Thursday, September 27, 2007

Names and Places, Pouches and Spaces


It's always with wonderment that I consider the pioneers of medicine, of surgery, of anatomy. To conceive of a time when every thought was a new one, when discoveries abounded for those with imagination, boldness, and curiosity, is to be thrilled, jealous, and.... bemused. What could it have been like, opening the body and its mysteries to the world, engraving your name on the way out? As I let my mind jazz, thoughts fizz like a Sapphire tonic.

When it takes some effort -- maybe a microscope or some really careful dissection -- to discover something, it seems reasonable that your name gets attached. Islets of Langerhans. Ampulla of Vater. Sphincter of Oddi. Valves of Heister. Crypts of Morgani (he got "columns," too.) But where's the cutoff? I don't get why Gabriele Falloppio got to name something as obvious and macroscopic as an oviduct. That's not discovering. That's noticing. We don't have the Colon of Powell, or the Heart of Palm. (I don't know who March was, or why he got to name the Eyes.) The white line of Toldt is sort of macro-observational and a name seems an extravagance. On the other hand, if Toldt was the guy who figured out that it was really a dotted line on which a surgeon cuts to unveil the colon -- a move that thrilled me the first time I did it and still does, for its anatomic simplicity, for its sweet entry into secret space, for the way it translates embryology into practicality -- then he deserves the kudos.

"Foramen" (for-AY-men) and its pleasant plural, "foramena" are among those cool words we learn in med school. It means "opening." A hole, is what it is. There are many anatomic openings deserving of the name: foramen ovale (oh-VAL-ee) looks good and sounds good; works good in a fetus. Lots of bony holes, especially ones through which nerves or vessels pass, are called foramena -- the obturator foramen, optical foramen, yada yada... But Jean-Jacques Winslow (shouldn't that be "Winsleau?") discovered he could stick his finger in a place, and stuck his name on it, too. Borderline. I don't want to get into the Zen of what constitutes a hole, but his "discovery" is only about some things that are near each other. Inlet, maybe. We've got islets, why not inlets? Then it starts to sound nautical, which makes me think not of Winslow, but of Winslow Homer. That's it: it's the "Oddity of Homer."

Consider Morrison and his pouch. And Douglas's. They're just places, areas. To me, it's not earthshaking. On the other hand, Broca claimed his area with some effort.

I'm ambivalent about the Space of Retzius. As an anatomical concept, "space" doesn't have a lot of panache. On the other hand, the surgical dissection of it, developing it into a tissue plane, is cool: another of many places that spread themselves open for and yield to the surgeon, when their secrets are out.

Clearly the Greek and the Latin have fought for dominance of the nomenclature. It's a puzzle to me that they made a truce of sorts in the kidney. We speak "nephric" and we talk "renal" interchangeably. Even to the point of naming things twice: that little yellow top-hat to the kidney, the ad-renal or the epi-nephron, as of juice it makes, two names for the same thing: adrenaline, epinephrine. What gives? (Let me re-emphasize and diverge: like the robin's-egg blue of the gallbladder, the bold yellow of the adrenal is a starting splash of exuberant color among the otherwise earthy tones of the belly.) (Well, yeah, there's lemony lipid all over in there. But as organs go, the color of the adrenal is a surprise.)

Those solid surgical soldiers of old deservedly got operations named after them; and instruments, and procedures. Because there's no end to invention, it still happens, and will. Lots of the living have their names (and lucrative patents) on devices; techniques and new operations keep unfolding. I've mentioned in the past, I think, having a position named after oneself: Trendelenberg, Fowler (and his brother, Semi) managed to do it. If I had a position named after me (as I might have said already), I'd rather...

Nearly unique, though, among the namings, is to be remembered for a maneuver. Something about that is, well, transcendent. So I'll give it a separate post...

Tuesday, September 25, 2007

Pattern Recognition



A physician-seamstress and plastic surgeon emailed an idea into my head, bringing up an amusing consequence of the dawn of the laparoscopic age: docs are required to infer a patient's history from a bunch of cat-scratches on the belly.

Although it's not particularly rare that you point to a surgical scar on a patient and ask what the operation was, only to be told "I don't know," the more common situation is with a patient sick or injured enough to be unable to give a history at all. Finding surgical scars, we may need to make an educated guess about their past. Some scars tell their stories pretty well: long scar under and parallel to the right rib margin means gallbladder removal. Short one in the right lower quadrant: appendectomy. Flank scars likely mean kidney surgery. Some others that have a nearly singular signature: pyloromyotomy, umbilical hernia; splenectomy or sigmoidectomy if done in not-common ways. Others at least provide a short list: lower midline, upper midline, right paramedian -- you can narrow them down. If it looks like it might have been infected at one time, that can help: upper midline, maybe a perforated ulcer; lower, maybe diverticulitis...

Our brains are wired to recognize patterns, and to be able to add context. With laparoscopy, though, it can be confounding: bunch 'a little cuts scattered here and there, seemingly randomly. Some are counter-intuitive: to remove the appendix laparoscopically, the biggest hole is made on the left. Taking out a gallbladder, some people make an incision in the umbilicus, others avoid it; still, most have a fairly common pattern of three (or four!) additional scars. But there's a novel amount of variation, amongst surgeons, in where they like to poke their holes, and what size to use, for a given operation done laparoscopically. And if a person's had more than one laparoscopic operation, fuggedaboudit! I think surgeons can recognize the patterns pretty well, at least for the operations with which they're personally familiar. But I'm guessing we're in a transition period for ER personnel. (God knows what'll happen if an unconscious patient shows up needing tracheostomy, and who's had an axillary approach to thyroidectomy.)

Readers here may know of my mini-gallbladder operation, wherein I removed that organ through a single tiny (inch, inch-and-a-half) incision below the right ribs. I've seen ER notes from my patients' visits that refer to the fact that the patient had had a "lap chole," because no one had seen such a small incision done any other way (and suggesting the inability to note the difference between one and four -- not that it matters all that much, in that situation.) I had many patients tell me, years later, when having an exam that their doctor said, "Oh, you must have had Dr Schwab do your gallbladder surgery."

