Tuesday, February 27, 2007

Stuck in the Middle

Seem to be in a pattern here: post about something bad in the OR, then something cool. Here's another bad thing, based on a bad thing. Then maybe I'll get off it for a while.

Getting stuck with a needle has never been fun, even before it could be fatal. I've had my share. Converted my hepatitis titer while I was in San Francisco, though I never got sick. If nothing else, sometimes it hurts like hell, right in the middle of a case. Methods to prevent getting nailed are in the category of the desirable. Great minds attend to it. Less than great minds appear to be the ones, so far, to have come up with solutions:

And I couldn't even find a picture of the worst offender: probably got sold just before the sales force slunk out of town. The "safety" part looks like the back leg of a grasshopper, as it slides up and down the needle. Where I work, the hospital bought it by the pantload.

Anyhow, the point is this: laudable as the concept might be, the "safety needles" I've seen and used to date are anything but. Cumbersome, clumsy, and complicated to use, they interfere with the underlying purpose; namely, to inject stuff. Trying to fill up the muscle with local anesthetic through a small incision is all but impossible. So, at least in the operations I'm involved in now, we cut the damn sleeves off, defeating the entire purpose. The good news is that in doing so, we are actually making the procedure safer. The hospital recently completed a study: since the advent of the particular needle used in these parts, needle sticks in operating room personnel have gone UP!!!! Is anyone surprised?

Work-flow. Ergonomics. Energy expenditure: not my bag except in figuring out how to do what I do. But my two-cents worth says: the more complicated the system aimed at simplifying things, the more opposite from effective it is. The more people have to manipulate things in order to make their manipulations safer, the unsafer they get. Paying attention is really all it takes. However: I already admitted to my share of pokes. So, whaddya gonna do? Screwed. Either way.

Monday, February 26, 2007

Very Cool

Let's see if I can describe something. The scrub nurse for the case I was doing this morning has a very cool move he uses to hand us the towel for drying our hands. For comparison, the typical method is simply to open it up and hand it over, or drape it on an out-stretched hand. Efficient, classic really, but hardly noteworthy. This guy, he folds it into thirds length-wise, then rolls it up like a sleeping-bag or a jelly-roll. Holding the roll in his palm, he secures the end with his thumb, the rolled side up and facing away. This he's done while we're outside washing, and he's all ready when we walk in. A flick of the wrist, and the towel arcs toward us like a frog's tongue at a fly, like a back-hand yo-yo trick, the formerly inner end landing in our hands, after which he lets go of his end. I think had we both been ready, he'd have been able to do a simultaneous two-handed toss. He says he's been working on it for a while. Were I more blogompetant, I'd take a video and stick it here. It's one for the ages.

Saturday, February 24, 2007


It happens sometimes: finished with a suture, you pass it back to the scrub-nurse, the needle contained in the jaws of the instrument, less than carefully locked. In placing it down on the sterile tray (the Mayo stand), you might see the needle spring up as if alive, arcing across the table to land an impressive distance away, on the floor. Or they get laid down momentarily on the drapes; or transferred by hand, holding the thread, only to have it slip away. Needles, in other words, sometimes find their way out of the field and into the ethers. Incorrect needle counts being anathema, adding precious (and expensive) minutes to operating time, forcing several people to devote annoying amounts of time in the search, occasionally even requiring reopening of incisions, you'd think thought would be given to making the hunt as easy as possible. So why do the designers of operating rooms so often come up with Jackson Pollack patterns on the linoleum; and why do hospitals buy it?

Only a few days ago I was reminded of it again, as I was asked where the needle was that I'd just instrument-laid in front of the nurse. As I've done many hundreds of times, I'd pulled it out of a laparoscopy port without giving it any particular thought. Automatic move. But somehow she hadn't received it. Could I say for sure I'd watched it all the way to the point of release? Well, no. Yet there was no reason to think I'd fluffed it, left it inside, and I was sure I hadn't. (If you grasp a suture in the wrong part of the jaws of some instruments, the grip is flimsy, and withdrawing it through the port provides enough resistance to brush it off.) I looked at the floor near me, and noticed that ridiculous surface, designed, I guess, to allow people to ignore sweeping their kitchens too often: hides dirt like a miracle. Leave the lettuce, Lucy. Won't show till it blots out the whole damn pattern.

Going through the litany of look-sees, finding no needle, we had no choice but to re-scope the entire abdomen, and, finding nothing while continuously updated on the fruitless search around the room, we called for Xray to be sure that needle was nowhere within our patient. As certain as I was, I couldn't be certain. No needle. Satisfied as we could be, we returned to sewing up, the meter running. At some point, an eagle-eyed nurse found the needle, lying invisibly within the curled and multi-colored linoleum lines. It couldn't have been harder to see if the pattern were of millions of surgical needles.

So tell me: what would be wrong with a single-color floor, chosen specifically for its ability to highlight a wayward needle? It's a damn operating room, ferchrissakes! Doesn't a dirt-hiding floor seem a little out of place?

Thursday, February 22, 2007

a dusty trunk and a cardboard box

Ten days before I was born, my father died. Three and a half years earlier, my mom had been a twenty-one year old bride, excited and optimistic, proud of marrying the brilliant young physician whose given name I bear, and whose family name is my middle. I know he was brilliant because over the years I've heard it from many of his former colleagues and patients, and because when he married he'd just finished work as Chief Medical Resident at Johns Hopkins Hospital. At that time, the position was highly selective and much sought: the plumbest of the plumbs.

We're at our family home on the Oregon coast again, and my wife and I have been rummaging through old stuff, the contents of a trunk hiding in plain sight for many years. In it we found my mom's first bridal book (she married my adoptive dad when I was young enough that I have no real recollection of being fatherless. Their marriage lasted nearly sixty years, till my dad's death a little over a year ago.) Reading it for the first time is like re-reading a tragedy, knowing the ending: all the happiness, the smiling people, the florid and joy-filled notes vouching their certainty of the couple's future. Lists of gifts, with check-marks after each, denoting proper acknowledgment. Dozens of telegrams: congratulations and love. Stop. A dime-store booth-photo of the happy couple; a picture from the "society section" of the paper, showing Mom in a flowing gown, wearing a bonnet made from her mother-in-law's wedding dress. Perfectly preserved, there's an announcement of the opening of my father's office in the Medical Arts Building -- still standing in downtown Portland -- for the practice of "internal medicine and diagnosis," under which, in my mom's hand, is the breathless exclamation "the first of these went to me!!" It's easy to relate to the nervous anticipation of opening a medical office after all those years of study. But I know how the story turns out: none of them do. It's heartbreaking.

