Bugs, redugs

The previous post, on OR sterility, occasioned an email from a professor of surgery, who informed me of a study of which I hadn't been aware. I quote from his letter:

"I wanted to draw your attention to another surgical/OR dogma that has essentially been put to rest, the wearing of the surgical mask. The Karolinska Institute (and other groups) has evaluated wound infections in two groups, one in which the OR team wore surgical masks, the other without masks. The outcome, as you might predict, was that the infection rates are the same (4.7% with vs. 3.5% without). Here is one of the references: World J Surg. 1991 May-Jun;15(3):383-7; discussion 387-8."

Whereas, in this litigious society, I doubt you'll see anytime soon surgeons and scrub personnel eschewing their masks as a result of this study, I find it unsurprising; not to mention amusing and validating. Part of the inference to be drawn from my previous post is that some of what we do is not much more than ritual -- or, at least, it's unproven even if it makes intuitive sense.

In my earlier days, the ten-minute scrub (washing hands and arms before donning gloves and gown) was standard. So much so, that many ORs had timers above the sinks. Having never seen any studies comparing ten minutes with, oh, eight, or six, I can say I never scrubbed that long, unless someone was breathing down my neck. Later, studies were done: I was right.

Reading the email, I was reminded of a sort-of secret about my practice. For reasons of cost-saving, simplicity, and patient convenience, I did countless breast biopsies in my office, under local anesthesia. These were full-fledged surgical biopsies, not needle sampling (which I also did, in far greater numbers.) I had a small procedure room with a small OR table, a cautery unit (which I rarely used, preferring -- for cost saving, mostly -- the old fashioned suturing of bleeders), and I used instrument packs that we made up and cooked in an autoclave (eventually, after we built a surgery center in our building, we had them process the instruments.) Anyhow, my point is this: I painted the skin with antiseptic, used a small sterile drape, wore gloves and a clean cotton frock, short-sleeved and the size of a shirt. And no mask, unless I had a cold. I'm certain if some credentialing agency were to observe, I'd have been hauled off and boiled in oil. Yet, over a period of twenty-plus years, I never had a wound infection. Got a few hematomata, I'll admit, which I either drained or left alone, depending. But no infections.

I'm not -- repeat: NOT -- suggesting that sterile precautions are unnecessary. Quite the opposite; but I intuit there may well be a level of caution beyond which some measures are less important than we think. (As I said in the previous post, the extraordinary care taken in certain settings is vital.)

A related concept: skin prep. Sterilizing skin before operating is essential. But there are some parts of the process that have always amused me. To wit: it's expected that a reasonable zone of prepped skin will surround the area to be incised. Absolutely necessary and proper -- probably the most important of all the things we do. Yet I've watched with consternation as the prep is done for, say, an inguinal hernia. Unfailingly, the prep is carried all the way to the ribcage or beyond to the north, but only a couple of inches below the groin, where the actual incision will be. Similarly, unless I intervened, the prep for an upper abdominal incision went way down to the pubis or below, but only just above the xiphoid process, topside. I'm not aware (the cop-out that says I haven't looked it up) of studies that compare skin prep distances from incision. I'd guess there is a minimum necessary distance, and a point at the other end of the spectrum beyond which it doesn't matter (taking account of the possible need to extend or make a second incision.)

So what's the lesson? Nothing very important. It just happens to interest me that whereas it's best to err on the side of caution, it seems that much of what we do isn't necessarily grounded in science, nor makes sense. Does that surprise anyone?

Bugs

In commenting on my recent post about scrub clothing, Seaspray asked some good questions about operating room sterility. To give an excellent answer, I suppose I'd have to look up the latest studies. Fortunately for me, I'm quite willing to settle for anecdote and opinion, which is a heck of a lot easier. There's no doubt that maintaining sterility in the operating room is a prime directive. It's also true that, to a greater extent than might be expected, it's an illusion.

