You Are What You Eat

One of the most dramatic changes from the time of my training to the present is the nearly complete disappearance of elective ulcer surgery (reminder: as I've said before, "elective" means non-emergent, as opposed to unnecessary.) The revolution began with the advent of drugs which effectively reduce gastric acid production, and settled in for real when the relationship between ulcer formation and the bacterium known as h. pylori was worked out. I have to admit I lament the passing. Given time to plan it and give some thought to the available surgical choices, operating on the stomach for ulcer is technically interesting and therapeutically rewarding. Limiting the experience to emergencies, while setting the stage for drama, means narrowing the field to one of a certain untidiness.

I've always liked fresh corn and peas. Each brightly colored, with a crisp sweetness, and both best when cooked very gently. Sit those kernels on a plate, they make a nice visual statement as well. Slopped between loops of intestine, stuck above the liver, soiling the hidden spaces around the pancreas and duodenum, filling the pelvis, some of the sensual pleasure of what may have been a nice meal gets lost, and dealing with it puts me off the feed for a while. Doesn't smell all that great, either. If it's embarrassing to get a drop of soup on your tie, imagine how it'd feel to see your omentum harboring a whole salad. Hanging down from the transverse colon like a wet apron, it can hide lots of cranberries in its crannies; getting them loose requires individual plucking, and can take a while. The upside is that a person with a perforated ulcer is generally in a lot of pain, and sewing up the hole, cleaning out the food, and copiously irrigating away the acids means s/he is likely to wake up with a smile. I can put up with a little personal unpleasantness when it produces results like that.

Stab wounds don't seem to happen on an empty stomach. Maybe it's because victims of such things are not always entirely innocent. Drinking all night in a bar, washing down peanuts and chicken wings appears to be a necessary precursor to picking a fight, and losing it. Knife holes in the stomach are generally much larger than ulcer holes, and can empty prodigious amounts of stomach content into the abdominal cavity. The odor of alcohol and partially digested food in the belly is not much different from when it appears on a fraternity floor; sticks with you a while. But once again, a few well-placed sutures and some high-class janitorial work predictably results in a happy patient. The process can require an amazing amount of saline wash before the irrigating fluid looks clear enough to drink.

Of all the new words I learned in medical school, "bezoar" (pronounced BEE-zor) is among my favorites, just for the way it sounds. It means an aggregated lump of stuff that can clog the stomach, or the intestines, and can look quite impressive. They come in two main varieties: trichobezoars, meaning those containing hair, and phytobezoars, referring to those resulting from undigested vegetable matter. A feline furball is a trichobezoar, as is one occurring in a human who chews hair. Where I learned to be a surgeon, springtime often produced a victim or two of over-indulgence in a not-yet ripe local fruit: persimmon bezoar was on the list of possible diagnoses of abdominal pain. I've opened a few stomachs to extract bezoars, typically in pieces. The usual word sequence, spoken to the scrub nurse, goes something like "stay stitch... one more.... cautery.... suction.... ring-forceps.... eww gross...."

I must have dozed a bit during the lecture on bezoars in med school: not at all unusual, I confess. Hearing vaguely through my daze about eating hair, fur-balls, undigested organic matter, tricho- and phytobezoars, for a while I thought I'd heard that a hair-ball was called a Fido-bezoar, as in the generic doggie, good ol' Fido. When I was corrected by a classmate, I was less embarrassed than disappointed.

Memorable Patients: part seven

I first met her when I consulted on her hospitalized son, who'd been in and out several times with transient abdominal pain. He'd already been through various tests and consultations, each time improving before a diagnosis was established. When I was asked to see him he was once again on the mend, but I concluded that he likely had the uncommon condition of recurrent appendicitis, and proposed surgery. Taking out his appendix, which I did shortly thereafter, permanently cured him, and the pathologist confirmed the diagnosis. Mrs. Davidson told me she knew God had sent me to them, and thanked me prayerfully. As her son recovered, she prayed with him as well.


When next we met a few years later, she was the patient, having discovered a lump in her breast. With a fine-needle aspiration I confirmed the diagnosis of cancer, and before long we were together in the operating room. Based on my physical exam, I expected to find some lymph nodes containing tumor; but when I got into her axilla, I was surprised -- sickened, really -- by how many. There's a clear correlation between failure to cure and the number of lymph nodes under the arm. Whether removing those nodes is therapeutic or merely diagnostic is a matter of disagreement: in other words, does removing them improve prognosis in any way other than telling us what we're up against? Regardless of further therapy, is it good to remove all the nodes you can? I think so, until clearly shown to be otherwise. When the cancer has marched its way all through the axilla, the odds are very strong that it's gone beyond as well; but in the absence of proof of spread outside the axilla, it's still theoretically possible that removing all the tumor in the breast and under the arm will be curative. Theoretically. That's what I did for Mrs. Davidson, and of the fifty or so lymph nodes found in the tissues I dissected out, thirty-two had tumor in them. I think that's the record, in my practice. Her risk of relapse somewhere in her body was dauntingly high.

At each stage of the game, Mrs. Davidson prayed, and her faith seemed to carry her. The lump would be OK, she felt, and when it wasn't she knew God would be with her. But when she got the news about the lymph nodes, and the implication for cure, and when she heard the recommendation of her oncologist, she fell apart.

Not far down the road from my area of practice, there was an on-going study of women with advanced breast cancer: removing and preserving bone-marrow stem cells, giving massive doses of chemotherapy and radiation -- enough permanently to kill the production capabilities of the marrow -- followed by returning to the patient her saved marrow cells to regrow her blood-making ability. It was tough stuff, taking the women to the brink in a most literal sense, suitable -- if at all -- only for those with very poor prospects. (The therapy has fallen into disrepute, in a pretty messy set of circumstances featuring another patient of mine who'd come to me with widespread recurrence.) With cancer all over the body, it was a desperate "hail Mary" of a treatment. In a situation like Mrs. Davidson's, it made more sense, at least from some points of view: take a woman with a very high statistical chance of having cancer somewhere, but undetectable, in her body, throw the therapeutic book at her on the theory that the best chance to cure lay in getting those cells when they were at their fewest in number. (Which is also part of the rationale of removing all the involved nodes.) That's what her oncologist recommended, and I concurred.

For Mrs. Davidson, it was hell on earth. Unable to eat, nauseated, dependent entirely on intravenous feedings, bleeding what little blood she had, fighting infections -- she was as miserable as it gets. Per protocol, she remained hospitalized for the entire treatment and well after the stem-cell reinfusion. Her husband, who worked at a coffee shop I frequented, told me on many occasions that she'd said she wanted to die, that she'd begged them to stop treatment. He wouldn't let her; he wanted her around. But she sank deeper and deeper into depression; how could God do this to her, she asked, after everything she'd done for God?

Her anger and depression outlasted her therapy. After her release from the hospital, I saw her fairly regularly, even though she'd healed her surgery: she just wanted to come in and ventilate. As hard as it was for her, it was frustrating for me: surgeons like to fix things, and I had little to offer except an ear. Seeing her continuing to lose weight, to descend into darkness, I finally suggested anti-depressants, which she accepted with a "why-bother" shrug. In the periods between visits, which eventually tapered off, I frequently saw her husband at the coffee-shop. He was nearing the end of his rope as well. She remained despondent, he said, despite the passage of time with no sign of cancer.

I've generally observed that when people have deep religious faith of any sort, in most cases it helps them cope with bad news: "God's will." Despite her attitude when I cared for her son, in Mrs. Davidson's own crisis it seems to have done the opposite. Funny thing is it's over fifteen years since all this happened, and she's doing great. Her depression is long gone, she's active, and there's not been any evidence of disease since her operation. In our relationship, I never initiated discussion of her faith, and I don't know where it ended up in her life. In medicine, nothing is 100%. She seems to have beaten very long odds. How? Maybe I actually got to her at the moment before any distant spread, and my operation cured her. Maybe the hyper-intense therapy did exactly what it was intended to do. Maybe she'll recur still, and we just bought her some time. Or maybe....

