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Showing posts from September, 2006

Take Your Lumps

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What to do with a patient referred for a finding that you can't interpret on a test you'd never have ordered? It's a tough one, and not as rare as you might think, especially in the area of breast lumps. As a topic for posting, the subject comes up in a roundabout way. A couple of other medical bloggers picked up on my mammorable patient" post, and a comment on Orac's site raised the issue of the morbidity of medical screening. It's a fruitful object of scrutiny: false positives, for example, (a finding that requires further evaluation, possibly invasively, that turns out to be nothing) add up on the other side of the ledger. If a person suffers harm -- or even death -- from investigation arising from some sort of routine screening (for whatever...), when the issue raised turns out to be harmless, well, that's not a good thing. There's lots to say about it. I won't, exactly, now. It's just that it reminded me of something that used to drive m

Opportunity lost

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I've seen people reject mainstream (read: rational) treatment for alternative therapies, despite my attempts to shed light. When they came back with their cancers or other chronic diseases advanced far beyond where we started, I've not said anything. I've listened patiently to recitations of the value of what I've known to be useless approaches. I've encouraged my patients who wanted to, to supplement their recommended treatments with whatever herbs and potions they liked, as long as it was not in lieu of standard therapies. When I had nothing left to offer, I've not tried to take away the last straw for grasping, if I thought they had their eyes wide enough open. And, of course, I've wondered how many of the purveyors of fraudulent care actually believe in what they're doing. But it's not often that I've lost a patient because of the success of mainstream therapy; which is why the case of Orchid bothers me so much. She'd been hav

Mammorable patient

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It was so unusual that I wanted to write it up and send it to a journal for publication. But I didn't want to embarrass my colleague, who was a good guy. So I tell the story here for the first time. When something shows up on a mammogram that warrants investigation, but can't be felt, you need to sample it using some form of Xray guidance. (If you can feel it, you can poke a needle into it in about two seconds, taking a sample for analysis. Or do a surgical biopsy. But when you can't feel it, there's no simple way to get at it in the office.) There are two main choices: wire localization , or sterotactic biopsy . In the former, the radiologist guides a wire to the area, and the surgeon then operates, following the wire to the target. In the latter, the radiologist does the whole procedure, with the woman lying prone, breast hanging down into a device which is aimed by Xray and then sends a biopsy-needle to the zone. There are, as usual, pros and cons of either meth

Arthur Of The Missing Stomach

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Speaking of gastrectomy, as I was in the previous post, there's another patient I'd like you to know about. But first, a word regarding gastric surgery in general: it's fun. Unfortunately, it's much less common nowadays, because those doggone scientists have come up with excellent drugs to prevent and/or treat ulcers, which used to be by far the biggest reason for operating on stomachs. Too bad for me, good for you. Anyhow, there are several things that make stomach surgery fun, uncommonness being high on the list. Also, richly endowed with blood supply, the stomach tends to heal well, no matter what you do to it. And, depending on how much stomach is removed, there are lots of ways to put things back together, each with its own nuance and technical challenges. Plus, you get to say the very cool surgical name, Billroth, when talking about a couple of those reconnections. Christian Albert Theodor Billroth  was one of the inventors of abdominal surgery. Born in t

Memorable Patients: Part seven

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I'm certain that if I hadn't been just finishing a midnight appendectomy, Daphne would have died. Not fully balancing all the bad luck in her life, she fortuitously chose to exsanguinate when a surgeon and OR staff were immediately available. Nevertheless, vomiting all that blood, she damn near died before she got to the hospital. Niceties like passing a scope to find the source go out the window when someone is bleeding to death from her stomach. When I'd gotten the call, I was writing orders for the previous patient. I let the OR know they'd be getting someone in a big hurry, flew down the stairs to the ER, and met Daphne, who wasn't in a position to be sociable. In shock, confused, continuing to vomit blood, she was also very obese and showed obvious signs of Cushing's syndrome : side effects of high dose steroids . Whatever I might find and do, healing would be severely limited by those drugs. And you can't stop them for surgery: it would cause genera