That's not to say that maintaining proper technique is unimportant, or that breaks in such technique aren't to be avoided like, well, the plague. It's just that there are inconsistencies that might seem strange, but which don't seem to matter all that much, mostly.

I recall a study that was reported when I was in training. I don't remember where it was done -- it could have been there, for all I know. In it, some sort of stuff was placed on the gloves of surgeons and scrub nurses, detectable in some way -- I think it was by Wood's Light. In the course of routine operations, it showed, touches went to places they shouldn't have: the top of the ether screen, IV poles, face-masks, parts of drapes that were close to the floor. (I assume the stuff was applied after all the draping was done, otherwise it would have been meaningless.) From that report I took a couple of messages: one, we could do a hell of a lot better; and two, it might not be as important as we think. Clean is important. Sterile, maybe not so much. After all, at least in the sort of surgery I did, nearly all wound infections (which -- despite what you may be wrongly concluding is a cavalier attitude -- were vanishingly rare in my practice) occur from the patients' bugs, not the OR's.

Don't misunderstand: my point is not that sterility is unnecessary. It's that, other than cooking instruments and using properly packaged attire, there's much that goes on in the OR that falls short of exemplary. But it's also that whereas it's impossible to achieve perfection, you should take heart: it'll be okay. Under most circumstances, being plenty clean and taking various other precautions (such as proper and judicious use of antibiotics) does just fine.

[OK, let me dispense with one situation: when prosthetic joints are implanted, extraordinary steps are taken, and well they should. Often the scheduled room is specially cleaned the night before surgery, and is then shut down. Rooms have laminar airflow, to minimize the raising of dust; surgeons and scrub nurses wear special all-encompassing gowns, along with full head-gear. Traffic in and out of the room is prohibited. This is because when bugs come in contact with implanted foreign material, they are extremely hard to eradicate. And whereas such steps would probably reduce wound infection in any operation, the incidence in routine operations is so low, and the implications so much less ominous, that following such protocols universally surely would not be cost-effective. (I use the word "surely" in the spirit of my opening paragraph.)]

Between cases, floors are mopped, some equipment in the room is wiped down. But people come and go. Some wear shoes that they keep in their lockers only for OR use; but they aren't cleaned, and if shoe covers are used, they may not be changed for days. Gurneys are wheeled in and out. During some operations, despite the claimed water-proofing on gowns, fluids may leak through to one's non-sterile scrubs, or to one's skin. Also, one must presume, back again. And the operating lights? Don't ask! So. Operating rooms simply are never completely sterile, nor, after a time, are most surgical fields.

Once again, we can only marvel at the wonders of the human organism. I've said in the past that were it not for the ability of a body to heal itself, surgery would be impossible. Surgeons are not healers; we are tippers of the balance, setters of the stage. Likewise, if there were no intrinsic ability to repel bugs, we could never safely enter, because we'll never reduce the load to zero. I've always believed that what goes on under the skin is more important that what we do outside it, surgically speaking. Strangulated tissues don't heal, nor resist infection. Brutalized, they can harbor infection. Carelessly handled, bacteria-bearing organs can be made to seed others. Surgical technique matters, at least as much as the pre-incision measures.

Overload

(Here's another of the posts I wrote a while back, and didn't publish, in my "why bother" phase.)

Once again (it seems this keeps being reported, about annually) we have a report which states that doctors (especially surgeons) are doing a poor job of informing women about reconstruction options after mastectomy. I'm at a loss; I simply don't know what to make of it. My mind is filled with conflicting thoughts.

The first thing that comes to mind is a question: is it true? And: if so, how can it be? And: if it's not true, what's up with the report? And the ones before it. And before those.

I've written about what a complicated and difficult mission it is properly to explain breast cancer treatment to patients. And it's not just because the subject is complicated, with many components to treatment and options within those components; it's also that such a discussion takes place in the context of a mind near to or beyond blowing, enwrapped and nearly erased by fear and shock. There's only so much that can be absorbed.

