It Seems Like a Year

Well, as of today it's been a year since I began this blog. Months before that, "blog"was a vague concept, something I'd heard about. Probably had read a few of a political nature, but the idea of having one of my own didn't register. I stumbled upon medblogs as I began to think about ways to hawk my book on the internet. I overdid it. Got deservedly chastised for some egregiously self-promoting comments on a couple of very worthy blogs. Shameful. I still cringe, Orac. Sorry.

Eventually, it dawned on me that I should just start my own blog, and I was amazed at how easy, how free it was. At first I was pretty clueless, and my cherry-popping post was some sort of terrible toe in the water. Back then, I had no idea about site meters, tagging one's posts; didn't include pictures or links. I've gotten a little more ept. Among the great things, in fact, is the ability to link. Readers of my book will have found a surfeit of footnotes: linking to relevant info is a boon. In fact, if I write another book, it's gonna be harder -- I'll be wanting to hot-link all over myself.

I'm not exactly swamped with readership, but there has been the occasional mention on a widely read site, with resulting viagral changes in visitor graphs. A couple of times, Surgeonsblog has been mentioned as a worthy read among medblogs. Best of all, I've loved reading comments from all over the world, and I've gotten emails from readers with really wonderful ideas, or testaments that reading here has been informative, entertaining, even inspirational. All that is highly gratifying. If this all began as a self-promoting book hook, it's become way more -- way better (to me) -- than that. Heck, I hardly even broach the book anymore.

On the other hand, with my surgical life now pretty much limited to assisting others, the inflow of ideas derives from a diminishing reservoir. Not unlike my urinary stream, there's more effort required to maintain the trickle. I have a few more ideas up my sleeve, but at some point they may start running down my leg. I will, however, in a what's-the-worst-that-can-happen frame of mind, post a poem I've had sitting around a while. At least one English major puked in public print at a previous post of perceived putrid purple prose. But what the heck. I've got a year under my belt. I can take it. Besides, it's been vetted in Mexico.

Shoe/Foot (other)

I wish I'd had a tape-recorder. I'd have gotten it all and sent a copy to the doctors and the nurses. If I were nasty, I'd have sent it to the hospital administrator...

Having had a number of people close to me in the hospital lately, I've spent plenty of time at the bedside. It leads me to conclude that if every doctor and nurse did the same, without letting on that they were "medical," they'd change their behavior overnight. I was a visitor in a hospital just this morning, in a two person room. The roommate was a nice lady, fresh from surgical repair of a broken leg. A few months ago, she'd had breast cancer. A doctor came to see her: thin, dressed in a crispy thigh-length white coat, dark slacks, academically correct glasses. Medical guy, clearly.

"Hello," he said. "How are you feeling?"
"Hi. I'm ok, I ...."
"I saw your scan. It doesn't show the cancer. Does it hurt when I press here on your liver?"
"That doesn't hurt, but..."
"Are you feeling better than yesterday? Does your liver hurt when I push here?"
"A little, maybe..."
"OK." Exits.

Seriously. That was the exact interaction.

Meanwhile, the lady had called the nurse because her drain had come apart, leaking into her bed. As the nurse checked it out, she noticed what was evidently more than the usual amount of swelling in the lady's leg. "Oh, this is pretty swollen. Is it bigger than yesterday?"
"I don't know. I guess so, looking at it..."
"I'm going to call your doctor." Exits. Returns with another nurse in a couple of minutes. "Does this look swollen to you?"
"Yes, and it feels tight."

Someone sticks her head in the door. "You page Dr Ortho?"
"Yes, I'll get it." Exits, returns in a couple of minutes. "He said not to call him urgently, it scared him. He's coming." Rustling around, passing back and forth in front of me and the person I'm visiting, urgent, but no eye contact our way.

Dr. Ortho shows up in about five minutes. "Let's have a look... You have some bleeding into the muscle. It happens. We cut apart the muscle to fix the bone. And you're on blood thinners. You need to be on them, but when they cause problems, we have to stop them. We'll take out the drain. Try to lie right on the leg. The pressure will help."
"Thank you, Doctor."
"You're welcome. Goodbye."

Nurses return to patient, and talk while changing the bandages: "He acted like it wasn't important, like I didn't need to call him. I think it was important."
"So do I. It's a problem."
"Well he sure acted like it isn't."
"It is."

No point in listing the issues: I assume they're obvious, and that if the people were to see or hear a playback, they'd feel bad. Nor did I say anything, because I wasn't part of it. Last time I was, I did.

When my dad was admitted for what turns out to have been his final hospitalization a couple of years ago, it was first to a room on the medical floor. (I arrived a few hours after admission, to find him working quite hard to breathe, and asked the nurse how long it'd been since his oxygen level had been checked. "It was fine when he came in, but I'll check again.... 75%. That can't be right...." But that's another story, maybe for another day.) The point was that while we were awaiting the arrival of his physician, some attending came in leading an audience of admirers, consisting of a resident, an intern, and a student. Never acknowledging my mother, who was sitting by my dad with her fear and concern as obvious as if she were on fire, the attending told my dad he was going to listen to his lungs, and did so. No introduction, no preamble. Without another word to my dad, he asked his charges to do the same, which they did, wordlessly, after which he began to talk to them about it as they exited the room. The student turned and (uncomfortable, I'd like to think, at the absence of humanity) said "thank you" as he left. "I'll be right back," I said to my folks, launching from my chair with the fury of righteous indignation thrusting me like a bottle rocket.

"Excuse me, I'm Dr Schwab, and those were my parents," I intruded into the gaggle outside the room, ignoring entirely the attending and looking only at the student. "I've been in practice over twenty-five years, and I've never seen a worse example of how to behave in front of patients and family. I hope you took notes, because it's really important, more important than whatever you heard in my dad's chest. No one introduced himself, no one explained why they were there, what was going on. If you couldn't tell my mother was scared to death, you're all blind. Yet no one acknowledged her at all. No one even turned her way. She didn't exist to those people. That was the most egregious behavior I've ever seen.... and I'm a damn SURGEON!! Maybe you can learn from this -- (still looking at the student and paying no attention to the doctors) -- I'm guessing the rest couldn't care less." As I walked back into the room, I noticed the eyes of a couple of nearby docs aimed in my direction. I don't know what they were thinking.

