home as long as possible, even to the end. As exhausting and draining as it often is, the family members who did it seemed to gain a palpable measure of comfort themselves, a deep sense of... satisfaction. (Can we agree forever to ban the word "closure?" What a load of new-age crap that is! In the death of a loved one, there's no such thing. Acceptance, finding a way to live with it: yes. But closure, like it's over, like going through a door and shutting it behind? Please. )

I realize it's a tricky subject: not everyone is able -- for a huge number of absolutely important reasons -- to manage it; nor would I want to imply here, or to have created then, a sense of shame in those who couldn't. What I did was to offer as much help as possible, such as arranging all the needed equipment, a visiting nurse, and (less often than I'd have liked, but as often as I could manage) to visit myself. Irregularly, briefly, when I could; when they didn't live too far away. When I visited, I got as much (more!) out of it as did the patient and family. Sometimes I'd notice something that could be changed for the better. Usually, though, it was just a matter of saying hello, of holding a hand, smiling and touching. And of being impressed at how people managed. More often than not, it was a small house, sparsely furnished, a living-room dominated by a hospital bed and commode. The center of everything, quite literally.

The mechanical stuff -- beds, commodes, assist devices -- was just stuff. It was the idea of the actual moment of death and its aftermath that was the biggest hurdle to overcome in encouraging home care. People needed to know two things: if it got to be too much, all they had to do was call and I'd admit the patient. Some did, some didn't. And they were reassured to know that they could contact a funeral home in advance, and could call them to take the person whenever they were ready. It's a brave undertaking (!). Among the most cherished notes I got from patients and families are those thanking me for encouraging and helping with death at home. More than a gift to the loved one, it's a gift to oneself. With hospice, of course, it's a much more comprehensive program, giving much better support than I ever did, and taking care of all of the details. Thankfully, hospice came to our community around the time I was busy enough that it was harder and harder for me to take the time.

When I decided on med school, I had no idea I'd end up as a surgeon. Good 'ol Doc Schwab, driving his Model T to the homestead, feeling pulses, shaking down thermometers, and delivering the occasional baby on the kitchen table, was how I imagined it. The closest I ever came was making those house calls to the dying. Like the days of old, there wasn't much I could do -- check a bandage, lay my hand on a belly (one in which I'd usually been, earlier) for no particular reason other than a sense of connection to it, write the occasional prescription. Sometimes trying to answer the question, "How much longer, doctor?" But in being there, just being there, I felt more like a true physician than at any time I can think of. Even in failing to cure, there's never nothing to do. I wish there were more time to do it.

On Death. Two.

We went to New York a few years ago, mainly to see a production of "The Iceman Cometh." Expecting to be impressed by Kevin Spacey in the lead role (we were!), I was blown away by Paul Giamatti's portrayal of Jimmy Tomorrow. Near the end he gave a soliloquy of such pain, his emotions naked and raw, that I was moved to tears. So was he. Afterwards, among other things I was left to ponder was what it must be like -- how is it possible? -- to do that night after night, to tap into those feelings so deeply as to move himself to tears, repeatedly. Is it just acting, or is he there each time? Is it as cathartic to him as it was to me? Can he move others so, without moving himself? Is it exhilarating, or exhausting? Could it be neither? As an analogy, perhaps it's a bit off; yet that's what came to my mind in thinking of my role in the death of a patient. It's not that it's an act -- for me at least, it is anything but. Yet if there are courses in talking to patients and families about death, books about it, doesn't that mean that for some health-care professionals, dealing with terminal illness and death can be scripted? But having a script is not enough; there are bad actors and good ones. To make it happen takes more than intention. I was always there. But -- confessional -- I was also always aware. The meta medicine man. Maybe that's how to do it and survive.

