Ugly as Hell

I've been asked it a lot: what does cancer look like? The questions don't usually refer to the microscopic view, of which the above is a good example: big and dark and variable size and shape of vacuolated nuclei, discohesive, not much cytoplasm. People want to know what I see when operating.

Our apprehension of beauty has much to do, I'd guess, with the expected physical attraction to our own form. Smooth and supple, graceful curves. (Is there anything more lovely than the female breast?) And if most people are repelled by the sight of viscera -- as well they might be, spilled in some tragedy -- the essence of that beauty is still there. Our innards have the same characteristics: glistening smooth surfaces, slippery, fine edges, gentle transitions. Those organs that are solid have a cushiony firmness: there's give, there's welcome. And their shades are of the earth: ruddy, fall colors, comfortable ones, like autumn leaves, sleepy and warm.

Cancer is many things, but it's none of those. Arising as it does in every different organ, it has varied forms. It's not one shape or size or color or even texture (although mostly it's hard as bleached bone); but without fail it's ugly. Ugly as hell. And I don't think it's just because of what it signifies, or because of the hollow hole it forms in the gut of the surgeon who sees it where s/he didn't expect it. It's because of what it does to that sculptural perfection. Cancer is Lazlo Toth to the Pieta.* It's warplanes to a rice paddy.** Like a gnarly claw, cancer grabs tender tissues and pulls them toward itself. It distorts and discolors; it pocks, it kinks, it bends and it cracks. As it insinuates inward and hauls back, it transforms the sensuous and the smooth and the curvaceous into the discontinuous, the asymmetrical, the knobby, the pustular, the sudden. When you see it, you know it; when you touch it, there's no mistaking.

In the liver, cancer is a pallid and spidery pucker. The normally purplish smooth surface is studded with gray and hard nodules which, when below ground, pull inward and form jagged depressions. When originating elsewhere, the liver lumps are round but imperfect, like a dirty snowball. In bowel, when advanced and at its worst, cancer glues itself to surrounding structures, dragging them in like a vortex: other loops of bowel, omentum, all tugged and knotted together radially, like arms reaching in desperation out of a whirlpool. Inside, on the inner surface, it rises like an eruption, up-heaved and rolled edges, cratered down in the center, stealing the red and making it into a mucoid leer. Sometimes, as it outgrows its blood supply, cancer putrefies in its core, conferring the sensation of rotten fruit. Usually, though, it's hard in a way that our tissues are not: there's no give, none of the fluid turgidity that feels like life.

Of course, it does have meaning beyond mere sensation, and that is part of the perception. It's not possible to recognize cancer without being impacted by its portent; and that most certainly confers much of its repulsiveness. To operate with intent to cure, and to find those unmistakable signs that it's gone beyond is to have sorrow become physical and palpable. There's no way to count the times I've examined a woman with a lump in her breast and known with near certainty within a second of laying on my hand. In that moment, for me anyway, it's not possible to pretend. I know what's inside: that spiculated gristle, gritty and hard, pus-colored. If there's time, we'll be okay. But it's still ugly as hell.



*An artistically blindered science major, I stopped in Rome on my way to a research summer in Yugoslavia, during medical school. A friend of my family -- a priest, later a bishop -- happened to be there, and took me on a personal tour of the Vatican. Seeing the Pieta was stunning, broadening. That a person could have wrought such beauty from a piece of rock... I detoured to Florence just to see more of Michelangelo's work. And it was not very long after I was there that Lazlo Toth -- whose name has stayed with me ever since -- wreaked his destruction.

**I saw that, too.

The Key

The best thing about having written a book is hearing from people who read it. At the top of that list is the friendship I've established with JB, who trained at the same place I did, UCSF, about ten years ahead of me. I'd never met him (still haven't, other than via many emails), but I'd heard stories: like Hawkeye Pierce, he got away with some memorable stuff there because he was a really good surgeon. He was also a surgeon in Vietnam, where he ran an Army trauma unit; and he's done a little writing. He's lived an extraordinary life; in the words of a mutual friend, he's "the real deal." I'm honored that he contacted me. And his feelings about the place where we became surgeons are a lot like mine.