Docs, nurses, students: when someone you know is in a hospital where you aren't known, make it a point to visit. Watch and listen. It'll be better for you than a dozen sensitivity classes. Way better. Acknowledgment, explanations. Listening. In that first case, about twenty extra words from the docs, and twenty fewer from those nurses would have made all the difference. For all of 'em: empathy. It's all about empathy. The absence is about 90% of what's wrong with medical care. And you know what? I'll say it. I'll take a chance on sounding like a pain in the ass: I know I was never perfect. I don't have the fastest hands nor the deepest knowledge on the planet; I've made mistakes in technique and in judgment. But I always had empathy. I treated my patients as I'd have wanted my parents to have been treated. I never acted like any of those idiots. (Not to patients, anyway.) And I'm still pissed.

Ommmmmm......

My last post seems to have sunk without a ripple, so I'm letting my mind coast for a day or two. Letting neurons fire randomly and record the blips. Downhill sledding. Clutch in, no effort. Empty the mind, see what rises...Here's a couple of memories that popped up, for no particular reason that I can palpate, using the least amount of effort possible:

Training in San Francisco meant seeing a broad swath of humanity. I once operated on an ancient Chinese woman who spoke no English, and who'd been subjected in her distant youth to the practice of foot-binding. Entirely unrelated to the problem that led to my surgery, it was nevertheless memorable enough that the image is fresh in my mind, sticking amongst the otherwise decaying RNA. Her feet were a lot like this:

It hurts to think about it. Here's how the Xray would, no doubt, have looked:





The mind now ping-pongs to the arrival of another Chinese person, this one a male, looking to be at least a hundred years old, and not planning to get any older. He'd been ministered to for a few days by traditional healers of some sort, including having the stigmata of "cupping." What I remember most was the rigidity of his abdomen: "board-like abdomen" is a classic sign of severe peritonitis, the muscles involuntarily tightening up in a protective response. I've seen a few, but this was the only one ever that was truly like a plank. With enough of them, you could have walked across the Golden Gate without a bridge. I was working in the ER at the time, and as I sent him to the floor, I wrote the presumptive diagnosis on the ER sheet: "Perforated viscus; rule out death..."

Boink. Another cerebral pinball hits a bumper. When Chief Resident, I cared for a man locally described as "The King of the Gypsies." Whatever he was, he came with an extensive and colorful entourage who literally camped outside the ICU for the several days he was there. Many families of other patients were understandably disturbed; still, it was a unique and in many ways irresistibly enjoyable group. They cooked, they played music, they set up little tents, all inside the hospital. For some reason, security let them stay (maybe the King had an army.) The women were beautiful, the men a little scary; but they attended to my every word as I updated them daily on the man's progress. He made it. And when they left late one night, they took several chairs and a TV with them.

And speaking of TV, I was making rounds as a horny intern during the baseball playoffs. Attending more to the bandages of my patient than the televised proceedings, I slowly became aware of a female voice singing the National Anthem. Clear and crystalline, straight up like a perfect martini, this was the purest version ever; the Platonic ideal. No quavering, no self-centered arrangement. The real deal. Stunning. I looked up to see a dark-haired beauty (I married a dark-haired beauty not long after), clad in short shorts and a LA Dodgers jacket. "Who the fuck is that?" I uttered (not easy to do, with the lower jaw non-participatory), zoned far away from the work at hand. And it was then that I became a life-long fan of Linda Ronstadt.

Two Spleen...

If the concept of "a little bit pregnant" isn't a useful one, it turns out it IS possible for a spleen to be "a little bit ruptured." It wasn't always the case. Not much more than a couple of decades ago, the algorithm was pretty straightforward: a) see ruptured spleen; b) remove ruptured spleen. No need for a mnemonic. Very surgical. Now, God help us, we have lots of choices. a) see ruptured spleen; b) admit to ICU; c) insert thumb in ass; d) get lots of blood tests. If operating, it's repair spleen, remove part of spleen, remove all of spleen. If removing, slice up a few pieces and stick them somewhere (actually, that's a cool concept, and I liked to do it: theory being it might take hold and provide the immunity unique to the spleen). 

Some of the early work in splenic salvage for trauma was done where I trained, one of the first major designated trauma centers in the US. Here is an early article by a guy I taught a thing or two when I was chief resident and he was junior, and one of my professors. And here is an article that suggests it's all a bunch of b.s. Hard to know. Data suggest it's very much worth the effort in young kids, in whom the immune consequences of splenectomy seem to be greater than in adults. As I said in the previous posts, much of the data on OPSI (Overwhelming Post Splenectomy Infection) is muddied by not always separating those who lost their spleens for trauma from those with hematological problems. Still, I'd say there's general agreement among surgeons, this one included, that operative salvage and non-operative observation need to be in our bag of tricks. Judgment; that damnable, infuriating and aggravating judgment. Is what it takes.

Patient with multiple bad injuries -- head, liver, spleen, couple of femurs -- in shock, getting pint after pint of blood. No brainer: get that thing outta there. Middle school footballer, isolated spleen injury on CT scan, little crack in the surface, small collection of blood, stable normal vital signs. No brainer: park the kid and keep an eye on him (although, assuming he recovers without surgery, telling him how long to take it easy, and how easy, is matter of some uncertainty...) Woman in auto accident, small crack in liver, bleeding slowly from the inferior pole of her spleen, broken leg. Brainer. Toddler ran into coffee table at home, tender belly, squirming, spleen with fracture and collection of blood on CT scan, pulse a little fast. Brainer. And, I assure you, that last one in particular is not at all comfortable. 

The CT scan has both made life more complicated and easier in this regard. Complicated, in that it was the ability of the CT scan to identify injuries without the need for exploration that was part of what raised the tricky issue of non-operative management of an injury. Easier, in that time has allowed the development of CT image criteria by which it's possible to be at least somewhat predictive about what sort of injuries are likely to resolve on their own, and which will need intervention. Yin and yang. Tough stuff.

Word has it -- double sourced, as they say -- that a certain surgeon with an operation named after him often injured the spleen when he did that particular operation. As was routine for even small injuries back then, he'd take it out. AND CHARGE FOR IT! Peeling a bit of the capsule off the spleen occurs not rarely when rooting around in that part of the belly; in the past, lots of spleens were removed because of it. Now, simple application of any of several topical agents -- powders, cloths, glues -- is almost sure to stop the sort of bleeding that that creates. Repair of a bigger injury is a bigger deal: sutures don't get much purchase in that soppy substance. Likewise, deciding when it's hopeless before losing lots of blood in the effort is a skill best learned -- and applied -- early.