I'm not doing the dying. Nothing in my position as physician is as hard as what the patient and family do. In trying to delve into this doctors-and-death subject, I don't pretend otherwise, and I accept that some might see the whole enterprise as a self-serving sympathy-fest. Perhaps. It's something I'm trying to understand, myself. But I see it as an important inquiry, involving pain, preservation, humanity in its essential good and bad. Fundamental. And if (some) doctors need to do a better job of it -- and if it's possible to get them to -- then at some level we're talking about teaching compassion. Which strikes me as bizarre, albeit necessary.

I vaguely recall some words in medical school about dealing with the dying. The term "healer" doesn't have only to apply to beating back disease: whether that's the exact message they were sending us or not, it seems to be what I took away. Such a message falls on fertile soil, or it doesn't. I don't think I needed to be told that continuing connection with the dying ought to be part of the job; on the other hand, there are plenty of ways to shirk it. And, for that matter, excuses. I have lots of patients that need me; there's no way to spend as much time with a dying patient and his/her family as they'd like. (It's true, of course. I've said that about anyone on whom I've operated: having literally been allowed in, it seems there ought to be an obligation to spend every waking hour with each one.) But it's amazing how little it really takes.

It's at this point that I hesitate in writing about death and doctors. For one, I'm hardly a source of wisdom; I'm no psychologist, no professor. Hell, I'm not even a primary care doc. For another, I'm afraid of it coming out wrong. When I talk about observing myself, I assume I'm not speaking for any other -- much less all -- doctors. If I say I was nice to people but was also aware I was being nice and telling myself how nice it was that I'm being nice, I'm trying to express and deal with the dichotomy I feel: does consciously behaving in a particular way diminish the behavior? A little compassion goes a long way. If you don't have it, fake it. But it's better if you have it.

If saying it doesn't automatically negate it, I believe I always had compassion for my patients; for their fears, for their pain, for living with illness. Or dying with it. It wasn't lack of feeling that I had to overcome; it was the acute sense of failure. If I had a problem looking dying patients and their families in the eye, it was because I felt I'd let them down, and that at some level they must have felt the same way. Guilty, and ashamed, is what I felt, as if an apology were in order. But how do you apologize for letting someone die? So it's in fact very complicated, and I don't intend (now, anyway) either to work through it or to try to understand it in terms of my own upbringing or makeup. As opposed to the author of the book I'll be reviewing (as I mentioned in my previous post), I think doctors' problems over dealing with death have not to do with threats to their own mortality, but with shame. And maybe that explains, in part, my sense of self-observation: in talking with a dying patient or her/his family, I was looking over my own shoulder, accusingly.

Facing the dying and their families can -- and must -- be done. I have, in fact, said I'm sorry. Many times. I suppose the meaning was deliberately vague: in this context, "sorry" means sad more than it implies apology. But it's the word I used. "I'm so sorry this is happening." I know I didn't always speak the truth, but danced around it. If a patient didn't ask if he/she was dying, I didn't always bring it up, and I probably should have. Somehow I'd at least mention that we'd come to a critical juncture and whereas we were going to continue to strive for and hope for the best, plans ought to be made for the worst. Meaning "getting affairs in order." But when they did ask, the answer was yes. And then we'd talk: I'd wait to see what they had to say, or ask what they'd like to say. I'd assure them that I could keep pain away. And sometimes -- both because I meant it and because I assumed they'd like to hear it -- I'd say how much I cared about them and that I'd remember them and the effect they'd had on me. When tears came they were real. But I also noted it in some lizardly part of my brain, and then chided myself for noting it. Was I just a damn phony? If tossing and turning at night over dying patients meant it wasn't phony, it wasn't. But I also slept.

Families need to know things. They often ask, when a patient is unresponsive, if that person can hear them. "I'm sure he's not in pain," I'd tell them. "But at some level I've always thought that there's comfort from hearing a voice. So talk to him. Tell him about your day or remind him about your life together. I think it makes a difference. Touch him. I think he'll know." Where's the harm in that? Waiting rooms outside of intensive care are painful places. I could leave the ICU and turn right to avoid them; or left to see the family and friends. In a hurry often, I turned right. But at least once a day I turned left. And sat down (there was a private gathering-room as well into which we'd go for some discussions). It can be frustrating, especially when people keep showing up and asking the same questions, but in fact a lot can be done in only a few minutes. It goes without saying that it's part of the job: but in the ICU there are a lot of doctors involved. Some surgeons I know leave the talking to the intensivists. As painful as it can sometimes be, had I not participated, I'd have felt much worse.