Readers of my book will know that a central character is that classic county hospital, San Francisco General Hospital, and the trauma center within it, Mission Emergency Hospital. Maybe the source of the phrase "brick shithouse," the place was memorable in countless ways. First and foremost was the building itself. Decades old, made of brick adorned incongruously with a sort of Gothic roofline and containing unexpected marble floors and carved wood banisters, "The County" -- as we called it -- served most of the destitute of the City-by-the-Bay, and provided trauma care to everyone of all walks of life, housing them in open wards, providing the most modern of care in the most ancient of settings. Containing surgical amphitheaters from the days of surgeons operating in suits in front of an open audience, in more recent times, just preceding my arrival, it had also been the living set of famous movies. Becoming Chief Resident on the Trauma Service was the pinnacle of years of training: the top of a steep and tall pyramid, the most demanding, the most exciting, the most responsible job there was. Having looked with awe at those chiefs as a lowly intern, working slowly and exhaustingly toward the goal over many years, finally finding oneself in that role was magical. Unbelievable. Both daunting and exhilarating. And you lived in a cool place. Deservedly, since being Chief Trauma Resident meant staying in the hospital, instantly available round the clock for sixty days straight.

It wasn't much, really, by most standards. Off a dark hallway on the second floor of the hospital was a small bedroom just large enough for a single cot and a bedside table, outside of which was a larger room where the senior residents slept (the trauma service consisted of two teams which alternated twenty-four hour shifts -- plus time required for joint rounds and finishing of work; more like thirty-plus hours on and twelve-plus off -- each headed by a senior resident, with a single chief of both teams, who stayed put.) Big enough to house the occasional liver rounds, that outer room also contained a chair or two, a bookcase, and a display of various items that had been extracted, over the years, from the recti of many clients... Despite being sparse and bare-walled, it was a cool place, if for no other reasons than throughout the hospital only the Chief Resident of the Trauma Service had access to such a room; and that so many generations of surgeons had occupied it, including some pretty big names in American surgery. When I moved in, I was very aware of the river of history that flowed through that suite and was deeply humbled by it. A storied nook in a fabled place. And I was the last ever to occupy it.

For much of the time I was there, a new hospital was being built -- modern, sterile, with private rooms, narrow corridors with none of those great and gloried ghosts walking them. It was while I was Chief Resident that the work was finished, and the move to the new facility made. (I did the first operation in the new operating room, it having been very important to the Chief of Surgery that the trauma team do so.) All we had for sleeping in the new place was an unused patient room, devoid of all that history. And having vacated, they took the wrecking ball to the old brick house. It put up a good fight; took much longer than had been planned, so sturdily constructed it was. (As opposed to the new place, wherein holes were punched into walls by door-handles within days of opening.)

I wrote about the mysteries of the old County in my book, and of the sense of loss as I moved out. JB read it and, because he'd felt the same way about that place, he wrote to me. He told me stories of many of the characters in my book, and said how much he'd loved reading mine. And he said he had a gift for me, something he'd had for many years and with which he'd always felt there'd come a time when he'd know what to do. Unaware of its impending ignoble end a decade later, he occupied that Chief Resident room with a sense of devotion and awe like mine, and when he left, he'd kept a little piece of it, which lay for forty years in a dresser drawer. He read my book, he retrieved the memento, made for it a proper repository, and gave it to me. A most wonderful thing. It is this:





Thanks, JB.

[Update, 2012: turns out the key isn't what I thought. In fact, I have no idea what it's for. I remembered the chief resident room was room 320, lovingly called "The 320 Club." It's all poetically appropriate, since it's turned out JB wasn't who I thought he was, either; namely, a true friend. But that's a long and sorry story, not worth repeating yet another time.]

Off Center

The latest in the never-ending quest to define quality medical care is the designation of "Centers of Excellence." It's a grand goal. In theory, it sounds like just the thing to help consumers find their way to the best of care. Going to a COE (as folks are wont to abbreviate them) ought to give one a great deal of confidence; and from what I know there's truth to the idea. If you go to a COE, it's not likely the care you receive will completely totally suck.

I'm not naïve; nor, I'm pretty sure, are you. It ought to surprise no one that the criteria for qualifying as a COE are generally imperfect, sometimes political, and not always central to uncovering what is, in fact, excellent care. I say this as a person no longer directly affected by such things, one who has worked in some pretty excellent places and who has delivered (yes, yes) occasional aliquots of excellent care; but whose time in practice pre-dated being in a position to be so designated, or not. So I carry no grudges, bear no wounds, have no need for excuses. An observer only, I'm still working enough to see, from within, the workings of the process; enough, I think, to make comments based on experience. Thumbnail version: hypo-impressed.