If you don't mind joining me for another of my trips to "back in the day," I'll mention that during training, about the worst thing anyone could do in the ER was miss the diagnosis of ruptured spleen. It happened, but not often. In those early days we didn't have CT scans or ultrasounds on which to rely, so the prime directive was always to consider the possibility. In the multiply-injured for whom a laparotomy was inevitable, it wasn't a problem. In the questionable situations, we'd very often do a "diagnostic peritoneal lavage," or DPL, or "peri-dial," in which a catheter is popped into the belly, saline infused then returned, and the fluid analyzed. High tech in the extreme, the criterion by which there was judged to be enough blood in the effluent to warrant laparotomy was inability to read newsprint through the fluid in the clear plastic drain tube (cell counts were done, too. But this was shown to be pretty reliable). Be wrong, you got some 'spleenin to do... 

Our chief at the trauma center would almost never criticize us for having a look and finding nothing; to miss something serious -- that could be cause for the rapid ending of a career. It may be true (it is, I'd say) that CT scans are over-used nowadays, but missed injury in a trauma victim is pretty rare now, because of them, and because of ultrasound, now available in many ERs, used by the ER docs, not radiologists. Progress, for sure.

In doing elective open splenectomy, I liked to wear a headlight. It gets dark up there behind the ribs. Delivering the spleen into the midline, light isn't a problem. It's in the cleaning up after: that empty space where the spleen used to be is high up and back there a ways. Getting it up and out involves dividing the filmy but firm attachments between the lateral surfaces of the spleen and the peritoneal gutter in which it lies. In a dry field, it may be done sharply: long-handled scissors, or extended-length cautery with a nice bend in the tip. When the area is full of blood, you tend to do it dickless (in the sense of not dicking around. And what the heck, this is already an NC-17 blog, right?) Reach in -- in large people, it can be up to the elbow -- paddle the spleen with your fingers, like playing a sticky piano, to sense how bad it is; diggle your fingertips into the peritoneal attachments until it breaks free. Once the spleen is out, one of my favorite -- if simple -- maneuvers is the stuffing of a large sponge into the hole and then slowly rolling it back out, while looking carefully at the raw surfaces left behind as they ooze up from under the sponge, like rising dough. Spotlight, cautery, suction held by the assistant at the wound's edge to inhale the smoke: clean and dry by the time the sponge rolls to the surface.

A belly full of blood changes everything: it's about assessing and getting control as fast as possible, while not missing something important. Suctioning blood in that circumstance is too slow: you slush it out with your hands -- gelatinous black clots sliding across and out of your palms, over your fingers, like sickness itself, as you dip and dip again. And you sponge blood and clots out with pad after pad: keep 'em coming, please. I need a bunch of 'em. Force wads of dry pads into the corners while you look at the bowels, the retroperitoneum (where missed injuries are highly lethal), then come back to where the action seems to be. A broken spleen doesn't usually spurt, it oozes. Clots and liquid, in a sorry soup. Venous blood is darker than arterial; if the patient is in shock, it gets so purple it's almost black, and that's a scary sight. Rising through and around clots, it's like those satellite views of a muddy river delta: colors swirling and unmixed. It could be beautiful if it weren't so threatening. Seems like some posts on trauma might be worth considering at this point...

Warning

OK, so several blogs have found this little ditty and posted their results. Here's mine:

Mingle² - Online Dating

Here's the best part:



So kids, ask mommie before coming here. Oops, I said "coming."

Maybe I'll just talk about tummies and bandaids. Boo-boos, I suppose, are out. Depending on punctuation.

One Spleen...

The above is snapped off a page of the book that might have saved my life. Well, no. But it kept my mind off self-pity when I was in the waning months of my tour of duty in Vietnam. Rather than attending only to that part of the world which was within three feet of me, I could ponder the power of the human mind; could hope the stories therein weren't just chemical aberrations. (Likely, of course, they were.)

The book is "Be Here Now," by Ram Dass, formerly Richard Alpert PhD, associate of Tim Leary at Harvard; tripper on and contemplater of LSD. A friend sent it (the book, not the pharmaceutical) to me while I was serving my time. (Cool fact: all you had to do with mail to and from Vietnam soldiers was write "free" on the corner, and it got where it was aimed. I hope that's still true for the troops and their families.) The volume is divided into three parts, one of which is actually readable. In the snippet to which I refer, Ram Dass describes his first meeting, in India, with the man who would become his guru. Along with "how was the cookie?" (guess you'd have to read it), "Spleen. She died of spleen" still brings a smile when I think of it....

* * * * * *

Soon after I arrived in my current location, I was sent a patient in need of splenectomy. Neither for the first time nor the last, the operation proceeded in such a way that I plopped the organ in a pan about five or seven minutes after laying knife to skin. "Wow," said the scrub nurse. "Wow," said the anesthesiologist, turning dials and scrambling for drugs. Thanks again, Vic, I said to myself, giving homage to my most influential teacher of technique. "The spleen is a mid line organ, Dockie," he used to say, as he harassed me into quickly loosening it from its attachments to the diaphragm and pulling it toward me.

The spleen, you may properly infer, has a special place in my heart. Under it, actually. And a little to the left. Despite Vic's surgically relevant aphorism.


It's nice to have a spleen, but you can live without it. Put simply (and I'm a simple guy) that red-mahogany and spongy organ does two unrelated things: it acts as a giant lymph node, and it filters out aging blood cells. Absent the spleen, those functions can get carried on elsewhere, and so it is that people who lose their spleen, either from injury or because of various blood disorders, generally have no occasion to miss it. But the world is imperfect, so the previous statement is not always true.

There is, in fact, an incidence of overwhelming and highly fatal infection in a small percentage of people who have been splenectomized; the good news is that the infections tend to be by organisms for which vaccinations are available. Those vaccines ought to be given in advance of a planned splenectomy, and soon after an unplanned one. And since infectious consequences seem more frequent in children, it's recommended by some (not universally, for various reasons) that kids who lose their spleens be given daily antibiotics for prophylaxis. Who, and how long: not agreed upon.

