Surgeonsblog

I've been asked it a lot: what does cancer look like? The questions don't usually refer to the microscopic view, of which the above is a good example: big and dark and variable size and shape of vacuolated nuclei, discohesive, not much cytoplasm. People want to know what I see when operating. Our apprehension of beauty has much to do, I'd guess, with the expected physical attraction to our own form. Smooth and supple, graceful curves. (Is there anything more lovely than the female breast?) And if most people are repelled by the sight of viscera -- as well they might be, spilled in some tragedy -- the essence of that beauty is still there. Our innards have the same characteristics: glistening smooth surfaces, slippery, fine edges, gentle transitions. Those organs that are solid have a cushiony firmness: there's give, there's welcome. And their shades are of the earth: ruddy, fall colors, comfortable ones, like autumn leaves, sleepy and warm. Cancer is many things,

The best thing about having written a book is hearing from people who read it. At the top of that list is the friendship I've established with JB, who trained at the same place I did, UCSF, about ten years ahead of me. I'd never met him (still haven't, other than via many emails), but I'd heard stories: like Hawkeye Pierce , he got away with some memorable stuff there because he was a really good surgeon. He was also a surgeon in Vietnam, where he ran an Army trauma unit; and he's done a little writing . He's lived an extraordinary life; in the words of a mutual friend, he's "the real deal." I'm honored that he contacted me. And his feelings about the place where we became surgeons are a lot like mine. Readers of my book will know that a central character is that classic county hospital, San Francisco General Hospital, and the trauma center within it, Mission Emergency Hospital. Maybe the source of the phrase "brick shithouse," the

The latest in the never-ending quest to define quality medical care is the designation of "Centers of Excellence." It's a grand goal. In theory, it sounds like just the thing to help consumers find their way to the best of care. Going to a COE (as folks are wont to abbreviate them) ought to give one a great deal of confidence; and from what I know there's truth to the idea. If you go to a COE, it's not likely the care you receive will completely totally suck. I'm not naïve; nor, I'm pretty sure, are you. It ought to surprise no one that the criteria for qualifying as a COE are generally imperfect, sometimes political, and not always central to uncovering what is, in fact, excellent care. I say this as a person no longer directly affected by such things, one who has worked in some pretty excellent places and who has delivered (yes, yes) occasional aliquots of excellent care; but whose time in practice pre-dated being in a position to be so designated, or no

OK, I realize that in the order of things this is really small stuff. But I must have my say. Having watched (why, oh why do I persist?) "House, MD" last night, I conclude that if they ever had medical advisers, they must all have been fired, quit, or -- more likely -- committed suicide. There was the usual leitmotif of erroneous diagnosis, treating for some disease and discovering another. There was the added sub-plot of women too old to do it, running around wearing thongs, or no underwear at all. (The import being too ridiculous to elaborate.) And the ducklings (what are they? residents?) as usual are doing things that no medical people would be doing: operating MRI machines, and drugging their mentor and biopsying several body parts. (What drugs can do that, by the way? Is there something you could put in coffee that would knock a person out cold in three minutes -- is there such a drug at all, let alone one that wouldn't be tasted?) But the final straw was seeing D

The parents of Matt Groening, creator of the Simpsons , were friends of my parents. It might interest his fans to know, if they don't already, that his parents' names are Homer and Marge. Several years ago, my mom got Marge Groening to finagle a favor from Matt: he sent our son, on his birthday, several items of wittily signed simpsonalia, along with a couple of original drawings of Bart offering greetings, relating, as I recall, to a cow. This does not keep me from criticizing Mr. Groening on surgical matters. On the most recent Simpsons episode, which I watched with my usual devotion, Homer underwent weight-loss surgery. During the pre-operative meeting with the surgeon he was told about "gastric bypass surgery," but the explanation, complete with diagram, was of placing a band around the stomach. There's a lot of misunderstanding out there. Before I became a blogger, I spent some time voluntarily answering medical questions on a couple of online medical fora. W

A very nice lady (and, one infers, an excellent doctor) who sutures for a living asked me a question which reminded me of a good story. Rarely seen nowadays, there was a time when super-long intestinal tubes were used to treat certain conditions of the bowel; particularly in a person with many prior obstructions in whom reöperation was undesirable. Snoogled through the nose and into the stomach, these tubes had bags of mercury on the end (for its heaviness and loogilability, allowing passage) and were fifteen feet or more (guessing) long. The idea was that once in the stomach, the muscular action of the gut (peristalsis) would drag the bag and the tube downstream to the point of obstruction, decompressing it by sucking out the backed-up juices, and allowing unkinking; maybe by eventually working its way past the blockage. Sometimes it actually worked. Having passed the tube, often over regurgitive objections, and having had the patient lie for hours on his/her right side so the bag w