Coming full circle, plastic-surgeon-in-the-post-wise, I once two-teamed with my favorite one, starting off with my little mini-gallbladder on which he assisted, followed, in the same patient, by a tummy-tuck with which I helped him. My scar, though smaller than one from a typical appendectomy, ended up in the lady's right lower quadrant, where anyone seeing it later would properly assume it signified an absent appendix. I had to impress on the woman the difficulty she might anticipate in convincing a future physician that she
still had her appendix, and it was her gallbladder that had been removed.

Monday, September 24, 2007

Curses

[This post is inspired by (though barely related to) one from that eminently readable medical blogger, Dr. Rob.]

If I didn't know better, I'd say there's a curse: when a new surgeon arrives in town, he or she will have a very weird or embarrassing case within a short time, while all eyes are still upon him/her. I've seen it repeatedly. (With me, far as I can recall, it wasn't too terrible: my first operation after I moved to my final destination was a very routine hernia repair. I recall the anesthesia person mentioning something positive about how quick and smoothly it went. And his snarky smirk when, for the only time I can remember with an inguinal hernia repair, I had to bring him back an hour later because of bleeding.) One guy, even more arrogant than the typical surgeon, whom I came to dislike more and more over the years until he went elsewhere, began his career by leaving a sponge in an otherwise routine gallbladder patient. Another, whom I liked from the beginning and whom I admired more and more as the years went on, had, within a couple of months of each other, two patients who presented with peritonitis and suggestion of intestinal leakage, without ever finding the source.

I helped him on the first one. The abdominal cavity was funkified with the fibrinous, gooey and liquid stuff that one sees with perforation. Globular glops of gunk gluing together loops of bowel, thickened stubs of omentum pulled and stretched and stuck everywhere. The normally shiny and slippery-pink surfaces of the viscera were dull and thickly-red. Fully to inspect the entire intestinal tract from esophagus to rectum takes a while under the most favorable circumstances. You can't see the backside of the stomach, for example, without cutting your way into the lesser sac. Normally easy -- and among those favorite secret spots that we learn along our path to competence -- it can be hard to identify, much less work through, when everything is swollen and stuck. Same with the mid-portion of the duodenum and much of the colon: the very act of cutting them loose enough to be sure about them risks damage of another sort.

There's an entity known as Spontaneous Bacterial Peritonitis. Pretty much limited to people with fluid in their abdomen from liver disease, after our fruitless search it was tempting to invoke it as an explanation. Except that there'd been "free air" seen on the man's Xray before surgery, indicating perforation. (To me, it's not inconceivable that bacteria could generate enough gas to show similarly on an Xray.) Try as we might, no definite source was found. We cleaned the man out as much as possible, tucked in a couple of micro-suspicious areas, covered him with big-time antibiotics, and he eventually recovered with no explanation.

"You won't believe this," Dr. J said when we saw each other in the doctors' lounge a few weeks later. I was girding for the day, glugging coffee and reading my mail, the latest directives from the hospital overlords. He'd walked in before heading home, after a long night in the OR. "I just had another case like that first one. Perforation with no source. How many of those can there be? I never saw a single one in training! I spent hours looking, and couldn't find a damn thing. It's like I'm cursed..." And then, vibrating like a dinner bell, tattooing his feet on the floor like a kid ready to go into tantrum mode, hands clenched white, he said, "I hate this. I hate this. I hate this."

I suppressed the urge to laugh: he was so vulnerable, so honest. So... cute. "J.," I said. "I think it is a curse. Seems like every new guy goes through it. And really: if you didn't feel like this, I wouldn't want you to be my partner. Everyone's going to have tough cases and bad outcomes. What would bother me is if you didn't care this much. I'm sorry for you and your patient, but I've worked with you enough to know you're an excellent surgeon. You're gonna be fine. This, too, shall pass."

And, like the curse of the Bambino, it did.

Friday, September 21, 2007

Signs


I mentioned signs in a recent post, at the time referring to those unofficial (as opposed, say, to Battle's Sign) but somehow meaningful constructs we all get to know. To wit:

The "O-Sign," signifying a level of coma such that the person's mouth is open.

The "Q-Sign," meaning the same, with the tongue hanging out. More serious.

The "Lipstick Sign," when a lady puts on makeup/lipstick after surgery or other illness, signifying recovery. I suppose a male equivalent is shaving.

There are many others. (Throckmorton's has already been done.) And I've seen a few compendia of abbreviations. Here, I'm thinking signs.

It needn't be medical. Got any amusing or dead-on signs to add, relating to your profession? In particular, anyone ever come up with one of his/her own? I think I did.

I used to refer to Schwab's sign (of imminent death): when the hematocrit and bilirubin cross. I think, in fact, it might also apply to hemoglobin/bilirubin. For all I know, it's already been named; but I haven't heard it. What're yours, new or used?

Wednesday, September 19, 2007

Self Medic-ated


It's considered a truism: if you have a doctor or nurse for a patient, it's gonna be a horror show. I'm not convinced, but to the extent that it could be true, the fault -- as Shakespeare probably said -- is in ourselves. The problem is the nearly irresistible pull to treat doctors and nurses differently than we do the rest of our patients: to abbreviate explanations, to avoid recommending things that are inconvenient, to bypass the ordinary steps taken to get from encounter to conclusion.

In the formative days of this blog, I posted about operating on my partner when I was a very young pup. Any way you could look at it, it was a horrible experience; after removing a section of his bowel, he had a problem I'd never seen before, nor have ever again. Without question, had I closed his mesentery the way I'd always done (and still would do) instead of the way he liked to do it (I figured he'd be happy when I told him), I'm certain it never would have happened. By the time it was over (and before he made a complete and full recovery!) I was ready to push him out a window and jump after him. Amazingly, within a day of his much-delayed discharge, I was asked to see another fellow physician in need of bowel surgery. OK, I thought. You fall off a horse...