The greatest risk is within the first two years after splenectomy. Some people give antibiotics for that interval; others till age 21; some advocate it for life. Much of the data are muddled by the fact that people lose their spleens for differing reasons: when it's removed for hematological reasons, the long-term risks are probably higher, since those people have remaining underlying pathology. Splenectomy for trauma has a higher risk of infection at the time of surgery (in part, I think, because of concomitant injuries to other organs) but lower long-term, compared to hematologic patients. Still, there's no doubt there are some risks. The only case of overwhelming post-splenectomy sepsis I ever saw was in a person who'd had it for hairy-cell leukemia. Never in a person with trauma.

The other potentially adverse consequence of splenectomy can be turned into a good thing: it's common after the operation to note a rise in platelets, those little packets of clotting paraphernalia that float in the bloodstream. Too many, and there's a risk of thrombosis (clots when you don't want them); too few, and there's risk of spontaneous or prolonged bleeding. In the condition known as ITP, for "idiopathic thrombocytopenic purpura," in which the platelet (thrombocyte) count can get dangerously low, splenectomy may be curative. That was always my favorite situation in which to see a patient needing the surgery, because, under the right circumstances, there was a pretty good chance it would work out well.

Among people with ITP who require treatment, the mainstay drug is prednisone (as you can read in the above ITP link, there are others, too). It's those people in whom it works well that I liked to see; and if that sounds like the words of a knife-happy surgeon, hear me out. Steroids like prednisone can be very effective, but, depending on dose, they can have significant side-effects. Some lucky people with ITP get their drugs, respond well, and it's over. Others, though, either require prolonged treatment with high doses, or they get a good response but recur whenever the drugs are stopped.

At some point surgery becomes a consideration; and the good news is that response to drugs is quite a good predictor of response to surgery, which is why I liked to see those people. The news isn't as good -- the outcome much less certain -- when splenectomy is pursued as a last resort after all other treatments have failed.

In many cases when the platelet count is low in ITP, bleeding during or after surgery is not a great worry: the platelets that are present are young and sexy, and clotting is less affected than in other situations with comparably low platelet counts. Surgery proceeds apace, and it's rewarding to see the counts begin to rise immediately after surgery. In those more questionable situations -- very low counts with no response to medical treatment -- surgery is carried out with more drama: platelets at the ready in the OR, the splenic artery clamped as early as possible in the proceedings, after which the platelet infusion begins (the clamping keeps the new platelets from being gobbled by the spleen.) No five-minute job; great care is taken to avoid and to control the tiniest bleeders. I should also mention that it's not rare to have "accessory" spleens, little grape-oid items tucked in various abdominal locations, failing to locate and extirpate which can lead to recurrence of the disease. Mostly, they're close to the spleen, so the search tends not to require dogs and flushers.

Residing high in the left upper abdomen, attached to the colon and the stomach as well as to the pancreas, kissing the left kidney, not far from the adrenal and stuck to the diaphragm, the spleen is anatomically more daunting on paper than in the flesh. Unless the organ is really huge, operating is usually straightforward; and yes, it's even quite amenable to the laparoscopic approach (takes a lot longer than five minutes to get it in the bucket, though). I think it has the makings of at least one more post. And we haven't yet talked much about ruptured spleens...

Cold Comfort

I've never hugged a bear, but I'm glad there are bair huggers. Because there's one way in which I'm in major conflict with my patients: I like it cold in the OR. They need it warm. Like the dual-control electric blanket that may have saved my marriage, heating devices in the OR allow dichotomy; the patient can be kept toasty while the surgical folk remain cool. Cooler.

Anyone who's arrived in an operating room awake enough to recall the experience is likely to have noticed it was cool as the frost on a champagne glass (some may know the rest of that one...) "Yeah, we're trying to cut down on heating bills," I'd say when a patient mentioned it. But the fact is, it's personal: it gets darn hot under surgical gowns, especially the newer water-proof ones. Add a little stress, a little anxiety, and a warm room becomes destructively uncomfortable. Nor is sweating a good thing. Dramatic and surgeon-affirming as it may be to ask the nurse to wipe one's brow (I've done it many a time: I find it more embarrassing than off-getting), dropping a bead or two into a wound is poor form. Not that you'd think it necessary, but there have been studies. I've asked more times than I can count to cool a room down. Some ORs have a a sort of power-cool mode, which is like a gift from above. I don't think I've ever complained about a room being too cold: my idea of perfection is seeing the anesthesia person wearing an extra gown and a towel around the neck. Seeing their bare feet in a pan of hot water would likely elicit chills of joy.

Unfortunately, it's also true that letting a patient get cold in the OR is a bad thing. A common explanation for the icy room used to be that it reduces infection. But it's been well-shown that when a patient's core temperature drops, wound infection goes up. And when there's low humidity, there's more static electricity, which (theoretically) can lead to explosions with some of the anesthetic gases. Plus, it's said that particulate matter floats around more easily in dry air. So rooms are kept on the muggy side, making it feel warmer.

Blowing warm air through a flexible hose connected to a puffy air-blanket with holes in it, segmented sausages of soothing sunniness, the bair-hugger keeps people comfy. It was originally a total-body cover, laid on as soon as a patient made it into the recovery room (where people used to arrive, frequently, shivering.) Now there are ones shaped in such a way as to lay across the chest and arms, or the legs, with adhesive strips to keep them in place, and they're becoming almost universal in operating rooms. Perfect. Warm patient, cold surgeon. Crank up the cooler, Carly: I'm goin' in.

[Note: not only do I have no connection to bair-huggers or their company stock, I'm using the term generically, like "kleenex" or "xerox." I'm pretty sure there are other companies and names for similar items.]

Seeking Cover

Fully clad in black, she walked the hall toward my office carrying a cane but not using it, accompanied by a daughter and grand-daughter, the latter to be her translator, the former her guide. Clouded over and looking like ivory, her eyes were blind; her face worn and wrinkled, weary and severe; yet her posture was erect and her dignity so profound that I felt as if I were in a regal presence. Her family treated her with deferential honor, and it was clear that I was expected to do so as well. It wasn't hard. If I didn't, it seemed, I might be struck by lightning.