When I applied to colleges I indicated "pre-law" as my probable direction, but treading non-flammable bridges, when I got there, I took all the pre-med courses I'd need. During my first summer back at home, my mom brought out a box of letters and cards she'd gotten when my father died. They were from friends, colleagues, and patients, all with pretty much the same sentiments: a tragic loss, a brilliant career cut short, a young widow with two babies (my brother, a year-and-a-half at the time). Many made mention of the continuity of life: his death, my birth. That box (along with a nascent realization that I liked labs more than libraries) had much to do with my eventual decision in favor of a career in medicine.

My father died after an operation. He developed thyroid storm -- feared and frequently fatal in those days, virtually unknown now with the advent of greater understanding and better drugs -- the prevention of which was the purpose of the operation in the first place. I've done that operation many times for the same condition -- here's what I said about my first, in my book:

I’m no shrink. I’d given no thought to the factors that made me choose medicine, and then surgery, and then the kind that did thyroid operations, until I found myself doing the very operation that had killed my father, having made the simple preparations that would have saved him. As I entered the OR, I wondered: would it be a B-movie moment, a zoom-in on my sweaty brow as I froze up, the nurse looking worried, asking, “Is something wrong, doctor?” It didn’t happen. The operation flowed like any other. Had it been a way of meeting the man I never knew, and who never knew me? Of symbolically saving his life, while the quest saved my own? A meeting of souls in the ether, as it were? I’ve thought about it a lot since then. I like the idea, but I’m pretty sure the answer is no.

Looking through these precious things, I think maybe I was a little flip in the book. I wish I'd known him. He looks a lot like my brother and little like me, but I think I got his sense of humor. The last thing my mom remembers hearing from him, as he went off to surgery, is "You look really cute. I think I'll keep you pregnant all the time."

Tuesday, February 20, 2007

Beating The Spread

If I could actually accomplish something with this blog, I'd like to put one notion forever to rest (I'm reminded of it by a commenter on a recent post.) There's an all-too-common conception out there; pernicious and pervasive, untrue as it can be, it's scared many prospective surgery patients nearly to death. In some cases, in believing it, it has quite literally done so. I've written the occasional humorous post: about this I'm deadly serious, so I'll say it very clearly:

Surgery does NOT cause curable cancer to spread.

I've heard the thought expressed a million times, and I have no doubt that every other surgeon has as well. "Doctor," they'll say, earnestly, fearfully, directly. "I heard that surgery makes cancer spread. Soon as they open your belly, when the air gets to it, it goes all over the place, and you die. I'm really scared to have an operation." Who wouldn't be, having heard such a thing? I think I know where it comes from: as with, I'd suppose, some other superstitions, there's a kernel of truth.

I've been there: operating with the intention of doing a curative (or at least durably palliative) cancer operation, only to find, entirely unexpected, that the cancer is widely spread throughout the abdomen. Sometimes the only option is to close up, accomplishing nothing. And surgery which doesn't do good is, by definition, bad. The effects of anesthesia, the demands of healing are, by themselves, adverse. So it's reasonable to think that the angle of decline could be made steeper by an operation that produces nothing positive, in the context of already far-advanced cancer. But it's not that surgery spread the cancer; nor that exposing it to air had an adverse effect. It's that it was too far gone at the time of the operation. Sadly, it happens. Even when palliation is attempted, it's not always as long-lasting as we'd have hoped. The stories, I think, are born of this.

When asked the question -- which I was, frequently -- I pointed out that everyone who's ever been cured of cancer -- and there are millions of them -- began with an operation. No cancer is treated without first being diagnosed in a laboratory, and that means, at minimum, getting a surgical sample for analysis. In most cases, it means an operation to extirpate the tumor. So clearly, surgery doesn't cause cancer to spread like wildfire: were that the case, there'd never have been a cure. Ever. Because virtually every cancer patient has had some sort of operation, often a major one, right at the start.

In approaching cancer, we are as far from the ideal as one can imagine. The day will come -- I'm certain of it -- when treatments will be devised based on a specific tumor -- quite possibly each individual one -- and which will attack only the cancer cells, leaving everything else undamaged. Radiation and chemo, if they exist at all, will be highly targeted and specific. The inklings are here already. Surgery, when needed, will be much more minimal than now; what we do currently will be considered, in a few decades, barbaric. But it does work. We all know people who've been cured, brutal as it may have been. I know lots of them, intimately.

Take it from me, who has been fortunate to have done many hundreds of curative cancer operations: when the timing is right, surgery works. If it happens to you, get yourself a surgeon and oncologist you trust, find out everything you need to know to get comfortable, and go for it. I want you around, so you can keep reading my blog.

Sunday, February 18, 2007

God of the Appendix: Of Truth And Worms

[OK, here I go, stepping off a cliff. Can't say why I want to, exactly. ]

Of Design and Darwin, the appendix speaks to me. With my finger through a hole in the abdominal wall, I sense it, and at two in the morning it tells the truth.

In the appendix, we have a thing within us of no demonstrable value, but which is capable of doing us great harm. People may argue at the edges, but there are two things we know with central certainty: the presence of the appendix kills a lot of people or makes them real sick, and its absence is of absolutely no consequence. Evidently, that's a threat to the concept of intelligent design/creationism, and in a sort of endearingly weak effort, Ken Ham, a major ID guru, once tried to explain it away. Believe it away. Faith it away.

If you take a position in matters of science, says I, you need to keep at least one hand on the fact wall at all times; otherwise, you fall down. So whereas I'm not the first to address the appendix as religious icon, I'm only aware of a couple of people talking about it who've held a thousand or so in their hands. That's concrete: I assert my credibility. (The article to which I linked above has a reference to an article by a surgeon. It's from the same website, "Answers in Genesis," and is impaction-full of the same sort of pseudoscientific assertions. The author is an evolution denier and a creationist.) In the human body there's no other structure of any importance that feels and looks like a silly noodle, and which varies in people from a little stub to several inches long. (I hear one of you thinking something, and you should be ashamed of yourself.) I've removed a bunch of 'em, and I (nor anyone else) have never seen an adverse consequence of appendiceal non-existence. But I've seen a hell of a lot of carnage from appendicitis.

Here are examples of the arguments about appendicoloid importance in the article I cited.

"Today, the appendix is recognized as a highly specialized organ with a rich blood supply. This is not what we would expect from a degenerate, useless structure."

Highly specialized? As defined how? Recognized by whom? He offers as proof of the appendix's function, a statement that the appendix has function; lacking are any actual studies. And it hardly has a rich blood supply. It does have blood, alright: it's alive. But rich? The stomach has a rich blood supply: it's fed by several arteries, coming at it from all directions. You can hardly kill the thing. The appendix? A single artery, the bare minimum, I'd say.

"The appendix contains a high concentration of lymphoid follicles. These are highly specialized structures which are a part of the immune system. The clue to the appendix’s function is found in its strategic position right where the small bowel meets the large bowel or colon. The colon is loaded with bacteria which are useful there, but which must be kept away from other areas such as the small bowel and the bloodstream."