For one thing, like a lot of other awards -- or like the boxing world last time I paid any attention -- there are lots of agencies and organizations handing out hardware; not only different ones for different types of care, but even within a given field. (And, of course, they charge for it. Some more than others.) Can't get one? Get another. Criteria? Variable. In addition -- as is true universally for such things -- it boils down, to a very large extent, to the filling of various boxes, the ticking off of a checklist, which may or may not reveal what really goes on in the delivery of care. Evaluators show up with a list of demands, such as having protocols printed out and available for review, folders with the credentials of participants, plans for gathering data. All of which can be assessed with feet up, smoking a cigar, sipping a nice port. (Nothing changes: when I was in the military our facility was evaluated regularly by any number of inspectors general from any number of command levels. It was always and only about buffing up the paperwork, period.) The depth of penetration, as it were, can depend on the individual with the clipboard, what kind of day they had, who knows whom. Meanwhile, the actual rendering of care, in the flesh -- because that's hard to measure and to evaluate on any meaningful and reproducible basis -- may get overlooked entirely or looked at only in the most superficial ways. Many have spoken up about inadequacies and inanities of the current P4P efforts ("pay for performance," ie tying reimbursement to the meeting of certain criteria).

I tread light-footed. As one neither directly affected by nor intimately involved in the details of the process, I don't want to say more than I know; nor, because of my once-removed level of insight, do I want to cast specific aspersions on specific institutions, neither the purveyors nor the receivers of evaluations. But in places with which I have at least a passing acquaintance and from organizations of which I have at least passing knowledge, I've seen COE designations received or withheld without any obvious correlation the the care people are actually receiving. In both directions: COE awarded to programs of questionable quality, denied to ones providing superb care because of some sort of bookkeeping glitch, and vice of all the versas. Moreover, since in some settings the COE designation is given to a program in a hospital and not to the physicians, all doctors who provide that particular care inside those walls can claim the mantle, no matter on which end of the spectrum they may fall, excellentologically. And spectra there are.

The implications are great: not only is it important that the title of COE has meaning for people seeking care, there are trends toward insurers not paying for care rendered in a non-certificated place. So it is behoovenized that the process is meaningful. And here's the reason I bring it up now: A place at which I sometimes work recently was designated a COE, in a field of care with which I have familiarity. They'd previously been denied, having mostly to do with which three-ring binders were lying where. At its best, the care in question is indeed excellent. The difference in that care, comparing pre- and post-certification, in terms of the work going on where the latex meets the playtex, is zero. And the first time I worked there after the COE was announced, the scheduled OR crew consisted of people mostly unfamiliar with the work being done, necessitating the standing around at several points in the proceedings, while the proper instruments and equipment were scouted out. The outcome was fine, the patients as expected did well. But whatever that kind of support is -- adequate, satisfactory, safe, good enough -- it's not excellent. I'm just saying.

Bringing Down The House

OK, I realize that in the order of things this is really small stuff. But I must have my say. Having watched (why, oh why do I persist?) "House, MD" last night, I conclude that if they ever had medical advisers, they must all have been fired, quit, or -- more likely -- committed suicide.

There was the usual leitmotif of erroneous diagnosis, treating for some disease and discovering another. There was the added sub-plot of women too old to do it, running around wearing thongs, or no underwear at all. (The import being too ridiculous to elaborate.) And the ducklings (what are they? residents?) as usual are doing things that no medical people would be doing: operating MRI machines, and drugging their mentor and biopsying several body parts. (What drugs can do that, by the way? Is there something you could put in coffee that would knock a person out cold in three minutes -- is there such a drug at all, let alone one that wouldn't be tasted?)

But the final straw was seeing Dr House once again barge into an operating room, hatless, maskless, gowned and gloved. The only way you can get gowned and gloved is if the scrub nurse helps you (ain't no sterile stuff like that sitting around outside the OR, at least not readily available), and no nurse would allow it. Not to mention the surgeons standing by dumbly while the guy reaches into their patient and pulls out a key in two seconds. Like Jack Horner. Like the surgeons were too dumb to have... Sigh.

It's not that I should care. But since reality is driving me crazy of late, it'd be nice if a simple attempt at escapism didn't make me want to slit my throat.

The Groening of Weight Loss Surgery

The parents of Matt Groening, creator of the Simpsons, were friends of my parents. It might interest his fans to know, if they don't already, that his parents' names are Homer and Marge. Several years ago, my mom got Marge Groening to finagle a favor from Matt: he sent our son, on his birthday, several items of wittily signed simpsonalia, along with a couple of original drawings of Bart offering greetings, relating, as I recall, to a cow. This does not keep me from criticizing Mr. Groening on surgical matters.