Tales From the Right Lower Quadrant, Part four

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I used to have certain prejudices, one of which was that people who'd attended college were smart. I'd managed to hold onto that one for several years, until I met George, in the emergency room. He'd been sick a few days, getting more feverish, vomiting, suffering increasing pain in his right lower belly, putting up with it long enough for his appendix to rupture and form a quite impressive abscess, easily detectable on exam. That's not the un-smart part; I'll get to that eventually. There are several ways to handle an appendiceal abscess , most of which don't involve removing the appendix right away. Since the body has, in forming the abscess, managed to keep the infection from spreading all over the place, it's generally a good thing to keep the barriers in place; rooting around within the abscess cavity in order to find and remove the appendix can tear down the wall (Mr Gorbachev) and spread infection around. So quite often, treatment consists of drain

Tales From the Right Lower Quadrant, Part three

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She was among the sickest kids I've ever seen: as close to death as any who eventually made it. And I never figured out if her parents were just incredibly clueless, or criminally negligent. When I saw her in the ER, her pulse was thready, barely palpable, and slow -- as in nearly agonal . Undoubtedly, a day or two ago it had been rapid, a desperate staccato plea for help. She moaned a little to deep stimulation, but her eyes -- like a doll's, like a pathetic imitation of some cliched cartoon -- were rolled up with only the whites showing. Instead of flushed and hot, as would be consistent with the rigid abdomen that told me her likely diagnosis, she was dusky and cool. Temperature below normal, heart slowing down. Jesus Christ!!! This little girl is dying of a ruptured appendix. I was as shocked and angry as I was scared I couldn't save her. It had started over a week ago, her parents said: upset stomach, vomiting, fever. They put her to bed, figuring, they said, it was

Tales From the Right Lower Quadrant: appendixes I have known. Part two.

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"Get a crew ready!! Guy coming in with a ruptured splenic artery aneurysm !! Order blood and a cutdown tray , be there in the ER. He's arriving by medevac in five minutes!!!" Wow! This was a big deal. The only intern on the vascular surgery service, I was already swamped with work, but this was going to be an amazing case. As I sort-of knew, the splenic artery is a pretty big one, heading from a take-off point on the upper part of the abdominal aorta, across to the left behind the stomach and on the upper edge of the pancreas, to the spleen, which lies in the left upper abdomen. (Since I now have a search box on this blog, and since I'm sure you've read all my previous posts, in which I've mentioned those organs now and then, I'll assume you don't need hot-links to all of them. Gets a little showy, I suppose.) Splenic artery aneurysms are pretty uncommon: once in a blue moon you'll see an ovoid rim of calcification in the right spot on an Xray th

Tales From the Right Lower Quadrant: appendixes I have known. Part one.

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Dr. Dunphy (J. Englebert "Bert" Dunphy, Chairman of the Surgery Dep't, UCSF, RIP) used to tell us: when evaluating abdominal pain, never have appendicitis lower than second on your differential . It's a good thought to keep close: whereas classic appendicitis is most often a fairly straightforward bedside-makeable diagnosis, it can do pretty strange things, and be a major diagnostic challenge. Not to mention being the cause of a few good stories. First, some background: the appendix -- its spanking name is appendix vermiformis , which means wormlike thingy -- looks, in its normal state, like a little worm, 'bout half a night-crawler. Doing nothing that any (reliable) research has ever identified, it hangs down from the cecum like a sad little rat-tail in the right lower part of your belly. Most people never have any reason to know it's there. When they do, in by far the most of cases, it's because it becomes infected: infection of the appendix is call