And that's the point: avoiding the dying and their people may seem easier than connecting, but it's a huge mistake. A surgeon can rationalize: my job is to operate and give the best post op care I can. They have other doctors for the other stuff. But it's amazing what sitting down and holding a hand can do for the person attached to each hand. Rightly or wrongly -- I truly don't know -- for me there was a sense of absolution.

On Death. One.

I've been asked to review a book for Medscape. As it happens, its central subject is a theme about which I'd been planning to post at some point, and the reading has jogged me into it. After the review is posted, I think I'll mention more about the book. Meanwhile, some thoughts on death and doctors.

To a physician, death rarely comes unannounced. Because of what we know, we can see it coming before others do. That doesn't make the arrival any easier; in fact, because our essential aim is to cure or prevent disease, death is a repudiation -- perhaps even a humiliation. The author of the book I'm reading sees it as wrapped up in physicians' fear of death, in their need to convince themselves of their own immortality. I don't happen to buy that. But I do agree that, for complicated (because humans are complicated) reasons, we tend to turn away from our dying patients. Willing to do almost anything to stave it off, when death becomes inevitable in those under our care, we either fail to acknowledge it, pressing on no matter the reality, or we begin to detach ourselves from those most in need. Perhaps the "we" is presumptuous on my part: I think the tendencies are widely seen, but maybe I should speak just for myself. I learned by observing others, and by looking inward to my own behaviors.

The need for uncomfortable candor comes in many forms: telling a patient and loved ones of a fatal disease before starting treatment; dealing with a failure of therapy; informing of a sudden and unexpected death. Luckily, the last one is pretty uncommon: cataclysmic, I think it's the worst of all. Wholly unprepared, the family receives a horrible shock, often in the form of a phone call. The worst case of mine was doubly awful.

I'd done a routine operation on Mrs. Jones. In her seventies, diabetic but pretty healthy overall, she'd seen her doc before surgery and had been given the all-clear. On the first post-operative morning, a nurse had done a routine check, found her to be recovering appropriately. The nurse left the room for as long as it took to get a fresh IV bag, and returned to find Mrs. Jones dead. It was a heart attack; the biggest of the coronary arteries, occluded. "Just one of those things," some might say. I was stunned when I got the call, came immediately to the floor, found the husband's phone number. The idea of making such a call, of having to say what happened with no warning and to do so in some sort of gentle way seems so impossible, and is so repellent that there's a temptation to lie: to gain time, to prepare the family by saying she's taken a turn for the worst and they need to come right in. To meet them then, and tell them in person that it's too late. Would that be easier on them? On me? (Probably not on me: as hard as it is to make such a call, it's over -- in the immediate sense -- when I hang up the phone.) (Actually, it isn't: the gut aches after. And there's the need to be there when they arrive, no matter what.)

As I was talking to Mr. Jones on the phone, telling him the crushing news, a daughter arrived on the floor to visit her mom, unaware. Out of the corner of my eye I saw her heading toward the room, knowing there was no one in there but her mom. Like everyone's recurring dream, unable to move fast enough, I tried to signal a nearby nurse, but it was too late. I couldn't have torn away from the husband on the phone, could I? The daughter opened the door and walked in, coming out a moment later. Her shock-shredded face, perforated by the unnaturally widened holes of her eyes and mouth, is carved into my memory, as are her words, said with her hands held inches from her ears, as if unsure whether she wanted to hear the answer: "Is she dead? Oh my god, is she dead?" With the phone in one hand, and my head in the other, I didn't know where to turn. Waving and garbling, I managed to get the attention of the head nurse and point to the poor daughter.