This part of the Pacific Northwest is a melting pot. Forty-seven languages are spoken in our school district. Every day, give or take, a new ethnic deli or exotic restaurant opens; I salivate thinking about them. My patient population included many with whom communication was difficult, if fascinating. (My middling Russian, po moyemu nye plokho, comes in handy.) This lady, it was made apparent, was to be referred to as "Persian," not Iranian. And she absolutely would not allow me to see or touch her skin.

With clear-cut lab and sonogram and a classic history, that her gallstones were the problem was not in doubt. I didn't feel bad about doing a no-frills physical exam (like a surgeon!), through her clothing. Explaining the situation, describing the needed surgery and its aftermath were the most important issues of the encounter. It would be necessary, I said, stating the obvious, that when it came to surgery there'd be a need for exposure and more intimate touching. As long as it all happened after she was asleep, she was OK with it. Reluctantly.

She arrived in the pre-op area garbed as the day we met, and remained so while wheeled into the OR, and as she went off to sleep. No one in the crew had a problem with it. In exposing her for the operation, I raised her clothing to above her ribs, while keeping her lower body covered with a blanket. My patented mini-gallbladder operation went quick and slick; on her post-op visit to my office her gratitude and satisfaction were indicated by her grand-daughter. I took her word for it: the lady's demeanor never changed, not a crack.

Recently I had a conversation via email and comments with a reader about body-exposure during surgery. It's an interesting topic. I think it's true that there's more recognition of the issue recently than there has been in the past, but as with much about surgery, there are no straight lines from thought A to thought B. There's more dissonance now when I see a completely naked body on the OR table than I felt in training. There are times when the visage has caused a lump in my throat and moist eyes. Frailty, total vulnerability, responsibility, honor, beauty, are words that come to mind when I consider it. Callousness? Crassness? I don't think so. Sexuality? Does that fall into the category of beauty? Perhaps. But what, more than the sight of a human being having laid him- or herself before you, naked and paralyzed, bespeaks the responsibility and trust a surgeon is given?

Finally, it's just "let's put on the paint and get to work." Been there, seen that. I know it's a concern for many people. Whereas I can't say that modesty and dignity are maintained at all times in all operating rooms, exposures are pretty universally met either with decorum or boredom. As long as it happens after going to sleep, is it OK?

I think I've always empathized with my patients, whatever the situation. Dress -- or lack thereof -- was a thing of unspoken concern, and I don't recall it ever being mentioned in training. It was matter-of-fact, job at hand, not an issue. Even then, though, I never uncovered any more than absolutely necessary, even after the patient was asleep. And I was always very careful in my office: I've never had people fully undress, usually waiting till the last minute to expose anything. Hernia: lower the pants, not remove them. Rectal exam: slide 'em down, keep 'em on, lay on your side. Given the number of women I saw with breast problems, and the time constraints of keeping the office running, I did have them put on vests before I formally met them (when I brought them into the room myself, I'd introduce myself, confirm a bit about why they were there, hand them the vest, then exit for a few moments.) The vests -- unfashionable as they may have been -- did allow the preservation of modesty.

I once recommended a surgeon to my dad, who went to see him for a pretty routine, minimalist sort of operation. The surgeon's nurse instructed my dad to strip completely and lie down on the exam table to wait for "doctor." When they first met, dad was totally naked and supine. Angry more than embarrassed, he never forgave that surgeon. Nor did I.

When I was in the military a fellow doc said he had a sure-fire way of dealing with a self-important officer who'd come in and try to pull rank. "Remove all your clothes, Colonel," he'd say. "I'll be back in a minute." Guess it cuts both ways.

Details, Details

Having posted most recently about those bad -- if lovely -- drug and equipment reps (also known as "detail" reps), wouldn't you know I'd work with one today? It reminds me there's another side of the coin.



There was a scandal a few years ago when it was made known that salespeople for orthopedic prosthetics (hips, I think it was) were actually doing major parts of some operations -- fitting and inserting the joints because the surgeons weren't familiar with them. I never have, and never would allow such a thing (nor is it allowed anywhere, anymore), but there are times I've welcomed such detail folk into the OR. Most of them know their products very well, and when there's some sort of new wrinkle, it's nice to have them around. Here's the likely scenario:

Joe's Surgical Supply and Auto Shop comes up with a variation on a stapling device. Or an electrocautery unit, an adhesive dressing. They contact the hospital, or surgery center, and gain permission to show up with their device. Most often, they're hanging out in the surgery lounge when I arrive to do an operation. Sometimes, their impending presence has been announced: next week the rep from JSS/AS will be here to demonstrate a new foofratz. I look it over. In the case of staplers, which are extremely handy in certain situations, and which are quite regularly improved in terms of ease of use or extra features, I'm more than open to the latest innovation. If the demo looks promising, I'll let the rep know when next I'd be doing an operation for which it could be appropriate. They're there early the day of the operation, usually bringing doughnuts or pizza for the nursing staff. Who'd begrudge that?

I know how to staple bowel and when to do it. I know the various techniques, the tricks, the danger zones. But with a new instrument, I may not know how the re-designed handle works, or how to get it to bend in the newly-invented way. So the rep is there, in the OR (with the patient's permission!), and when the time comes he or she can give some instructions. From the sidelines: NOT scrubbed in. It's helpful, and I don't see it as any sort of breach of propriety. Sometimes I find the new item is no better -- and/or more expensive -- than what I've been using. Other times, it turns out to have major advantages, in which case I'll tell the OR it'd be nice to have them available (which may or may not happen!) It's even transpired that, after input from me and many others, a rep will get ideas of how their product could be improved and will take those ideas back to the shop. It is, I think, a mutually good thing.

Rants about over-use of staplers aside, I think I've made it clear I find them very handy in several situations; and I've always been impressed at the brilliance of the latest advances and the speed with which they occur. Reading about it isn't enough to decide; nor is it necessary -- given the fact that it's a trickle as opposed to a sea-change -- to take a course in the use. Having a knowledgeable rep around is just right.