Fortunately, he was a pediatrician, which meant I could treat him like a person who hadn't a clue about surgery. Close as you can come, really, to operating on a civilian. (Kidding. I'm kidding. But I do admit to telling that to myself at the time, given my closeness to never operating on anyone again, let alone a doctor.) He did fine. Whether it played a role or not, I treated him exactly as I did my "usual" patients: explained in the same detail, using the same understandable terminology, saying the same things to him on rounds, in the same way, as I would have had I not known him at all. During surgery, I simply put who he was out of my head. Operating on "Doug" early in my practice, horrible as it was, may have been a good thing: it taught me to wipe away any assumptions and treat everyone the same. (It must also be said: many doctors and nurses have an expectation of and/or try to wheedle their way to exceptional treatment. Myself included. I'm not opposed to giving and receiving certain perks -- fitting in a visit, removing a lump or bump off the clock, off the record. It's the big stuff that needs discipline.)

Until I saw the mystifying choices some of them made, I used to consider it a compliment whenever a nurse or doctor came to see me or sent a family member. OK, maybe it was. Still, I'm not sure -- with the exception of people who actually worked in the OR -- what they really knew about me. (I'll never forget my shock at hearing an excellent recovery-room nurse mention who her OB/Gyn was: a guy constantly under scrutiny for poor decisions and outcomes, who was -- happily -- at the time only weeks from his eventual banishment from the staff.) For whatever reason, I did operate many times on colleagues, co-workers, and their families. And notwithstanding that early horror, it never again bothered me. When red flags flew, it was for the same reasons they unfurled for "regular" patients: co-morbidities, unpleasant personality, weird behavior. Not, in other words, because they were medical folk. But after my ugly initiation, I did make it a point always to eschew short-cuts or shorthand, speaking and behaving in my usual manner, drawing the same simple diagrams. Some even made it a point to thank me for it. The ones that lived.

Monday, September 17, 2007

Word!

[Credit to Judy for suggesting this picture.]


I think it might be about 8,000. Or is it 12,000? Anyway, somewhere I've seen the number of new words people learn in medical school, and whatever the correct amount, it's impressive. Here and there in this blog, I've mentioned some words I really enjoy just for the saying: bezoar, inspissated. How about radiculopathy? (Sounds like a word that could be applied to most politicians, whether you pronounce it "rih-diculo... or "raa-diculo...) Neovascularization. Tachyarrythmia. Pancreaticoduodenectomy. Intussusception. Bezoar.

Bee-zore. Say it like the taunting "air-ball" at a basketball game. (Digression: It's been shown that at every venue, whenever the chant is chunt, it's always in the same pitch, the same notes on the scale. F - D, matter of fact.)

OK. The point I want to make is that in addition to the neo-vocabulary we learn, there is also a more esoteric lexicon: words or terms that bubbled into the vernacular and have become universally understood, at least within certain sub-cultures: gomer; O-sign; Q-sign; flail. Let me tell you one of my favorites. It has it all: nice sound, excellent meaning, and, in my case, a connection to one of my favorite people. The word is

NOOGER.

In my book, I described learning how to dissect through distorted, inflamed, difficult anatomy. I called the method "delicate brutality." (Too late, it occurs to me that that would have been a great title for the book.) Central to the technique is the ability to nooger; namely, to ootz a finger into a sticky place and wiggle it, pinch it, insinuate it until you find a way through without poking a hole into something important. Noogering can be done with other blunt instruments: a sucker, a round-ended clamp, closed scissors, often along with the finger. Indeed it requires a combination of delicacy and brutality, plus some sort of either learned or innate (or both) sense of touch; of tissue turgor (there's another good word: turgor, turgid) and confidence of anatomy. If you can't tell where a thing is, you need to be fairly confident of where it isn't.

Not all surgeons need to nooger. Orthopods and neurosurgeons don't. Bone isn't noogerable, and brain, well, God help us... But a non-noogerescent general surgeon is bound for trouble. Important as it is, I can't think, exactly, how I learned it; or how properly to teach it. But I did, both. In a situation requiring one to nooger -- precarious as it usually is -- I'd rather do it myself than try to tell someone else how.

Among my favorite characters from training was the chief cardiac resident, a gangly, good-humored, soft-spoken, slow-walking but fast-thinking southern boy, Joe (full name: Joe) Utley. (The picture is from much later, in his evidently post-gangly years. Like mine.) In stark contrast to the other men populating that department -- who were volatile, egomaniacal, bad surgeons, crazy, nasty, or pretty much any combination of those characteristics -- Joe was laid-back, engaging, and highly talented. He told dumb jokes, quoted lines from movies, played the fluglehorn while wearing a sombrero, and treated me -- his over-worked intern -- with respect and caring (although, it could be argued, having an intern and his girlfriend [now wife] over and subjecting them to the horn and the hat was anything but respectful). I loved the guy. (Joe died a couple of years ago. I sent a copy of my book, in which he played a prominent role, to his wife; she wrote back that she knew he'd have loved it, and she could imagine him laughing out loud while reading it. That made me feel good.)

In hooking a person up to the heart-lung machine, it's necessary to control blood returning to the heart via the venae cavae. That requires (did then, anyway) slinging the veins with ties; to do so necessitates dissecting within the pericardium, behind those delicate structures, completely encircling them. Joe had a favorite instrument for the job, a very large clamp with a curved and bluntly-rounded tip. This he referred to as a "Giant Noogerer." Open heart surgery has a certain drama, and, in those relatively early days on the time-line, tension compounded by lengthiness. But as an intern on the service, because there was always lots to do, stretching into sleeplessness, time in the cardiac room was -- depending on who was in charge -- rarely pleasant. With no opportunity to do anything but stand there and answer questions, the hours dragged me down, while pushing the day's work further into the night. Except with Joe. I found myself looking forward each time, as the moment approached, to hearing him ask for the tool. "Giant noogerer," he'd say, hand out, and it always arrived with no need for clarification. With his gentle accent, it sounded like "jahnt nurgrer." I wanted to link here to a picture of one. But I have no idea what the real name is.