With no preparation at all, the shock carries forward for a long time. I met with that family en mass at the hospital, and weeks later in my office, as they sought explanations. As unpleasant as the meeting was, it's the initial call -- and others like it -- that sticks to my mind like tar. "I have terrible news," it begins. Cliched, formulaic, mechanical. It's as if I'm split in two, watching myself play a role, detached, yet feeling real pain and searching for a way to make a human connection. Out of the blue, it feels like there's no way. The desire not to make the call is nearly overwhelming. Acute, immediate, finite and final, it's impossible, it seems, to do it properly. No way through it for either party. On my side of the phone -- and this applies to all of the death scenarios -- as I speak, I hear myself as if in an audience. As much as I am aware of the humanity of the situation, I also know I'm playing a role. I know the need to be sensitive: and look, here I am being sensitive. Where's the truth of it? If doctors tend to turn away from death, is turning back a matter of willing it? Can it be carried out effectively by rote?


When death gives us time, we can -- if we realize it and face it -- make an enormous difference for our patients and ourselves. The question is if we can do so without chipping steadily away at ourselves. The answer, in my case, is yes. And no. I'll try to write my way through it, next.

Judging Judgment

I remember a party my folks had when I was in high school. A couple of their doctor friends were talking -- a general surgeon and an orthopedist -- and the subject was whether, given the choice, they'd like to have more brains or more brawn. At the time, their answers impressed me: surgery was such a physical enterprise, they both agreed, that they'd want more strength, more endurance. Back then, I think I thought "wow, what a tough job." Now, I think "wow, what bullshit!" What makes a good surgeon is judgment. A strong back? Useful, no doubt. Deft hands? Sure. But -- stereotype to the contrary -- surgery is a thinking person's sport, one where thoughts have immediate and profound consequences. In retrospect, maybe those guys were kidding or otherwise off-point. My dad made a mean gin and tonic.

Since I've been writing I've been thinking a lot about the concept of judgment -- surgical in particular, but also medical in general. From where does it derive? Can it be taught? Why do some doctors seem to have good judgment in greater quantities than others? Do bad experiences build judgment more than good ones? If so, do you have to be bad before you can be good? (I'm not real serious about that one, although it brings to mind a study I once read, showing that people who have surgery for colon cancer, and who have post-op infections from leaks ((and who survive!)) have a higher chance of cure than those who don't have such problems; the theory being that somehow infection activates immune response. It made me worry that by being a careful surgeon who didn't have bowel leaks I was doing my patients harm. Where do you go from there?)

Dino and I seem to have developed a friendly (I think it's friendly) tweak-fest on occasion. I imply family docs know a little about a lot, and he suggests surgeons sit around waiting to be handed a diagnosis on a silver-plated (it would be sterling, were it the other way around) platter, then operating thoughtlessly and collecting bigger bucks than deserved. (I'll admit one of his "rules" suggests he may believe otherwise.) Still, there's a perception out there -- not wholly undeserved nor free of self-propagation) that surgery is just about cutting, and then running. I've seen a few for whom that's a fair description. But I think they're very much the exception, at least in the worlds I've inhabited.

As I think about it, one interesting aspect of the process of acquiring judgment (it's always seemed to me that there should be an "e" between the "g" and the "m" in that word, and I really wish there were) is that having a bad experience can adversely affect the process. You know the saying, "once bitten, twice shy." You hear it a lot in operating rooms. During my training I saw a couple of patients who'd been transferred to us after undergoing surgery elsewhere for acute diverticulitis and who'd had horrendous complications. I concluded the decision-making involved in that disease -- when to operate and which operation to do -- must be among the most difficult and danger-laden there is. And, really, sometimes that's true. But in looking back, I think I can make out among the foggy forgotten a couple of times when I dragged my feet unnecessarily, and operations when I may have committed my patient to a temporary colostomy -- taking an unarguably safe route -- when I could have avoided it. Had I not seen those catastrophes during training, my perspective would have been different.