Of Flames and Flamers

I suppose I should be happy that I've been around long enough to have been noticed. A couple of highly flaming comments have finally appeared on my blog, which has forced me to consider the concept of deletion. (This post, brief as I hope it to be, violates one of Dino's admonitions of not blogging about blogging.) My first instinct is to think that I should let people say whatever they want, and in general that's what I believe. On the other hand, it's my blog, and guess I can do what I please. People don't have to read it if they don't like it. So I have now officially deleted three comments: the first, a long time ago, was because someone attacked personally another commenter. The next two were today: one was a quite personal attack on me, based, as far as I can tell, on a comment I'd left a while back on a post on another blog and having no relevance whatever to anything I've ever said on this blog. [Appended note to that person if he happens to read this: I found the original thread on the other blog, and left a comment there, in response to yours. It seems the more appropriate venue.] The commenter evidently couldn't see, from his side of the screen, the tongue in my cheek. The other (posted the same day on another of my posts, so, for all I know, by the same person) was also a very nasty one that had likewise missed (or disapproved of) another attempt at humor. I know I will not always hit the mark in trying to be funny. And I love reading comments that see things differently from me, or have a different take on what I've said. I believe in constructive argument; and I'm more than aware that my opinions don't represent some sort of ultimate truth; nor is my writing above reproach. (Most of all, of course, is this: it's not as if anything I say or don't say, or do or don't do on this blog has any significance in the larger order of things. Let's solve energy independence and global warming before we get too excited about my blog.) I've left on this blog more than a few negative (or disagreeable/disagreeing) comments, and will certainly continue to do so: I like to read what people think. But if you want to attack me personally or if you choose to get so far off point as to approach the undecipherable -- and do so excessively nastily -- you should do it on your own blog. And if you do, I'd love to know, so I can come over there and defend myself. Over here, depending on tone, my mood, and how long it's been since I've eaten, the really nasty stuff will self-destruct. Thank you. And merry blogging, one and all.

Surfing for Science

Google has changed healthcare delivery. Once a rarity, it's now common that patients sitting across from their doctors are primed with lots of information, largely downloaded. Medicine is not unique in this, nor is it a bad thing: if you take the time to find out dealer invoice before your automobile purchase, surely you ought to inform yourself about your gallbladder. A good doctor considers it an essential part of the relationship fully to inform a patient, whatever the subject. Eschewing the cookbook pre-packaged booklets available for most surgical problems, I wrote my own, developed a few handy visual aids, and spent as much time as it took to educate those entrusting to me their care. In general, I liked it when they came to me already well-informed. Well-informed. It won't come as a surprise, however, to learn that many had filled their heads with crap.

The internet, while a most remarkable source of information on every imaginable subject (and some I could never have imagined), is also an equal-opportunity fount of bullshit. Debunkery is not my mission here: others (notably Orac, who regularly and brilliantly [and respectfully!] skewers medical mendacity) do it much better than I ever could. My point is that as much as I want to inform and educate and answer all questions, it's more than irritating to have to admire a jar of stool proudly produced to show the "dissolved gallstones" resulting from a snake-oil recipe googled and then gobbled. Knowledge, as they say, is power. Misinformation kills. Failing that, it annoys.

I still haven't gotten around to posting on the subject of the gallbladder, the surgeon's best friend. I will, I will. In the interim, I can report that whereas taking lemon juice and vegetable oil, along with some herbal flavorings, can produce some sort of curdled mess that becomes indigestible enough to burble out the backside in lovely little lumps (say it out loud: it's fun), it does not a damn thing to stones in the gallbladder. I guess there's no real solution to the problem of disreputable downloads: at least they're asking me about it, as opposed to going off on their own. On the other hand, I'm not seeing the ones I'm not seeing.

In that most non-existent "best of all worlds," doctors would be entirely worthy of trust, and trusted. How nice it would be if medicine had all the answers, I knew them, and perfectly shared them. How excellent if people could happily, confidently, and realistically leave everything to their doctors, could feel they needn't arm themselves with data before the consultation. They can't, of course; and shouldn't. You'll never hear me argue that doctors have god-like omniscience, or that patients should just shut up and take what we dish out. I'm well aware of doctors who are poor communicators, and/or who (amazingly enough, in this modern world) still take a very condescending view of patients and their need for information. And yet, one wonders: is there a limit, an end-point? When does patient advocacy become an impediment to the necessary rapport between doctor and patient? How much information is too damn much? Unsurprisingly, I don't have the answers. I do, of course, have opinions. Feelings. That's the kind of guy I am.

At the extreme, I've had patients bring "advocates" to the office. Steely-jawed, humorless, with an "I've got your number, buster" look and an ostentatious finality, they've produced tape-recorders and planted them on my desk. "Now just try to bullshit us, you self-satisfied doctor, you. You establishment dick. We know about guys like you, and you're not getting away with it..." Or so it seemed. I'm a garrulous person, but that's sort of a show-stopper. I've also seen the glazed look of information overload, at a time when it's least welcome. Breast cancer is the prime paradigm, applicable as an example in both of the preceding situations.

"If your surgeon recommends mastectomy," it's been said, "find another surgeon." "No woman ever again needs to lose her breast," has been written and read, widely. And it's absolutely untrue. But tell the woman who has extensive high-grade DCIS that she ought to have mastectomy, and you might see her get up and leave. (Not really, in my experience. But it takes a long time to explain why what she'd heard is, in this fairly uncommon situation, wrong. Having watched her initially recoil at the information.) Conversely, try to enumerate all the options of primary treatment in the usual circumstances; explain the role of radiation and chemotherapy, and the types of each; the kinds of lymph node procedures, the different forms of mastectomy. List all the options for reconstruction, starting with immediate versus delayed, and get into the operative choices once that decision is made. As you watch the mind sizzle, you want nothing more than to say "here's what I think you should do, and here's why." In fact, it's not rare to be asked to do just that. Choice, it turns out, and abundant information can be -- for some people -- more than they want to handle.

I've always thought it a cop-out for a doctor to give a patient a list of options and then mutely leave the decision to her/him. Part of our job, I think, is to say what we think should happen, and to explain exactly why, yet to do it in such a way, when there are several options, that doesn't close the door to patient preference. Instinct sometimes tells me that this person or that needs more, or less, information. This person wants direction; that one doesn't. It's a subtle and somewhat mystifying thing: how different the relationship can be. But this part isn't mysterious: when there's a tape-recorder whirring on my desk, I'm highly inclined to do the list thing, and say, "let me know if you need more information, or if there are other ways I can help you with your decision.... Next."


Addendum/Update: I suppose I should clarify. This isn't really about the wisdom recording your doctor visit. I understand the desire to do so in order to remember what was said, and when I've had patients ask if it was ok, I always said yes. Likely I'd also mention I'd be giving them self-written booklets that would serve the purpose as well. In the cases I mentioned above, it was an in-your-face I-don't-trust-a-thing-you're-about-to-say encounter, initiated not by the patient but by a gun-slinging sidekick. Different animal.

A Winter's Tale

Tending toward the heavy myself (losing it when I get back into cycling, periodically), I have sympathy with those who are overweight. Nevertheless, it's a fact that the obese present a broad spectrum of problems for surgeons: higher risk of wound infections or hernias, slippery hands when tying knots, harder to find the proper tissue planes for dissection. Difficult anesthetic management, blood sugar issues, blood pressure, too.

Lots of things make it less than pleasant to have patients who are significantly overweight. So when the guy showed up in the ER and I was called, I wasn't thrilled. On the other hand, his problem was one I'd not seen before. I like a challenge, most of the time. Not necessarily in the middle of the night, in the middle of winter.

It being late when I got the call, and cold outside, my first thought was that I could punt the case to the plastic surgeon. But they'd already tried him, and he was having none of it. So with my usual expletives and foul wee-hour mood, I got out of bed and headed to the hospital. "Circumferential pressure sore," they'd said. Fat necrosis, risk of a necrotizing infection. Gonna have to take him to the OR, cut away a huge amount of tissue, maybe a few times. Dressing changes for weeks. Skin grafts. Royal pain in the ass. Such were my thoughts on the dark drive, watching out for black ice, sliding on snow.

In the ER, reading his chart before going into the room, I could hear the man referring, it seemed, to every nurse within shouting distance as a "ho'." So I was primed for an unpleasant encounter when I walked in, and I must admit I was a little rude to him. Didn't ask how he'd gotten the injury, didn't exchange pleasantries. Just lifted up his garish shirt and had a look (what was this guy, a pimp? He called me a "ho," too. Several times.) Occupying the entire circumference of his enormous belly (the kind that transmits waves across it, like Jello -- not a good prognostic sign, in terms of pleasant surgery) was a band of mottled skin, maybe five or six inches in width, pocked here and there with open sores; oozing, and dirty.

Mixed in a disgusting brew, with what looked like a bunch of tiny hairs, was a fine black powder, like pencil-filings without the wood. Like uniformly ground dirt. Like soot. And despite wearing gloves and boots and the most ridiculous pants I'd seen in a while, the man had cold skin, without the erythema you'd expect in someone successfully being re-warmed.

Clearly, he'd been out in the cold for a long time, raising all sorts of other possible untoward scenarios. Given the potential for rapidly progressing infection I reluctantly opted for immediate surgical debridement, put in a page for the anesthesiologist, and called the OR.

Uncharitably, as I contemplated the problems this guy was going to entail, possibly for weeks, I noted he was a "John Doe," from out of town, no local contacts, no insurance. Of course not: if he'd been insured, they'd have called one of the fancier docs.