One of the coolest improvements in a common technology of recent vintage is the development of "spray" mode for electrocautery. Electrically zapping something that's bleeding is generally quick and effective (assuming it's not the sort of bleeding you can hear, in which case you better have a big clamp handy.) But there's a problem: until recently it was usually necessary to touch the end of the cautery "pencil" to the tissue being cooked; and that tends to create a sort of black gob of charcoal glue, such that when the grilling is over, pulling away the pencil can pull away the char, and bleeding resumes. That's especially true for liver or spleen. You may have to try to control the bleeding with suturing, but those organs don't hold a stitch all that well. So when a rep hanging around the lounge approached me with his unit (should I rephrase that?), I was interested. It's perfect for liver and spleen, he said, because when you set it to "spray" and hold it close to the target, a broad electric arc jumps from the device to the bleeding area without the need to touch the two together. By golly, I had a gallbladder operation to do that very day, and it's not rare that a little bleeding needs attention where the gallbladder comes off the liver. It did, I did, and it did. Fantastic device, and I was glad to have the rep there to show the nurses how to set it up. Been using it ever since. And by the time I was finished that first time, all the doughnuts were gone.

Bag Man

There's a recent post by Orac about the "'swag" given to docs by drug companies at medical meetings. It reminds me that when I was in med school, my class was -- far as I know -- the first ever to refuse the personalized black bags traditionally given to students by Eli Lilly Company. I was of two minds.

My consciousness was a little late in the raising. It hadn't yet occurred to me back then that there were issues with taking goodies from those guys. We were also in the midst of the Vietnam war, and my class was active in protests. I attended a meeting in which a moratorium on classes was being planned, for the purpose of war protest, and the dean -- a bullet-headed guy much admired by all -- burst in and, in his most gravelly of the graveliest of voices said "What we need is a moratorium on bullshit." So it was a transitional time; but things were beginning to dawn on me. (By graduation, I was one of only a few wearing a "peace-sign" armbands at the ceremony. Ironically, I'm pretty sure the only member of my class to serve in Vietnam was me. And I'm glad I did.)

I'm proud to say that when I went into practice I was -- until there evolved a like-minded clinic-wide policy -- one of the very few in a large clinic to refuse to see drug reps; nor did I -- despite the attraction of great restaurants and a the occasional gratuity -- attend dog and pony shows put on in the name of some new drug or another. (Truth: I went to one, and felt dirty.) But back then, I wanted the damn bag.

"Right on," I said, gritted teeth hidden behind a powerless pasted smile, signing on to the class-wide refusal. Fuck The Man. But I wanted the damn bag. I'd worked hard; med school was a goal sought and achieved, getting the MD sheepskin in one hand and a black bag engraved with "Sidney Schwab, MD" in the other was something I'd envisioned for a long time. Screw activism. Gimme the bag. In the end, of course, I didn't take it. There was always my grandmother...

During my internship there was a company hawking a very long IV catheter, to be inserted in the arm (a theoretically safer route than some others) and threaded far, to where it could be used to measure central venous pressure, or to provide high-calorie intravenous feedings. Today such tubes are routine, and work well. Then, there were problems with the first iterations: inflamed veins were nearly universal. At our weekly conferences, complications were regularly reported. But the rep.... the rep.... She was a beauty. We were (excepting the one female in my group) a bunch of overworked and underpleasured guys. Her blond hair, her sweet smell. Her lovely form, those welcoming, eager br.... (Sorry. My wife reads these posts...) Suffice it to say that whatever the latest problem, she had a way of sidling up and explaining it away and talking us into using the catheter again. And again. And oh yes, oh yesss, again. Standards? Yeah, I have 'em. But don't we all have a price?...

I Never Meta Blogger...

Just for the record, as I'm about ready once again to take up the gauntlet, let me describe the thought process, as I understand it, that led me temporarily up to dry:

I was raised among political junkies, and have always been one. My dad was on the Portland school board for three terms, was on the Oregon Supreme Court, the Court of Appeals, and headed a quite important commission to address race and education during the sixties, another to revise the Oregon constitution. In retirement, he was mayor of Cannon Beach. My aunt was on the Portland City Council, the planning commission, and the port commission. My brother was a US Senate page, rubs shoulders now with a number of politicos. Table-talk was always about Big Issues when I was growing up. Governors, Senators, Congressmen and Congresswomen came to dinner (and, I assure you, it decidedly wasn't about money!) (Phone call when I was a kid: "Is Herb there?" "Who shall I say is calling?" "It's the Gov!")

So "junkie" is perhaps too pejorative: it's important to me. Which of course means that the current state of affairs in the US and the world at best drives me crazy, and at worst depresses me to the point of immobility. Maybe the recent round of presidential "debates" was the last straw. Between the people who would be president, and the journalists who would cover them, I really don't see how anyone can but think we're well and truly doomed. "Raise your hand if you...." demands Wolf Blitzer. The only thing more pathetic than a "journalist" who thinks asking ANY question of that sort in that format, is the fact that none of the people called him on it. And that is, of course, the very least of it. So few candidates (I'm certain the root word is not "candid") are afraid to speak the truth; so many are unabashed at pandering. AND IT WORKS!!!

It's not that I'm out of surgeon-blogging ideas. I've started typing a few. But of late there's a why bother? reflex. Can I ignore the things I think are cataclysmically important, and write instead about adhesions? And then, to some extent anyway, I figured it out.

First of all, getting 1200 page views a day is a cosmically, monumentally, minuscule slice of the populace. More than that, any political rants of mine will (I know this because I spend lots of time reading and occasionally commenting on political blogs) NOT change a single mind or alter the trajectory on which we find ourselves, despite the fact that there are some things I consider so obvious that it baffles, befuddles, and be-depresses me that anyone could disagree. Some that are so important I can't imagine why people aren't out in the streets with pitchforks and torches; or at least -- like me -- constantly frothing at the mouth.

On the other hand, small as my readership may be, I have heard from people. I've heard from some who've been sick, or family of the sick; they've told me that something I wrote helped them to understand, calmed a fear, gave them hope. I've heard from high school and college students, from med students that said they read something here which inspired them to consider medicine, or surgery (or not to, which, I suppose, is equally as useful). And I've heard from people who got a good laugh; what can be better than that? So I concluded: whereas spouting off on politics might be cathartic, it won't do a damn thing except change the whole point of this blog and piss off and/or turn away a bunch of readers -- many of whom are from all over the world.

To hold my tongue in this venue is not to abdicate my political beliefs; I have other avenues. Nevertheless, as deeply as I feel about our current political world -- as angry and frustrated as I am about where we seem to be headed and as pessimistic as I am about prospects for recovery, it's damn hard to think about anything else....

