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Showing posts from August, 2006

Breast cancer: some basics

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Based on comments, I'd say readers of this blog are pretty sophisticated; so at the risk of boring some, and before flying off in various directions on the topic, let me establish a few basic breast cancer bits. First, the most basic of all: what is cancer? Most all of the tissues in your body have a cycle of life and death, as cells die off and are replaced by new ones. This is especially true of surface cells, like skin and those that form inner linings: glands, guts, various tubes. Different cells have particular rates of division and reproduction, timed exactly to replace those that die off: dandruff is proof of the process, if you need any. For a few reasons, a cell may mutate in such a way that it loses the control of the replication rate, dividing more rapidly than needed to replace its cousins. The cells formed in that division process have the same misinformation, and the process continues, producing a cluster of cells: a tumor. If that tumor grows slowly and stays wher

Breast Cancer; prologue

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Driving to the hospital on a Saturday morning several years ago, I was listening to NPR , which happened to be airing a discussion about breast cancer. One of the panelists was a woman surgeon with whom I was vaguely familiar; in fact, it's possible she sewed me up once. While training in San Francisco, in an incident well-documented in a certain book I'll not specifically hype (just this once) I suffered an intra-operative cut to my finger, which necessitated a trip to the ER for stitches. At the time, some surgical residents training at Beth Israel in Boston spent time at our trauma center for the unique experience (their boss had trained at UCSF; plus it's well-known there're no training programs in Boston that compare with mine....) I've forgotten the name of woman who sewed me up (and did a fine job), but I know it was one of those residents. And I know that the NPR panelist had done time in that capacity while I was there. I'd been grateful for the repai

Interlude

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While gathering thoughts on my planned series on breast cancer, allow me a brief interlude. I had reason recently to recall something of interest: My wife is the oldest of nine kids, and all her siblings live within shouting distance. As a result, I've been to many a graduation of many a niece or nephew. Always I find myself not particularly looking forward to them, and always they turn out to contain pleasant surprises. Since it involved graduation from U Dub (as we like to call it), a huge university, I was particularly not happy about going to see my niece graduate, a couple of years ago, with her degree in marine biology. To my great relief, her group had their own ceremony, in a friendly little auditorium. And the speaker turned out to be Jonathan Raban , a British writer now living here, who's written novels and non-fiction about the sea. In his buttery British voice, ennobled by the accent of the erudite, he gave a wonderful talk on mankind's relation to the sea, a

Book report

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Well, for anyone who's interested, the reading actually went pretty well, in that several (well, around a dozen) people showed up to my reading. And they all bought books, which tells me they liked what they heard. If I say so myself, I like performing (high school: Sir Joseph Porter, KCB in "HMS Pinafore; Judd Fry in "Oklahoma." College: Conrad Birdie in "Bye Bye Birdie.") and make it pretty entertaining. If it'd been advertised, one can only imagine an impressive bunch of sales. Oh well. More importantly for this blog: I'm back home now, and after a day at work tomorrow, I plan to begin posting on a subject I've planned for some time: breast cancer. Numerically speaking, breast problems made for the largest part of my practice. There's a lot I have to say about it, I think. So stay tuned.

Beach bust?

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I'm doing a reading of my book tonight at the Cannon Beach Gallery. It's been on the books, as it were, for a couple of months. Beach time: they never got around to running announcements in the paper or putting up any of the thirty posters I had the publisher send them. Can't say I blame them: the weather's been beautiful, the beach beckons at any time of day or night. Who'd want to take the time to arrange things, much less show up on a Saturday night of vacation? I'm thinking I'll be talking to pictures on the wall. Which reminds me of one of the more bizarre evenings I've spent: on a trip to Death Valley, having heard about her somewhere, we stopped at a small auditorium in the middle of nowhere, desert on all sides for miles, heat shimmering even toward night. There, a woman named Marta Beckett danced her ballet every night, to music played on an old phonograph on the front of the stage, and with an audience of kings and queens and their subjects,

Heartfelt

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Still at Cannon Beach, we've been driving into Portland frequently to visit my mom and my aunt. Yesterday my aunt told me a story I hadn't heard before, and it moved us all to tears. She has a friend who had a heart transplant, nine years ago. He'd been an Olympic-class athlete, and now, with his new heart, he's again able to climb mountains, run marathons. In fact, he's participating this weekend in the annual and insane run from Mt. Hood to the Oregon Coast. A team event. But still... Before his transplant, he'd come very close to the end. My aunt describes the two months he was hospitalized, awaiting a heart: she visited regularly and saw more machines and hoses than she imagined possible (I infer he was hooked to a ventricular assist device ). All the while, the man maintained humor and optimism. When the heart arrived, it had come from a young college student, killed in an auto accident. It was a perfect match in all senses of the term. My aunt's f