"You're going to hate me for this," I confessed to Larry, who happened to be one of my favorite anesthesiologists. "He's huge, I'm going to have to reposition him two or three times during the case, and he has an enormous beard [anesthesia guys hate beards: they make it hard to fit a mask while inducing anesthesia, obscure the view while intubating, and resist taping to secure the tube] which he refuses to let anyone near. Dirty as hell, too. Soot or some crap like that." Trying to be candid up front, letting the man know what he was in for. "Great," said Larry, as he hung up the phone. "I'll be there when I get there."

By the time I next saw my patient, in the pre-op holding room, they'd removed his clothes and put them in a couple of bags. Boots, gloves, heavy coat with fur-crested sleeves (who wears crap like that? Heard of PETA?); and now, in the warmth of the room the stuff smelled like a barn. So did he, for that matter. Looked like cow-shit on his boots, too.

I don't mean to denigrate the man -- he was a human being, after all -- but a fat smelly guy at three a.m. or whatever it was by then: I like to think of myself as more empathetic than your typical surgeon, but it was just a bad situation, getting worse at every turn. Larry was much more mellow than I, probably getting a laugh over my obvious displeasure. He gave the man the usual once-over and piloted the gurney to the OR.

It took six of us to move him onto the OR table. He'd told us he was two-eighty, two-ninety pounds, but he was three-fifty if he was an ounce. I work with bariatric surgeons of late, and we have these very ingenious Hovermats for moving the patients: they literally float on cushion of air, and glide so easily you have to worry about zooming the patient off the other side. No such thing this night, in this OR. My back hurt, to make a bad situation still worse.

I won't belabor the surgical details. Suffice it to say it was as depressing as I'd imagined it would be: fat upon fat, greasy, slippery, smelly. Rolling the man from side to side, to Larry's grumbling (he'd crossed over to my mood half way through trying to intubate), I cut away a belt of skin and subcutaneous crud which, had I been able to do it all in one piece, could have wrapped twice around a telephone pole. It had taken the poor nurse fifteen minutes to scrub clean the man's stomach: ground-in dirt, intertriginous gooey grime. What had he been doing that he couldn't stop for a shower once in a while? No running water where he lives? Everyone had his or her own reason to be repulsed by the whole thing.

Having written post-op orders and assured myself it looked like he'd wake up OK, I went to take a shower. Unlike the description in my recent post I wasn't covered in blood. It was just the stink of the whole situation that needed cleansing, I guess. When I came back to the recovery room, the man was gone.

Gone!! Kathy, the world's best recovery nurse, seemed uncharacteristically befuddled. "What the hell happened?" I inquired (you might call it). "Where's my patient? What's going on around here???" I was pissed: I hadn't yet decided whether to send him to the floor or the ICU. Who'd made that decision without me??

"He checked out," Kathy said.

"Checked out?! What are you talking about?? He died??"

"No. I mean he checked out. He said he felt fine, and had to leave. Pulled out his IV, insisted I take off his bandages. Said he had important work to do that absolutely couldn't wait. He said he'd been so cold in the ER he couldn't even remember who he was, could barely talk."

"You gotta be kidding. There's no way he... How could you let him..."

"I don't know. Really, I don't. I know he couldn't, shouldn't... he just talked me into it, like I was a child. I know it's wrong, but it's like I couldn't argue. I didn't even think to call you, or security, or anyone. I don't know, I just went blank, like he..."

"Oh, man! This is really bad. We gotta call the cops or something. He's gonna die out there..."

"I know you won't believe this, but he looked great. And the wound? Either you did an amazing job or, or, I don't know what. It looked like it was healing already. Almost like it never happened."

"Jeez, Kathy! What have you been drinking? I don't believe this. This is.... I'm calling the supervisor. We gotta..." I was as flummoxed as I've ever been; didn't know what to do. Finally, I just decided to go home. It was the most screwed up thing I'd ever heard of, and I just wanted to pretend it hadn't happened.

"Sid?" Kathy asked as I tried to storm out the recovery room door.

"What!!??" I responded, with zero patience.

"How about his story? About how he got the injury?"

"What story? I didn't even hear the story. What story?"

"Getting stuck trying to get into someone's chimney, being pulled out by some animals. The way he said it, he seemed serious. Oh, and he left these for you," Kathy grinned, tentatively, as she handed me half a dozen wrapped boxes.

"Yeah, right. Keep 'em. Guy's a liar, some sort of sociopath. I gotta get home and get Danny's presents under the tree before he wakes up. Merry frickin' Christmas."

The Gambler

An anonymous commenter on one of my pancreas posts said "I think ... surgeons tend to see things from a "look to the past" view as opposed to "look at the future" when it comes to individual patients..... I don't expect a surgeon to be God....but I do wish he could be God-like and consider the past, present AND future." He had undergone extensive surgery after which he was evidently left with severe side effects, and a miserable quality of life. As I understand it, he seems to be saying he wishes his surgeon had given some thought to what he was about to do to the man, and -- I infer -- not done it. The implication -- well, the clear-cut statement -- is that this person believes surgeons do what they do with no thought at all about the consequences. If you can cut, do it; the more, the better. Period. Nothing could be further from the truth.

Bottom of the ninth, game seven of the World Series. The pitcher has struck out the first two batters, looks like he's in the zone. Up comes Casey, who's already gotten a homer and a double, and who has a .480 record against Lefty. Manager brings in Righty O'Doul, who strikes out Casey. The crowd goes wild, carries Righty and the manager off the field. Great manager: brilliant moves, knows the game, damn genius.

Casey hits an arching 450-footer into the stands, dead center field, the Cephalopods lose. Beer cups rain down, sports-writers foam at their laptops, the manager loses his job. Bad manager? Didn't think about the consequences of his move, didn't have cold sweats over it then, and after? Trivial analogy?

In my book, (yeah, time for another plug!) I said that what we do is a sophisticated game of odds-playing. We have had lengthy training; we keep current on the latest developments; we have our experience on which to draw. My commenter knows we aren't gods, but wishes we'd be god-like in looking at the future. And exactly makes my point. Obviously, we can't. We can guess, hopefully in the most educated and well-grounded ways. We can bring to bear every bit of our knowledge and use all of our experience; listen to our "gut," even reflect it all against our sense of right and wrong. Some doctors undoubtedly pray over tough (or easy?) decisions. And inevitably, we will have some lousy outcomes, some patients injured as a direct consequence of our decision making. If I know with 99% certainty (rarely is any outcome that sure) that if I do A, B will occur, and if I do A a hundred times, the odds are I'll have one very unhappy (or dead) patient. I will have been right every time. Tell that to the one patient.

If my commenter were my patient, I'd feel horrible. I feel bad for him as it is. In fact, it's entirely possible that his surgeon screwed up, made a bad decision, or did exactly what my reader infers: figured there was an operation that could be done, and did it, because that's what he does. But I doubt it. We're an eclectic bunch, us surgeons, but most of the ones I know are thoughtful and careful -- exactly because we know that what we do is imprecise and unpredictable at best. We understand what improves the odds: meticulous technique, careful planning, knowing as much as possible about all the options, thorough knowledge of what's going on with our patients. To use "anonymous"'s words, we look to the past for our knowledge, to the present to assess what's going on, and to the future to make the best choice possible for the situation at hand. That we're not always right -- or more likely, that we made a careful and thoughtful decision the outcome of which was lousy -- doesn't mean that the process was flawed in the way my reader implies.

Perfect surgeons (if there were such a thing, and there isn't) will have imperfect outcomes. And I wouldn't deny for a minute that there are some bad docs out there. The nature of surgery is that bad surgeons can do especially bad things. I'm not making excuses. I am, I think, stating the case as it is: yet no matter how happy the ninety-nine are, it doesn't change a thing for the one who came up on the short end of the odds. And here's the part I'm not sure I can say without sounding callous: I have an obligation to do everything I can to get as close to perfection as possible, including thinking long and hard about the possible outcomes of every choice I make. But if I were to dwell too much on the admittedly deeply disturbing and regrettable folks like my anonymous commenter, I couldn't do what I (used to) do. And lots of people would be the worse for it. Assuming I am in fact fulfilling my obligations to try to be the best surgeon I can be (and assuming my best measures up), at some point I have to accept there will be failures, and to hope that on some level, patients will, too. Or else I'd jump off a bridge. There were times when I came close.

That's a couple of downer posts in a row, on more or less the same subject. Got a good one coming up. Y'all come on back, hear?....

God of the Operating Room

It's an old joke: a long line of people waits at the Pearly Gates as St. Peter slowly checks them in, taking an eternity. Little guy in a white coat shows up, carrying a leather bag, stethoscope around his neck. St. Peter waves him through. "What the hell was that?" someone asks. "Why does that doctor get cuts?" "Oh, that wasn't a doctor," Pete says. "It was God. He just likes to play doctor once in a while."