The fact is I never repeated the mistakes of those other surgeons. But did I react too strongly in the other direction? As time went on I came to re-think many of the attitudes I learned in residency -- sometimes because of data presented by others, sometimes after considering my own experience. Still, when it comes down to making a decision, for example looking at an inflamed section of colon and deciding what length to remove, gauging the safety of sewing the ends together instead of bringing them temporarily to the skin, one calls upon all sorts of tangible and intangible things that mysteriously coalesce into what we call judgment. It tended to work out well for me and my patients, yet I'm not sure I understand why. I'll have to write more about it before I do. If ever.

Risky Business

By way of introducing the subject of surgical risk, as requested a while back by a reader, I present a couple of noteworthy patients:

Harry was a crusty old fart, mid eighties, wiry and wheezy. Grizzled about the muzzle, straightforward in speech and unrepentantly profane, he'd been admitted with a touch of pneumonia, following upon an episode of aspiration. Burdened for years with severe symptoms from a hiatal hernia with reflux (wherein the stomach slips up into the chest and its upper valve loses the ability to keep stomach content from backing up the esophagus), he'd been rejected in the past as a surgical candidate by at least two surgeons before I was asked to see him. Harry's heart, it was felt, was too precarious to withstand a major operation. It was a little puny, all right -- a dollop of a-fib, question of congestive failure in the past (although that had been at the time of a previous episode of aspiration) -- but far from the worst I'd seen in someone considering surgery. My favorite cardiologist, a pragmatic and sober sort of guy, agreed that Harry figured to pull through with a little combined effort and a good operation. It's been said (not sure by whom, but I tend to agree) that as good a measure as all of the fancy tests we can muster is the ability to walk up a flight of stairs. I took Harry into the stairwell and turned him loose.

Nor was leaving him to his repeated reflux without risk. It was adding up. I told Harry what was involved in fundoplication and hiatal hernia repair. "Those other docs told me I was too old for it. Sounds good, but won't it kill me," Harry asked? "It could," I told him. "But I don't think so, and neither does the heart doctor. For the shape it's in, your heart's in pretty good shape." "Hell, let's do it. Sure as shit this ain't no way to live. I can't sleep, I can't tie my shoes without puking."

Harry, as the expression goes, didn't turn a hair, went home right on schedule. On his first office visit afterwards, I asked how he was doing, whether he could tell yet if it had been worth it. "Doc," Harry said, firing his eyes at me like pistols, "I spent four years in the Philippines in dubiya dubiya two." He said it in a way that suggested the next words would be and I thought I knew what suffering was. But what came out was, "and until now my hero has been Douglas MacArthur. Now, it's you." He said it like he meant it.


Then there was Phil. For the last dozen of his ninety-six years he'd worn a hernia belt for a gigantic inguinal hernia, because no surgeon would touch him with a ten-foot scalpel. Truss me: no appliance works worth a damn, especially on such a large rupture. He was constantly miserable: trouble walking, trouble keeping clean. Sore, worse when he strained to pass urine or stool. Uncomfortable in any position, he was reduced (no pun) to spending life in a recliner. In short, after suffering his way through and well past his golden years, for some reason he'd finally had it with the thing and decided to try again to find him a surgeon. Unlike Harry's, Phil's heart had been run well beyond its warranty. And yet here he was, practically begging for help, saying the wretched thing had made his life finally not worth living. I don't believe in choosing surgery as a pleasant alternative to blowing your brains out. But I do think it's a rare situation that precludes surgery no matter what, in a person capable of making decisions. Besides which a nicely done local anesthetic with an anesthesiologist sitting by to keep an eye on a couple of monitors is a pretty low-risk way to fix a hernia, even in a frail fellow like Phil.

On his office followup, he and his live-in buddy told me they'd had a truss-burning party a few days earlier.


