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Showing posts from October, 2006

Doctors, Working Together

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One of my more naked screw-ups during training occurred when I was Chief Resident, and in the blink of an eye (quite literally) it took me from feeling like God's gift to surgery to certainty that I was the village idiot. (Turns out that form of rapid decompression continues more or less weekly throughout the career of any busy surgeon. Nevertheless, this was as deflating as hearing "That all you got?" from Scarlett Johansson.) I'd seen a man in the clinic who'd had several operations for fistula-in-ano , recurring within a short time on every occasion. Brilliant surgeon that I was, I considered the possibility that he was one of the less common victims, having a connection from skin to colon, well above the anal area from which fistulas most commonly arise. So I ordered a barium enema . Sure enough, I got a call from the radiologist telling me there was a fistula between skin and sigmoid colon . Hot damn! Not only could I demonstrate my acumen to my attending,

A Little More Gas

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The anesthesiologist is the surgeon's best friend. The only times when that's not true are the times when that's not true. In thinking about the relationship (because Enrico asked me to), I've come to some conclusions, most of which are less than earth-shaking. As with most collegial relationships, the best are those in which there is mutual understanding and respect; and that, for the most part, comes from working together consistently. I had the luxury, for the better part of my career, of working with excellent anesthesiologists, and working with the same ones on a regular basis. So. What makes for an excellent anesthesiologist? Pretty simple: don't drive me crazy. OAFAT (pronounced "Wah-fat"). It stands for "Obligatory Anesthesia Fucking Around Time." Surgeons -- me at least -- are just the teensiest bit impatient. If I've got a case to do, I want it to get going. Patient's in the pre-op holding area: I want to go in there, talk to

It Can Be a Gas

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While assisting on a carotid endarterectomy (wherein the main artery to the brain is clamped off, opened up, and reamed out) one time during my surgical training, I noticed the anesthesiologist was rummaging around a bit more than usual: opening drawers, drawing up drugs, checking monitors. Finally he casually looked over the ether screen and said to the surgeon, "Jack, you might want to stop what you're doing for a while and push on the man's chest." * * * * * * Shortly after I'd arrived in town, the new guy on the block, I told the anesthesiologist assigned to my impending breast biopsy in a frail elderly woman that I'd be happy to inject a bunch of local anesthetic if he thought it would simplify his anesthetic. "I don't need some pipsqueak punk telling me how to do my job," he yelled. * * * *

Big Joe

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When I think of Big Joe, I see his overalls, and how he filled them. And how a couple of months after I operated on him, there was room for both of us in there. Big Joe: farmer, salt of the earth, tough, stoic. On the day I met him, if it'd been Halloween, I might have tried to stick a candle in him. That's how orange he was. My initial recommendation, while probably justified, damn near killed him. Big Joe hadn't been sick a day in his life. Well, he was diabetic, but it hadn't been much of a problem. He worked his tractor every day; took a hell of a lot to slow him down. He'd been feeling a little poorly, less appetite than usual, no pain really. It was the white stools that worried him, along with the brown urine. His color, well, he was in the sun all day, so that hadn't seemed too strange to him, although his wife was starting to notice. So he saw his doc, who ordered a battery of blood tests, an ultrasound followed by a CT scan, and then shot him over my

Request?

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As I look ahead, bloggingly, it occurs to me that it would be fun to hear from readers about subjects they'd like to see addressed. Anything you'd like to hear a surgeon (this one, anyway) talk about? Because I just might.

The Rupture; End Times

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Someone once said that a pediatric surgeon is one that thinks a hernia repair is a big deal. Personally, I think that's quite off the mark; especially when you think of the really big deal operations they do for any number of severe congenital defects, and since it was a pediatric surgeon who taught me how to turn a pedi-hernia repair into a piece of cake. I have watched a couple, on the other hand, who made it seem like building a Swiss timepiece. As I mentioned in my initial post in this series, most groin hernias result from incompletion of a process that begins and should end in utero . When groin hernias present in kids, in most cases it's much simpler to fix than in an adult: if you remove the sac that didn't regress, and since the kid still has growing to do, the muscles around the hole will tend to slam shut as they should have; so closing that hole, either with stitches or with placing mesh, isn't necessary. And that makes it quick and close to painless to f