Like most of the intestinal tract, the appendix has lymphoid tissue. Which in and of itself proves nothing. Take out the appendiceal lymph tissue, it might cover the nail of your pinkie. From the rest of the GI tract, you could haul it away in a bucket. Nor is its location a "clue," absent any data to support the assertion. Mr. Ham shovels us an implication that the appendix has something to do with keeping bugs out of the bloodstream: a statement only, with no proof, no studies. A theory perhaps? To the contrary: take out an appendix and poof: no bugs in the bloodstream. Appendicitis, on the other hand, seeds the bloodstream with bugs in many a victim. Bacteria in the small bowel? Plenty of 'em, especially right next to the appendix. He implies the appendix keeps them out. It's simply silly to say such things.

"Through the cells in these lymphoid follicles, and the antibodies they make, the appendix is ‘involved in the control of which essential bacteria come to reside in the caecum and colon in neonatal life’. Like the very important thymus gland in our chest, it is likely that the appendix plays its major role in early childhood. It is also probably involved in helping the body recognize early in life that certain foodstuffs, bacterially derived substances, and even some of the body’s own gut enzymes, need to be tolerated and not seen as ‘foreign’ substances needing attack."

The quote within the quote is from the surgeon's treatise, on the same website -- so in effect, the article quotes itself. Again, an assertion, made up out of whole cloth. Not a demonstration, not an even an attempt. Why? No evidence. Couple of scientific words. He goes on to say the appendix is "probably" like the thymus. Probably? How so? PROBABLY?? What kind of science is that? We know a great deal about the thymus' function in early life. Removal in infancy has significant consequences, demonstrably. Removal of the appendix in infancy has none that have ever been shown. In fact, it's in infancy that the appendix is most deadly: because appendicitis is harder to diagnose in a babe, rupture before discovery is more common at that age than in older people. If I'd had a magic way to remove it from my newborn son, I'd have done it. But here's the best stuff:

"But if it has a function, why can it be removed without ill effects?

Our body has been brilliantly designed, with plenty in reserve, and the ability for some organs to take over the function of others. Thus there are a number of organs which everybody agrees have a definite function, but we can still cope without them. Some examples:

*Your gall bladder has a definite function—it stores bile from the liver, and squirts it into the intestine as required to help with the digestion of fat. However, it can be removed and the body will cope—for instance, by secreting more bile continuously.
*You can cope with having a kidney out, because there is still enough kidney tissue left in the other one. (In the same way, a part of the Gut Associated Lymphoid Tissue, which includes the appendix, can be removed, and the remaining lymphoid tissue will usually be enough to carry on the total function). You won’t suffer from having your thymus out (if you’re an adult), because this extremely important gland, which ‘educates’ your immune cells when you are very young, is then no longer required. This is likely to be very relevant to the appendix."

Yipes. Except for the appendix, there's no organ out with which we can do without some chance of problems. Removing the gallbladder, while tolerated by most people, is associated with known and specific problems in a number of patients. It even has a name: post-cholecystectomy syndrome. He might have mentioned the spleen: you can live without it. But there are known risks: increased chance of blood clots, and increased susceptibility to certain life-threatening infections. Without flim-flam, we know the exact functions of these organs. The kidney analogy is so self-evidently stupid as to require no comment at all. And the "likely to be very relevant to the appendix" statement pretty much speaks for itself: another assertion ex cathedra. Because the appendix threatens his world-view, he's making stuff up: no function has ever been demonstrated, and no adverse consequence of its absence has ever been shown. There's no other organ about which it can be said. Face it, guys: the appendix is useless. (I mean it no offense. After all, it's put bread on my table.) That's just what the facts are: the sun rises in the East, and the appendix is useless. Assimilate it.

The study I cited most often to my patients when asked about adverse consequences of appendectomy is one done by the Mayo Clinic: they studied records of thousands of patients who'd had appendectomy, and compared them with equal thousands who hadn't. (Back in the day, it was very common during any abdominal operation to remove the appendix. Like flicking a bug off your shoulder. No extra charge: just did it to prevent further problems: took an extra couple of minutes, is all.) The groups were statistically similar in every way other than presence of the worm. There were no differences in incidence of any disease. It's as convincing as it gets, given the impossibility of doing a prospective double-blind study.

That the appendix has no unique or physiologically important function is as certain as it can be, based on what we can easily observe. I know it from direct observation, from operating countless times. Maybe if it weren't for us surgeons saving fertile people from their vermiformera, the little rascals would be gone by now. But the existence of a vestigial organ which, when it does anything at all, only does harm, is a threat to certain narrow religious views. Vestigial bespeaks evolution, so let's make something up. I find that interesting. And I find the attempts to will it away amusing. If you don't like certain facts, make up some new ones. If the facts don't fit your faith, change the facts. That sort of thinking has been known to start wars. And it gives faith a bad name.

By its existence, the lowly and useless appendix would seem to deal a fatal blow to the idea (at least Ken Ham's version) of Intelligent Design. Slain, by that ignoble worm, that surgeons'sidekick, my midnight mistress. If you deny evolution, then you have to say the designer wasn't paying attention, says the appendix to my scalpel; or the designer acted deliberately to stick within us something which serves only to harm. Even more scary. Unless, of course, you're a general surgeon.

Addendum: a study in Sweden found an increase in Crohn's disease after appendectomy (we're talking very small numbers here). What's not clear is whether we're seeing chicken or egg: ie, is it that people who will develop Crohn's are more susceptible to appendicitis, or does appendectomy somehow increase susceptibility to Crohns? Interestingly, appendectomy has been associated with a lower incidence of ulcerative colitis. And appendectomy before age ten, in this study, seemed to have no impact at all. To me, that suggests that the Crohn's link, if real, is indeed that Crohn's disposition is causing the appendicitis in that small subset of people. In other words, as you get more toward the age when Crohn's occurs, you'll see more of the connection. If appendectomy caused Crohn's, you'd expect the effect to show in the young kids as they grew up. Or at least I would.

[Update, 8/09]: In another (and quite unrelated) thread I've been asked about this study, which argues that the appendix could function as a sort of storehouse to replenish bacteria in the gut. In fact, it's an interesting speculation, but is no more than that. Also, it states that appendicitis is due to defect of some sort in the immune system -- made with no data to confirm. The study makes plausible extrapolations from the evidence that the appendix has evolved at least twice in certain animal lines. To leap from that to the idea that there must be a function in humans, and to propose without evidence what that function might be is hardly dispositive. The fact remains that in many studies of the appendectomized among us, no real evidence has emerged of a negative impact. Not at a rate that is very suggestive. And the paragraph above this suggests if there are effects, they about cancel each other out. Given the numbers of appendectomies done around the world, it's logical to think something would have shown by now. Nor does the study in this paragraph give credence in ANY way to the out-of-the-orifice statements of Ken Ham.]