But it's no joke. Whereas I don't buy the "playing God" aphorism, I've had to make life-and-death decisions on occasion, and I don't like it. I mean "life and death" literally: this person lives. That one dies. Saving a life is nice, and part of the job; failing to save one is horrible, yet inevitable. But deciding in advance -- looking at a situation and concluding it best to let things go, or choosing to render help when the outcome might be regrettable -- is a responsibility beyond understanding. Maybe it also comes with the territory, but who has the roadmap?


Bowel infarction is a good example. Dead bowel happens for a lot of reasons. Untreated, of course, it's fatal. In operating, one may find -- depending on the cause and the anatomy -- a small segment of intestine the removal of which is not only life-saving but free of side effects; or you might find essentially the entire gastrointestinal tract dead and black. Removal in that case is possible, too, leaving the person entirely dependent upon permanent intravenous feedings. Or there might be enough small and large intestine remaining to handle oral intake with or without intractable diarrhea, with or without the need for complicated supplemental nutritional support.

And there you are, in the operating room at three in the morning, looking into a belly. No crystal ball, no outcome-prediction software; no moral counseling or ethics committee with two-cents worth of advice. What resources do you marshall; how do you decide whether to close up and deliver the bad news to the family, or to go ahead? Can you make a decision without interjecting your own moral values? Should you? Surely it's conceivable that two people might make different decisions; ergo, it's subjective. Who, then, has the right? Rarely, you may know enough about the patient to have an idea of what he/she would want. But how can you apply that when you're not sure what kind of life will result from going ahead? Wrongful death? Wrongful life?

These people don't come to see you in the office, don't participate in a leisurely give-and-take about their illness. They show up in the ER in pain, sick as hell, in no position -- much less able -- to philosophize. Nor do they come to you because they like what they've heard about you. Luck of the draw: they show up when you're the guy on call. Their lives are in your hands because of the most random of circumstances. But there's no avoiding it.

It doesn't take long to realize the power of influence you have. In fact, it's my impression that often people -- patients, their families -- WANT to be relieved of the responsibility. Grandma has been in a nursing home for a couple of years. Ninety years old, not always recognizing everybody, she suddenly is complaining of abdominal pain and is now in the ER with signs of some sort of abdominal catastrophe. "We need to get her to surgery right away," you can say. "Or she'll die." Clearly that stacks the deck toward going ahead, and, frankly, it's the easiest way out -- for the surgeon. I know many who always take that approach, and I think it's neither that they love to cut above all, nor that they want the money (what little they'll get from medicaid.) It's just that it avoids all the moral wrestling; with the people, with yourself. But it is, of course, just as subjective.

"It's obvious something serious is going on, something that would require an operation to fix. It may or may not be fixable; she may or may not be able recover from what we'll have to put her through. This could be too much for her no matter what we do; so I want you to know that it's possible to be sure she's entirely comfortable, to be sure she doesn't suffer in any way, and to let her go. You know her better than I; you know her life. I'm willing and comfortable with either approach. What do you think?" That's another way to handle it, one which I've done many times. And sometimes, either when such an approach doesn't lead to consensus, or when even before I've said such a thing I see a family in turmoil, I'll ask, "Would you like to know what I think?" That's where it gets hardest of all.

"We can take a look. I can see what's going on, and make a judgement: if I think it's a solvable problem with a reasonable chance of recovering, I'll do what I can. Or I'll come and talk to you before making that decision." "I think whatever is going on in there, it's too much for her, given her condition, and I think making her comfortable would be a kindness." I've said each of those, more or less, on many occasions. Some people think that if there's a one in a million chance of recovery, it should be taken: as a general rule; as a moral principle. I don't share that idea, but I can't say it's objectively wrong. If a patient in a one-in-a-million situation got me as their surgeon, they'd be more likely to die without an operation. If another surgeon, they'd likely die with one. Should that be a matter of chance? From one point of view, always going for the one-in-a-million chance seems the purest, cleanest, most honorable (life-affirming?) approach. From another, it looks like the ultimate moral cop-out, an abdication of responsibility. Can anyone say for sure?

It doesn't end, of course, with the decision for surgery. In the case of the dead bowel, you'll likely be confronted with operative uncertainty. In the example of the old lady, if virtually all her gut is dead, it's nearly automatic: take a look, and close up. ("Peek and shriek," is an oft-used phrase.) But what about a twenty-year old? It could happen, as a result of blood clots. Most likely you'd remove the bowel and do everything you could to get the person through the crisis, knowing they'd be facing a very abnormal existence. Having the whole gut gone is pretty rare. Having most of it gone, though, is not; enough that you could hook a foot or two of small intestine to a foot or two of colon. Again, it's not something I'd do with an elderly and sickly person; but I did it once with a young person. In both cases, it was entirely up to me, and I made the decisions -- necessarily, far less than fully-assured. And if not ninety, but yes twenty, then where's the line? Sixty-seven? Or what accompanying factors? Heart disease? How many vessels? More than that: what factors am I bringing to bear from within myself? Experience, knowledge of what I can (or can't) do, what decision I'd like made if it were me? Am I allowed those colorations? Given that there are no clear answers, it's not hard to understand how some surgeons would take the approach always to operate, and always to do what's technically possible, no matter the consequences.

A commenter in one of my recent pancreas posts described the misery of his life after a big operation, implying, I think, that he wishes the surgeon hadn't done it, hadn't saved his life. No one that I can recall has ever said that to me, not even the lady I left with severe short bowel syndrome. But I didn't end up seeing her for long after the operation, and I imagine her life was miserable in many ways. I'd not be surprised to learn that she's said it to someone, since. If it were to me, I'd feel really, really bad.

Boxers, or Briefs?

Early in my training, I noticed that some attendings would strip raw before putting on their scrubs and heading to the OR. Given who some of them were, I found it sort of creepy, as if at some point they'd lean over to the scrub nurse and whisper, "I'm not wearing any underwear." I never liked seeing my dad naked, for that matter, and I certainly didn't want to watch those old guys parade around. But, it turns out, there's a good reason. Sometimes, surgery is really messy.

When I started in this game, AIDS was unknown. We took certain precautions, of course, but getting drenched was just part of the deal, especially at the county hospital, where we treated every instance of trauma that occurred in San Francisco. Neither the cloth gowns we used at first, nor the paper ones that came along later were particularly water-proof. Operate on a guy bleeding out from a few stabs or gunshots, and you'd finish the case soaked in blood; literally, it could fill your shoes. Remove the gown, and the scrubs were wet with sweat and blood. Remove the scrubs, and your front side might look spray-painted. Pink pubic hair: not a good look, at least on me. The smell and stickiness of blood: not pleasant. Showering after looked like the scene from "Psycho," only in color.

My friend Bill Schecter, now Chief of Surgery at San Francisco General Hospital (he was one of my junior residents when I was chief resident), tells his residents if they want to see their grandchildren, they need to wear rubber gowns, full facemasks, and tall boots. At SFGH, it's assumed that everyone they operate on has HIV. In my practice, it was rare indeed. On the occasions when I knew in advance I was operating on someone with AIDS, I wore a rubberized gown, and it didn't work for doodly. I was still gooey at the end. And for some reason, I never made it purely habitual to remove my shorts before operating. Decorum? Shyness? Don't know. But more often than not, at the end of a thrash of a case, I'd be washing out my underwear in the sink, wrapping them in a hospital towel, and taking them home. I've got a nice stash of towels embroidered with "Central Supply." They make perfect bath mats.

One of the old surgeons where I live used to like to speak to his patients' families still fully gloved and gowned, particularly if bloody. I assume he thought it made him look like a knight in dripping armor. Made him look like an ego-addled jerk, was my opinion. And it would never be allowed today.

Thinking Out Loud....

(I'm hurriedly trying to change the subject from my sorry post below, so I'm rushing to print before fully fleshing out something I'd been working on. In retrospect, I wish I'd not posted my little fiction piece; but I've decided to leave it and move on. Quickly.)






This may sound self-indulgent and egotistical (what? from a surgeon??) but bear with me: I have a point.

I think I can honestly say my patients did well to have me as their surgeon, even as my wife may have gotten the short end, husbandly, and my son likewise, fatherly. By which I mean I spent my career, for whatever reasons, highly devoted to my patients and my practice, at the expense of my family and personal life. I simply had no choice in the matter: it's how I was trained, and what I believed. I was never entirely comfortable ceding surgical care to anyone else, even my closest partners. And for the first few years in practice, until I realized the folly, I even abhorred medical help: I felt obliged to manage even the intensive care of my patients. For a while, I was probably as good at it as the intensivists (of whom there weren't a lot, early on). As time went on, and I (happily) had only the occasional critically ill patient, I came to realize I wasn't the best one for the job. But surgically -- well, I never felt my partners would take as good care as I did. It might also be true that they felt likewise, in reverse. One would hope that all doctors felt that way. Or so I think. Thought. Wonder....