On the most recent Simpsons episode, which I watched with my usual devotion, Homer underwent weight-loss surgery. During the pre-operative meeting with the surgeon he was told about "gastric bypass surgery," but the explanation, complete with diagram, was of placing a band around the stomach. There's a lot of misunderstanding out there.

Before I became a blogger, I spent some time voluntarily answering medical questions on a couple of online medical fora. Weight loss surgery, I discovered, is a little like religion. Criticize gastric bypass in favor of lap-band, and expect serious flaming. When I predicted that, as the word got out, lap-band would replace gastric bypass as the procedure of choice, personal epithets were flung far, fast, and furious, as if I'd said Osama bin Laden ought to be president. The fact is that when most people think of bariatric surgery, gastric bypass is what comes to mind; and to date, it's what most have had (although the teeter is tottering). Good branding. Like MP3 player = iPod. But iPods don't kill 1.5% - 3% of their owners within days of purchase.

Disclosure: to the extent that I'm still a surgeon, it's only as a participant in the laparoscopic placement of lap-bands. Further disclosure: they pay me by the hour. Got no dog in the fight. Statement: if I were going to have a weight loss operation (and, depending on where I am on the sine-wave of my devotion to cycling and other factors, it's not inconceivable) there's no doubt I'd have the lap band. Why? Cheaper, safer, faster, doable as an outpatient procedure, quicker recovery, equal weight loss in the long run. More disclosure: not even all bariatric surgeons would agree with what I just said -- mainly the last phrase.

It's a strange world. Until pretty recently, those insurers who covered bariatric surgery (not many, for a long time) only paid for bypass, despite significantly higher initial cost and much more frequent (and very dangerous -- not to mention expensive) complications. In part, they claimed it was because (despite much world-wide experience with tens of thousands of patients) they considered the band "experimental." Cynical me: I think it's really because they figured that in covering only the more expensive and more dangerous operation, fewer people would choose to have it. Short sighted? Surprised?

Ain't no free (small) lunch. The main downside of lap band, as I see it, is that it affords less of having and eating your cake. Bypass works in significant measure by causing malabsorption of food. Stuff passes through. Although that often leads to diarrhea and nutritional problems for which the typical patient must take lots of supplements (as opposed to the typical band patient who needs none), some people are attracted to it because they may not be as restricted on intake. With a band, you can't eat as much, and you may need to give up certain things, like bread. On the other hand, a high percentage of people with a band in place find their appetite is wiped away like spilled crumbs in a white tablecloth restaurant. And there's this: the best results are with programs that are comprehensive and provide ongoing support. Some surgeons, of course, don't like that; which, I think, accounts for the disagreement amongst them. Cut and run, is what they prefer, and that's what they can more easily do with bypass patients. The people with whom I work set a very high standard of continuous followup.

Adjustability is another attraction of the band. There's a small "port" placed under the skin into which fluid can be injected, which fills a balloon on the inside of the ring. You can make it tighter or looser, depending on a patient's needs. Women who'd had trouble conceiving a baby while fat may get pregnant when thin, and need a little more room to eat for two. No problem.

Since there's none of the cutting of bowel and stomach that happens with bypass, there's practically no incidence of leakage or serious immediate surgical problems. Mortality rate is much lower (for the group with which I work, it's one (last I heard) in about three thousand.) The most irksome problem with the band is an incidence of "slip," wherein too much stomach ends up above the band, often requiring reöperation to reposition it. I think it's generally a misnomer, because in most cases it's not that the band has slipped, but that the originally small portion of stomach above the band has become stretched and dilated; which nearly always happens in people who go off the reservation, meaning people who force in too much food and end up vomiting a lot. Technical issues that might also be a factor are slowly being investigated and placement techniques have changed, which has lowered the incidence. That, of course, says that not all the problems are related to patient coöperation. (Love that ¨ thing, since I discovered how to do it recently.)

So. If you're like me and you get most of what you know about the world from watching the Simpsons, be of good cheer. As long as there are people around to correct the (very rare) occasional divergence from reality, you can keep watching with confidence. The internet is a wonderful thing.

Snakes On A Pan

A very nice lady (and, one infers, an excellent doctor) who sutures for a living asked me a question which reminded me of a good story.

Rarely seen nowadays, there was a time when super-long intestinal tubes were used to treat certain conditions of the bowel; particularly in a person with many prior obstructions in whom reöperation was undesirable. Snoogled through the nose and into the stomach, these tubes had bags of mercury on the end (for its heaviness and loogilability, allowing passage) and were fifteen feet or more (guessing) long. The idea was that once in the stomach, the muscular action of the gut (peristalsis) would drag the bag and the tube downstream to the point of obstruction, decompressing it by sucking out the backed-up juices, and allowing unkinking; maybe by eventually working its way past the blockage. Sometimes it actually worked.