Much as we'd like it, there's no even slightly precise way to answer the question, "What are my chances, doc?" Studies tell us a breakdown of a thousand patients, but not what will happen to the one sitting in front of you. Nor is there some easy algorithm for calculating risk/benefit. Implicit in recommending surgery is the belief that the danger of the proposed operation is less than the danger of the disease being treated. But that's really just a (hopefully) sophisticated game of odds-playing: since nothing is 100% -- neither the surgical outcome nor the behavior of a pathological process -- the right decision will end up wrong for some people. Moreover, it's obvious that a given medical status -- say, various heart or lung problems (or both!!) -- figure in a different equation if the targeted disease is the occasional gallbladder attack, versus colon cancer. And if someone shows up with a perforated colon causing generalized peritonitis, you're going to have to operate no matter what the pre-existing factors are. You take as much time as is safe to tune the patient up (balancing the ill effects of delay vs. the increased safety of correcting the correctable) but unless there's virtually no hope of getting the person through (and it's rarely possible to be absolutely certain) you'll likely go ahead. Which is why I said above that it's a rare situation in which surgery can be said to be impossible.

Diabetes, obesity, heart failure, chronic lung disease, liver or kidney problems; reduced immunity, taking certain drugs, smoking. All these things increase surgical risk, meaning they add to the chances of peri-operative problems. We can -- assuming there's time -- address them ahead of the operation: get blood sugar well-controlled, optimize heart function, taper off steroids when possible. Stopping smoking before surgery makes a measurable difference. Many plastic surgeons will refuse certain cosmetic procedures in smokers, because of known interference with healing. Even reconstructive surgery is jeopardized: smoking decreases circulation in small vessels, putting fancy flaps at risk. It's easy to tell smokers by they way they cough on the breathing tubes during surgery, and by the crap that needs sucking out of their lungs during and after operations. Stopping for even a week may make some difference; a month or six weeks is way better.

When the risk of not doing surgery is greater than the risk of doing it, we go ahead. Which makes sense. The difference between medicine and some other worlds is that the most precise medical data are by their nature imprecise. How amazing it is to be able to fire off a rocket from Planet Earth and know exactly when and where it will arrive at Mars; to be able to send a signal at exactly the right second to initiate a burn, to send a lander bouncing to the surface within yards of the target a million miles away from the pushed button. Doctors -- because it's true -- point out that no computer, no algorithm can reproducibly predict specific outcomes of diseases and the interventions aimed at them no matter how close we are. Layered upon all the information assembled from past studies, from personal experience is some sort of instinct for doing the right thing at the right time. In the best of all worlds, instinct would count for very little. Who wants to think their doctor is just guessing? We're not there yet, and it seems doubtful we ever will be. Among the aims of medical education and research ought to be always to strive for more precise ways to diagnose and treat disease, more accurately to understand the variations in which an illness behaves among victims and by which it responds to a treatment. To eliminate the need to guess, trust the gut, make a leap of faith. To crank out doctors who vary not at all among themselves in their ability to diagnose and treat, the outcomes of whose care will be as interchangeable as a set of pistons. Ain't, of course, gonna happen. There's more of a chance of narrowing the differences among doctor performance than there is of getting to the point of perfect predictability of pathological process. "Educated" and "guess" will never be separable from one another in medical care. Even as the former increases and the latter decreases, they will remain hand in hand, an imperfect marriage. Don't smoke.

Junkies

A while back, a reader brought up the environmental impact of surgery, suggesting that it ought to be a consideration when planning an operation. Whereas I don't think that's possible in an individual sense (one can try to use as much re-usable material as possible, but you have to take what's available at the moment), it raises a valid point: operating rooms produce a horrendous amount of trash, much of it non-biodegradable and painfully wasteful. It started, I think, because of medicare madness, insurance insensibility, payor pettiness and egregious economics.

