Showing posts from July, 2006

Memorable patients: part four

I didn't know her name until it was over, much too late. What I knew was she was thirteen and that on this winter day someone in her family had been pulling her behind their car, on a sled. No doubt laughing and looking in the rear-view mirror, the person driving had whipsawed around a corner, and the young girl -- probably screaming (fear? delight?) -- held onto the sled as it careened off the road and into the side of a concrete culvert. The girl took the blow in the middle of her right side. Reportedly, as they helped her up, crying, she fainted. The family member did what a family member who'd pull someone behind a car on a sled would do: took her home and laid her on the couch. About forty-five minutes after that, when she was unarousable, 911 was called. Half an hour after that, she arrived in the ER, in full cardiac arrest, which was also the way the medics had found her. There was still electrical activity in her heart. Her pupils were dilated, we couldn't measur

Memorable patients: part three

She was a Korean woman, spoke passable English. We always exchanged pleasantries, and she called me "doctor" when I picked up my laundry. This time she was notably quiet, distant. I didn't figure it out until I got home and hung up my jacket, on the inside of which I noticed she'd pinned an envelope. It contained a photo I'd taken months ago, left and forgotten in one of my pockets. What it showed was a nude female torso, sixteen stabwounds up and down the left side -- chest, breast, abdomen -- with the handle of a 12-inch butcher's knife buried to the hilt, protruding a couple of inches below her left breast. (Shakespeare said it so beautifully: "Over thy wounds now do I prophesy,--- Which, like dumb mouths, do ope their ruby lips..") Self-inflicted, after killing her care-giver. The police had been called to a trailer park, where neighbors had heard screams. A schizophrenic woman in her twenties, living with a man in his forties who cared for her,

Memorable patients: part two

"Musta been the ham sandwich," he said as he leaned onto the operating table and belched a couple of times. We were half-way through a thyroid operation and Doug, my partner, didn't look all that good. I'd been in practice for all of a year, and Doug, ten years my senior, was my guardian angel, my guide through the vagaries of the world of private practice, and the best surgeon I'd ever seen. Suddenly, he was definitely off his game. We managed to get through the operation. Doug had an appendectomy teed up to follow, but instead of showing up to get it going, he'd gone to the ER, from which I got a call telling me Doug was down there being evaluated, and requesting that I do his case. Introducing myself to the patient, explaining the strange situation, convincing the man that this shiny-faced kid (a 33 year-old kid, but still...) was a satisfactory stand-in, I had more on my mind than the operation at hand. But the patient was fine with it, and I finished rem

Memorable patients: part one

I got the call from the ER because I was the "no-doc" surgeon, meaning I was the guy to call when a patient showed up needing a surgeon, and who had no primary care doc to direct the referral. Usually it meant trouble. A drunk who smashed his car and himself, possibly others. Stab-wound, gun-shot. People who don't have their own doctors include more than those down on their luck; not all of them are nice. So when the ER doc calls and starts with "You're the no-doc surgeon, right?" it raises hackles. "Got an acute abdomen down here. Older lady, goes to Seattle for her care, comes in looking real bad." Jesus, I'm thinking. We're not good enough here for her elective care, but when the shit hits the fan, she takes a shot at anyone? Little did I know. About the shit, I mean. Gotta admit, it's annoying. Turns out this lady had had innumberable orthopedic operations for horrible arthritis. New joints, fusions. Infections, removal of joint

On the bandwagon

Other than during training, when we were investigating a weight-loss operation now abandoned, my experience with bariatric (weight-loss) surgery has come during my recent semi-retirement. As mentioned in my last post, I'm exclusively assisting on laparoscopic surgery, and it happens to be with a group of bariatric surgeons. By osmosis, I've become more knowledgeable in the field than I was in my own practice. And I'm here to tell you: I've become a believer in the value of bariatric surgery in the right circumstances, and if I were to have it myself or recommend it to another, I'd unequivocally recommend the laparoscopic adjustable gastric band ("lap-band.") For the sake of brevity, and my previously admitted laziness (as well as a so-far less than easy relationship with the intricasies of this blogging stuff) I won't get into the indications or the "morality" issue of weight-loss surgery. Let's just talk about mechanics. Although the

Global warming: an inoperable truth

Here it is: It came to me yesterday, in the operating room. Surgeons are the cause of global warming. My practice now consists entirely of helping with laparoscopic surgery, in which operations are carried out via very small incisions in the abdomen, through which long thin instruments are inserted, along with a camera with a tiny lens. In order to see what we do, the abomen is inflated with gas, which separates the abominal wall from the organs it covers. And the gas we use? Carbon dioxide, released into the air during and after the operation. Is it coincidence that global warming is accelerating at exactly the time that such surgery is growing at expodential rates? I don't think so. In fact, I might just publish a paper on it. As Orac has shown us, there are medical journals out there that'll print it up for me. Amazingly enough, I had the solution during the peak years of my practice, but no one listened. If I were a better marketer (buy my book, by the way) I could ha

Ding ding

We doctors have come a bit late to the accountability game. There are lots of reasons, I suppose, not the least of which is that it's very hard to come up with meaningful parameters. And comparing one case to another is fraught with difficulties: no two are exactly alike. Nevertheless, it's laudable that attempts are being made. And yet... The WSMA (Washington State Medical Association) Newsletter arrived today. In it was an announcement of a new program for quality improvement. Primary care docs (another reason I'm glad I'm not one) will be receiving "registries" which will contain patient names, conditions, treatments, and those treatments will be compared to "best practice" guidlines. Sounds good? Sort of. It's a good concept. Fact is, at the end of my book (hawk, hawk) I bloviate about things needed to fix healthcare, and one of them is figuring out why some docs get better results, and spreading the word. But there's a catch. It's

Hard case

"I just want you to know," she said, "I hate surgeons. Surgeons have mutilated me. I don't want to be here." This was before I had a chance even to say hello. I'd flipped through her chart (Darlene G., her name was) before entering the exam room, opened the exam-room door, and walked in as usual, hand extended to introduce myself. This took me aback abit. Thought one: turn around leave, let the referring doc know, and move on to the next patient. Thought two: I'm not the usual surgeon. Rapport R Us. I can overcome this and hear what she's really saying. So I stayed. Darlene G. was a mammogram referral, one of many I saw every day. She'd had a regular followup study for her previous breast cancer, treated elsewhere by lumpectomy and radiation, along with hormone therapy. Her initial cancer had been detected on mammogram, by the finding of small calcium deposits: the way mammography is most useful and life-saving. That's the good news. The ba

Love Note to a Scrub Nurse

What better way to begin the surgery part of my surgical blog than with a love note to a scrub nurse? A scrub nurse is one who participates directly in the operation, setting things up, passing instruments, and, with luck, adding her (usually its a "her") thoughts to the proceedings. She can make a huge difference in the flow of things, raising it to an art-form. So here's an excerpt from my book, in which I try to make that point very clear. It begins as I find myself on the neurosurgery rotation, early in my training: Esoteric and tedious, neurosurgery impressed but didn’t attract me. Charlie Wilson, however, amazed me. Chairman of the department, he radiated enough energy to power the place had the lights gone out. A marathon runner before it became widespread, he spent the rest of his time at the hospital, all hours, day and night. He was a superb operator, tackling brain tumors others refused, getting results far better than expected. He looked you right in the ey