Giants of the Jungle

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In a previous post, I mentioned stopping on my way to Vietnam, to participate in jungle survival school, in the Philippines. I want to tell you more about it, even though it's not at all surgical. Before heading off to the great war, I'd spent three months in San Antonio learning to be a doctor for fliers, at flight surgeons' school. Much of it was fun and interesting: I learned about the physiology of flight, about baro-trauma, about particular afflictions that affect one's ability to operate aircraft. Playing soldier, I learned to fire an M-16, went up in an altitude chamber (note: gas expands at altitude. Colon gas.) I found out what hypoxia (low oxygen levels in the blood) feels like; how you can be completely gorked out from lack of oxygen and believe you are functioning just fine. Showing how tough we were (or ought to have been) we went into chambers filled with tear gas wearing gas masks, and were made to take them off. Then, while choking and coughing and nea

Dirty Sex and Soldiers

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There. That ought to get a few new viewers. And here's a warning: grossness follows. Medically speaking, my time in Thailand was boring. There were no attacks, no casualties of the sort I'd seen in Vietnam. Since guys weren't scared all the time, there was much less of the depression and jitters amongst the troops. We did get an occasional cobra bite, which could be exciting. The flying I did was also not as much fun: in Vietnam I mostly flew with a squadron of spy planes, low and slow. There were creepy guys in the back doing things I didn't have clearance to know about; but the flying was uninteresting to the pilots, so they were glad to turn the controls over to me. "Roger, rollout one-five-zero," I'd say, as I followed directions from the back. "Roger, climb to flight level eight thousand." Cool hardly describes what I was. Us pilots: shit-hot as we liked to say. In Thailand, I flew on tankers. Converted Boeing 707s, flying gas tanks

Shrinking from duty?

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I know I have at least one psychiatrist reader who passes by these parts. So Dr W , this is for you: As I mentioned a post or two ago, when I was in Vietnam, part of my job was that of a humdrum office doc, when we weren't being rocketed or, rarely, shot at. While humdrum, being in Rocket City wasn't exactly your normal existence, and it was not infrequent that a GI came to see me with the complaint, "Doc, I can't take it anymore." For most of these poor guys, there really wasn't a hell of a lot to do: sympathy, the occasional specific suggestion, once in a while a kick in the pants. Except in rare circumstances, there was no choice but to send them back to duty. On one or two occasions, I'd give a guy a break, and bed him down in our small inpatient facility for a day or two. There were lots of backaches, headaches, sore this or that which begged a duty excuse (and I must say that during the time I had to lift my right arm to the desk using my l

Beach to beach, cont'd

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I figured out right away what had happened: a rocket had, by pure chance, hit my barracks -- slammed into the revetment protecting the bottom floor of the two-story building. It turns out there was far less damage than you'd conclude from the crash and the subsequent chaotic yelling. My mental inventory made note of a pretty painful shoulder, and some blood dripping into my right eye. Dripping, not flowing: I was ok. I got up and out, checked the hall and, seeing no obvious carnage, headed downstairs. The building was dark, and it was nighttime outside. In front of the door lay a guy familiar to me but unknown by name. He was rocking slowly and moaning. "Get a flashlight!" I said to an onlooker. "Get an ambulance here!" I said to another. Meantime, I could see blood on the man's shirt, by his left shoulder. Tearing open his shirt by the neck, I saw that part of his shoulder was missing; when the flashlight arrived, it was apparent that it was bleeding prett
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Beach to beach

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Beach blogging is harder than I thought: prying surgical stories out of my surf-soaked brain ain't easy. Here comes the best I could do, taking a circuitous route from the sands of the Oregon coast to the gentle breakers of China Beach, in Danang, Vietnam, and then beyond. A major difference between Cannon Beach and China Beach is that at the moment there aren't helicopters patrolling the beach, gunners dangling their feet out the doors, making it safe for us to swim. Plus this water is way too cold to attract me. And there are no Army nurses peeling off their camos to get to their bikinis. Attention span shortened as it is by the lure of walking on the beach, I might have to tell these stories bit by bit. I got drafted during Vietnam war, at the end of my surgical internship. After three months in San Antonio learning to be a flight surgeon, and a brief stop in the Philippines to take a course in jungle survival and escape and evasion, I found myself in Danang, near the nort

Beach blog

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I'm blogging from the beach. Cannon Beach, Oregon, in particular, hitchhiking on wifi in a just-opened bakery/coffee shop, "Waves of Grain." My family has had a home here for several decades; my folks retired to that home about twenty years ago, after which my dad became mayor for a while. One of his crowning achievements was negotiating getting the cars off the beach. The local business folk feared that the attraction of being able to drive on the beach was what brought folks here. Hardly. It has become one of the best beaches in the world. Not wanting to push my luck with the proprietors of the bakery, who offer free wifi with a purchase (how much is time is appropriate for good coffee and a tasty cinnamon roll?), I'm loath to spend the extra time needed to provide my usual litany of informative or witty or annoying links. I may not even get around to topics surgical today. Before my parents bought this house, we came here every summer since I was a toddler, ren