Having passed the tube, often over regurgitive objections, and having had the patient lie for hours on his/her right side so the bag would drop into the duodenum (which heads to the right out of the stomach), it would occasionally occur that the tube -- draped in some way by the bed and hung to allow unravelling -- would take on a life of its own and begin disappearing into the person in question, slower than but not unlike a baited line that had been glugged by a fish. (After many years of use, studies were done which showed no difference in non-operative success using these tubes as opposed to the much more hassle-free ones that just went into the stomach. Which is why you don't see them much any more, except in museums.)

It's one of those stories you hear: not actually witnessed, but told by unimpeachable sources. I think it happened where I trained, when I was there. A woman had been treated with such a tube, and it had passed as hoped. She seemed to be improving: belly decompressing, cramps gone. But suddenly one day things took a turn. Her urine output dropped and the amount of drainage from the tube began to climb -- signs of recurrent obstruction. With diminished urine output, it could mean even more dire things. IV fluids were increased, labs were checked, and on paper at least things didn't seem scary. But the upped drainage and downed urination continued, flummoxing her caregivers and frustrating the patient. Until observation solved the mystery.

The long tube had passed through the lady's entire intestinal tract, and was hanging out her rectum. When she sat on a bedpan to pee, it sucked the urine up and away, draining into the bucket for collecting intestinal juices, turning her fluid accounting upside down.

Let's ignore a couple of obvious questions and just agree: it's a great story.

Veins and Ducts

Inside a vein, it's always perfect. No matter the state of the rest of the body, when you open a vein and look inside it's smooth and shiny and slippery. The inner wall glistens and lavishes the eye with a creamy-khaki surface. Not that it's common to get into one on purpose: but for things as minor as a cut-down (directly opening a vein to insert a large IV), or as major as a portal-vein decompression (a finger-in-the-dike procedure to stave off the effects of cirrhosis), the lumen of a vein seems impervious to the ravages going on around it. It's like pushing through an old house stacked full of garbage, and finding a tiny closet, empty and clean, floor all waxed and sparkling. A private, preserved space, kept pristine for secret reasons. (Arteries, not so much.)

The bile duct is like that, too, if a little less certainly. When there's obstruction with infection, it can get red and thick, the inner surface knobbly and cobbled. Mostly, though, it's a similar wonder: clean and crisp and sparkling on the inside. There's something about these vessels and ducts that foster their own brand of amazement. Springy and soft, yet turgid and tough. Sewing a vein, unlike anything else, (as long as it's not during a mad rescue attempt) is almost meditative. It's quiet; maybe because the suture is finer, the instruments more delicate than with other kinds. And because it demands the perfection of needlepoint: even bites, close, careful and exact. There's rubbery resistance to the needle which gives way with a little recoil. There's no tissue quite like it. If creating, say, an arteriovenous fistula for dialysis, or if sewing a vein-patch onto an artery, you go through the vein first with the needle, and the textural difference is clear. Sometimes, you hold the slender suture between thumb and index finger of one hand, gently tugging upward to tent and approximate the edges, while suturing with the other. Very gently. The vein is more plastic, thinner, versatile. And, always, cleaner. When you release flow, the vein bulges, and holds.

Sometimes, it's the same with a bile duct: you might be closing a hole, sewing edge to edge. More often it's to make a connection between duct and bowel, and the two couldn't be more different. (Well, yes, they could. But if they were, you probably couldn't connect them at all.) Then, it's more of a puzzle: getting together two things of entirely different thickness and texture, one of gross and separating layers and another of imperceptible ones. It's a challenge and has its own rewards, but not the quiet kind that veins provide.

A vein, laid open but stilled of flow. A silky surface even when lying next to corporeal corruption. It's not a big thing, really; but seeing it time and again, is somehow reassuring. A signal that things might be made right. If one place in this person is still okay, maybe the rest can still get there.

No Alternative

The world seems to be losing its collective mind, so it shouldn't be surprising that even vaunted medical schools are making "alternative medicine" part of their curricula. Several bloggers have been and are doing a fine job of venting; I come late to the party. (For the record, it's my view that in swallowing the pill, these schools and other hospitals are in it for the marketing. Which is more cynical than the therapies they're touting.)