There's a certain self-absorption in all blogging, it seems to me. I don't spend a lot of time thinking about why I do it. But it's interesting that while I stopped doing anything but posting a couple of rebuses (rebi?; reberi?; rebusim?), page views continued approximately apace. Lots of people end up here because they've searched a topic; the blog pops up in the top ten -- sometimes numero uno -- of a million hits on some google searches for a few fairly common surgical topics. It's not outlandish, in other words, to think that microscopic as it may be, there's a purpose here; there's usefulness. Were I blogging in the political sphere, that would absolutely, unarguably be untrue. I have at least some claim to credibility medically, and none politically. Alas.

So I think I'm again ready. And whereas I'm certain no one was out there nubbing their fingertips awaiting it, I've allowed myself this small indulgence of an explanation before climbing back on. The world is driving me nuts. But, not unlike picking up a knife and laying it to human flesh, I can shut everything else out when I have to.

P.S: It delights me when I get suggestions for future posts.

P.P.S: OK. I can't resist this one political comment: couple of days ago (well after writing the above), I heard an interview with Rufus Wainwright. Asked about his often politically-charged music, he commented in a way I'd not heard it put: people are in mourning; he wants to help them grieve. That struck a chord. Speaking out in these times is not about hating any leaders, nor is it -- contrary to some of the more popular sloganeering -- about misunderstanding the conflict we're in. It's about grieving loss. Of respect, of the rule of law, of the moral high ground. Of reason, of discourse. Of people who disagree with one another being able to seek common ground for the common good.

It's about remembering a time when a plurality of people didn't argue that only those with certain religious beliefs had a claim on rectitude; and that having those beliefs absolved one of the need to face facts. You don't grieve from hate. It comes from love lost. That's something, I'd like to think, on which most people could agree.

And with that, I pledge to return to first principles: this is a surgery blog, and so it will remain.

Get Ready

Update

I'm Sure It's Temporary

Operation; Epilogue: post op ergo propter op

A reader suggested that after finishing my long-winded description of an operation, it would be interesting to see how it all would look in a typical operative report ("op note.") I like it!

It is said -- and I happen to agree wholeheartedly -- that op notes ought to be dictated immediately, else the content stales likes a bagel. I was pretty fanatical about doing so; nothing bugs me more (OK, lots of things bug me more) than being told by medical records that I'm delinquent on a dictation. ANY dictation; but particularly op reports, because I always did them instantly. Usually I'd write with a flourish that I HAD dictated and give the date. It was not entirely rare that they insisted it wasn't anywhere, so I'd go to my office and find the copy that I'd already received, and tell them if they'd send me a self-addressed stamped envelope and a dime, I'd copy and send it. But that's neither here nor there. (Usually, though, it WAS there.)

To me a good op note is succinct and stripped of irrelevant data. Surgeons read lots of them, because we like to know what went on inside someone who's fallen into our care after prior surgery. It's amazing. Some people tell you their shoe size, what soap they used on their hands, every sort of instrument they used. "Metzenbaum scissors were used to cut... Sutures were tagged with Kelley clamps..." Who cares? I want to know what was found, what was done in enough detail to predict what I'm likely to find. "The patient was brought into the operating room... (check that.... the operating suite!)" As opposed to what? Operating in the hall?

I sit at a desk in recovery; or if the patient is taking a while to awaken, I grab the phone in the OR and bend it into the corridor, punch in the numbers for the dictation system, the campus, an op note. There are numbers for start/stop, repeat, back up, etc; I never learned them. Blast on through fast as I think someone can transcribe, giving spelling when necessary, and punctuation. I heard a lecture once given by a guy who'd just finished dictating a bunch of charts. He kept saying to the audience things like "Hello comma I'm Dr Jones period. I'd like to talk to you today comma and I'll leave time at the end for questions period.... Sorry exclamation point."

This is Doctor Sidney Schwab dictating operative report on Blah (bee ell ay aich) Blah (bee ell ay aich).
Date 5/14/07 to 6/1/07.
Assistant: Joanie.
Preop diagnosis: diverticulitis.
Postop diagnosis: same.
Operation: Sigmoid Colectomy.
Indication: recurring episodes of diverticulitis.

Findings: The mid-sigmoid was indurated and thickened and contained multiple diverticula. It was stuck laterally to the pelvic sidewall. A couple of loops of small bowel were stuck to it medially. There was no evidence of perforation or abscess. The uterus and ovaries were normal.

Description: After induction of general anesthesia the abdomen was prepped with one-percent iodine and draped sterilely. A lower midline incision was made and the peritoneal cavity was entered without difficulty. Wound edges were covered with moist laps and a retractor was placed. The sigmoid was mobilized off the pelvic sidewall with blunt and sharp dissection, and the small bowel was mobilized sharply without enterotomy. A portion of tissue remaining on the pelvic wall was removed sharply and sent for frozen section. Bleeding was controlled with cautery. Packs were placed to expose the operative field. Sites for division were selected and cleared of fat. The peritoneal reflection was incised laterally and within the pelvis to achieve adequate mobility. Mesentery was divided using clips and vicryl ties. The field was covered with betadine-soaked pads. Bowel clamps were placed and the bowel was divided sharply and the specimen was removed. Bowel ends were wiped with betadine. An open end-to-end anastomosis was accomplished using interrupted 4-0 silk and running 3-0 vicryl. There was excellent circulation to both sides of the anastomosis, absence of tension, and wide patency to palpation. Mesentery was closed with running 3-0 vicryl. Packs were removed and the field was copiously irrigated with dilute betadine solution. After final inspection for bleeding, peritoneum was closed with 0-vicryl, wound was further irrigated with betadine solution, infiltrated with quarter percent marcaine plain. [note: I used to use it with epinephrine, which lasts a bit longer; but I use so much that I don't want any confusion: if the patient has tachycardia, I want to know it's not from the local] Fascia was closed with number one vicryl running. Skin was closed with a few interrupted subcuticular 4-0 vicryl followed by steri-strips. Sterile bandage was applied and the patient was brought to the recovery room in stable condition.

Complications: none

Estimated blood loss: negligible

Specimen to pathology: sigmoid colon and biopsy of pelvic sidewall. Endofdictationthankyou.