Time was, we re-used a lot of stuff: cloth was cooked, needles were nuked, staplers were sterilized. But as cost-control became a priority and payers were looking for ways to be non-payers, operating room expenses came under close scrutiny. And it came to pass that hospitals couldn't pass expenses related to re-processing materials. They could, however, charge -- including some sort of reasonable (whatever that is) markup -- for single-use materials. The upshot was that it became a money-loser to reuse anything, and a money maker to buy stuff you'd use once and throw away. For all I know, it can be shown to be of economic benefit in some areas: but it's quite amazing to see how many large plastic bags we fill with various paper products, all treated to be flame-proof (cloth didn't need that) with some sort stuff that is unlikely to be good when it soaks into the ground somewhere; plasticized, glue-laden, dye-containing. And that ain't the half of it.

Surgical instruments win the prize. When staplers were first invented (and believe me, they are a boon in many areas) the bulk of the hardware was stainless steel, cleverly engineered to accept a disposable little rack of staples. Keep the big handle, resterilize it, pop in a new small set of staples. The hardware is of many types and shapes, designed to do an array of cutting, connecting, clamping. Ask for a stapler nowadays, and you get a cardboard box containing a plastic box containing a complex instrument of steel and plastic which, in most cases, you fire once and toss in the trash. (Some allow re-insertion of staples for another use during the same operation. But then it's AMF.) Much as I appreciate the technology, it nearly kills me to throw all that stuff away.

In the early days of laparoscopic surgery (wherein the belly is filled with gas and instruments are inserted through little port-holes [called trocars] poked through the abdominal wall), lots of material (particularly the aforementioned trocars) were re-useable. But once again, we now open boxes, plastic, use the pokers and toss them. Same with some of the instruments that are poked.

The good news is that the disposable things we use are of ever-increasing quality; brilliantly designed, allowing us to do things that weren't possible even five years ago. The bad news is that the ethic of conserving resources seems, in the context of the OR, to have gone the way of ether and leather straps. On the other hand, if you're into leather straps and you know someone who works in an OR...

There's a small irony: as payments to hospitals have shifted -- in some cases -- to "global fees" (meaning "here's what we'll pay you for hosting a colon operation: spend it however the hell you like") some have re-discovered conservation. Draping with and wearing cloth, and revisiting reusable instruments happens here and there, once in a while. And although the manufactures don't officially approve, many disposables are perfectly safely being reprocessed as well. It appeals to me.

Stones and Knives

No chemist I, unable to explain solubility constants or crystal formation, I can only note and admire: gallstones come in all sizes, shapes, and textures. Hard and shiny like agates, faceted like emeralds, crumbly like clay. Mulberry-shaped, round, uniform or uneven; surfaces determined by their neighbor, or identically shaped as if manufactured. Green, black, bright yellow, fecaloid. They can occur by the hundreds in a single gallbladder, or fill up an entire bag in the form of one gigantic rock. Feeling like a magician, I liked to save a few from the lab and present them to their owners, more amazed than if I'd pulled a quarter from behind their ear. I always enjoyed looking at gallstones. Unless they were oozing out of a gooey gallbladder in the middle of an operation, like cockroaches from a garbage bin.

Learning surgical technique is an incremental process. The student may be allowed to cut some sutures, maybe even tie a few. Simple as that is, it allows a sense of tissue tension, unlearns the old way of holding scissors, teaches the new. Taking up a knife and cutting through the skin requires overcoming practically everything you ever knew. I was eventually allowed to "do" a hernia as a student (a rarity indeed), although I really had no idea what was happening, anatomically speaking. The resident held something in such a way that I had no question of what I was to do, and I did it. As an intern, I did more of them, getting better at maneuvering instruments, placing sutures where I aimed them, cutting without shaking so hard it was visible across the room. Taking out a gallbladder was, where I trained, too big a deal for an intern. It was real surgery, inside the abdomen, close enough to structures of significance, demanding enough of dissecting skills that we waited a year before getting the chance. So it always held special significance: like passing through a portal, like being taught the secret handshake. Tourists in fancy eateries are shown to the main dining area; locals get invited to the wood-paneled special rooms upstairs.