Many years ago I watched, drop-jawed, the television commercial of a local chiropractor as he stood by a couch-full of young kids. Recommending monthly preventative adjustments for these four- to six-year-olds, he touted the obvious benefits: look how healthy they are. Not, he seemed to imply, a heart attack among them. Nary a stroke. Probably not even a case of colon cancer. And I wondered: is he stupid enough to believe or is he simply a cynical and dishonest charlatan? I got a partial answer a few months later when a woman arrived in the emergency department, acutely paraplegic. Her chiropractor had continued manipulating her increasing and unresponsive back pain until she became paralyzed. The "doctor" must have known about her history of breast cancer, because he was also her husband.

Until that time, because the theory behind chiropractic is so obviously loony, I'd assumed practitioners all knew it and were simply crooks who'd found a surefire way to separate the credulous from their money. (And yes, I acknowledge that manipulation has a place in certain specific anatomic disorders of the back itself. But using it to treat or prevent systemic disease is nothing but laughable. Except that it's not funny.) Stupid, careless, lacking judgment: yes, the man must have been all that. But unless he hated his wife, I had to conclude he believed in what he was doing.

I still haven't figured it out, and I'm sure I never will. Of what do the cerebral lacunae consist in these people? How can (some) otherwise intelligent people (givers and takers) become convinced of the efficacy of whatever woo they wish? Is truth just too hard to take? At some primordial level, is it just that we need to believe in silly stuff? What is it about humankind that pines for magic, for simplicity, for answers that pave over the painful? Why isn't inquisitiveness universal; doesn't skepticism confer survival benefit? Or would we all be jumping off cliffs if we didn't have mythology? Maybe that's it. Maybe too many skeptics have already jumped.

The frailty, the neediness of the human brain, when stacked against the obvious power of it -- the ability to create, to invent, to inquire -- is a probative paradox. It may be a stretch to write my way from anger about alternatives and chafing at chiropractic, to the death of skeptics and skepticism, but in my mind it's of a piece. I have a friend, a brilliant physician and much more of a scientist than most, who tells me he knows, based on his particular faith, exactly into which level of heaven he will enter; as if he's already done a mapquest search and downloaded the directions. Given that there are about six billion people on the planet who believe something else, and with just as much certainty, I find it amazing. And revelatory. It's a need. It's built in. It's human.

My conclusion is that the desire to believe in certain unprovable things at one time was good for us: when the dangers in the world were mostly external -- volcanoes and saber-tooth tigers -- and the need to organize and stay together was clear, supernatural beliefs were of obvious benefit. And now, as society has gotten impossibly complex, and the dangers are mostly human-generated, it's become a detriment. Rather than helping mankind to cleave together and help one another, magical beliefs -- whether on couches or in the clouds -- are causing us to fall upon one another in hate, in fear, in the unreason that comes from a mind blown by the awful realities we have brought upon ourselves.

Magical thinking is who we are, I guess. If it were only that it serves to enrich some at the expense of others, maybe even make some people feel better, what the hell. If they're only hurting themselves, or the willingly deceived, should I let it go? But they are hurting people, and it's pretty clear that eventually it will hurt me. When I see this mainstreaming of stupid, I can't keep myself from thinking of the other side of the same coin: people flying into buildings, blaming hurricanes on gays, invading the wrong countries, laughing as we pee in the pool. The need for crazy-stupid is great; if straws they be, still grasp at them we must. We've gone from flivvers to Ferraris in a sigh and a gasp; from Kitty Hawk fields to the seas of the moon in the eye of a bat; Allan Pinkerton's shoes to spies in the skies: the power of scientific method is obvious to the most casual glance. Yet despite -- or is it because of -- the amazing progress we've seen at the hands of science in less than a lifetime, people willfully and seemingly in increasing numbers simply ignore it at their convenience. Need to ignore it. Demand to ignore it. Demand that I ignore it.

I don't think you should get to pick and choose. Don't believe in evolution? OK, then don't get on an airplane. Earth is twelve thousand years old? Fine. Take back your laptop. Homeopathy makes sense to you? No problem. Put down that cellphone, never avail yourself of GPS. Because if man and dinosaur occupied the same space and the same time, if carbon-dating is bogus, atomic clocks don't work and transplants are impossible. If vaccines cause autism, Rovers aren't on Mars and nothing will happen when I push the button to post this.

I Could Clean Up

The medblogosphere is sizzling with talk of medical woo, which has got me thinking about the next big thing. People are already spending billions on bottled water, and now on vitamin-packed, herbal, performance-enhanced waters. And on quackery? Uncountable. So how to cash in on gullibility, desire for effortless improvement, universal needs, and credulity when it comes to pseudoscience and health alternatives? I may have it.