Friday, February 16, 2007

On My Honor

So I received this thing in the mail the other day. Nearly threw it out along with the rest of the junk, but it was shaped like and had the heft of a possible CD of some sort, so I opened it.

"Congratulations!" it grinned (or was it a wink?) "Your listing in the "Guide to America's Top Surgeons" is most impressive. You are among a select few..... Accomplishments like yours should be displayed proudly...." It went on to provide me with a number of options for flaunting my inclusion, from nicely framed, personalized and plaqued, to etched in glass. (Sadly, none carved in stone; but one of the glass panes is a proud erection on a faux marble base.) $149 to about $229.

Included was a single small blue-tinted page, about four times the size of a post-it, evidently from the people who produce the actual book. "Consumers' Research Council of America is pleased to announce your inclusion in.... [that thing in the previous paragraph], 2007 Edition.... The selection is based on a point value system that awards points for education, years in practice, affiliations with professional associations and board certifications. No fees, sponsorships, donations or advertising are accepted from physicians, medical treatment facilities or hospitals to insure an unbiased selection." Mind you, this is inserted into the high-gloss fold-out display of my showcase options, handy ordering form included. It (the blue page) ended with a website and an address (P.O. Box?), right there on Pennsylvania Ave, in my nation's capitol.

As many readers of this blog may know, I haven't had my own practice for over five years. I've been assisting others regularly, have done half a year as a surgical hospitalist, a little mentoring here and there. But I left my clinic a ways back. During the denouement of my active practice, I got a nearly identical mailing; at that time it was for being included in a national "Guide to Top Doctors." That one produced its list by asking physicians around the country to whom they'd go or send their family, among doctors practicing the various specialties. On the current one's website, it's correctly pointed out that that other system favored docs in big clinics, like me. The prior package included, of course, a similar set of impressive plaques and plates.

Each "guide" is available for public consumption; I actually got the first one, just to see what the heck it was. It's a real book, organized by regions of the country, and nicely produced. Having asked practicing physicians, I suppose it has at least some sort of credibility, although it's absolutely true that it disfavors the solo or small-group docs; and having none but that single criterion? -- well, doctors' choice are subject to surprising whims, just like real people. And this new edition (I'm unaware of any prior ones, by the way), with its "point system": that I'm listed as a 2007 winner -- raises more than a few questions, eh?

Hey, if I still had an office I could have ponied up and gotten each of those, stuck them somewhere prominent (although I didn't for the first one, when I was still in practice. I've mentioned it in hawking my book, though). My clinic probably would have paid for them. And I bet some patients would have been damn impressed.

Any point here? Yeah. All forms of data-gathering aimed at providing consumers (or payors or government agencies or financial fascists) with info on which to judge doctors or hospitals -- no matter how well-intentioned or plotted (and less evidently cynical than this one) -- are subject to such a wide range of sampling-error and other problems as to make them nearly useless. Any I've seen to date, at any rate. Yet it's a worthy goal, and in fact I'd always thought that if there were meaningful ways to measure and compare surgical outcomes I'd float to the top (so do turds of people with fat-malabsorption, but that's another story). Once or twice such lists appeared, based on an insurance company's data, and indeed I looked really good. Those who didn't screamed loudly enough that the lists got pulled. So, unfortunately, the state of the art remains for now, caveat emptor. And the poor emptor has a mighty meager set of resources on which to base his/her caveatizing. I might write more about that, later.

[Addendum: Curious, I emailed the Consumer's Research Council, asking who they are and requesting more information about their publication. I got an automated response promising a reply within 24 hours..... 96 hours, and counting. Were I you, I'd take them off my list of possible doctor reference aids. Those plaques, however: some are quite attractive....]

Wednesday, February 14, 2007


Ever soaped your sweetie in the shower? Or, to be less (so I've been told) disturbing: have you held a piece of hardwood, turned and sanded smooth as glass, oiled and rubbed until it's like hot ice; passed your hand over the surface, thrilled at its silkiness, its undulating shape? Did you find it stunningly beautiful? If so, you have an idea of what your liver feels like. But really, because it's warm and taut and alive, the first question conjures it more closely. In terms of touch.

Surpassingly smooth, firm and full as a biker's buttock (I ride a Trek 5500), resolutely protected by the ribs and sealed snugly -- by surface tension and suction -- under the diaphragm, the liver releases itself with a certain reluctance. To explore it, you must make it come to you, but its barely-moist slipperiness resists exposure: you have to insinuate your latexed fingers gently between its lower edge and the underside of the ribcage, usually far to the left, while bending your wrist back to get the angle right. Then, as you glide upward and over, feeling the corrugation of the ribs across the back of your hand, you can guide yourself all the way to the dramatically domed apex.

There's not much space; what little there is tightens rhythmically with each breath. By pulling gently but insistently downward you precipitate a releasing of suction, and the liver falls partly toward you, not always silently, an exhalation. Too forceful, and the capsule could tear into the substance, like what happens sometimes when pulling the membrane off a boiled egg. You sweep over a mass larger by far than your open palm; chunky, chocolate, yet feeling as if it could shine in the dark. Nearly luminous; like a living agate. Sometimes, in order fully to free the liver, you need to slide your hand all the way across the top surface; in doing so your hand is more than full, and with it, your senses. The glide, the only slightly-yielding thickness, the meaty heat, the landscape as it moves your palm up and down, the fingers together and apart. Close by, separated by the thinnest part of the diaphragm, beats the heart; its throb is on the back of your hand, and under it. In some people, the pattern of the ribs is inverted onto the surface of the liver, making furrows and waves.

This is beauty a lucky few are privileged to experience. I've said it before: to me it's exhilarating. A gift given only to some, it is in no way based on worthiness. Which is why it's also humbling. And why I keep trying to convey the feeling: to give everyone the amazement I've been lucky to know. Once more I find myself using sensual terms, sounding sexual. But other than enabling transcendent joy from physical sensations, it really isn't; not like that. Not any more than being overwhelmed at the sight and smell and sound of the ocean, feeling like you could fly. The insides of the human body have awed me, filled my senses. I'm trying to let you in on it.

The liver, for its bulk, in its bastion, seems to preside over it all. To the ancients, it -- not the heart or the brain -- was the seat of the soul. And, while literally sensational to me, it's also terrifying. A dark crystal ball, the liver truly augurs your future. Unlike the soothsayer, it doesn't misinform. As delightful as it is in perfection, so are its imperfections portentous. Nothing in the operating room savages me more than when that sliding hand finds its way to something awful. It augers unwell for life. Searching the abdomen for signs of trouble when operating on cancer, -- say, of the colon -- feeling it in the liver sinks the heart, deflates hope, robs you of a job well done. It changes the climate with the suddenness of a thunderstorm; forces into your head terrible truths, from which there's no escaping the need to be told.