Saturday, September 15, 2007

Sleeve (Up)

[This is another post that's been sitting around in draft form for a while. It might be obvious why I hadn't posted it. More cleaning of the attic -- or in this case, maybe the basement. It's conceivable that some day one person might find one thing useful.]




In no particular order, and for no special reason, here's a few surgical "tricks." Most are amalgams of observations, teachings, and trial and error. Surgeons will shrug, non-medical types (and non-surgical medical types) will say "who cares." Credulous and ingenuous students might make note and tuck them away, against the possibility -- remote as it might be -- that they'd prove useful in a future life. Whatever.

1: In thyroidectomy, "walking" to the outer parts of the poles by sequentially placing suture-ligatures provides excellent traction for exposure -- much more wieldy than Leahy clamps, the sutures can be pulled any which-way as you work.

2: The same technique facilitates the removal of a breast fibroadenoma.

3: The biggest mistake people make in open appendectomy is placing the incision too far medial. Go lateral to the rectus muscle, come down on the cecum, and you won't have to wave your finger all over the place to find the appendix.

4: At the base of the appendix there's almost always a clear window through the mesoappendix. Poke a clamp through, pull back a tie, have your assistant tie it while you snip the mesoappendix.

5: Developing flaps in thyroidectomy doesn't accomplish much more than increasing post-op swelling.

6: Use marcaine in all incisions: generously, up to 1 cc/kilo of 1/4%. Get the peritoneum. Use it all around the pectoralis muscles for mastectomy. Use lidocaine when infiltrating the sac in inguinal hernia, in case you flood the femoral nerve.

7: Sweeping a finger circumferentially around the surface of the peritoneum and behind the fascia in open appy, before entering it, greatly facilitates closure later.

8: In the proper plane, sweeping a finger in front and behind a thyroid lobe allows it to be flipped forward and out of the wound.

9: There are two ways to handle the laryngeal nerve: be sure you see it, or be sure you don't. I prefer the latter.

10: Squirting marcaine into the gallbladder fossa reduces the chance of "phantom" biliary pain in the recovery room.

11: Nearly any umbilical hernia can be repaired using a curved incision within the umbilicus.

12: Nearly any adult umbilical hernia is best repaired with mesh.

13: To make a nice mastectomy scar, draw one side of the elliptical incision, then "measure" it with a tie, placing it in the jaw of a clamp at one end of the incision, laying it onto the marked arc, and clamping it at the other end. Then use it to lay out the other arc: each will be the exact same length, eliminating bunching on closure.

14: Use curved Mayo scissors to develop the flaps in mastectomy; grab bleeders with a Debakey forceps and cauterize them.

15: For tracheotomy, place 2-0 silk sutures vertically on either side of the first tracheal ring before dividing it vertically. Use them for traction when inserting the tube, leave them for several days in case the tube needs replacing before the tract is firm.

16: Non-inflamed/infected sebaceous cysts can be removed through a tiny hole by poking them with a 15 blade, squeezing the gunk out, and continuing the squeeze to expel the sac.

17: Don't shave around a scalp cyst. Tape the hair apart with paper tape.

18: When draining an abscess under local, keep injecting with one hand and make the incision with the other, into the blanched area.

19: When operating on the chronically ill, if not giving TPN, add multivitamins to the IV; and use post-op nasal oxygen for healing.

20: Make rounds at least twice a day. Sit down in the patient's room (on the bed is OK.) Read the nurses' notes, preferably before seeing the patient.

20a: Sit down when seeing a patient in your exam room, too.

20a, i: Don't make the patient undress any more than absolutely necessary.

21: If, after many years in practice, you can only come up with this many items, you probably should have kept your mouth shut (hands in your pockets). I think there were more, but it's been a long time...

Thursday, September 13, 2007

Hospitality


My first encounter with the concept of the "hospitalist" was a sour one. As with many of my long-held medical beliefs, I eventually came to another way of thinking. (You may have read about my own gig as a surgical hospitalist, and about the fact that it was a period of unmitigated pleasure for me.) But that first time -- which involved the medical iteration of the concept -- was a bummer; not for what it was, but for what it wasn't.

When the internal medicine department of my clinic announced they were moving to the hospitalist model, I considered it a terrible idea. Patients expect many things of their doctors; among them, that they'll be there in their hours of need. I understood the practicality: having docs at the hospital meant more immediate care for those housed therein, and it meant the rest of the internists could remain in their offices. Among other things, there's more money to be made by keeping up a schedule there than by running back and forth. Considering the time required, hospital medicine isn't all that well reimbursed. But I'm a three-rounds-a-day guy. My reservations had to do with assuming patients would feel abandoned. And I was right.

In the very first week of the trial period, I was called in to see a young man in extremis. Suffering from long-standing AIDS, and cared for by one of the really excellent internists (my doc, as a matter of fact) in the clinic for years, he'd been brewing, unbeknownst, a rare tumor of the small intestine. Probably a day before being brought to the ER, it had perforated, and when I met him he was a very sick puppy. The diagnosis was as yet unclear, but the need for surgery was obvious.

Regular readers know how much I enjoy intestinal surgery. Other than for releasing obstructions, operating on the small bowel is less common than on the colon: despite there being four times as much of it, conditions requiring removing a chunk are fewer. A couple of things make it more fun than colon resection. First, it's looser. You can grab a handful and deliver it through the wound, where working is easy; most parts of the colon require cutting it loose before you can address it. Second, small bowel heals like crazy. With its rich blood supply, generously provided in all directions in all locations, it takes real effort to screw up putting it back together after removing a part. Much more so than with a colon anastomosis, in other words, leakage is highly uncommon. Don't get me wrong: there are some situations where small bowel surgery is a nightmare. It can stick to itself so densely that you can't tell where one edge ends and another begins. Dilated from chronic obstruction, it can become as thin and friable as wet tissue paper, turning every touch into a potential perforation. In those cases, you more than earn you pay. Other times, it's purely recreational.