More than just imagining it, I lived it: I made hospital rounds no less than twice a day, and more commonly three. Except on the critically ill or unstable or as-yet undiagnosed: then it was four or more times. Six a.m. Between cases. Before heading to the office. At the end of the day. Go back in in the evening. I always took calls on my patients, whether I was the "on call" doc, or not. If a patient needed a re-operation, I'd usually do it -- on call or off. Although I think I may have overdone it, I'd say most surgeons of my era have similar commitment, if for no other reason than hearing the admonitions (to put it mildly) of our mentors in our heads. But it's more than that. To choose surgical training twenty or thirty (fifteen, ten) years ago was eye-openedly to enter into a contract; to agree that caring for patients was going to be the prime directive, and that it would be a never-ending commitment. That it was pounded in over and over for six or seven years of nearly twenty-four/seven training simply reinforced what was already implicit.

Considering my behavior mostly in hindsight, I have questions. How necessary was it? Did it really make a difference? Was it essential? Or delusional? An excuse for other shortcomings? In semi-retirement, it's clear my sense of irreplaceability was an illusion. But what of the rest? My younger partners never rounded as much as I. Unlike me, they took their full days off, and their allotted vacation days; weekends off were off. Their patients did well enough. Complications, for the most part, have their roots in the operating room. Data, when they were made public, confirmed my complications were fewer; but I think it had little to do with my post-op care. I do think those habits were part of why my over-all costs were less: in rounding frequently, I was able to expedite necessary testing and to get orders written sooner, discharge more efficiently. (Bureaucracy alert: the powers that be once decided to review afternoon discharges, intending to encourage doctors to make rounds in the morning to get patients out earlier. Afternoon discharges were to be some sort of black mark. Making rounds multiple times, I often discharged patients in the afternoon because some mornings they weren't ready but were later. I pointed this out to the medical director, asking if he'd rather I not make those afternoon rounds and wait till the next day, in order to avoid being dinged. The plan ended.) If my patients didn't have to get to know another surgeon during their hospital stay, if their hospital bills were lower, to whom did it really matter? No one mentioned it to me, much.

So what's my point? This: if any of this stuff actually did matter, I think it's moot. It's my sense that, as a generalization, things are changing fast. I'm not the first to blog about the recently restricted hours of trainees. In fact, nothing I'm saying is particularly original. I do, however, have several friends who are surgical professors in some high-level training programs, and I'd say it's unanimous among them that they are concerned about the surgeons of the future. "Shift-worker mentality" is a common theme in our conversations. The current crop of trainees, they say, aren't as committed as we were. They're happy to diddle around until the next shift arrives to solve a lingering problem. More importantly (but maybe a bit off the subject of this post), there's concern that the restricted hours lead to less experience, which works its way up the hierarchy: fewer hours means fewer operations. Senior residents are less likely to let the juniors do cases, which means those juniors, when senior, are less experienced. The need for formal mentoring after training is a concept being discussed seriously.

It's not entirely clear-cut: are patients better served by doctors less single-minded? The restrictions on hours resulted from a lawsuit over a death presumably due to mistakes by a fatigued resident. Avoiding fatigue, clearly, is desirable. But limiting experience? Selecting people less willing to make a full commitment? I imagine patients prefer a well-rested doctor. But one that plays the piano? Skis like a maniac? Coaches Little League? Not sure. Really. Not sure.

I burned out. After twenty-five years, chronically tired, dreading the phone-calls, missing family gatherings, I managed to wangle a temporary (I thought) leave of absence. It felt so good, I couldn't convince myself to go back to full practice. Had I been less crazily compulsive, maybe I'd have lasted longer; maybe I'd have, over a longer career, cared for more people (part of my problem was never saying "no." I did twice as much surgery as my partners, more or less.) So maybe it's better, from a cost-benefit sort of calculation, to have docs who want and have a life. And this: whatever else is true, the new crop aren't idiots. Surely they hear the cries; they know about decreasing reimbursement, malpractice, interference from all points of the compass. If there's much about the job that's become abhorrent, why give up your life for it? That's my point: is the current trend a bad thing, or a good one? Honestly, I don't know. Until a few years have passed, no one else will, either. And if it's true that the people choosing medicine now are different from those of a couple of decades ago, or have different expectations, I don't blame them. The essential rewards of being a physician, the privilege of caring for people, remain at the core: but the pleasures have become elusive, diluted by the myriad of impediments disguised as controls. It's illogical to expect docs to walk in the same way on ground that has fundamentally shifted under them.

(Creative?) Interlude

I've not ever tried my hand at fiction, so when Cathy announced the second in her series of writing challenges, I figured what's the worst that could happen? Lose all my readers? Embarrass myself across all of cyperspace (or at least my little corner of it?) Well, yeah. But I did it anyway. So below is my (completely inexplicable, in terms of the direction that happened) blessedly brief and failingly feeble attempt at creative writing. The game, as ordered, was to write something the final line of which (from Ian Fleming) is: "I shall not waste my days trying to prolong them."




A natty dresser, he. Spiffy, he liked to think, what with the ascot, the jacket tailored just so, tastefully adorned with a perfectly folded handkerchief, crisply saluting from the breast pocket. (God knows he'd never use it: who could possibly carry mucus around in his pocket, heaven forfend.) Yes, Roger St. James-Beecham Fairfield Campbell was an impeccable man -- a man not generally given to self-doubt, much less self-assessment. Even his automobiles were perfect: the Jaguar (jag-you-are, not jag-wahr!) Vanden Plas oiled and polished for everyday use; the Bentley for when Bailey was sober.

The only person who knew Roger had been born in Queens was his mother, and she didn't remember much any more. Not that it mattered. Roger St. James BFC was ensconced and insulated, well away from the boroughs, where his practiced sublimity could be fully admired. Waco was undeserving of its reputation, really. That Janet Reno mess: how calamitous! Yet it had, in its own way, precipitated a new sensibility. Waco needed some culture, and Roger was just the man to provide it. He'd seen enough movies to know how. Cary Grant, William Powell, Basil Rathbone. Accouterments, and the right diction, make the man. For the purposes of this story, it's not important to know how Roger obtained his wealth. In fact, it would unnecessarily taint the reader's notion of him. Anyhow it's not as if everyone gets Platinum Card offers. There are standards. If Mr. St. James Beech...etc, etc, didn't deserve them, he'd not have received them. He had them, he used them. Enough said.

Proud as he was of his suavity, as carefully as he'd cultivated it, groomed it during countless hours of reflecting on his reflection, Roger knew he'd never be seen as anything but foppish in Waco, absent a woman on his arm. Even Cary Grant -- or his agent -- understood the ways of that world. So he set about finding one. Finding one: not particularly difficult. Keeping her: sticky wicket. Roger, it seems, had a problem. Other than with himself, he'd not... he couldn't... well, discretion requires a certain reluctance here. It wasn't just on his arm that Roger had never had a woman. Waconian women, it seemed, were quite taken with a clean and powdered man and his silky automobiles; more than willing to take a ride, as it were. But they were not without certain expectations. "Roger," they'd say, after a few weeks of good diction and tea. "I like you and all, and you're really smart and stuff like that, but, well, you don't seem to know shee-it about women. It's been real fun, you're a fun person and all, but damn, Roger! Don't you even want to hold my hand??"

"I should like very much to engage a female for the purpose of instruction," Roger St. James-Beecham Fairfield Campbell announced as he strode -- less confidently than his demeanor would suggest -- into the drawing room of the Mustang Ranch. Driving nonstop from Waco to Storey County, Nevada had been easier on him than on Bailey, who was noticeably tremulous by the time the Bentley glode to a stop, gate-side. He made eye contact with the Bombay Sapphire before considering how else he'd spend his time during his boss's tootelage. While piloting the auto, he'd tried to offer advice and encouragement. "It's messy, sir. You'll have to expect a certain, well, a splash of liquidity. It's a bit of the animal, sir."
"Yes, yes, I'm not exactly a child, Bailey. I've watched "It Happened One Night" a hundred times. I'm quite aware..."
"Of course, sir. Nature will have its way."

Oh my goodness, thought Roger. Claudette Colbert was so much less... so... there was a sheet, after all. This is quite provocative. Quite. And yes, threatening. I'd had no idea. There's so much... it's so... How can this ever do? Why, it looks so... untidy....