The Rupture, part three

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Hernia repair is surgical bread and butter. It's so much so that "hernia equivalent" has been used to measure surgical work: how does the difficulty of an operation compare to that of a hernia; how many "hernia equivalents" does the average surgeon do in a week; how many should she? And when attempts have been made to quantify surgical difficulty in terms of relative reimbursement, hernia repair is often the base unit. If a hernia is worth "X" bucks, then a colon resection is worth 2.3 "X" bucks. Or something scientific like that. Repairing hernias, evidently, is the essence, the mother's milk, the calling card of the general surgeon. Ridding the world of ruptures is what separates the surgical sheep from the surgical goats. Is that why it's an intern's case? Other than removing various lumps and bumps, fixing a hernia is generally the first crack an intern gets at "doing" an operation. It's a good example of how i

The Rupture, part two

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Well, OK, I'm no good at suspense. Plus, I guess my hints were too obvious anyway. It (new reader: refer to previous "rupture" post!) was indeed a uterus, a teensy one, complete with a couple of sort-of-ovaries, smaller than BBs. (For the record I've also, as suggested by commenters, seen several appendices in hernias, some requiring a little maneuvering to get it out. One case of acute appendicitis in a hernia.) It was as if Ken had read "Surgery for Dummies," and operated on Barbie, dropping the pathology specimen on his way to the lab. It's not my intent to make this a post about hermaphrodites (I'd have to look it up, anyway); but the first thing that came to my mind (second thing, I suppose, after the WTF moment) was the question: what do I tell the man, and his family? "He's doing fine. Operation went great. You'll be able to see him in about an hour." And, while walking out the door, turning back, "Oh, and by the way, he

An "Ah-Ha" moment

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Allow me a brief diversion, not intended to delay the return to hernias. In my recent post, " Taking Trust ," in which I tried to describe an aspect of the mysterious relationship between surgeon and patient -- being allowed, given the privelege, to reach inside another person -- my words "creeped out" a few people. Of course, that makes me feel bad, in that I'd like as a writer to be able to express my thoughts clearly enough that they aren't misinterpreted, and in that as a surgeon my relation to my patients is and was anything but creepy. In my ruminations and recriminations over the post, something just occurred to me: something I of course assumed, but which not everyone who read the post may know. Us older surgeons, who trained before CAT scans and laparoscopy, were taught (required!) to "explore" the abdomen as part of any abdominal surgery. Before attending to the problem at hand, in a systematic and thorough way, we felt every organ in or

Awaiting the Rupture

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I'd have to say he was a typical grandfather: grey, bald, with the usual crescent of remaining hair. His skin was, perhaps, a little more vibrant than you'd expect, and he had a pleasant peachy sweetness of face that I didn't attend to in any particular way. I was more concerned with his groin, in which there resided the typical tender mass of an incarcerated inguinal hernia. It had been that way for several hours, and he was feeling nauseous and quite uncomfortable. He had earned a round-trip ticket to the operating room, on the express route. His family was there with him: wife, couple of kids, grandchild or two. Nice guy. In the simplest of terms, a hernia means there's a hole somewhere with something poking through it. Those holes, for the most part, are ones that we're born with but which, for some reason, have become enlarged, allowing protrusion though it of something that doesn't belong in the hole. By far the most common of the "natural" (my

Oops

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One of my mentors (in my book, I referred to him as Ken Rockford, and described him as a "goddamn grenade") used to go crazy if anyone said "Oops" in the OR. It was a ticket to the exit door, quite unceremoniously. Indeed, it makes sense: "oops" is not exactly the thing an awake patient would want to hear from the other side of the ether screen , knowing people were taking liberties with his various parts. But, when you think about it, the term is as common as an itch: saying it, in most cases, is no more conscious or important than scratching your head. The word is quite loosely tossed around, at the least of opportunities. I was thinking about it as, for the millionth time, I let an "oops" pass my lips this morning in the OR. The occasion: placing a simple stitch in the skin, closing the small stab incision I described a couple of posts ago. One end of the suture slipped through my fingers as I tied it, leading to exactly zero problem, and t

Not Lately...