With this patient, it was somewhere in between. It's hard to luxuriate in the pleasure of operating when a person is as sick as this man was; still, the need was clear, the pathology easy to recognize, the conduct of the operation self-evident. (I should also say operating on AIDS patients is never without at least a little concern for oneself: the errant poke with a needle, the splash in the eye. In this case, the soaking through of the supposedly impermeable gown. I'd add that, in my practice, AIDS patients were among the most likable people I met.) After removing the part containing the tumor and sewing the ends back together, I washed out the belly with liters of fluid -- the last dose containing antiseptic solution -- closed the mid line and left the skin open.

On the first post-operative day, he looked a million times better than when we were introduced. "When will I see Dr. Jones," were among the first words out of his mouth. Not that he was unhappy with me. He just really wanted a familiar face; particularly one that had cared so closely for him for so long through so many previous mini-crises, with whom he had a deep level of trust. I had to explain the new world to him. The disappointment -- and concern -- was obvious on my patient's face. Sure he'd want to know, and that he'd come by, I called Jonesie and told him of his patient, and of his desire to see him. "OK, I'll get there during lunch," he said. "But only to tell him why I won't be there any more." (To be fair, in this case it wasn't that I needed help in managing the patient. Still, then-to-fore, Dr. Jones would absolutely have been making hospital rounds and would have at least dropped by to say hello.)

Times have changed. As hospitalists have become nearly ubiquitous, I think patients' expectations have changed, too. Moreover, it's become clear to me that the care provided exceeds that of good ol' Doc Jones, for lots of reasons. People are managed as outpatients who'd have been in-house in the past. Many operations are done in surgicenters -- ones that no one could have imagined a while back. The average person in the hospital, therefore, is sicker than a decade or two ago. There are pressures to get people home; management is more difficult; both diagnostic and therapeutic interventions are more complex. Clearly (in my opinion, anyway) docs who do nothing but manage today's in-patients are better at it, and more efficient. What's lost by the absence of the personal doc is more than made up by the fact that the people rendering the care in the hospital do it really well.

Surgery, by the way, is a little different: our stock-in-trade is the hospitalized patient. There's really no such thing as a purely office-based surgeon; nor would any self-respecting surgeon operate and turn the post-op care to someone else. So the surgical hospitalist -- such as I was for a while -- is a different concept. Surgeons manage their own hospitalized patients -- with, for some, the help of intensivists.* Taking acute consults and doing emergency operations, the surgical hospitalist makes the life of the rest of the surgeons far more pleasant, allowing them to see their patients, carry out their scheduled surgery without interruption. ORs run more efficiently because of the more ready availability of someone to fit in the unscheduled cases (surgeons with an office full of patients tend to want to do urgent -- not emergent -- cases at the end of their day, making for an ever-increasing backlog at that time. Present company excluded: I always did 'em at the first available opening, even before I was the on-the-spot guy.)

I think the hospitalist concept turns out to be a good deal for everyone.

* To this day, some of my mentors eschew the idea of surgeons ceding any care to the intensivist. I think that attitude is an example of the disconnect between academe and what I'd call, oh, I don't know, real life. When I was in training, I had multiple patients at all times in intensive care, and was comfortable with -- not to mention good at -- their management: ventilators, cardiotonics, renal failure (up to but not including dialysis), the whole nine yards. In private practice, I'm happy to say, critically ill patients were fewer by far. And, for the same reasons I listed above regarding the better care given by hospitalists, docs who are constantly managing the critically ill are better at it than I became over time, after leaving the shadow of the ivory tower. I didn't -- nor, I'd guess, would any surgeon (general surgeon! -- you can't drag an orthopod into the ICU with a cable. A neurosurgeon will go, but will not look below the forehead) -- give over the entire job of critical care. But collaborating with intensivists is mutually satisfying and edifying, and beneficial to the patient. My mentor's castigations to the contrary.

Tuesday, September 11, 2007

Thoughts on a Tragedy


On the anniversary, I feel like writing something about 9/11. This will have nothing to do with surgery, or medicine. If political rants on a medical blog annoy you, please click away now.

My brother was living in NYC at the time, and had colleagues in the World Trade Center. He went to some funerals, after. At first I watched the images and wondered if he was OK, unable to get through. Like virtually every American, I was dumbstruck and horrified. And I wondered about people who hate that much, who have a sort of faith that allows such a thing as mass murder by way of suicide. I felt the world change, and indeed it did.

I had no reservations whatever about the correctness of going into Afghanistan. Aware of the Russians' failure there, and having a sense that it had at least some role in the later collapse of the Soviet Union (I'm no Russian scholar, but having studied the language for many years and traveled there in the apex of the Cold War, I have an interest), I wondered how we'd do better; but figured it needed to happen, and that war had changed in twenty years. The relative ease with which the Taliban were routed was impressive to me and to the rest of the world; and it was a humiliation to those who saw Osama bin Laden as some sort of god-like hero. Would that we had consolidated the victory and seized the opportunity to discredit their philosophy by showing how much better we are. Instead, we turned to the most disastrous foreign-policy mistake any president has ever made.

When our president made it clear he was going to invade Iraq no matter what, I thought of the words I'd heard many years earlier, from a Yugoslavian med student with whom I worked on a research project in Yugoslavia when I was in medical school. (Hey, this does have to to with medicine!) Like Iraq, that country was an ethnic mish-mash. When Tito (the autocratic leader) dies, my fellow researcher told me, this country will come apart. Hatred will bubble up and people will kill each other. He was, of course, exactly right. Even not knowing a hell of a lot, I felt sure Iraq would follow suit when Saddam went down. (Hell, even Dick Cheney said exactly that, at the end of the first Gulf War, explaining why he and George the First hadn't gone to Baghdad.)