The memo, at last

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THE BOARD OF TRUSTEES IS PLEASED TO ANNOUNCE A NO-HOST BARBECUE TO CELEBRATE THE OPENING OF OUR NEW BURN UNIT ALL STAFF INVITED. BRING YOUR OWN BUNS We are delighted to announce the immediate opening of the Catherine O'Leary Burn Unit. As this project may not have been well-known to all, there follow herein some details, in a question-and-answer format, designed to show our sensitivity and desire for thorough -- albeit ex post facto input. Q: Burn Unit?? Where the hell is it going to be? A: Patients will be housed on the surgical floors. Q: Aren't those floors already at capacity? A: Data have shown that on weekends, there are quite often available beds, and it is on weekends that people typically ignite. Q: Who will be taking care of the patients? A: The plastic surgeons. Q: Uh, what do they say about it? A: What possible difference does that make??? Q: Aren't there only two of them? A:Yes. And that's the beauty of it: there's nothing they can do

Hospital politics: the infamous memo. Part three

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Where was I? Something about trauma centers.... So this Level Two thing was occurring at a time when the hospital was in a major funk. Nurses, as I said, were feeling lousy. Care was spotty, despite the presence of a bunch of the best nurses I'd known: they were overwhelmed with work, frustrated by lack of support. And despite this, because of the combination of sustained growth in our area, and the recent converting of many of the beds in the former competition to long-term care, the hospital was jam-packed much of the time. Having made commitments to using those beds across town for other purposes, and still running deficits, locked into an old building, the options for increasing bed space were few. And weren't happening. The ER (soon to become a high-level joint, evidently) was not rarely on "diversion," meaning the medics were told not to bring in new patients because there were no beds in which to put them. Elective operations were occasionally cancelled. Post

Hospital politics: the infamous memo. Part two

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In offices all over town, doctors were busy trying to survive. The clinic, of course, had a significant advantage in many ways: we had excellent management, and we were getting large enough that we could throw our weight around. In a move that sent shockwaves across the entire US -- since it had never been done -- we'd actually fired an insurance company (ironically, the one with which we'd a few years earlier signed that exclusive contract): having had enough of the annual cuts in reimbursement, and having figured out that we were actually losing money on their patients (Old joke: how do you survive when you're losing money on each widget? Anwer: you make it up in volume) we told the insurer that that was it, sent letters to all our patients covered by them, offering help in hooking up with a new insurer. Set up a special phone line. Set a date. The insurance company caved. Of the bad new days, those were the good old days. As private docs and small groups got into more

Hospital politics: the infamous memo. Part one.

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In an earlier post , I made reference to a memo I once distributed to the medical staff which was so inflammatory it disappeared from every doctor's mailbox before most ever caught wind of it. Although there might have been suspicions, I don't think it was ever known who did it. I'm ready to let the cat out of the bag. It might take a couple of posts to explain the whole scenario. Done well, it ought to shed light on many aspects of what has been wrong in medical practice in recent years. Done poorly, it could bore you to death. But first, a disclaimer: Let me say in all sincerity that this occurred some time ago, when medical relationships were at their nadir in our town. And the hospital in question has turned things around in remarkable fashion, so much so that it's as if I'm talking about another place. So understand this: although it's all true, without question, categorically, undeniably it is not a reflection of the current situation. Politics have impr

Breast Cancer Women

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Something you may not know, and won't get by looking at most renditions of them, is that the legendary Amazon warrior women are said to have cut off their breasts. One, more accurately. In order to shoot their arrows with their bows, the left breast (assuming right-handedness) was removed. (The linked article above has it wrong, I think.) Pantomime it on yourself: the left breast would be in the way, particularly if bare-breasted, as they were, so it is said. And here's the kicker: it's in the name. Amazon. A (for absent); Mazon (same root as mastectomy: referring to the breast.) Of course, none of this is confirmable, but it is an accurate account of the legend. And so I told it to Gloria and her husband, competitive archers. Women are tougher than men, no doubt in my mind, having operated on both more than a few times. The fact emerged first in medical school, when a fellow (male) student fainted dead away as we heard a lecture on blood types. A lecture, not even a