Inside a vein, it's always perfect. No matter the state of the rest of the body, when you open a vein and look inside it's smooth and shiny and slippery. The inner wall glistens and lavishes the eye with a creamy-khaki surface. Not that it's common to get into one on purpose: but for things as minor as a cut-down (directly opening a vein to insert a large IV), or as major as a portal-vein decompression (a finger-in-the-dike procedure to stave off the effects of cirrhosis), the lumen of a vein seems impervious to the ravages going on around it. It's like pushing through an old house stacked full of garbage, and finding a tiny closet, empty and clean, floor all waxed and sparkling. A private, preserved space, kept pristine for secret reasons. (Arteries, not so much .) The bile duct is like that, too, if a little less certainly. When there's obstruction with infection, it can get red and thick, the inner surface knobbly and cobbled. Mostly, though, it's a similar w

The world seems to be losing its collective mind, so it shouldn't be surprising that even vaunted medical schools are making "alternative medicine" part of their curricula. Several bloggers have been and are doing a fine job of venting ; I come late to the party. (For the record, it's my view that in swallowing the pill, these schools and other hospitals are in it for the marketing. Which is more cynical than the therapies they're touting.) Many years ago I watched, drop-jawed, the television commercial of a local chiropractor as he stood by a couch-full of young kids. Recommending monthly preventative adjustments for these four- to six-year-olds, he touted the obvious benefits: look how healthy they are. Not, he seemed to imply, a heart attack among them. Nary a stroke. Probably not even a case of colon cancer. And I wondered: is he stupid enough to believe or is he simply a cynical and dishonest charlatan? I got a partial answer a few months later when a woman

The medblogosphere is sizzling with talk of medical woo, which has got me thinking about the next big thing. People are already spending billions on bottled water, and now on vitamin-packed, herbal, performance-enhanced waters. And on quackery? Uncountable. So how to cash in on gullibility, desire for effortless improvement, universal needs, and credulity when it comes to pseudoscience and health alternatives? I may have it. Here's the science: ano-rectal tissues absorb medications pretty decently. Anti-nausea suppositories are quite useful for some post-op patients, or puking people. And I'm a doctor. The "pseudo?" Turning it into gold. Or, in this case, brown gold. So. Toilet paper, the perfect vehicle. Haven't decided whether to make it homeopathic (advantage: no need for any additives) or "natural." It could be infused with, oh, any of a zillion choices. Combined. Why stop there? I could claim ( "these statements haven't been confirmed by th

Newer-vintage cardiologists are quite capable of independent play, but there was a time when I put in lots of pacemakers. Originally that meant doing the entire procedure, and back then the devices were enormous. Heavy, clunky, grapefruit-sized (if the sour sweetie were squeezed more flat than one might see in the supermarket [but think how stackable they'd be]), the battery/pulse generator required some work to implant. Producing under the skin a pocket large enough to receive the beast was a job for one with at least a modicum of surgical skill. And I'd thread and properly locate the pacing wire as well; the first iterations thereof were stiff and therefore fairly easy to direct, which carried a corollary danger of poking all the way through the ventricle. Never did it. Heard about it. (It could work its way through much later, as well.) Gone the way of Univac , those giant items have evolved impressively; current (huh huh, current ) pacers are tiny and complex, capable of sp

(Last year, several readers took advantage of an offer so generous, so irresistible, that it was nearly unparalleled in the history of book-selling. Since I was never in it for the money, and since I'm nearing the level of sales that will bump my royalties up close to the price of a stamp, I'm going to do it again.) It occurs 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, signed by me: 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 and sign it 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 s

[It's another testament to the universality of rock and roll that the lyrics of the title-referenced song make mention of a "song about a knife." And may I add that when presenting my biology honors thesis in college, the subject of which was intra-allelic recombination in the Ruby Eye locus of D. Melanogaster , the results of my inquiry into which were sorta surprising, I made another musical reference. "The fact," I said, "that Ray Charles, when he sang ' They say, Ruby you're like a dream, not always what you seem, ' predicted the very results I am about to reveal says much not only about Mr. Charles in particular but about popular music in general." So we have a pattern here. And I'll just assume that everyone recognizes the picture.] During the planning stages of the surgery center in the creation of which I was a proud participant, it came to be revealed that we'd be having the patients walk into the OR under their own power