In the injured person brought rapidly to surgery, my hand goes first to the liver, over the top; and when a finger finds its way to a crack, and falls in, my pulse rises faster than the patient's, fearfully. Broken, the liver can defy every effort to put it back together. Fractured like a melon, it bleeds in a way that wells up and overflows, too fast to see into the depths, defying attempts to stanch it. Silent and relentless, it's the most dire sort of bleeding there is. (Some lacerations are very simple to care for, actually. Big, deep, and stellate, however, they often aren't.)

Nor does the liver lightly suffer indiscretion. Hammer-hard and knobby as knuckles, transformed from a lovely earthy purple-brown toward ghastly gray, the liver of an alcoholic rejects its most crucial blood-flow, forcing it back to the gut whence it came, pressuring veins till they might burst. Or, filled with fat by dietary excess, it morphs to mournful mush -- red-specked and muddy yellow; sick and squishy, like putrid paste.

Makes you want to step back into the shower, alone.

Monday, February 12, 2007


I consider surgery -- yes, even surgery -- to be grounded in science. Positing an idea, subjecting it to testing and peer scrutiny, healthy skepticism, constant re-evaluation: all those things, we do. Doctors are heirs to those who invented transistors, calculated moon-shots, figured out DNA. Still, it's not as if we're pure as snow, scientifically. I'm not, anyway. My gut -- which has metaphorically and metabolically grown over my career -- still plays a role. Here's one example, and I'd bet other surgeons (and to the extent that the concept applies to other docs, they too) would agree with this: you can tell who's going to do well as soon as you meet them. I doubt it's testable. For that matter, it may not even be true. But I'm saying there's a vibe about some people, good or bad, that can fill a room -- signaling strength or portending problems, making me light on my feet or feeling doomed. Demi-doomed, anyway. Wish I'd been able to bottle the good stuff.

We're talking gut here, so I'm not sure I can elucidate. It's not about particulars, although surely there are some at play: eye contact, family interactions, general health. Attitude. Practicality. Not fear, per se: everyone's afraid. How and where the fear fits, how it's broadcasted. What questions are asked: about pain, side-effects vs. how soon can I get back to work. Humor. (Especially, appreciating mine!) And you know who's predictably among the best? Little old ladies. Let's hear it for little old ladies. Maybe it's because they've seen it all; perhaps it's because they are innately trusting. It's not, certainly, because they're worn out or don't understand. They just know they can handle it, is all, because they've already handled so much. Yeah, maybe that's it.

It's widely held, I'd say, that positive attitude improves outcomes; optimism helps to cure cancer. At least one study says otherwise. As squishy a thing to measure as is "attitude," I'm sure the study is subject to criticism. Still, the result doesn't surprise me. Stress maybe. Attitude? I'd question it. But I have no doubt (just don't ask me to prove it) that how you feel going into an operation has much to do with how you come out of it. Even little things, in my self-regarded opinion, make a difference. Here's one: in the recovery room, when patients are just struggling awake, most nurses ask them "are you in pain?" When I'm there, I ask "are you comfortable?"

If, as studies tell us, a more happy patient isn't necessarily a more cured patient, nevertheless you'll never convince me (until a study is done) that a happier patient isn't a quicker-recovered one. I'm a hand-holder, a sitter-on-the-bed, a patter-on-the-knee. I'm a cracker of jokes, a looker-for-the-lipstick-sign.* And my patients, mostly, got home happy from surgery, PDQ. For that, I do have data. And the ones that didn't? Well, I just knew it.

*Positive lipstick sign: when a lady makes the effort to put on lipstick after surgery, you know she's on the home stretch.

Saturday, February 10, 2007

Windy Beneath the Wings

People are strange. For the life of me, there's one thing (right: only one!) I could never figure out. As I said in a recent post, I made a major effort to gain patients' confidence, and to have them approach their operations with a positive attitude. With hardly an exception, they'd leave my office in a good frame of mind. Mostly, they'd show up for surgery the same way. But not always. There was that damn Uncle Joe, or the neighbor Alice, or good friend Betty. What the hell were they thinking?

"Joe/Alice/Betty told me he/she/she knew someone who had (insert any operation you can think of) and (insert horror story here.)" Died. Couldn't walk. Woke up left-handed. Turned green. It's mystifying. Were they trying to help? To show off their knowledge? Were they deliberately trying to scare the shit out of them? What, ran out of small talk? Why would anyone do that to someone, right before they're going to the hospital? Nuts. And it's not at all uncommon. What ever happened to "good luck?" Be thinkin' of you. More like, guess you won't be needing that car no more? 'N I have it? With friends like these....

The only thing more annoying is the person who accompanies a patient to the initial consult and who has to make the encounter about him/herself instead of the party of the first part. "Yeah, I had sompin' like that. Worse, really... damn near lost my leg/colon/life/sense of proportion. It started about ten years ago. Got a minute?...."

Thursday, February 08, 2007

No Frickin' Way, Doc!

Among many, many who've needed it and accepted it, I've had two patients who refused colostomy. One is dead, the other alive and well. More than that: both eventually had colostomies, and each said, nearly identically, "If I'd known how easy it is, I'd never have refused."

No one likes the idea of a colostomy. When talking to a patient who needs one, I try to point out that there's nothing -- NOTHING -- a person who has one can't do. I list a few famous people who've had them, talk about the various ways to handle it. With enough education -- which, unless there's no time, always includes a visit ahead of time with an ostomy nurse -- people generally accept the idea and we move ahead. Not these guys, no frickin' way. I tried. I really did.

Step one in curing colon cancer is removing the portion of bowel that contains it, with some room on either side to be sure you're not leaving any tumor behind. Fairly early in my surgical life, it was learned that for rectal cancer, it's not necessary to give as wide a berth on the south side as had been believed: lymphatics and blood from the low rectum tend to flow upward, so if cancer cells were to spread locally beyond the obvious tumor, they'd be heading north. Less than an inch beyond a tumor in the deep pelvic part of the colon is considered safe as a point of division. If that leaves enough ano-rectum to sew to (staple to), you can re-attach the ends after removal, avoiding colostomy. People with tumors located pretty far into the pelvic confines have been able to have curative operations with re-attachment -- but it's not always possible to be sure ahead of time whether things will work out. You have to leave open the possibility that, in the name of safety -- in the name of choosing cure -- you might not be able to hook the ends together, and the patient will end up with a colostomy. No frickin' way, doc, these guys said. I'd rather die than have one. Period. Non-negotiable. Try as I might, educate till my brain was empty, there was no budging. So I operated anyway.