Misty Sunshine did all she could. Her client was certainly not the first to seem so reluctant, so unfamiliar. So. Repulsed? By certain measure, he was obviously game. And resilient. Yes, his interest, it was evident, rekindled quite quickly, and impressively often. Yet she could tell he was not engaged. In addition to insisting on complete darkness, he'd brought moist towelettes which he used disconcertingly liberally. And rapidly. Everything, rapidly. "Hon," said Misty Sunshine, touching him most intimately, "You came here to learn, didn't you? And I'm trying to tell you as nicely as I can. You got to learn to like the, well, the whole thing. The noise, the sweat. It's gotta be fun, sugar, and you really gotta try to slow down. Make our little hugs last a while."

"Madam," spoke Roger St. James-Beecham Fairfield Campbell, drawing himself purposefully up from the bed, mustering as much dignity as one can do, absent pants; releasing the latest towelette with a dismissive "p-tooey" motion of his fingers, buttoning his never-removed shirt. "These little hugs, as you so quaintly call them, are quite long enough for me." He smoothed his hair as he walked toward the door (he'd not removed his shoes, either.) "In fact," he said, as he turned the doorknob with his handkerchiefed hand, "I find them entirely abhorrent, and most certainly I shall not waste my days trying to prolong them."


Many others have responded to the challenge, more successfully than I. Here's a list of links to everyone (far as I know) who took up the gantlet:

Wolfbaby

Laundress

At Your Cervix

Kim (Emergiblog)

The Wandering Author (?)

KT-RN

Frequency of Silence (JCR)

Truth is Freedom (Brian)

Patient Anonymous

Pearls and Dreams (PK)

Mimi Writes (Mimi)

Potpourri Of Writing (Mary Emma)

Charlie

Ladybug

Musings of a Distractable Mind (Dr. Rob)

Bankerchic

Cathy

Pancreas stuff, #3

"In the matter of Patient X," read the letter from the state board of medical licensing, "we find no evidence of improper dispensing of narcotics. In the future, however," they went on, most helpfully, "we suggest you pay more attention to how your prescription behavior may appear." The fact that the letter was sent to my colleague and not to me made it no less infuriating. You did nothing wrong, they'd told him. But you need to pay more attention to how idiots like ourselves may react to your practice-habits, rather than to the needs of your patients. Brilliant.

It's been said that the main indication -- without which you ought not go ahead -- for surgical treatment of chronic pancreatitis is addiction to narcotics. Pain, in other words: pain unmanageable by any other means is what provides the rationale for operating on people with chronic pancreatitis. When Patient X had been sent to me, that's exactly the situation he was in, along with the typical debilitating malabsorption syndrome. The non-disciplined disciplined doc was a gastroenterologist, the best around, the one I'd go to if I needed one. Circumspect, brilliant, ethical, dedicated, hard-working, in case the idiots on the board hadn't noticed. But I'm getting off point. Bastards. Sorry. Pin-headed pricks. OK; my bad. Where was I?

Patients suffering from chronic pancreatitis are rarely if ever (as opposed to those with the previously-posted acute form) at death's door. Instead of (or as a result of) boiling away in an acute froth, their pancreases have hardened into a wooden wedge, stuck to and behind colon and stomach, functioning poorly, generating constant and sometimes crescendoeing pain. Neither able to produce the needed amount of digestive juices nor to dribble them freely into the gut, the chronically inflamed pancreas also may short its owner on insulin, making him/her diabetic. In pain, having stinky fat-laden diarrhea, diabetic: those people -- as I said in the first post in this series -- can be miserable enough to wish they were dead. Ol' Patient X was: he was at the end of his rope when I saw him. Coincidentally, the letter from the board announcing an inquiry (initiated by a concerned pharmacist) arrived at my friend's office about the time Mr. X arrived in mine.

Let it be said: surgery for chronic pancreatitis is no panacea. Outcomes are unpredictable, as they are with any therapy whose primary goal is reduction of pain. To the extent that surgical treatment is rational (well-selected, it is, in my opinion), it breaks down into two options: drain or remove. And the choice between those two approaches depends mostly on the pancreatic duct. If it's big and dilated, drainage is probably the way to go. If it's obliterated and/or filled up with tons of calcification, you might want to remove most (or all) of the pancreas. Given the previously described tough location, now distorted by scarring, and given the debility of losing all digestive enzymes (they can be taken in pill form, to marginally adequate effect) and of becoming a brittle diabetic, surgeons (this one, anyway) tend to choose door number one, when the opportunity presents itself, and to avoid door number two like the plague. But it's not simple. When there are lots of operations to accomplish the same goal, it follows that the perfect one hasn't been invented. This gives you an idea of the problem with pancreatitis. But I'm a simple guy. There's one operation I especially like.

Here's an example of a normal pancreatic duct: (the big thing on the left [black arrow] is a scope; the red arrow shows the duct.)




And here's a nicely obstructed and surgically approachable one:




I don't want to get all technical here. Let's just say it's fun do to this:





(And here is an example of why operative photographs are pretty much useless, compared to diagrams.)


Patient X loved it, too. Taking huge doses of narcotics for months, you'd think (especially if he were a drug seeker) that he'd soak them up like a parched pig post operatively. He didn't. In less than two weeks, he was off them for good. (Which sorta pudding-proofed the GI doc's argument that he was treating legitimate pain, and halted the inquiry. By the way: it's not the inquiry per se that hacked me off: it was the pissy letter.)


Because they've saved my hide a few times, I really have no business complaining about radiologists. But they expropriated some of my favorite operations; namely, draining pancreatic pseudocysts. Like draining pus, it's deeply satisfying, because it works: see cyst, drain cyst, say goodbye to cyst. Unlike people housing pus, however, most people who have a pancreatic pseudocyst don't feel bad; so you have to convince them they need it treated. It's true. But it's never comfortable to feel like you're talking someone into an operation. It's one reason I haven't gotten totally depressed over losing the operation to the radiopods. Another is that it comes along pretty rarely. Plus, in some locations, surgery is sometimes still the better choice.

A true cyst is a collection of glandular secretions fully surrounded by a wall made up of duct lining cells. A pseudocyst, in the context of pancreatic secretions, is a collection of pancreatic juice left over from acute pancreatitis, formed into a defined sac, but surrounded by, well, just stuff. Scar tissue, whatever. Small ones, recently formed, have a decent chance of going way on their own. Big ones risk getting infected, or spontaneously draining into the rest of the abdominal cavity; which is why draining them is a good idea. Paradoxically, I suppose, the dangerous anatomy I've talked about in this series turns out to be good when it comes to draining pseudocysts: stuck to the back of the stomach, a cyst can be drained by opening into the front of the stomach, confirming the location with a needle out the back, then cutting down on that back wall and into the cyst.

A row of sutures around the edges of the hole prevents leakage, and eventually the cyst just withers away into the stomach, sealing back up like it was never there. The radiologists do that, now, with a needle (followed by a tube) poked through the abdominal wall, the front and back of the stomach, and into the cyst. Works great. Dammit.

Another Brief Commercial

In case anyone missed it, I'm repeating my offer, it having occurred to me that my book makes a wonderful gift -- and 'tis the season. Here's how you can give it to your most favorite person in the world (actually, I'm guessing you have dozens of favorite people in the world) with a personalized inscription:

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

Pancreas stuff, #2

Hmm, seems like I've been a bit tardy getting back here. Sorry. Life: the blogger's enemy.

As I recall, I was saying something or other about the pancreas, pointing out its difficult anatomy, tucked back there behind the stomach and the colon (did I mention that the main artery to the spleen, a big one, passes right along the edge of the pancreas?), and suggesting ever so subtly that when aroused it can turn from a fluffy and pink-cheeked organ into a devouring juice-dripping and slobbering monster, the bane of a surgeon's existence, and the most awful of threats to its owner. Or something like that.

It's acute pancreatitis that's the most horrible (not that chronic pancreatitis is particulary serene: it might not kill you like its acute cousin, but under some circumstances it might make you wish it would. More later on that subject.) In a tidy private practice the bulk of the acute pancreatitidies show up as a result of gallstones. In the county hospital, mostly it's alcoholics on a bender. The latter are the worst, in part because they are generally in worse physiologic shape to withstand the assault, and in part because alcoholic pancreatitis just happens to be the baddest actor.

As I explained all too briefly, gallstone pancreatitis occurs when a stone passes out of the gallbladder into the bile duct (I've also been tardy in getting around to a series of posts on gallbladder disease. It'll happen.) If you refer to the diagram in my previous post, you can see that if a stone were to lodge in the south end of that duct, below where the pancreatic duct joins it, bile could, instead of passing into the gut where it belongs, be forced backwards into the pancreatic duct. Experiments have shown that squirting bile into a (mouse's, I think. Maybe a fruit fly's) pancreas causes pancreatitis; so that's the presumed mechanism. If the stone passes finally, the process may be self-limited; in fact, the bulk of patients with gallstone pancreatitis -- sick as they might be, and impressively scary as their lab work can get -- tend to get over it in a few days with only supportive measures, followed by a properly timed operation to get rid of their gallbladder. So ideally, when such a patient is admitted, the surgeon is involved early on, consultatively speaking, and hopefully the patient has the good fortune and the surgeon has the good sense to avoid early intervention, scalpelly speaking. If not, it's a hell of a mess.