So I got invited to blog for money. Truth be told, I'd not heard of MedPage Today before the offer came along. Even though it amounts more to tribute than treasure, I said yes. My tat for their tit is to have placed a new scrolling news-widget in my sidebar, over there to the right. And I've agreed that although it's OK to post stuff from here over there, I'll be writing some "exclusive" posts as well. I assume it's OK to let readers here know when I've dropped one there. So, other than a post of self-introduction, here 's my first offering. Funny how it works. This comes at a time when I've been feeling like I've squeezed my blogging brain pretty dry. Given a contractual commitment, I'm worried about giving this blog -- my one true love -- short shrift. We'll see. It could be the end of me in both places. Poetic justice.

image from damnitimvixen.com To the essential questions of modern life -- paper or plastic; boxers or briefs; regular or decaf -- add this: fingers or palm? In what way, with which appendages of the hand, should one grasp a needle holder ? I was chastised, during my formative years, for transgressions of either type; now, I feel strongly both ways. Huey Lewis said it : "Cool is a rule." I doubt any student of surgery, from earliest medical school forward, failed to practice the technique of palming a surgical instrument. It is cool. Rather than putting fingers through the rings, the whole handle is placed in the palm, one side on the thenar eminence . The ring finger and/or the little one, when pressed onto the part of the handle that's not resting at the thumb, can be made to unlock the ratchet, and widening the palm makes the jaws separate. The index finger is laid along the shaft of the instrument, with the tip near the very end. The index finger is really the most im

In no way is it false modesty to say that physicians are not healers. At best, what we do is to grease the way, to make conditions as favorable as possible for the body to heal itself. For without the body's amazing powers of defense and repair, nothing we do -- especially we surgeons -- would be lasting at all. The most immediate and palpable reminder of this is the process of sewing someone up, and watching what happens. Wound healing is a wonderfully complex process, and it would be folly for me to attempt explanation in detail; mainly, because I've forgotten the pathways, the kinins and the prostaglandins involved. I'm not going to look it up again, but you can if you like . Anyone who's had an operation, from minor to a big deal, has had the opportunity to witness it. Maybe you were too sore to be in awe. But I always liked to point out the easy evidence to my patients. I've gotten calls about red incisions (despite trying to explain it in advance.) Of course,

Image from hippocritis.com Like most training programs, mine had a weekly conference in which deaths and complications were displayed, discussed, and dissected (most are called "M and M" conferences, for Morbidity and Mortality. Standing for Death and Complications, ours was called "D and C." Given the scraping of the flesh until blood was drawn, it seems very descriptive.) In recent years there's been a trend, I think, toward deëmphasizing those meetings; despite the so-called "privileged" legal status of such discussions, time and litigation have caused people to fear exposure. Which is damnably bad, because those conferences are, in my opinion, indispensable to teaching and learning. But that's not my point today. In the conference, take-backs for bleeding were not-infrequently addressed. In fact, the phrase "It was dry when we closed, Dr. Dunphy" (Dunphy was our chief, and usually he ran the sessions) was so common that one chief res

[As I did for a past post, I begin with a warning: this is a political rant, so people who come here for surgical stuff should turn away now. But come back: tomorrow it'll be back to usual.] News item : US Senate rejects measure to provide path to citizenship for children of illegal aliens, if they serve in the military or complete two years of higher education. By "reject," of course, it is meant that it received a majority of votes, but not the super-majority of 60 required to prevent filibuster. (Anyone remember when the Republicans were screaming over Democrats' use of the same ploy -- which is to say both sides are a bunch of shameless hypocrites.) Personal item : Earlier this week I was a community volunteer, evaluating senior projects at a local high school. The first presentation was by a native-born Caucasian person, who did a lazy and entirely unimpressive job. The next was a young woman who was born in Iraq, sent to a refugee camp in Saudi Arabia, and fin

Check this out, then we'll talk: OK. Aside from the fact that W.C. Fields was one of the funniest physical comedians we've had, there's a serious point to be made: laparoscopic surgery does not come naturally to everyone. [Aside: in college I put on a W.C. Fields film fest as a fund raiser. His stuff is timeless; his short films are classic. I've repeated the "Honest John" story, and demonstrated with a pool cue, off and on for the last forty years. If you can find "The Barbershop" (or is it "The Barber"?), watch it, although it could ruin your concept of shaving and of puppy-dogs forever. And, of course, in addition to the physical comedy, Bill left behind some of the best lines ever uttered...] Watching the ol' curmudgeon's struggles to control his pool cue is an exact replication of observing (some) neophytes in their first attempts at laparoscopy. Newly-minted surgeons have had the advantage of training in laparoscopy over time