My rule of thumb (rule of finger) is that when the tumor is high enough that I can't feel it with my finger on rectal exam, I'll have enough room to get it out and hook the free ends up. In each of these men, it was barely beyond.

Patient A was in his forties, and his tumor was a big one. There's no question that, had he not refused, I'd have given him a colostomy: I could work my way past it, but not far enough within the safe-connect zone. I wanted to go further, but he'd given me no choice: I got a little bit beyond, removed that part of the rectum, and stapled it all back together. Patient B was late sixties, with a smaller tumor. In his case, we elected (I with some reluctance) to remove the tumor simply, transanally. Both men got local radiation: A got it pre-op, B post-op.

I followed Patient B very closely; Mr A came in for a while, and then disappeared. When B's tumor recurred a year or two later, I told him he was out of options: the remaining chance of cure was ano-rectal resection and permanent colostomy. Unhesitatingly, he agreed. Despite the prior radiation, he healed fine and never looked back (as it were.)

Patient A wasn't as lucky. When he re-appeared, he was in big trouble: the colostomy was because of impending obstruction. Not long after, his kidneys were obstructed, too. But before he died, he'd noted that the colostomy was nowhere near as bad as he'd thought it would be.

It may be apocryphal (if you're reading this, medblog-addict, maybe you could de-lurk and let us know): I've heard of doctors being sued for failing to talk someone into an operation. More properly, it was (so the story goes) for enumerating possible complications to the extent that the patient freaked out and refused, later to suffer the consequences of not having had the surgery. Short of tying him down and dragging him into the OR, I don't think there's anything more I could have done for Patient A. But it still bothers me. Mr B was glad to have had a couple of extra years without a stoma, and is cooking along just fine. I wish I knew the lesson.

Looking at comments on my previous post, and knowing from my own experiences, it's apparent that consent is a much cloudier issue than those who urge those forms upon us would have us think. Both for doctors, and patients. What we say, what they think we say; what they heard, what we think they heard -- it's as flimsy as a curtain of fog. When you're sick as hell, any consent you give is subject to the effects of the illness, maybe the drugs you're getting. Even when it's an operation planned well in advance, it still is questionable what "consent" really means. I've seen the fear-glazed eyes, whose opacity blocks words. Consent is just a concept, a hall of mirrors. It's vapor.

In that impossible best of all worlds, where people eat well and wars don't happen, where lawyers spend their time painting and planting flowers, all doctors are worthy of trust, and all patients trust them. Doctors, in other words, are like me. Patients are like you.

Wednesday, February 07, 2007

Age of Consent

"Whatever you say, doc." "Just tell me what you're going to do, and forget about all the rest." Once in a while, you still hear that sort of thing. There are times when "informed consent" isn't all it's cracked up to be.

Don't get me wrong (not that no one ever would, or could, or has!): I believe in full disclosure, think an informed patient is a good patient, and in fact I always took pride in my ability (and willingness!) to take plenty of time to explain things clearly. And yet... I also think instilling confidence and a positive attitude facilitates smooth recovery. Nurses regularly told me that my patients always seemed calm and confident when they were admitted, and I considered that a very good thing, and high praise indeed. So I hated, at the end of a conference with a patient and family wherein I explained the plan and tried to alleviate fear, to whip out a consent form and ask them to put their name on a shopping list of horrors. It made me feel like Snidely Whiplash. Which is why I generally didn't.

What I liked to do, rather than list all the things that can go wrong, is to enumerate the steps I planned to take to make it go right. It's better, to my way of thinking, to say "putting you on a liquid diet and giving a dose of antibiotic lowers the chance of infection or leakage to less than one percent" than to intone "the suture line could leak and give you a serious infection or kill you." That there is danger is implicit; yet the emphasis is on safety. "To protect your lungs and prevent clots, we'll get you up right after surgery and walk you around, and we'll give you a mild blood-thinner" sounds better and is more positive than "you could get pneumonia or drop dead from a blood clot."

With regularity, I was regaled with the latest consent form generated by lawyers and insurance execs, each more detailed, cold, and frightening than the last; always with the admonition to use that form or suffer unspeakable consequences. Cover your ass above all, they'd say: forget about the patients' peace of mind. I never did. My office notes included what I'd said and how I'd said it. For most operations, I gave handouts or booklets that I'd written myself, and I referred to that in my notes as well. I solicited questions, asked if there were things they were worried about, and I noted that, too. But I wanted my patients to leave my office feeling OK about what they were facing, and I worked hard at it. Foisting a frightening form full in the face after all that is sort of a spell-breaker. So I left the consent signing to the hospital, when they got there. No one ever called me on it, and I never had a reason to regret it. I'm not sure I could get away with it today.

Monday, February 05, 2007

For Bongi: mini - steps

Bongi, whose blog "Other things amanzi" is truly amazing and should be read by everyone for its look into a world most of us can't imagine, mentioned in a comment that he'd like to know details of how I did my mini-gallbladder operation. In his hospital in South Africa, they don't have laparoscopic equipment: for his situation, the "mini" makes enormous sense. So this post is specifically (but not exclusively) for him; I suppose I could have posted it in a comment on his blog, but I thought maybe others will find it of passing interest, for their own dark reasons. Bongi: my only advice would be to work your way slowly, over several patients, down to a really small incision. And don't hesitate to enlarge a very small one when you feel uncomfortable: it's amazing how much difference even a half-inch makes.

The following is a snippet from something I wrote when I first "retired," having in mind a booklet of tricks and tips for surgeons just beginning practice. (Pre-saging my book, I called it "Cutting Through the Fog" and sent it to a couple of friends in academe. They were luke-warm to warm on the idea of handing it out, but I never pursued it. So it sits in my hard-drive, all fifty pages or so.) (The links to pictures of instruments, etc, below, are for the enjoyment of the non-surgeon reader, should s/he find it amusing.)