I don't think I know -- and I'm not optimistic that history will tell us -- what the fundamental reasons were for invading Iraq. (It's amazing how little one hears about the UN inspectors that were there before we invaded. They were given, we recall, free rein. They were finding nothing. "Everyone believed there were WMDs," we keep hearing nowadays. Right. Before the inspections. But the inspectors were there.) It seems pretty clear that spreading democracy, in some messianic vision of our superior ideas, was at the center of that disastrous decision. Along with a catastrophic and inexcusable misunderstanding of what Iraq society was really about. "9/11 changed everything," we are told ad nauseum. OK, it did. But it didn't change what Dick Cheney understood back there: that invading Iraq would open a Pandora's Box. So if it was right (it was wrong, but if it was right) pre-emptively to invade another country, it's incomprehensible that our leaders didn't plan for the worst case scenario and send in more than enough troops; that they assumed after Saddam was toppled there'd be no need for security and control. If I can get sued for the death of one patient when I did everything right, how can our leaders remain in office when they did everything wrong?

I get that some think the invasion was a great idea. I can't fathom how a single person can support our leaders for how they've bungled it. And I can't see how anyone can disagree that the invasion, as it now stands, has made us less safe; in fact, that it's exactly what bin Laden would have wanted. Did you hear General Petraeus respond to a question that he couldn't say that the war has made us safer?

Think about it: you hate America, you want to inflict as much damage as is possible with the limited resources you have. You don't have an army, you need to depend on fanatics willing to blow themselves up to do what damage you can manage. Wouldn't this be perfect: get the US to invade a Muslim country that had nothing to do with 9/11, tie up hundreds of thousands of your enemy's troops, get them to spend a trillion dollars, exhaust the military; taunt them in such a way that they feel they can't leave without "losing face;" keep shooting their troops as if in a barrel; produce hatred for the US around the world, creating an endless stream of fanatics anxious to kill and be killed in the name of harming Americans. It's perfect. And there's no end in sight. Those Pakistani caves must echo with the slap of high fives.

I know that there are Islamic radicals out there who want to do us grievous harm. I couldn't agree more that it's a terribly serious problem to which we must respond in the most effective ways possible. And I haven't the slightest doubt that invading Iraq was the worst possible way to do it.

September Eleven was a horrible day for the US and for the world. It demonstrated the worst of which humans -- motivated by fanatical religious certainty -- are capable. It was a turning point. A slap in the face to every thoughtful person on the planet, it could have mobilized the world. For a while, it did. And George Bush turned it into unmitigated disaster. He multiplied the victory for al Queda beyond their wildest dreams: by invading Iraq, and with all that has evolved from it, he turned a situation that hurt us deeply but had no potential for bringing us down, into a debacle which could well spell the end of our democracy. No terrorists could destroy our country, no matter what they attack. Bush's response has the potential to accomplish what they couldn't, ever. I really believe that. The ramifications are as yet barely felt; and they are enormous.

Other than that, I think everything's hunky dory. And now you know: I'm a liberal. (Funny, isn't it? It's conservatives who ought to be the most outraged! I do believe in balanced budgets; I'm proud to have served in Vietnam; I think the US has led the world in many extremely important ways. Unlike our president, I think our Constitution is a document of surpassing brilliance, and ought to be followed; that a free and aggressive press and a balance of power are what keeps us safe from idiocracy, autocracy, and theocracy; and that they are failing us miserably of late. There are idiots to go around on both sides of the aisle in D.C.) And now that there's been a definitive study of liberal vs conservative brains, I'm happy to let the cat out of the bag.

Chickenshit


Speaking of diverticulitis, I once operated on a nice little old lady with what seemed to be a classic case of it, with early perforation. On exploration, I was a little surprised to find the colon absent the typical thickening and redness of acute diverticulits; and more surprised on closer inspection to find something poking out of the middle of the sigmoid colon.

What it was, was a chicken bone. Plucked it out (that's what we do to chickens, isn't it?), over-sewed the hole, left a drain for a while, and she did fine.

That's when I learned something I'd never been told: chicken-bone perforations are not entirely rare in people with dentures. They don't get the roof-of-the-mouth feedback that there's something there, and they swallow the bone. If it goes down OK, no one would do anything about it. But with bad luck...

Monday, September 10, 2007

Ken's Colon


Poor Ken Griffey, Jr. Seems like his body keeps letting him down, one thing after another. I was there at the beginning of his career in Seattle, and he was a joy to watch. Now [I began this post a few months ago] he's been having trouble with diverticulitis for the past several months. Guy his age? He's gonna need it out one of these days.

Among the design flaws of the human body (the hemorrhoidal veins and pilonidal dimples are also on the list) is the fact that the blood supply to the colon travels on the outer surface, feeding the inner lining (the mucosa) by sending little branches diving through the muscle layer to get there. Each hole-for-an-artery in the muscle represents a weak spot through which the mucosa can pooch outward, forming a pocket known as a diverticulum. In some people, it happens.



In the US, more than a third -- maybe half -- of people over fifty have at least a few diverticula. Most never know it. For some, it becomes a problem. Unusual in someone his age, Ken Griffey's diverticulitis is likely, according to the odds, to be a recurring problem. Instead of the occasional pocket here and there, I'm guessing his colon shows the typical sawtooth pattern of extensive diverticulosis. (Terminology time: having diverticula is called "diverticulosis, not in and of itself always a problem. Having an infected diverticulum is "diverticulitis. A problem.) The problems diverticula can cause are in two categories: bleeding, and infection. Because, by developmental definition, each diverticulum abuts an artery, it's easy to understand why inflammation or irritation in one can cause erosion into and bleeding from the vessel. Similarly, infection of a little pocket containing hardened stool isn't hard to figure, either. ("Inspissated" is the medical term for some substance that gets dried out and hardened, and it happens to be among my favorites of words learned in medical school. All those sweet and steamy sibilants, stippled by a percussive "p" and a tensile "t." Inspissated. Great word. And "bezoar." Already wrote about that, but feel like saying it again. Bezoar.)