Memorable patients: part six

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"You can't just let me bleed like this, Doc. I need to get out of here." So said John, a man in his seventies, with kidney cancer spread to his Ampulla of Vater . Renal cell cancer is among those that sometimes behave in very strange ways. John had had his removed, along with his left kidney, about nine months earlier. At the time, it was thought likely to be a curative procedure. Now, he'd been admitted anemic, weak, with evidence of blood in his stools. Workup, including endoscopy, had shown a friable bloody tumor right at the ampulla, and biopsy had shown it to be the kidney cancer, now spread to this ultra-highly unusual place. It didn't seem to be anywhere else. He wasn't bleeding much, as these things go: about a pint a day. Easy to keep up with; hard to send him home. Ordinarily, the operation for a tumor at this location is a choice between two options: local excision (done by opening the duodenum and carving the tumor out), or a Whipple procedu

Baby Killer

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The potential to do dramatic good, as is the case with surgery, means that sitting and staring back at you at the other end of the see-saw is a grinning dysmorphic ogre. He keeps his eyes locked on yours, staring with the smug certainty that you can't toss him off, up when you're down; down when you're up. The ugly little sonovabitch never goes away. It's an issue for every healthcare provider. Were it front and center at all times, it'd be paralyzing. But if it's completely out of mind, you'd become dangerous, or careless at the least. So there's craziness: much as I find doing surgery exhilarating and fun, and much as I'm amazed at and grateful for the willingness of people to turn their bodies -- with their most intimate secrets -- over to me, in the entryway to the back of my mind resides the awareness that it's a dangerous thing I do. Thin ice. There's a lizard under every rock. Sometimes the realization comes upon me like a buck

When Nurses Attack

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Maybe six months after I arrived in town, I was referred a patient with cancer of the distal esophagus . The perversity of being a surgeon is that despite the terribleness of the disease, it's hard not to be excited about the prospect of doing the operation to (hopefully) cure it. If you like doing general surgery, esophagogastrectomy pretty much has it all: the blue-plate special. First, you lay the patient on his back, and open his belly. Then you cut loose the stomach from all its attachments, tying off many many vessels, peeling it off the pancreas, separating it from the liver the colon, until it's hanging like a hammock in the breeze, suspended between the duodenum and the esophageal hiatus. You may or may not remove the spleen. If you're smart, you'll insert a feeding tube into the intestine (in case there are post op swallowing or other difficulties). I always did a very short pyloroplasty (slightly controversial: it's to prevent food from backing up in

Memorable patients: part five

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Sturdy and thickly-built, long since widowed, cheery in a sardonic sort of way, tough and opinionated, Flora's European roots ran deep; she'd been an Italian farm girl, and she'd rather be in her garden than anywhere else. The only reason she agreed to come inside and go to the doctor was that her bowel movements had finally gotten too painful, and too bloody to ignore. Which she had been doing, for quite some time. Still, she made it clear seeing me was pretty low on her list of things she'd like to do. I liked her right off the bat: she said exactly what was on her mind, she treated me with no deference, but with an expectation of straight talk right back at her. Wishing not to turn away readers, suffice it to say everything that was visible and feelable about her anus had been taken over by an angry, florid and unprecedentedly (in my experience) large cancer. She wasn't surprised when I told her what I thought was going on; she wasn't happy with what I

My (Nearly) Short Career

First time I laid a scalpel on a patient as a fully-trained practicing surgeon, he nearly died. Well, actually, I never laid a knife on him. Having moved to Oregon and set up shop after seven years of grueling training, including a couple of military years, fully competent to handle the most major of major operations, my first case was the in-office removal of a cyst on a young man's face. The man, in his twenties as I recall, lay comfortably on my operating table; my nurse -- a throwback, in her starchy white dress and perfectly-placed nurse's cap -- was standing attentively by while I prepared to begin a simple five-minute job. I'd explained to the man that this was a plugged up oil gland (sebaceous cyst) , given him the pros and cons of removal, and the routine game-plan. He'd seemed perfectly comfortable. Already having prepped the area with a germ-killer and draped some sterile material onto the field, I began a gentle injection of local anesthetic , using a ve

When Surgery SUCs

Several years ago, when I was chairman of the Surgical Quality Assurance Committee, the hospital medical director came to one of our meetings. We have a problem, he said. The Joint Commission on Accreditation of Hospitals had, on its recent inspection, given our hospital a list of criticisms, one of which involved unnecessary surgery. That, of course, got my attention, even though I've often said unnecessary surgery gets a bad rap: it's easier than the needed kind (nothing like disease to complicate things), and healthy patients generally do better than sick ones. NOTE: kidding. The problem, it turns out, was not that they'd uncovered instances. It was that there was no requirement that surgeons include surgical indications (the reasons for doing a given operation) in the operative reports. We had six months to implement a solution: they'd be back to recheck at that time. OK, I said, we'll do it. Forget that it's stupid. Because if a surgeon is willfully goi