There are two corollaries: one is that there's a tendency to compress the info, especially during the first encounter. The other is that -- and I know it well, having witnessed it time and again -- even the most careful discussions can be misunderstood, partially forgotten, or misconstrued in the horror chamber that is that initial consultation. Which is why I wrote a booklet recapitulating the information I shared, and personally handed it to each of my breast cancer patients. Even then -- and this really bugged me, because I prided myself in my commitment and ability to explain things to my patients -- I'd get the rare call from a pre-op nurse saying my patient hadn't signed the permit because she said I never explained things to her.

So what I'm saying is this: before swallowing the data without chewing, I'd think there's some number of people who actually did get informed but who zoned it out. Far be it from me to defend surgeons. I know the category includes many who are jerks, who can't be bothered to do much more than cut and run. But to the extent that the data are true -- and I question it -- it may not be entirely layable at the feet of the cutters. And it may also be the case that some surgeons practice in an environment where most of the counseling and decision-making is done with primary docs or oncologists, wherein the patient shows up at the surgeon's door with mind already made up. Or polluted. I absolutely rejected that style; in fact, I agitated to get involved as early as possible. But other approaches are not always unreasonable.

Without doubt surgeons could, as a group, do a much better job of talking to patients. But when someone says he or she was never told this or that, it ain't necessarily so. And when it is, shame on us.

Life Saver

In response to a post from long ago, about death, I recently received the following (in part) comment:

"July '03, I was dying in a hospital bed at the moment my doctor came in to check on me. I saw his face and I knew in that moment that if I let go, he would blame himself for the rest of his life--when it absolutely wasn't his fault. I saw in his face how deeply he cared about me, and I knew I couldn't do that to him....he needed me to live so much, and I needed so much for him not to be in pain for the rest of his life over my death, that that gave me the strength and will to live, gave me the emotion to hang on that I needed, pulled me through that horrendous night."

The more I think about it, the more amazing I find those words to be. I've been there. Much as I always tried to establish a relationship of trust and caring, much as I believe in the value of attitude in recovery from surgery (the writer had not, in fact, had an operation, as she told me in a later email; in addition, the doctor was not even the one treating her at that moment), I'd never have thought of it in exactly those terms. Living because of one's relationship to one's doctor. I'm still not sure how to process it. But it has made me think, once again, about the concept of "saving a life." What does it mean, really, and what are the relationships? Isn't it, at some level, hyperbole?

In one sense, perhaps every operation could be considered life-saving: fix a hernia, prevent strangulation and the death that can sometimes follow it. More clearly, doing a curative operation for, say, colon cancer, pretty inarguably fends off certain demise. Having done thousands of cancer operations, I guess I could say I've saved that many lives. But if there's anything at all to the term, in my mind the concept of saving a life suggests something most immediate. Rescuing someone from a fatal condition, right now, right here, with no time to lose. I've written about a few of those: here, here, and here. Oh yeah: and here.

I've been thanked directly for saving a patient's life. I've gotten cards, annually, on the anniversary of the event. When writing a check at some store or another, my wife (she has control of the checkbook) has been told, "Oh, Dr. Schwab is your husband? He saved my life." It makes me feel weird. I happened to be there at the right time, is all. And I'd learned enough to manage the situation. Whatever else it might be, it's not as heroic as the term -- saving a life -- suggests. There is, of course, another side to the coin. If I can save a life, what is it when I fail to do so?

When thanked for saving a life I always felt uncomfortable, and mumbled something to decompress the situation; to shorten the distance between us; to get us back on equal footing. One human being ought not be in that position with another, so it seems to me. Not a doctor, anyway. And yet, when being unable to save a life (as I described here), I've often felt so bad as to want never to pick up a knife again. And in those rare cases when I've wondered if I had erred... well, it's unspeakable. So maybe my attitude that it's less a big deal than it would seem is tied to my desire not to bear the burden of the opposite; even though I do.