I tucked the right arm at the side, and the left went on an arm board, extended. Even the very obese fit ok this way. I made a horizontal incision (about an inch in a normal size patient, somewhat larger in a larger person -- usually one and a half. Sometimes two), in a skin line, just below the costal margin at about the midclavicular line. Used a spring retractor (a Weitlaner or Gelpi would probably work), and the assistant placed an army-navy medially. I’d usually hook my left index finger in there laterally. I used cautery to get to the fascia, open it horizontally, somewhat beyond the length of the incision in the skin. I’d cut a bit of the lateral rectus, then spread my way to the transversus, deepening the spring location as I went, retracting in each lateral direction (my finger, her army-navy) and cut through the transversus, and enter the peritoneum either by spreading a scissors or making a small cut with cautery, then poke in my finger and spread open. The spring comes out at this point. In some cases the gallbladder was right there; if not, it could usually be seen by putting in a narrow (3/4 “) malleable. Once you find the gallbladder and grasp the dome with a clamp, you’ve got it made. If it was at all distended I'd decompress it, which greatly facilitated deep exposure. Slide in an unfolded moistened 4x8 toward the cystic duct, using a long deBakey, reposition the malleable on top of it, and have the assistant place a narrow Deaver over the liver medial to the gallbladder. Walk down the gallbladder using two long curved clamps (place one clamp, apply tension on the gallbladder, apply another further down, remove the first and apply it still further down....), while mobilizing adhesions with the deBakey or with a Poole-type suction catheter (metal, the inner portion of an abdominal suction without the sleeve.) When you get to the neck of the gallbladder it’s usually easy to clear off the cystic duct with the sucker. Then, holding traction on the clamps, incise the cystic duct, (usually with long Metzenbaum scissors) insert the Xray catheter with a deBakey and gently clip it in place. It helps to have the assistant hold the catheter at the skin level to keep from dislodging it when you pull out your instruments. Take the Xray with a C-arm and read it yourself, then doubly clip the cystic duct and divide it. I usually wait until this point to clip and divide the cystic artery. Then dissect the gallbladder off the liver with cautery. For some reason I found it easier most frequently to go from bottom up, sometimes dissecting with the sucker, sometimes with the cautery. Use a cautery extender and bend the tip a little. The assistant needs to keep the tip of the sucker near the edge of the wound, which keeps smoke out of the way. For bleeding from the fossa, I liked to touch it with the sucker (thus the need for metal) and have the assistant put the cautery to it. You need to be careful you don’t burn the skin edge with this maneuver. After irrigation and inspection, I’d squirt a little bupivicaine around the hepatoduodenal ligament, and close and infiltrate the wound. Usually three half-inch skin tapes would do it. In a skinny person, two. Rarely more than four. They’d get some ketorolac in the OR, and go home on hydrocodone, ibuprofen, and with some anti-nausea suppositories, for prn use.

Oozing from the fossa was usually controlled with pressure on a sponge stick, placed over a gauze in the field. In very large people, it was sometimes hard to see and/or expose the gallbladder initially. Helpful maneuvers included a deep breath by the anesthesiologist to push the liver down, or to serially walk the malleable clamp over additional sponges placed over the RUQ fat. I used to leave the ends of the sponges out of the wound, but when I got down to such tiny incisions I found they obstructed the view, so I pushed them in. In the very obese, I actually temporarily lost a couple, and needed the C-arm to find them. I finally started using laps when it looked like I might need more than two 4x8s. The only hi-tech goodie was a headlight, virtually indispensable.

I was selective about cholangiography, but did it more often than not. When there were stones unexpectedly, I could usually do an adequate exploratory maneuver through the small incision. Often that meant passing serially larger red rubber catheters into the cystic duct, dilating the ampulla, and flushing out the stone one way or the other. Sometimes a balloon catheter. If successful through the cystic duct, I’d clip it off and end up with no drain or T-tube. I tended to go ahead with a choledochotomy if necessary, and could usually fit a trimmed T-tube into the duct through the small incision, and suture. It might require a minor enlargement. Once we got high-class endoscopists, I felt OK about omitting opening the duct.

[So there it is. Please hold your applause until after I leave.]

Sunday, February 04, 2007

It's Complicated: part three

The idea behind surgery is a really simple one: you come to me with a specific problem, I fix it, you go away happy. And when you come back, you're still happy. What's so wrong with that? If I wanted to be miserable, I'd have gone into primary care.

When a surgeon screws up, his/her role is clear: admit it, make it better, or as good as possible, and stick with it as long as it takes. (Comments on the first two posts in this series indicate that it's not so clear for some surgeons, and it's depressing to realize it.) But what about when you don't screw up, and the patient is still unhappy? As I indicated last time, in some ways that's the most difficult situation of all. Once again, it's complicated: there are bad outcomes or side-effects that result from well-thought-out and well-carried-out surgery; and there are, well, who knows exactly what they are...

As an example of the first sort: it's possible nowadays, with certain beautifully engineered staplers, to remove a rectal tumor and hook the colon right down to the anus, sparing the patient from a colostomy that would have been a certainty a couple of decades ago. When approaching such an operation, I would always tell the patient that there could be difficulty controlling the bowels, temporarily or, rarely, permanently. Converting to a colostomy later is an outside possibility. Likewise, it's not rare for a circular staple-line to scar down to a point where it could need dilating, which is usually a simple office procedure but occasionally requires an anesthetic. Those things are, in fact, pretty straightforward: if the problems occur, the patient might be uncomfortable for awhile (or in the case of poor bowel control, miserable.) But it's a known thing, and not reflective of operator error. And there are fixes. If I'd ever had to convert a hook-up to a colostomy later (I never did), I'd have felt bad for the patient, and no doubt would have encountered disappointment. I could handle it without feeling like a screwup, and likely without losing the patient's trust.

Somewhere in between this and the most miserable circumstance, is the patient who doesn't get better. Early in my practice days, I did a text-book perfect thyroid operation for a young man with Grave's disease (over-active thyroid.) Taking out most of his thyroid, successfully avoiding the mine-fields of damage to laryngeal nerves or parathyroid glands, leaving him the perfect (according to my training) amount of residual gland with which to live without the need for thyroid hormone replacement pills, I felt great about the whole thing. Six months later, it was as if he'd never had an operation: big neck again, and all the symptoms. For me it was like falling off a nice sailboat into icy water. (And it led me to decide that people are better off taking pills than having a relapse; so I began -- without any regret -- to remove essentially the whole gland for all my future patients. Hell with what I'd been taught.) Faced with re-operation -- more dangerous the second time around -- he opted for radiation, which he'd strenuously rejected as an option initially. Feeling bad is bad. I guess it's better than feeling guilty; but I didn't like seeing the look on his face. Knowing I did everything right doesn't change the sense of failure. To me, it's like a robbery: I feel great about it, I have every right to, and then suddenly it's all upside down. "Gee, I hope you know I did everything right" is what I want to say. But I don't.

Sometimes a proper operation makes things worse. Known side effects, like dumping syndrome: it's like playing great odds and still losing. These can be the times when the surgeon sends the wounded patient back to his primary care doc -- or with dumping, to the gastroenterologist -- creating ill will all around: surgeons just operate and leave the problems to someone else. It's where the stereotype was born, I'd say. In my practice at least, it's an unfair characterization: I'd do everything I could for as long as I could. But there comes a time when other expertise is likely to be better; when it does, it looks -- and feels -- bad.