Operation, Deconstructed. Nine: finish line

Truth be told, sewing up holds no magic for me, other than the fact that in some cases it's a time to breathe a sigh of relief. (A main attraction of neck surgery is that once the fun's over, closing happens in the blink of an eye.) Still, it's not a time to stop paying attention. As in all aspects of an operation, there are dangers, and there are ways to screw it up. On the other hand, keeping your eye on the ball doesn't preclude a little relaxation. With very little encouragement (most often, without any at all) I'm liable to launch into my repertoire of Gilbert and Sullivan or Rogers and Hammerstein. I can do most of the parts in "HMS Pinafore," and a truly show-stopping "Pore Jud is Daid," keeping it up until the circulator, sighing with force that could break bricks, marches over and turns up the radio.

The anesthesiologist has a tough job: ideally, the abdominal muscles are fully relaxed (paralyzed) for closure, because it keeps the patient from pushing the guts into the wound, and it makes approximation of those muscles much easier. And yet it's also nice to see the patient fully able to breathe by the time the bandage goes on. Some are better at it than others; and surgeons make it harder by being unpredictable. Not me, of course. Today, it's one of the good ones; while I sew perfectly limp muscles, he tells me about his latest attempt to electrocute squirrels. Been reading about Ben Franklin, made a model of his capacitor or some damn thing.

Closing the peritoneum -- the freeing of which on the way in I described a couple of weeks ago (has it been that long?) -- helps. Not everyone does it. In addition to holding the insides in during the rest of the closure, it allows thorough irrigation of the incision with that nice brown solution I used in the belly. I place a couple of large and tough clamps on the edge of the muscle (the fascia -- the halves of the linea alba I divided when making the initial incision), at about the mid-point of the incision. Joanie lifts them up and together with one hand, and with the other elevates a small retractor I've placed at the apex of the wound. That's hard work (although it's good for the pecs) so it helps to be fast. I run a whip-stitch down the peritoneum, and give her a break while I wash out the wound. It's at this point that I infiltrate, generously, with long-acting local anesthetic: the peritoneum, above and below the muscle on both sides, just below the skin.

Having been trained -- as were we all back then -- to close the muscle layer with interrupted (individual, one at a time) sutures, of non-dissolving material, it took overcoming many voices in my head to switch to a running suture made of stuff that goes away in a few months. But it's better in every way, starting with taking less time, passing through less pain, and ending with better healing. Studies confirm it. I strongly believe in taking large bites, well away from the edge and widely spaced. Choking off the wound with too many sutures, placed too closely, and pulled too tight means more pain and less healing. You couldn't break #1 vicryl if you tried; I use it on a big honkin' needle, grab it and the fascia with monster Russian forceps, and it comes together as it should. When the bowel is distended or when there are other reasons why it's hard to keep things inside when closing, there are various tools you can slide under the muscle while the sutures are placed. What you don't want to do is forget to remove them before you finish:



The scrub and the circulator are pointing at piles of sponges and counting them together. "Seven, eight, nine, ten.... seven, eight, nine...." They rustle around. The scrub reaches up and picks at the drapes near my belly. "You missing a sponge? What kind? I know there's nothing inside... A four-by-eight? You got all the laps? The only four-by-eights were on the sponge sticks and I gave 'em all back to you..." I start looking around as well: under the table, lift up my shoes, peek under the drapes as far as I can without contaminating the field. Shit. Am I going to have to re-open? "Here it is! It was in a lap..." Most of the time, the counts are correct. When not, invariably the missing sponge or needle gets found somewhere outside of the patient. Twice, I think, I've actually had to reopen and have dug one out. Huge thanks to the nurses, abject embarrassment. Never have I left one in and taken the patient to the recovery room. I wouldn't like that.

My skin closure consists of a few fine interrupted sutures under the skin, followed by steri-strips. It's quick, cosmetically nice, and people can shower in a day or two. The only downside is the strips sometimes look a little bloody; but any disapproval of that is more than made up by the happy realization that there're no stitches to remove. Skin staples, plainly, suck. I put on the smallest bandage possible, believing that big ones are too scary.

I hang around to help move the patient onto the gurney; in fact, I usually go into the hall to get it, grab a roller on the way past where it's leaning against the wall, slide it onto the gurney while steering. Pump the gurney up to table height, roll the patient away, slide the roller under, then glide the patient onto the gurney, roll her the other way, remove the roller. "Thanks, everybody. See you in a few minutes."

When I have a line-up of cases, I head first to pre-op to talk to the next patient. Then to the family waiting area to talk about the just-finished case; then to the recovery room to have a look at my patient, write orders, dictate the op note. I always talk to the awakening patient, giving some good vibes, even though without exception, they never remember the conversation. If it's the A-team in the OR, by the time I'm done the next patient is ready to go into the room. The layout is such that I can see when the gurney is on the go. Usually, though, it's not that efficient. Stewing and brewing in the lounge while things happen too slowly for me... In this case, I have to run down to the ER to see what's going on with that acute abdomen they called about. I let the desk know I might have an add-on. And I guess I'll check to see if Carol ever got ahold of Dr. Smith...

I walk into the spacious surgery waiting room. Groups of families and friends have staked out their spots with pillows, books, blankets; couple of kids running around, TV on too loud. Heads turn expectantly, then look away, disappointed, when they see it's not their surgeon. I look for familiar faces, the volunteer at the desk helpfully nods toward the corner. Striding over, green-clad, I'm not unaware of the drama, the reading of my face as I approach. I give a smile and a thumbs-up before I'm in earshot. "She's fine, she's in the recovery room, everything went great." Getting the important stuff out right away, watching the tension dissipate, people visibly relax. "It was just as we expected, diverticulitis; everything went fine. I think she's gonna be really happy we did this. Did some of my best work... (Wait for the laugh.) She'll be in recovery give or take an hour and a half. They usually don't let visitors in there, but they'll let you know when she's heading to her room. Anybody have any questions?..." We talk a while more and, yes, I have to say I drink in the gratitude, the relief, the optimism. The sense of accomplishment. If that weren't part of it, what would be the point?

As I get up to leave, something occurs to me: "Oh, by the way, I realize I said it'd only take an hour or so, and it's been three weeks. Hope it didn't worry you...."

"It's OK doc," her husband says. "Blogging's a bitch."