Surgery for diverticular disease involves navigating numerous grey-zones, and a few of crystal clarity. Seeing someone exsanguinate is a sure signal to swing the scalpel. Bleeding from a diverticulum can be steady and severe. But even when the need to operate is obvious, the target may not be; so the extent of the operation can be in doubt, going in. Less likely nowadays, with better imaging and shorter delays in obtaining it, going to the OR with uncertainty as to which part of the colon contains the bleeder wasn't rare only a few years back. And the nature of diverticular bleeding is that it can stop and start randomly. The stopping, perversely, seems to like to happen just as the patient enters the imaging suite. So, short of unrelenting bleeding, there's a certain degree to which deciding when and if to operate is a crap-shoot. (Pun intended? You decide.)

By far the most common site for diverticula, and for bleeding there-from, is the sigmoid colon. (This probably has to do with pressure generated in having a bowel movement, and is why constipation and diverticulosis have an association; and why high fiber intake is really good for people who have it.) There are times when you find yourself in the patient's belly with a less than clear idea of where the bleeding is coming from: a negative or equivocal imaging study; no time to have gotten one. Then what? It might depend on how localized or extensive that person's diverticula are. You might resect the sigmoid if it has the dense concentration that one often sees; maybe even send it right to the lab to see if the pathologist can identify the culprit pocket. Some people advocate dividing the colon at about its half-way point, and seeing if blood keeps flowing from the upper half. Having been impressed with how well-tolerated is the removal of most of the colon (as long as there's a decent amount of rectum -- which never has diverticula -- left), I've not been reluctant, when the chips were down, to do a sub-total colon resection.

With diverticulitis, there are lots of decisions as well. It takes a residency and then some to understand the issues and the choices. Some easy (perforation with peritonitis; fistula -- these need surgery for sure, even if the perfect one might be a matter of opinion), some not (mild attacks, repeatedly -- how many, how severe, is enough.) Timing of surgery, and what exactly to do, are decisions into which judgment and experience are at play. For example, after a severe attack which subsides, it's nice to wait several weeks for things to cool down before operating; but recurrent attacks might occur in the interim. The ideal is to be able to do a one-stage operation -- meaning take out the bad part and sew the ends together. When forced to operate in the middle of a flare-up, it may or may not be necessary to make a temporary colostomy. That's crystal ball stuff. In the really old days, it was three stages: diverting colostomy, followed by resection, followed by a final operation to put everything back together. One of the signs that even surgeons respond -- if reluctantly -- to evidence is that a three-stager almost never is done any more, and many one-stage operations are now considered safe when, not long ago, two would have been the obvious choice.

I should add this: surgery for diverticular disease is gratifying. It's rare to have further problems after having the diseased area removed, and the comparatively small section that's typically taken out leads to no side effects at all. So it's a pretty happy group of patients. It is that for which we surgeons shoot.

Thursday, September 06, 2007

Dead Man Wasting


Even as I questioned the value of dog labs, I wonder still more about the most hallowed and time-honored tradition of medical school: the dissection of cadavers to which all first-year students are subjected. Because the bodies have been knowingly donated, it's not really an ethical issue, except to the extent that those who've made the gift might have a more exalted view of its value than is accurate. And before I say my piece, I must admit it's just one opinion, from a ways back. I'd hope more recent, and current, students might chime in and set me straight, if that's what is called for.

I'd guess we've all seen classic paintings, like Rembrandt's "The Anatomy Lesson." We've heard of grave-robbers hired on the sly to supply medical schools, of Michelangelo becoming one himself to facilitate his artistry; and we know the extent to which these dissections have been carried out, more or less in the exact way, for centuries. So in pushing yourself through the portal into the anatomy lab, you feel as if you're entering a space hallowed by history; taking up a challenge and a charge handed down by people willing to risk their freedom to advance science. Maybe more than anything I can think of, you're stepping into the past. Unlike, say, those who re-enact wars, or who sail on resurrected galleons, this is more than play. It's not make-believe. This is becoming what was, experiencing exactly (sort of) what the pioneers of our field felt, and did. In a couple of important ways, though, it's also a great deal less.

Much as I might have liked to be wearing the flowing clothes, the fuzzy collars and broad hats of Rembrandt's vision, it was rubber gloves and plastic aprons. If I'd imagined being in the thrall of a master lecturer and demonstrator, it was in fact a bunch of clueless students trying to follow written instructions, wrestling alone and together with their conflicted thoughts, working out who'd do what, with a lab assistant sometimes wandering by. (Was that a smirk on his face?) As far from life-like as they could be, the tissues reeked of formalin, and were leathery and hard, belying and opacifying the mystery they held. Or had held. And they were greasy. There's not much to be gained from the process of finding one's way through, by dissecting such unnatural material, spending lots of time getting there and often missing a turn. To the extent that there's knowledge to be revealed, in a preserved cadaver it's in the arriving there, not in the travelling. And marvelous and awesome as is living anatomy, what's revealed in a cadaver is a wooden shadow; as removed from real as a dried and pressed flower is from a bloom.

There was a need to acknowledge the gift this person had made, and there was a desire to turn away from it. To look at the face; simultaneously to absorb and to erase. Tightened, tanned, transmogrified, the body had already been dehumanized more than our dissection would do; still, in making the first strokes of the knife, there's an inward voice saying, "Sorry... sorry... sorry."

Is it like removing the sword from the stone? There's a sense in which this feels like a rite of passage, a symbolic qualification for being allowed to learn the long-guarded secrets. If you faint, if nausea overtakes you, if you can't get past the sense of transgression, you ought not be here. So it seems. Does it harden you? Or soften you up? For most, it's the first encounter with a real live dead body. There's fear of how you'll react, of embarrassing yourself. Some students have ceremonies of thanks to the person who gave their gift. Whom's it for? Is it being actual sensitive, or see-me-sensitive? To the extent that this dissection is ritual, we respond with ritual. We dance with the corpse, and it dances with us. So it raises a question: is it necessary?