Or maybe it's about "heroism." I've saved lives, whatever that means, but I'm no hero. (I also allow adequate spacing when driving on the freeway, and I've slammed on my brakes when someone made a stupid move.) First of all, the term is so over-used nowadays as to be nearly meaningless. Doctors don't risk their own lives (well, I've operated on lots of people with AIDS and hepatitis C); we don't run into burning buildings, or jump into rivers. Sometimes it falls into our laps to do a thing for which we've been trained, about which we've learned a few more things after training, and we do it successfully, when the chips are down. It alters the trajectory of another's life. I don't know why, but I just don't feel right about referring to it as life-saving. It puts me on a different level from my patients, and I never felt that way. Plus, if my commenter's words are true, it might even be the other way around.

A Step Forward

(This is one of several posts I wrote in the last few weeks, but never published, for a variety of reasons.)

In an ideal world (or, it could be said, a well-designed one) there'd be no cancer. Failing that, we'd have perfect treatment: one that destroyed every bit of cancer with no damage at all to normal cells and organs. That is at least imaginable at some point in the future. Even the not-too-impossibly-distant future. Meanwhile, we're stuck with imperfect treatments and we lack the ability accurately to determine who needs how much; who will get along just fine without extensive treatment (and, for that matter, who will succumb even with maximal therapy.) Recently there was news about some progress on that front.

As a surgeon who dealt extensively with breast cancer, I can say one of the most frustrating categories has been the entity known as DCIS, or "ductal-carcinoma-in-situ." It refers to the earliest possible form of breast cancer, wherein the abnormal cells are confined to the inside of the milk-ducts; as such, because it hasn't invaded across any blood or lymph vessels, it presents no danger at all, as long as it stays in that stage. A very rare diagnosis only a few decades ago, it's become increasingly discovered as mammography is more widely done and is of better and better quality. And it's become a therapeutic dilemma: how much treatment -- and what sort -- is necessary for this entity, not dangerous in itself but which has the potential to become so? As DCIS has been more and more frequently dealt with, it's become apparent that not all forms are of equal potential: some women who have it will never develop invasive cancer; others will. And whereas it's still not universally agreed what treatments are indicated for which types of DCIS in what sort of women, it looks like there's progress toward figuring out which women need treatment, and which don't. That's a good thing.

At a national meeting in San Antonio, a recently published paper was reported (by researchers at UCSF, where I learned to be a surgeon) showing that molecular markers have been discovered which can be used to predict when a given woman with DCIS will go on to develop invasive cancer, and which won't. As is the case with early results, confirmation is needed and the testing is not yet widely available. Still, it strikes me as a really significant finding -- one which will lead to much more precise decision-making, conferring confidence on both sides of the equation. Women who need treatment will really need it, and those that don't can safely be excluded. I hope it turns out to be the case; and I wish I'd had such testing available when I saw all those women, all those years.

Scrub Club

I've just received an email from a designer, in New York City. She's addressing the issue of surgical scrubs and related attire, and asks for my input. (I love the unexpected connections that have arisen from blogging -- and state once again that it wasn't falling out of love that led to my abloggia. Or the current hypobloggia.) I imagine her contact was a scatter-shot towards all the surgeon-bloggers she could google; still, I'm both flattered and intrigued. And it seems a good topic for a post. Writing about a thing, after all, is the best way to figure out what one thinks.

Simple and entirely functional, scrubs are nonetheless among the most recognizable of uniforms, and make an easily understood statement of authority. And not a little edginess: "I work in an OR. I know things you don't, and never will (unless you read Surgeonsblog.)" Assuming the wearer is legit, which more and more is less and less the case.

I think there are phases of scrub-wearing: at first, as a student, you feel entirely a pretender. But you like it. If you select surgery as your future, when you wear them it feels like a commitment; before long, they become comfortable and practical, and wearing them is a matter of convenience (and saving money on laundry.) Somewhere along the line they become a badge of honor; and, eventually, it's all of those at once. I'm most aware of them, self-consciously and proudly, when I'm talking with family members immediately after completing surgery on their loved one. Which means, among other things, that one wants them neither dorky nor unclean.