Nowadays, as a result of some better-late-than-never studies showing that even with infection, non-operative management may be better than operative, surgical treatment of acute pancreatitis is done less often than when I was learning the game. Back then -- and, unavoidably and miserably, sometimes even in the age of reason -- I got involved in some pretty horrible morasseri. The most memorable was a lady of high social, political, and academic standing in her native Asian country, transferred to us by a surgeon who'd trained years earlier at UCSF, where I was then chief surgical resident. He'd operated on her once in their country and had arranged a special flight to San Franciso. After a long ride, she arrived in bad shape.

It would take a better writer than I to describe the hell-hole created by acute pancreatitis at its worst. It's that combination of highly unfortunate location and the power of self-digestion that turns the upper abdomen into a seething and distorted mess. Imagine a nicely-tended garden overtaken by sewage. Think of trying to find your way through a mine-field, knowing a misstep could cause death, while wearing size twenty shoes, and blindfolded. Compare being required to reach into a shallow pan of water to find by feel a couple of well-defined objects, with groping into hot mush, mittened and scared. See? I takes a better writer than I. None of that does it justice.

In a normal person, maybe one on the slim side. exposing the pancreas is among those surgical moves that I find quite cool: it's one of those little revelations of anatomy, the knowing of which (every surgeon does) feels like having been taught a secret handshake. The transverse colon travels just under the bottom edge of the stomach. (Strangely, the best illustration I could find is from an article containing complete bullshit.) Perfectly placed, a cut into the tissues that bridge those two organs can open into a delicate place, the "lesser sac (lousy diagram, but one that might make you think "Wow, you surgeons really need to know your stuff.") Tucked behind the stomach and colon, that space is clean and quiet, opens sort of magically; and its backside is -- ideally -- that pink and normally-firmer-than-normal organ, the pancreas. There for your viewing pleasure. With acute pancreatitis, not only is that space completely obliterated, it's filled with indistinguishable stinky goo, and the edges of the stomach and colon -- out of which you'd dearly like to stay -- are absolutely undecipherable, unrecognizable, and half-digested. Not good. Which is why, as I mentioned in my previous post, we used to navigate it with a spoon.

Draining pus is one of the most time-honored things a surgeon does. Open an abscess, liberating a well-defined collection of stomach-turningly stinking cream, and without question you've done a body good. Pancreatic infection is nearly never like that: it's a quart milk-carton-sized uncircumscribed (read that word carefully) zone of corruption, at the periphery of which you know is extreme danger if breached, but the outlines of which are indefinable. Your goal is to rid the area of all the infected tissue and to provide multiple avenues of egress for retained and future collections. That spoon helps: you figure if you can scrape it out with a some-what delicate sweep, it wasn't meant to be there any more. It's blunt enough that you might avoid stumbling into the colon or stomach, or important vessels. The corruption thusly removed contains the occasionally recognizable chunk of pancreas, globs of saponified fat, and lots of crud. Almost by definition, you can't do a thorough job; nearly always is it necessary to go back and do it again, once you've decided to take the surgical approach. Again; and often again and again. In fact the need to do so has led to a few inventive methods to facilitate reoperation; including an actual zipper, applications of plastic place-holders, and tacking the edges of the abdominal wall down into the hole, exposing the target area, and holding the rest of the abdominal cavity out of the way (that's called marsupializaion, descriptively enough.)

We just closed our Asian lady loosely each time with monster sutures. We left huge drains in the field, tubes that allowed irrigation of anti-biotic solution in and out. During one of the operations it was apparent the infective-digestive process (remember the digestive enzymes of the pancreas have been released and are eating away at the fats and proteins in the area, making the process an ongoing and self-perpetuating one) was working its way into the blood supply of the colon, and that the transverse colon was compromised. A portion got removed (not easily, given the absent landmarks), accompanied by colostomy, which added an ongoing source of contamination to the soup. In between operations, her splenic artery blew, requiring a hand into the wound in the ICU, followed rapidly by a trip back to the OR. She nearly died a few times, from sepsis, from organ failure, from that bleeding episode. But somehow she made it. Somewhere I have a beautiful hand-embroidered silk tablecloth she sent me when she returned home. Not everyone I saw with that disease made it. Not everyone who made it -- the county hospital alcoholics -- expressed gratitude.

Surgeons, when forced into it, can change; can recognize or even promote progress. The radiologists -- damn 'em and bless 'em -- have produced all sorts of techniques to bail out surgeons, as well as to supplant them. When a defined abscess occurs in a pancreas, they can guide a wire followed by a drainage tube into the area; it's enough to turn the tide without operation in many cases. Some things those guys do have robbed me of surgical fun (pancreatic pseudocyst is one example -- next post): taking away the need to operate on infected pancreii is a job happily ceded. Bolstered by the evidence of recent studies, and by the up-sleeved tricks of the radiologist, I've successfully observed the resolution of acute pancreatitis in several patients on whom I might have operated years ago. Most excellent. Next post, I'll talk about the pancreatitis-related operations I actually like to do...

Surgeons and Sweetbreads

The good news is most of us will never have a reason to find out. The bad news is we all walk around with a self-destruct button in us, and I'm not getting all Freudian here. Of all the vital organs, there's only one that can -- sometimes with only the slightest of provocations -- turn on us and literally become our worst nightmare: it can eat us alive, from the inside. All the while, doing only what it thinks it's supposed to do.

Operating on the average person, this organ is hard to see, let alone get to. In someone healthy and maybe overly skinny, you can sometimes get a surprising view: delicate, fluffy and pink, demurely lying behind a shiny film that in the rest of us is more opaque. Looking at it, you'd never guess how destructive it can be. In that ideal patient, it looks like something you'd like to rest your head on. No wonder it's called "sweetbreads."

"The normal pancreas is firmer than normal," is what a professor of mine liked to say. He was right: in manually exploring the abdomen, there might be a tendency to think you've found a problem, discovering a rubbery-firm pancreas. It looks (when you can see it) like it ought to be softer. Maybe in the uber-normal, it is. Maybe it routinely gives itself a little trouble more often than we know. In any case, the pancreas is an organ of brooding and explosive mien, no matter how it looks or feels.

In any anatomic drawing, in order to show the pancreas it's necessary to leave something out. Here's an example:


You get the idea of the fluffy pinkness; you don't see the stomach or the colon, because those organs, seen from the front, cover up the pancreas, which lies crossways across the very backside of the abdominal cavity. Operating on it, in other words, can be challenging on the basis of anatomy alone. Add in inflammation, a few digestive enzymes, and tissue not really ideally textured for holding a stitch, and you've got tough surgical sledding. But I'm getting ahead of myself.

If you want details, here's a place to start. The basics are these: the pancreas does two important and unrelated things. First, it produces insulin which controls blood sugar levels, and diminished levels of which cause diabetes. Insulin is secreted by the pancreas directly into the bloodstream (that's the definition of an "endocrine" gland.) Second, it makes several digestive enzymes, which flow through ducts and exit into the intestine (that's what "exocrine" means.) The drainage end of the pancreatic duct joins the draining end of the bile duct (which carries bile from the liver into the intestine); that juxtaposition is important in a bad way, pancreatically speaking. It looks like this:


The complicated anatomy within and around the pancreas, in another context, provides surgeons -- especially surgeons in training -- a cornucopia of delight: removing the head end of the pancreas provides a little bit of everything a surgeon does. I've mentioned all that previously here and here. In its other iteration -- the center of an awful inflammatory process -- that anatomy is nothing but trouble. To give you an idea: we used to keep a sterile ladle, of the sort you'd use in a tasty soup, on hand in the OR to scoop out the stinking soapy detritus of acute pancreatitis. I mean that quite literally: add certain activated pancreatic enzymes to the fat in the area, stir in a little calcium salts, and you get saponification. Soap. Wash behind your belly-button, kids.

What we're talking about here is inflammation of the pancreas, "pancreatitis," which comes in two basic forms (acute and chronic) and has three main causes (no self control, no control, and no clue.) That last triumvirate is wordplay I just made up. It refers to alcohol, gallstones, and "idiopathic." Skimping on detail, suffice it to say that excessive drinking, especially of the binge type can severely damage the pancreas. With gallstones, it helps to look at the above diagram again: imagine a gallstone passing from the gallbladder and lodging at the very far end of the bile duct. Under that circumstance, bile may be forced backwards into the pancreas. That's the likely cause of "gallstone pancreatitis." As for the last category, it's sort of a waste-basket diagnois for "it could any of a number of things, and we may never know."