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My aunt tells me this: (I have no recollection, but it makes some sense, considering.) My dad, she says, was taking me and my brother to a baseball game one day, when I must have been around five. Excited at the prospect, I ran up the street to tell my friend, instead of heading to the car; engine likely already running. My dad was many good things, but patience was not an attribute. As he drove off without me, I ran after them, crying; then stopped and stood there, crushed. I really hate being late. Throughout my career, the only schedule more sacrosanct than my office was that of the operating room. I was close to insane about it. For reasons I could never understand, some surgeons are never on time, routinely showing up at least a half-hour after their scheduled start time. It is, in my opinion, the height of rudeness: start your case list late, and the effect dominoes through the day and into the night, screwing up the plans of patients, OR personnel, other surgeons. I know:

On the Other Hand...

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The thing about laparoscopy is that it's so impersonal. If open surgery is intimate, as I tried to convey in my previous post, laparoscopy is insulated, stripped of sensation; performed, in essence, outside of and separate from the patient. I like it. Don't love it. I'm no Luddite; not a troglodyte . I'm enlivened by the innovations that are a part of surgery, and I think it'd make an interesting post at some point to enumerate the ways in which things are different now in the care of the surgical patient, compared to the ice age in which I trained. Unlike some of my fellow elders -- unschooled in video games -- I found the transition to laparoscopy technically easy: the ability to do three-dimensional things while looking up at a two-dimensional screen is not intuitive for everyone. From the outset, for the most part, I could get a skinny instrument to where I aimed, and make it do what I Nintended. It isn't hard to see that certain operations done laparosco

Taking Trust

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When Tiger Woods addresses the ball, he's focused like a cat that heard a rustle in the leaves. He takes a few practice swings, moves up to position, adjusts his feet, steadies his shoulders, locks his eyes onto the target. He waits until there's absolute silence, brings his breathing under control, funnels all his energy into the impending swing; takes the club back, and explodes in an immensely balletic movement. It stops the breath of an onlooker, ripples the air in a wave that goes forever. Making a surgical incision is nothing like that. But it almost is; and it should be. Having held the patient's hand as she goes to sleep, having whispered "We'll take good care of you" as his eyes flutter to stillness, the personal remnant is still very much there as I begin, even as the person is covered in sterile green paper, exposing only the belly. It's the midline incision, especially the one in the upper belly, from breastbone to navel, that's the mo

Almost famous

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I was nearly famous. Coming this close to being on the PBS News Hour, I was fully prepared to receive love notes and hate mail, and probably would have. The subject was outpatient mastectomy, and I was for it. My patient made it on; I didn't. Let's get this part out of the way right off the bat: there's no way I would EVER advocate that mastectomy should be considered an outpatient procedure in the sense that insurance companies would urge or require it. The default mode (as we computer-literate folk would say) is and ought always to be that it's done in the hospital. As with many things, I think that when there are options, women having the right to choose is a good thing. Having done many outpatient mastectomies, I can say with complete confidence that it's safe, amazingly well-tolerated, and, for some women, is better in all ways than being in the hospital. Especially in a hospital where the nurses are made to care for too many patients, or to rotate to speci

Almost famous

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I was nearly famous. Coming this close to being on the PBS News Hour, I was fully prepared to receive love notes and hate mail, and probably would have. The subject was outpatient mastectomy, and I was for it. My patient made it on. I didn't. Let's get this part out of the way right off the bat: there's no way I would EVER advocate that mastectomy should be considered an outpatient procedure in the sense that insurance companies would urge or require it. The default mode (as we computer-literate folk would say) is and ought always to be that it's done in the hospital. As with many things, I think that when there are options, women having the right to choose is a good thing. Having done many outpatient mastectomies, I can say with complete confidence that it's safe, amazingly well-tolerated, and, for some women, is better in all ways than being in the hospital. Especially in a hospital where the nurses are made to care for too many patients, or to rotate to speci

Quick to the Cut

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The following is from my book. It might lead to some posts on trauma issues. Meanwhile, it's a passage I like, and it's handy: Real men open chests in the emergency room. Every surgical resident wants to do it; it’s exciting, dramatic, life-saving, and a little bit showy. We’d do it for any of several reasons, especially when there’s massive bleeding in the belly: getting a clamp on the aorta via the chest can slow the leak of blood into the abdomen, without getting into a mess before you’re in the operating room. Opening a belly in the emergency room for any reason—but especially for bleeding—would be disastrous. Because the belly wall compresses bleeding to some extent, pressure drops precipitously when you open and take away that compression, and you need all the resources of an OR to handle it. More exciting, chests also get cracked for heart massage. When the heart is empty from exsanguination, pushing on the chest from the outside does no good, so we’d open chests dire