You can do some operations without knowing how to operate. In my book I wrote "with enough bananas, you could teach a monkey to take out an ovary." Some gallbladders are so easy to remove, hanging loosely under the liver like a pluckable plum, that I refer to them as "gynecologic gallbladders." If your first couple of gallbladders are like that, you can get lulled into thinking you know what you're doing. (Way back in my early practice days, when our community allowed more or less unfettered surgery privileges, more than once I was urgently invited in to bail out a family doc who discovered dramatically the mysteries held in the right upper quadrant, and who'd been epiphanized into the realization that knowing how to hold a scissors in one's hand does not a surgeon make.) In those same ancient times, it was believed that operating when the gallbladder was actively inflamed was to be avoided at almost all costs. Whereas it's true that most attacks of acute cholecystitis simmer down without the need for emergency intervention, they don't always. Gallbladders can get severely infected and can rupture (especially in diabetics); acute attacks can flare up again during a cooling off period. More recent studies tend to show that early intervention isn't associated with more problems than waiting. But it sure as hell requires knowing how to operate.

While serving in Vietnam, I "flew" EC-47s. The pilot would arrange power settings and trim, giving over to me the stick and rudder. I "did" takeoffs and landings, accomplished some cool maneuvers over the China Sea. Shit hot, as we pilots liked to say. On final approach, if the crosswinds were a little too harsh and I was coming in crabwise, at the last minute he'd say "I got it" and keep us alive. Under tight tutelage I removed a few gallbladders early in training, and came to feel I could do it. When I first encountered the real thing while helping a young 'un -- a red, swollen, pus-filled gallbladder, speckled with the black spots of gangrene and stuck tightly to the colon and liver -- I squealed for help like a kid who'd wandered out of the shallow end. Throughout my career, when I'd be working my way through such a mess with confidence, at some point I'd always remind myself of that first really scary one, and allow myself a smile. Behind the mask.


In the illustration above, you can see how the colon makes a sharp left turn (the "hepatic flexure" -- "left," by the way, orients vis a vis the patient). In life, it's immediately below the gallbladder, very often touching it. Same with the duodenum, which isn't marked but is the C-shaped tube at the bottom of the stomach. Uninflamed, those structures easily peel away from the gallbladder. There's a thin covering of the gallbladder which holds it to the undersurface of the liver, filmy, as if it were sprayed on, easy to navigate, buzzing a few small bleeders on the way. Down at the business end, the tube that connects the gallbladder to the main bile duct, and the artery that feeds the gallbladder (cystic duct and cystic artery) are usually not to hard to identify and divide: in most cases it takes a little dissection through a layer of fat to find them, typically not a great challenge. Ironically, though, some studies show that it's when things are "easy" that injury is most likely to occur: when your guard is down, you feel relaxed and floaty, recreational, and you might not attend as intently to the anatomy. So they say. Subtle anatomic variations occur here, and they can fool you. Still, with care, it's fun and safe.

Oh man! Not when the gallbladder is acutely inflamed or infected or both. That sprayed-on film is now thick as a the peel of a grapefruit. The colon -- duodenum, also, maybe -- is plastered to the mess and has become inflamed, too, such that where one ends and the other begins is anyone's guess. The adjacent surface of the liver, caught up in the raging redness, is gooified and extra bloody. And the little duct and artery? Good luck! Encased in dense edematous tissue and often indecipherable. This is where everything you've ever learned about handling tissues, every trick you were taught and every wrinkle you've come up with yourself needs to come front and center. When nothing is normal, no move has a predictable outcome.

How can I describe a combination of caution and boldness, of confidence and trepidation? What does it take to enter such a zone recognizing the danger but believing you can do it? (Not as much as entering a burning building or a free-fire zone.) In "Cutting Remarks," I came up with the term "delicate brutality." I like it (in fact, I've since thought that would have been a better title for the book.) You can't blunder into the foray swinging sledgehammers like an orthopedist. But if you diddle around forever, nibbling at the edges, afraid of the water, you'll drag the operation out too long: the sicker you are, the less you need a long anesthetic. So you resort to techniques that can move along briskly but respectfully. Blunt baby steps. A careful cudgel. Delicate brutality.