And what of this: I operate, I fix the problem, make it gone. But the patient isn't happy: I can't sleep, he says; I get headaches all the time; my bowels are messed up. I'm sweating. Ever since the operation, I've been impotent, anorgasmic. My incision still hurts. It's a long and frustrating list, and it's likely eventually to lead to an unhappy parting of the ways. "Tie goes to the runner." "Benefit of the doubt." Such things need to be taken seriously; there are a number of known causes for various post-op symptoms. But after enough time, enough tests, enough maneuvers and investigations to have ruled out every imaginable cause, where do you go? What are you to think? Can you broach the subject of psychological cause without producing a pissed-off patient? Like post-partum depression, post-op depression is a known entity, and I've used anti-depressants sometimes, to good effect. But it's a touchy subject. And when that doesn't work, then what? It's tempting simply to say, look, I've done everything I can, you need to find a new doctor. Some do, I gather from this and other blogs. It really is the hardest of all: there's no pleasure or satisfaction, there's no explanation, there's no graceful exit, no fallback. It makes everyone miserable, the relationship is shot: in every way, it's the complete opposite of why you're doing this. It just sucks, that's all there is to it.

I also mentioned discussing the frustrations of cleaning up another surgeon's mess. Forget it. I'm already too depressed.

Friday, February 02, 2007

It's Complicated: part two

Speaking only for myself (but guessing I'm not alone), I can say when a patient develops post-op problems, there's a strong tendency to deny it: not to deny there's something wrong; not to dismiss the patient's concerns or symptoms. Just to grasp first at the less dire set of possible explanations. Maybe it's just the flu, constipation, drug reaction. That sort of thing. It's not about blowing it off -- because I never did. It's about hoping against hope, both for the patient's sake, and mine. Rationalization is a powerful instinct. In reading various forums and blogs and seeing innumerable patient complaints that their doctors took a long time to take them seriously, I'd guess that in many instances the desire to believe you didn't screw up is at work. That doesn't excuse it: maybe it explains it to a degree. For better or worse, doctors are human. I know I am.

When I saw my patient in the Emergency Room, her abdomen was distended, she had a low-grade fever and a bit of a red incision, and her Xray was the usual hard-to-be-sure early post-op belly film: possible obstruction, possible ileus (a condition of bowel laziness often seen for a while after abdominal surgery.) I admitted her, of course. Intestinal leakage -- from where the bowel has been sewn together, or from an unrecognized surgical injury -- is always on the list of possibilities in such a situation, but I didn't think so here. How tender is tender? How red is too red for an early incision? She didn't, I told myself, look all that sick. Time and a stomach tube, antibiotics for a possible sub-clinical (meaning not obvious) leak or abscess at her anastomosis ought to do the trick. Indeed, she looked better the next day. Not that "looked better" is an objective criterion.

When intestinal content began to drain from her wound after a couple more days, it all became clear. Since the point of the post is not to discuss treatment of intestinal fistula (leakage of intestinal contents to somewhere -- in this case, to the skin), let me simply say I opted for the safest and most frustrating approach: high-calorie intravenous feeding, local wound care, and waiting. And waiting. With drainage, she stabilized and we both hunkered down for a long haul. At some point, while inspecting the wound daily, I noted the suture with which I'd hooked the bowel while closing up. And I told her about it straight away. I explained why, in my opinion, going back in at this stage could cause more harm than good, and that there was a reasonable chance it could heal with no need for surgery; and that if not, it would be much easier and safer to go in after time for the reactions to settle down.

So there she was: a living, breathing testament to my failure, for all to see, for a couple of months. Each time I approached her room on rounds, I felt a tug in my gut. I imagined that everyone was talking about it, probably questioning my competence. (Years later, I sort of doubt it. But it's how I felt, with every complication, big or small.) The lady was remarkably hardy and good-hearted. That made it a heck of a lot easier. With each visit, we talked about it, about how it was going, about our comfort levels with the current plan. Frustrated at times, stir crazy on occasion, she never evinced anger toward me. I was deeply grateful for that. She healed. I fixed her incisional hernia a couple of years later.

It's a terrible triangle: the patient, the injury, and me. The patient first and foremost is in need. Whatever the effect on me, their situation is way worse. Yet facing him or her can be tough: it may be unspoken, but there's the sense of permanent accusation. My shame, my guilt, my sadness all interfere with my connection. Magical thinking can keep me from facing the reality of whatever is wrong. At some level, I want the patient and his complication just to go away, because of what they say -- or seem to say -- about me. So, as I titled this series, it's complicated. I was lucky, I guess: in those rare cases where bad things happened due to what I felt was an actual error, my patients stuck with me, and we got the problems resolved. It's a key point, however complicated in its own right: impossibly difficult as these situations can be, hostility from the patient only makes it worse. If my reaction is "complicated," the patient's is -- understandably and necessarily -- complex to the power of ten.

It is, of course, unreasonable and probably impossible to expect patients to hang in there no matter what. It's like, oh, saying questioning a war emboldens an enemy. If there comes a point when you think your surgeon is simply a screw-up, it's time to pack up and go. Yet, I'm trying to say, early on it's at least a theoretically good idea to give him/her a little breathing room. Sometimes figuring things out takes time; sometimes problems can't be resolved as fast as the injured party would like. Hell, they never can. I think it's a truism that the attitude of both the doctor and the patient is crucial to how things end up when facing complications. If it's true that the patient's attitude is heavily influenced by their doctor's, so is the opposite. But, given that it's the patient who's the injured party no matter how upsetting (violins, here) it is to the doctor, the patient has first right of refusal to take the advice. Still: in the ideal world (remind me where that is again?), it's immeasurably better when each side keeps his powder dry for a while.

A commenter on the first post in this series raised an important point (and had he not veered into vile vituperation and personal pejorative, I'd have kept it in.) Why, he asked (in a manner of speaking) had I not canceled my bill or offered to pay her expenses? (In fact, he has no idea what I actually did, but it's a good question.) It is something about which I've ruminated a great deal -- maybe it should be another post sometime. I have generally, for example, (and despite suggestions from insurance companies to the contrary) not charged for a re-operation for bleeding -- a rare occurrence. That's a small thing. The larger question, I think, ought to be addressed in a larger way: something like flight insurance, as a top-of-the-head analogy. Patients deserve compensation when things go wrong, and it ought to be available outside of the adversarial court system. But if every surgeon -- every doctor -- were expected to pay out of his/her pocket for every adverse outcome, I daresay even fewer good people would choose the profession than are now doing so. I don't have an answer. I've wished I did...

In my view, there are three categories of bad outcomes: the ones I've already mentioned are those that clearly result from an error -- the most horrible to face because there's nowhere to hide. The second is imperfect results from proper and well-managed care; and the third is.... having to clean up another doctor's mess. That middle one can be the most frustrating of all, posing the greatest challenge on many levels. I'll see if I can explain it -- and figure it out myself -- in the final post(s?) in this series....