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Showing posts from 2006

You Are What You Eat

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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 state

Memorable Patients: part seven

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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

Of Flames and Flamers

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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 re

Surfing for Science

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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

A Winter's Tale

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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

The Gambler

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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

God of the Operating Room

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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 understandi

Boxers, or Briefs?

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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 s

Thinking Out Loud....

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(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 obli

(Creative?) Interlude

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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 give

Pancreas stuff, #3

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"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

Another Brief Commercial

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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

Pancreas stuff, #2

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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 i

Surgeons and Sweetbreads

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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 t

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

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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 c

Skin to Skin

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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