Here's the science: ano-rectal tissues absorb medications pretty decently. Anti-nausea suppositories are quite useful for some post-op patients, or puking people. And I'm a doctor. The "pseudo?" Turning it into gold. Or, in this case, brown gold.

So. Toilet paper, the perfect vehicle. Haven't decided whether to make it homeopathic (advantage: no need for any additives) or "natural." It could be infused with, oh, any of a zillion choices. Combined. Why stop there? I could claim ("these statements haven't been confirmed by the FDA...") an infusion of natural derivatives that integrate with and chemo-analyze feces and, depending on what toxins are present, transform into the proper natural substance which is then absorbed via your most delicate membranes (which happen to have special immune powers due to their critical location, as anyone could naturally infer) in exactly the right mixture to restore the body's proper balance. Straightens bent shakras, directs qi into the perfect meridian, which superluxes the spine. And it's soft and gentle.

I'm working on the advertising campaign;









Still needs work.

Que Ball, Side Pocket

Newer-vintage cardiologists are quite capable of independent play, but there was a time when I put in lots of pacemakers. Originally that meant doing the entire procedure, and back then the devices were enormous. Heavy, clunky, grapefruit-sized (if the sour sweetie were squeezed more flat than one might see in the supermarket [but think how stackable they'd be]), the battery/pulse generator required some work to implant. Producing under the skin a pocket large enough to receive the beast was a job for one with at least a modicum of surgical skill. And I'd thread and properly locate the pacing wire as well; the first iterations thereof were stiff and therefore fairly easy to direct, which carried a corollary danger of poking all the way through the ventricle. Never did it. Heard about it. (It could work its way through much later, as well.)

Gone the way of Univac, those giant items have evolved impressively; current (huh huh, current) pacers are tiny and complex, capable of speeding up when physical activity increases, of being interrogated by telephone, adjusted non-operatively. Many of them pace both chambers of the heart. Wiggly wires have replaced the rigid ones. Safer. And harder to position.

To the newbie go the onerous jobs. By the time I came to town, cardiologists were placing the wires for pacemakers, but they still wanted surgeons to make the pockets. Some of them also liked to cede the poking of the subclavian vein. Nor were they comfortable with the production of a thorough local anesthetic. So for the typical two-team job, I'd meet the patient for the first time in pre-op, introduce myself as the pocketmeister, prep and drape, inject local anesthetic, and make an incision through the skin, which I'd deepen to the chest wall and then, with my fingers, nooger a space big enough to fit the battery. In some cases, I'd also slide a guide-wire into the vein. On a good day, that whole thing would take five minutes. On a bad day, six. And then, I'd stand. Because when the electrode was safe and sound, I had to hook the wires to the box, insert it into the pocket, and sew it up. Took about two minutes. Tried. How I tried to get them to learn to do it; that thumb-in-ass standing around was a gargantuan waste of time.

Many factors dictate the ease and speed with which the wire placement occurs. Certainly, skill of the cardiologist ranks well above the bottom of the list. I worked with several, and one of them usually drove me nuts. Not only did he frequently show up late ("communication problems" with the OR), so did the pacemaker rep, who brought the requested device ("communication problems" with the office). Not rarely, the wrong kind had been ordered ("communication problems" with the doctor). To the extent that I could plan my time around these procedures, it made a big difference whether one or two leads were to be placed. Plans, with this guy, were fantasy.

He was actually very nice. Reminded me of Mr. Rogers. Which, of course, made it even harder: how do you explode at someone who always smiles? But it was forever the same. Head-hurting delays while everyone showed up and the right equipment was assembled. Doing my five-minute thing and then, in the case of this person, invariably standing around for a looonnnggg time while he got the wires where he wanted them. A loooooonnnnngggggg time. How long? Let me tell you.

On one occasion I had injudiciously (optimistically. Necessarily, because of patient needs) scheduled a mastectomy to be done after completing the pacemaker procedure (on another patient, if that wasn't clear, in another room.) I figured the first job at an hour and a half, as I recall. As the time to start the mastectomy approached with no end in sight to the first case, I got increasingly annoyed. I'm pacing, the machine is not. My assistant arrived (the able Joanie, RNFA, mentioned in my book and here). My own patient was foundering in the pre-pre-op area. Finally, I could stand it no more. (I've written about how much I hate being late.) I had Joanie -- more than capable of stitching -- wait for the cardiologist, managed to wangle another nurse to help me, and had them send for my patient. When she arrived in pre-op, I left Dr. Mrrogers, greeted my patient, talked to her and her family, escorted her to the OR, made ready to and performed a modified radical mastectomy, applied bandages, helped move her to the gurney, went to the waiting room to talk again to her family, came back to write orders and speak with my patient, returned to the pacemaker room, excused Joanie, waited another half-hour or so, and sewed up the pocket.