In my view, there's only so much -- not much -- that you can get from working with stiffened sinews and pickled pieces. The anatomy I really needed, the relevant relationships I began to understand as a surgeon, I got in the operating room. Or in the basement: I participated in autopsies of unpreserved bodies, and the ones on patients of mine were infinitely more emotional -- and instructive and useful and important -- than that work as a first-year student. The sequence seems wrong: if such dissection is to be done, it ought to be by those more knowledgable and honed. Absent context, it can become clutter. Cardiologists need to have the experience of holding a heart in their hands (and to see one beating in the operating room); how much more meaningful to do it later in the process. As students, it's like a White House document dump: too much information, no hooks on which to hang it. Even books, with their diagrams and plastic overlays provide more understanding once you figure out what it is you need to know. And now, of course, 3-D imaging and computer programs allow interactive and highly effective work.

At the time I went there, my medical school was the leader of a revolution; it broke the timeless tradition of curricular structure. For ever, it had been anatomy, physiology, pathology, pharmacology, lined up in sequence and out of sense. Where I went, they'd just rearranged into teaching by system: cardiovascular, for example, including the anatomy, physiology, pathology, organized in ways to make it meaningful. So the old-fashion dissections were out of synch, and therefore out of use to a much larger extent than at other schools. We did, in other words, much less in the cadaver lab than our contemporaries. In hearing of that, at first I worried that I'd come out unprepared, anatomologically. It was almost embarrassing to reveal to college friends at other med schools how little time I'd spent doing the dissections and taking the tests that they and our forebears had done. But it's clear to me now my time was better spent. And whereas I do think all doctors need a working understanding of the anatomy of all systems, it needn't be -- and in fact isn't -- those first-year dissections which provide it. I'd go so far as to say that, other than imparting a sense of having walked over the same coals as everyone else, the first-year cadaver lab is over-rated and under-important.

Tuesday, September 04, 2007

Puppy Love


Looking back on med school, one thing crests the long list of second thoughts: dog labs. Growing up, I always had a dog. Having left home, when I returned to visit, a dog was always there. (From sublime to ridiculous: Buttons, my confidant, my purveyor of love when I felt otherwise, smarter than any; to Fred the disagreeable.) We recently returned from dog-sitting our grand-dog, a Chocolate Lab, the sweetest guy in the dog parks, Dutch the dog who has never known anger, doesn't even have it in his vocabulary, the luggiest of the big lugs. I love dogs. I approached my first dog lab with trepidation and discomfort.

Smelling musty and slightly feculent, the room held around twenty lab tables of the old-fashioned kind: little sinks, taps, gas outlets suggesting that at some time they supported bunsen burners. On a dozen or more of the tables were dogs, lying on their sides, already anesthetized, looking peaceful and vulnerable. One or two had evacuated their bowels. (We'd been spared the sight of the technicians accessing veins and injecting the pentothal. And the dogs had been spared having us doing it: we'd have made a mess of it.) I don't remember the goal of the work. I do remember that when my partners and I began to reposition our dog, he awoke with frightened cries. Without another thought I turned heel and vacated, waiting in the hall until I heard silence, after the techs responded and re-dosed. With persisting uncertainty, I re-approached the table and helped tie the dog onto his back, shaved his belly. I think I was the one to make the initial incision. If there'd been any further evidence of response by the dog, I'd have remembered it.

It's probably significant that I have no recollection of what it was we were to learn that day: some physiological truth or another. What I do remember is that at some point I got swept into the thrill of handling living tissues, seeing vessels pulsate; touching, smelling, holding. Using surgical instruments. If memory serves, it was my first clue where I was headed. But at the end, as we unceremoniously dumped the dogs into black bags and left, I felt it again: it seemed a waste. They'd told us these were strays from the local pound, doomed to destruction one way or the other. Still, I felt a sadness as I walked away. We'd done, for our own purposes, something not entirely honorable. Whatever it was that we studied that day, our education wouldn't have been less without it.

During the summer after that first year, I got a fellowship to work in the lab of a world-famous heart surgeon. There, we implanted prototype valves into dogs (I assisted some -- never did the actual surgery, of course.) We also worked on a membrane oxygenator: an artificial lung, of sorts. This was important work, and I had then nor have now any reservations about its rightness. But these were my kind of dogs: big mutts, bred there for their size and broad chests. Each morning when I'd arrive at the lab I'd head to the cage containing our latest patient, and he'd whimper and drag himself toward me for a pat on the nose, having no clue what had happened but happy to get a little love. Despite the certainty that it was proper, that there really was no alternative way to test these life-saving devices, it always brought tears to my eyes as I scratched behind his ears, the way my dogs had always liked it.

Dogs don't have differing blood types: a donor provides for any recipient. Our "donors" were greyhounds from the racetrack; the losers. By now, I'd learned to find and access their veins myself, which I did as I tried to calm their high-strung anxiety. After a dose of pentothal they went down, and I made a neck incision to get to a main artery to the brain -- the carotid -- into which I inserted a large catheter and let the dog bleed to death into blood bags. I knew what I was doing, they didn't, as I petted them and mishandled their trust. Dogs willingly jump into a fray to rescue their people, yet this seemed unfair.

Those particular heart valves have saved countless lives. (The oxygenator didn't work out.) It was an important project, and I was proud to have worked there. On return to school, my learned skills allowed me to help other students with some of the surgical aspects of the next dog labs, making the surgery cleaner and the labs therefore more meaningful. It's a little part of who and what I became. Later on, in training, I skipped over a potential research year where I'd be operating on monkeys. I didn't like the way they had to be kept in little high-chairs after, to keep them from pulling on their tubes.

I'm a pragmatist. I don't claim human superiority over animals in some sort of moral sense, but I can rationalize that we do research using them. I'd like to think that it's done humanely everywhere, but I know it's not. Ever more realistic, computer simulations and modeling are becoming widespread; surgical trainees can acquire a significant portion of the skills they need in such a lab. Boeing produces planes that fly just as predicted, and fit together without ever having been pre-tested, using only super-computers. If the day arrives when med students never play with dogs the way I did, I'll be delighted; and perhaps it'll also happen that mankind will figure itself out at a desk, with silicon chips instead of in a lab, with animals.