Some of the sickest patients I've ever cared for are those with the complications of acute pancreatitis, and their surgical needs are as daunting and taxing as it gets. Those with surgical issues related to chronic pancreatitis can sometimes actually be sort of fun. And now, I think I've done enough exposition. In the next post I'll get to the surgical stuff.

I'll Be Right Back, After a Brief Commercial Message

I'm stealing a good idea from Andrew Sullivan, it having occurred to me that my book makes a wonderful gift -- and 'tis the season. Here's how you can give it to your most favorite person in the world (actually, I'm guessing you have dozens of favorite people in the world) with a personalized inscription:

If you email me with a name and any sort of inscription request you have (within broadly interpreted rules of decency), I'll personally write it and sign on a nice adhesive panel you can stick onto the front page of your book. And I'll even pay the postage (which, as far as I can tell, is about equal to the royalty I'd get on the book). (I say that because I haven't heard from the publisher in a while...) Include in the email your postal address, which I promise I'll trash as soon as I mail your inscription, and will use it for no other purpose. Email me at jschwab at gte dot net, and title it "book inscription" or something even more clever. My spam filter is incredibly stupid. In addition to the fact that blogger almost never notifies me when there's a new comment on a post, when I get notified of MY OWN comment, my email labels it as junk. I'm trying not to take it personally.

I think this is a very cool idea, and a generous offer. I expect it to catapult me to best-seller lists around the world, and to generate a call from Oprah. And I'm quite sure your friend(s) will be eternally grateful.

Skin to Skin

Above all, interns love the fast surgeons. The longer an operation takes, the less time to do your work when finally released from the tiled temple. A whole OR day with a plodder guarantees a night without sleep. There are other reasons to appreciate fast surgery, and to consider why some surgeons are so much faster than others. But before doing so, let this be made clear: speed, per se, is not a sine qua non (or even the sine qua not much) of good surgery. Doing it right is paramount; a slow and careful surgeon is better than a fast and sloppy one.

An operation done fast, when done well, is better than a proper but slow one. Not often, necessarily: but given the ill effects of anesthesia, the additive impact of tissue trauma, fluid shifts, exposure of uncovered tissues to the elements, all other things being equal, the less time in the OR the better. Over a lifetime of procedures, I think it fair to say fast surgeons will have fewer complications than slow ones. Especially with critically ill or elderly patients.

Although I like much better the other images it conjures, "skin to skin" refers to the actual time of an operation -- from cutting the skin to finishing sewing it up. (Total OR time is longer -- often much longer -- depending on OAFAT and other issues.) Usually only invoked when it's good news, it's like this: "How'd the Whipple go?" "Two hours, skin to skin!" When not so good, it's "Oh man, it took forever..." Skin to skin -- as it should -- connotes goodness.

Vic Richards was the fastest surgeon I'd known. (Lots more about him in my book.) Former chief of surgery at the Stanford program when it was still in San Francisco, he'd gotten his MD at age 19 (!) and was chairman at age 30. Right after getting his degree, too young to do much else, he worked in an anatomy research lab, where he ended up teaching surgery residents much older than he. In the process, he figured out subtleties of anatomy previously not well-known, and thought about how to do things in the operating room based on his anatomic insights.

By the time I knew him he was well-established as one of San Franciso's premier surgeons, loosely associated with UCSF, where I was training. I spent some months with him as chief resident, and he opened my eyes -- although I think it wasn't until I'd been in practice at least a couple of years that I really understood what he'd shown me. "Slow down, Dockie," he'd say. "You're going too fast. I'm the slowest surgeon in town...." In one sense, he was: his hands were not a blur; he didn't tie knots so fast you couldn't see the moves, didn't flash his knife like a Ninja. His speed -- usually he took half the time of the professors who'd theretofore taught me -- came from his head, not his hands.

I can't quantify it. Fast surgery is greater than the sum of many important parts. Every move ought to make sense, and flow logically from the previous one. For that to be true, you need a global idea of what it is you need to do, and the idea has to be a good one. That's for starters. Clearly, you need certain basic skills; you need to understand the relevant anatomy; but also you need -- here it gets a little nebulous -- an instinct for economy of movement and for what makes sense. To clarify what I mean (if not necessarily to shed more light): I've assisted many surgeons on complex operations wherein we came to a point at which I felt I knew what the next move ought to be, only to see the surgeon go somewhere else. "Look at that!; isn't that something?; he had it and he lost it! He's not seeing it!"

That's what Vic would have said, in his non-stop running commentary on everything I was doing under his tutelage. Assisting, in those early practice days, I'd say nothing and do what I could to help with the new path. Eventually, the paths converge. It's not as if there is one and only one sequence of events for a given operation. The surgeons who take four steps where one might suffice are not bad surgeons, generally. We all benefit from the incredible resilience of the human body. If we get things pretty close, it'll do the rest.

But little things add up. Some surgeons are so wedded to specific instruments, for example, that if it's not available they'll stop everything in the middle of an operation while someone gets it. It's almost always the case that something else would do. It's desirable to have a predictable routine for any operation; it's not desirable to be unable to deviate from it. On the other hand, some routines themselves are counterproductive. You can make a midline abdominal incision, as an example, and be into the peritoneal cavity literally in a minute or less; or you can do it in a way that takes ten, using cautery, slow-cooking your way through the fat, leaving non-viable (yeah, but non-bleeding, they'll tell you) tissue in your wake. Any operation provides many such opportunities.

Maybe most important of all, and least understood, is knowing when you are in exactly the right plane, as opposed to close enough. The interface between tissues is (absent prior surgery or other damage) subtle but distinct: soft, easily separable, and comparatively bloodless: it will allow you in and welcome you like the gentlest of innkeepers on a cold night. If in exactly the right place, you can separate things easily, in ways that seem indelicate but are in fact the opposite. A few cell layers can make all the difference. When perfectly positioned, you can use your finger, the back end of a scalpel, the closed tips of scissors, and expose your target in a flash. Off by a bit, you'll need to dissect, probe, stop a bleeder here or there, be a little rough, before you've conquered the intended area. And never know the difference! You can spend a whole career unaware there's another way. The gods of surgery will let you pass; but they won't be singing you through the gate.

I've said before, and I'd say again: doing surgery is not really mysterious: those of us who do it are not extraordinary. People can learn it. But I think some are fortunate enough to have certain cerebral software that allows them to see the operative field more clearly; to understand instinctively how to avoid struggling. Among the good point guards (and mid-fielders! -- but you probably don't like soccer as much as I do), some just seem always to make the right pass at the right time: they see the whole game as it's being played out, know what's about to happen. A coach would say that can't be taught. Some just have it.

To a small extent, surgery and surgeons separate along similar lines. Can I say that I had some, without sounding too self-absorbed? The irony is that it surprised me to find it out. I didn't sense it when I chose to become a surgeon, or even as I was learning it. Like a rosebud, it opened with time. And in other ways, surgery was a poor fit for me: it drove me crazy because I couldn't stand imperfection to any degree: even a keloid scar made me feel like a failure. Every night, I lay awake stewing; I was overly paranoid. But I could do the operative work; that I could do.

I owe a lot to the fact that when I first started practice I was in a semi-lousy situation: a town with way too many surgeons. As the new guy, it took a long time to get a following. On the other hand, for lack of much else to do, I assisted every other surgeon in town, many times. Having trained in an in-bred place (meaning the majority of attendings had trained there) I was well-trained but exposed to a narrow range of techniques and surgical philosophies. In my first practice experience, I saw things I'd not seen before; both good and bad. My operative approach became an amalgamation of ideas I picked up from many sources; and as time passed, I added my own.

Because of Vic, I placed a nearly obsessive premium on efficiency, on considering everything I did from the point of view of whether it made sense -- whether there might be a better way. And over the years, I found some. I won't list them, but I was always either figuring out or stealing little tricks here and there for every operation I did, all for the better. Most surgeons do, I'd add.

So yeah, I was one of the fast ones. Faster, eventually, than Vic himself. Sure, I tie knots ok, but you'd definitely be able to see the fingers without blurring. I admit it: I liked being fast. Hearing people mention it. Appreciation from anesthesia people, scrub nurses. Taking some sick patient to the OR from the ICU, doing something serious, wheeling the gurney back to the Unit myself, hearing the nurses say, "Wow, you're back already?!" Being able to do more surgery in my assigned block of hours than anyone else. (That, of course, has obvious remunerative benefits as well.)

There were times I actually delayed talking to families in the waiting room because I figured they'd either wonder if I took some sort of dangerous shortcut, or decide the operation was so easy I shouldn't be charging for it. One of those times was when I removed a gallbladder, including taking an intra-operative bile-duct Xray (cholangiogram) in twelve minutes. Skin to skin.