And the picture is...

Once More, With Peeling

(Last year, several readers took advantage of an offer so generous, so irresistible, that it was nearly unparalleled in the history of book-selling. Since I was never in it for the money, and since I'm nearing the level of sales that will bump my royalties up close to the price of a stamp, I'm going to do it again.)

It occurs to me that my book makes a wonderful gift -- and 'tis the season. Here's how you can give it to your most favorite person in the world (actually, I'm guessing you have dozens of favorite people in the world) with a personalized inscription, signed by me:

If you email me with a name and any sort of inscription request you have (within broadly interpreted rules of decency), I'll personally write and sign it on a nice adhesive panel you can stick onto the front page of your book (that's it at the top of this post.) And I'll even pay the postage (which, as far as I can tell, is about equal to the royalty I'd get on the book). (I say that because I haven't heard from the publisher in a while...) Include in the email your postal address, which I promise I'll trash as soon as I mail your inscription, and will use it for no other purpose. Email me at sid dot schwab at gmail dot com (or, my profile at the right has a direct link) and title it "book inscription" or something even more clever.

Walk of Life

[It's another testament to the universality of rock and roll that the lyrics of the title-referenced song make mention of a "song about a knife." And may I add that when presenting my biology honors thesis in college, the subject of which was intra-allelic recombination in the Ruby Eye locus of D. Melanogaster, the results of my inquiry into which were sorta surprising, I made another musical reference. "The fact," I said, "that Ray Charles, when he sang 'They say, Ruby you're like a dream, not always what you seem,' predicted the very results I am about to reveal says much not only about Mr. Charles in particular but about popular music in general." So we have a pattern here. And I'll just assume that everyone recognizes the picture.]

During the planning stages of the surgery center in the creation of which I was a proud participant, it came to be revealed that we'd be having the patients walk into the OR under their own power. No gurneys, no wheelchairs. You walk, we'll carry the IV bag (or wait till you're in there to start it.) Being well into my career by that time, and having worked in a few previous surgery centers -- not to mention oodles of ORs of the olden ouvre -- I was surprised. Weirded out, even. Likewise, I figured, our prospective patients. On several levels, I was wrong. It is, after all, ambulatory surgery.

Outpatient surgery is all about the "out." To wake up quickly, and to be clear-headed when doing so, the less extraneous drugs the better. Sedation of the pre-op variety can add to time in the recovery room. If you're marching, you're not medicated. There's more to it, though. Walking to the OR sends a homey message: it's like coming into someone's house. Hi there, welcome. I'm Cindy, and this is Jane. It's unthreatening; there's some retention of control, of doing instead of being done to. And best of all, it gives those veins in the legs a final squeeze at the best time: right before lying motionless for a while and going all thrombogenic.

In medicine, involving, as it does, humans, nothing is 100%. The stroll is not for everyone. Some people, medically or emotionally, need that sedation going in. And to make it a tolerable trek, you need to attend to certain potential gaps in coverage. Still, I rapidly came around to liking everything about walking to the room. And with a nice robe, a few smiles on arrival, and a quick and comfortable exit, it's my perception that the patients did, too. I can't count how many times I heard from patients on their post-op visit, within a couple of words of verbatim, "I never thought I'd say this about having surgery, but that was a wonderful experience." A great facility and a superb staff had, of course, much to do with it (as did receiving a perfect operation!) But the walk, I think, played a part. And the rose petals we strewed along the path.

Selling Out

So I got invited to blog for money. Truth be told, I'd not heard of MedPage Today before the offer came along. Even though it amounts more to tribute than treasure, I said yes. My tat for their tit is to have placed a new scrolling news-widget in my sidebar, over there to the right. And I've agreed that although it's OK to post stuff from here over there, I'll be writing some "exclusive" posts as well. I assume it's OK to let readers here know when I've dropped one there. So, other than a post of self-introduction, here's my first offering.

Funny how it works. This comes at a time when I've been feeling like I've squeezed my blogging brain pretty dry. Given a contractual commitment, I'm worried about giving this blog -- my one true love -- short shrift. We'll see. It could be the end of me in both places. Poetic justice.