In surgery, we wear gowns of some sort over the scrubs. Claims of imperviousness to the contrary, they often allow, uh, fluids to penetrate and stain our scrubs. (I wrote about some implications of that fact here.) And, permeable gowns or not, when an operation is fluidiferous the cuffs of one's pants and the shoes or the covers on them bear witness. It behooves, in other words, a scrub-survey before heading to the waiting room. (I know of one curmudgeonly and generally embittered surgeon who liked to talk to families still engowned -- the bloodier, the better.)

Having checked for nastiness and changed, if needed, into clean scrubs, I nearly always donned some sort of cover before going to the families. Since I eschewed a white coat until the latter part of practice, for many years that meant grabbing a cover gown: color-matched but generally untidy and sloppy-looking. It's only in retrospect that I see the get-up as unimpressive. Functional, efficient, but inelegant. I absolutely don't think that the clothes matter much; but when I began wearing a spiffy thigh-length white coat, I found I liked much better the appearance of a clean and pressed lab coat over scrubs. And I took off my surgical hat, too. I hate how I look in hats, and, having fairly long hair, I always wore a bouffant cap anyway. If there's anything to presenting a nice image, that pretty much tears it.

I worked in one surgery center that provided pink scrubs. Having no choice, I wore them.

And now, let me get to the central issue of scrub-wearing, as it applies to the male of the species. Here, I'll let you in on one of the best-kept secrets of the club. I'll begin with an aphorism known to males of any occupation: "No matter how you shake and dance, the last few drops go down your pants." I trust I needn't explain any further. Whatever else it might be, when wearing normal pants drippage isn't a, uh, cosmetic issue. But thin light scrub pants -- well, a spot is easily spotted. That may play into the controversy of tucking one's scrubs in or not; walking back into the OR having taken a break between cases, there may be, on occasion, reason for self-consciousness. Particularly if the stock of clean scrubs is low.

A friend -- my favorite anesthesiologist -- handled it best. Before returning after relieving himself, he'd put a drop of water on his fingertip, and dab it on his scrub pants, down at about knee level.


P.S: what the heck are those people in the title picture doing, anyway?

Flush

It's gratifying that despite my absent posting for many weeks, this blog still gets over five hundred visits and more than a thousand page views daily. This I attribute to the fact that some of my stuff comes up on searches for medical information, which makes me feel as if, whether or not I regain my enthusiasm for bloggery, my work will have been of use. (Or maybe it's just that people like coming by when I'm not around so they don't have to worry about running into me.)

Anyhow, I still get comments and questions; quite frequently on the subject of gallstones, about which I wrote a series (one, two, three, four) of posts many months ago. A recent visitor asked some good questions about non-operative management of gallstones, and I was surprised and disappointed to discover that I hadn't really covered it in my prior series. So this is an attempt to rectify (a term which I used in a punny context -- and one which gets hits now and again, from the perverted and/or the easily amused, ever since -- here, and here.)

Let's start with a gentle statement of fact:

OF ALL THE BOGUS, DISHONEST, DISINGENUOUS AND STUPID BULLSHIT THAT MASQUERADES AS ALTERNATIVE MEDICAL METHODOLOGY, "GALLBLADDER FLUSH" IS AT THE TOP OF THE LIST. THE PURVEYORS OF IT ARE, AT BEST, CREDULOUS; AT WORST, THEY ARE CHARLATANS AND (LITERAL) SNAKE-OIL SALESMEN WHO WILLFULLY DECEIVE AND STEAL FROM THE SICK AND THE VULNERABLE, AND ARE TO BE COUNTED AMONG THE SCUM OF THE EARTH.

OK, let me tell you what I really feel.