The term "running the bowel" is one I've used before. Not to be confused with this , it refers to the process of inspecting the intestine from one end to the other, looking for trouble. Often it's done by pulling the bowel with one hand, through the gently closed fingers of the other. As the bowel is slippery-moist, it glides greasily over rubber gloves. Sometimes it slips the grip, requiring starting over nearly at the top, since the whorled loops retract gloppily into a pile, in a way that erases traces of where one was, quickly. It's very slithery. While performing the task on one occasion, on a person whose background was justifiably in question -- the less-than-innocent victim of a sharp object or missile of some sort -- my fingers found a circular object within the man's gut, the size and texture of which made me think it was a condom. Or possibly a balloon. My conclusion was that the punctured person was a drug-runner, since ingesting condoms and ballo

The body comes in layers. I've written here and at least one other venue about the need for surgeons to find the planes between those layers, and to work within them. Having used the technique to prolong a few lives over the years, I can now say I've done it to prolong my own. My wife is the oldest of nine siblings, all of whom live within (amplified) shouting distance of Puget Sound; and their parents do, too. Family gatherings are frequent, and for special occasions (which occur only once or twice a week) the entire clan collects at my in-laws' place, the northernmost homestead, nestled dramatically at the water's edge (of a lake, not the Sound). This weekend, the raison d'etre is their mother's eightieth birthday. Hilarity, lubricated and well-fed, will undoubtedly ensue. A damper has been narrowly avoided. It was delegated to me to pick up the special-ordered cake, produced in a fabled Danish bakery in Seattle; and I did. I'll accept only part of the bl

Still searching for better ways to get audio connected here, I've just set up a podcast site. I recorded another few pages of my book, and invite you to go there and have a listen. And this request: hang in there through the first minute or so. It gets better. The link is here .

A while ago I wrote about choosing a surgeon. Related is the decision to have care (surgery, of course, would be the subject here) in a community hospital, as opposed to the famous medical center. A commenter on a recent post referred to the BHD, the "big hospital downtown." I'll call it the BFH and let you figure out what I mean. Like everyone else during training, when I was at a BFH learning to be a surgeon, I basked in the belief that I was at the only place a person could go to get good care. I thought derisively of the silly referring docs; so did my confreres. I even wondered how I'd be able to care for my patients when I didn't have a retinue of people following me around happily (or not) doing whatever I asked, as I did when Chief Resident. It took a minute or two in practice to disabuse myself of the mythology. Think about it: if those BFH's are so wonderful -- and in many ways they really are -- ought it not be the case that the people they train

Before arriving in town to begin life as a practicing surgeon, I got a call from my pre-assigned medical assistant, asking what size and style white coat I'd prefer. Well, I thought, these guys think of everything. This private practice stuff might be cool. But then I wondered, who says I have to -- or even want to -- wear a white coat? Having spent the past ten years or so wearing the white coats of learning, and despite thinking those thigh-length ones that some of the professors wore looked pretty spiffy, I couldn't wait to get out of them. I'd also noted that in the teaching hospitals at which I'd spent all my time, the full-time professors were generally the only ones who wore white coats. The private guys mostly didn't. Not that I was emulating one or the other. But it said there was a choice, and I went nolo-alba. I've only owned a couple of suits in my life, but I do have a few sport coats, and that's what I wore in practice. Always, back then, with

My para-previous post mentioned getting second opinions. I think it's a concept worthy of separate rumination; and because I'm not entirely coherent on the subject, I'll be interested to read what I have to say. So it doesn't get lost in the morass, let me be totally clear: whenever a patient wants a second opinion, for whatever reason, s/he ought to get it, and I'd never ever discourage or disparage it. Being comfortable with whatever medical intervention is at hand is essential, and if the first doctor resists it or gets huffy, well, that's probably confirmation of the need. But it has always bugged me when the reason is a requirement by some insurer or another, or when it's because someone (an agenda-driven talking head; a relative; a BFF) has made the patient feel guilty or inadequate if they don't demand it. It's possible -- and I always made a hell of an effort -- to establish a relationship of trust based on being fully informed, respectfu