Over the years, particularly after the dawn of that series of tubes called the internet, patients have asked me about "gallbladder flush" as a method of eliminating gallstones. They've handed me recipes (which commonly include some sort of oil and something acidic like lemon-juice, with a few plants thrown in), and, in some cases, have proudly presented me with little cartons of their stool, containing what they are certain are stones they have pooped out as a result of drinking their herbalicious and natural remedies. 
Fortunately, as a surgeon, I'm well-used to staring at excrement in its many forms, both within and without the confines of the viscera generally expected to contain it. What I saw was curds. I know stones, and I know curds. These was curds, is what they was. Evidently, if you drink some kinds of oils and chase it with certain acidic substances, what you get is curds in your turds. What you don't get -- and trust me, I've seen the proof in pre- and post-glugging ultrasounds -- is change one in the number and nature of stones in your gallbladder.

As with most other forms of medical woo, the pharaohs of phlushes toss around terms like "toxins", and "weak liver," and "detoxify." They make extravagant claims with no proof. Potions of prevention, like methods that keep the elephants away, are hard to disprove. If my writings over the past couple of years confer me with any credibility at all, please trust me: it simply doesn't work, and the proof -- when there actually are stones -- is easy to obtain. If you really believe it, do it. And then get another ultrasound.

There are, of course, those who push these flushes onto the healthy, onto those with no gallbladder problems at all. Generally those are the ones who have something to sell, and, sad to say, they easily manage to separate the credulous from their cash. Like chiropractic on healthy kids and homeopathy on anyone, it most often does no harm, other than to one's economic well-being, and in the situations wherein it delays needed and actual treatment.

A truism: people who produce the kind of bile that can precipitate crystals will, as long as they have a gallbladder (which is where the crystallization occurs), form gallstones. A corollary: treatments that eliminate stones but retain the gallbladder are generally followed by the return of the stones.

Indeed there are pills that can dissolve gallstones. I've prescribed them, for people who really, really want to try everything to avoid surgery, or for people in whom I've thought the surgery would not be tolerated. The main problems are with side-effects (nausea, cramps, diarrhea typically), and the fact that success depends on the nature of the stones (big ones are unlikely to dissolve, as are ones that contain calcium), as well as the tendency for stones to come back again, eventually. Also, it takes months for the stones to dissolve. But since -- as opposed to flushes -- they may work, such pills are an option, and should be part of the discussion for people facing surgery.

You can also smash gallstones. Twenty years ago, extra-corporeal shockwave lithotripsy (ESWL) got a fair hearing, if for no other reason than it was cool to say the phrase. Results have been predictably disappointing. (My hospital contracted a privately owned, trailer-borne machine to occupy the physicians' parking lot once or twice a month, into which the gallstone-bearing were rolled and pounded. I was told -- by the owners, not the hospital -- I could accompany my patients into the unit and sit there while the technicians did all the aiming and calibrating, and then I could push a button and charge a grand or so. I demurred.)

Similarly, you can guide a catheter directly into a gallbladder and irrigate with a form of ether which, in addition to giving you weird breath for a while, has a chance of dissolving stones comparatively instantly. Long-term, the results are as expected. Short-term, there may be the really rare situation in which it could make sense.

Of all the things a person can do to live non-operatively with gallstones, dietary changes make the most sense. Typically, gallbladder attacks happen after eating a fatty meal, so, theoretically, modifying one's diet to avoid fat and any other personal triggers makes sense. Theoretically. In some people it's a very linear relationship: eat fat, have attack. Don't eat fat, don't have attack. But for many, the attacks come in no relation to eating.

On the other hand, by far the majority of people with gallstones who have symptoms (NB: not everyone with stones has problems from them. I was among those surgeons who leaned away from operating in the absence of symptoms) don't go on to have the really serious complications that can occur with gallstones. So for the average person, absent risk factors that could make complications more serious were they to occur (diabetes being high on the list), and absent a crystal ball, trying to live without surgery by judicious dietary behavior -- and, for some, trying pills -- is not entirely unsensible. Just, in the name of all that's holy -- or unholy, if you prefer -- don't waste your time, or your money, or your self-respect, on flushes. Really. It's the poster-child, the sine qua non, the Platonic ideal, the Mona Lisa of quack.