Ugly as Hell

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, but it's none of those. Arising as it does in every different organ, it has varied forms. It's not one shape or size or color or even texture (although mostly it's hard as bleached bone); but without fail it's ugly. Ugly as hell. And I don't think it's just because of what it signifies, or because of the hollow hole it forms in the gut of the surgeon who sees it where s/he didn't expect it. It's because of what it does to that sculptural perfection. Cancer is Lazlo Toth to the Pieta.* It's warplanes to a rice paddy.** Like a gnarly claw, cancer grabs tender tissues and pulls them toward itself. It distorts and discolors; it pocks, it kinks, it bends and it cracks. As it insinuates inward and hauls back, it transforms the sensuous and the smooth and the curvaceous into the discontinuous, the asymmetrical, the knobby, the pustular, the sudden. When you see it, you know it; when you touch it, there's no mistaking.

In the liver, cancer is a pallid and spidery pucker. The normally purplish smooth surface is studded with gray and hard nodules which, when below ground, pull inward and form jagged depressions. When originating elsewhere, the liver lumps are round but imperfect, like a dirty snowball. In bowel, when advanced and at its worst, cancer glues itself to surrounding structures, dragging them in like a vortex: other loops of bowel, omentum, all tugged and knotted together radially, like arms reaching in desperation out of a whirlpool. Inside, on the inner surface, it rises like an eruption, up-heaved and rolled edges, cratered down in the center, stealing the red and making it into a mucoid leer. Sometimes, as it outgrows its blood supply, cancer putrefies in its core, conferring the sensation of rotten fruit. Usually, though, it's hard in a way that our tissues are not: there's no give, none of the fluid turgidity that feels like life.

Of course, it does have meaning beyond mere sensation, and that is part of the perception. It's not possible to recognize cancer without being impacted by its portent; and that most certainly confers much of its repulsiveness. To operate with intent to cure, and to find those unmistakable signs that it's gone beyond is to have sorrow become physical and palpable. There's no way to count the times I've examined a woman with a lump in her breast and known with near certainty within a second of laying on my hand. In that moment, for me anyway, it's not possible to pretend. I know what's inside: that spiculated gristle, gritty and hard, pus-colored. If there's time, we'll be okay. But it's still ugly as hell.



*An artistically blindered science major, I stopped in Rome on my way to a research summer in Yugoslavia, during medical school. A friend of my family -- a priest, later a bishop -- happened to be there, and took me on a personal tour of the Vatican. Seeing the Pieta was stunning, broadening. That a person could have wrought such beauty from a piece of rock... I detoured to Florence just to see more of Michelangelo's work. And it was not very long after I was there that Lazlo Toth -- whose name has stayed with me ever since -- wreaked his destruction.

**I saw that, too.

The Key

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 place was memorable in countless ways. First and foremost was the building itself. Decades old, made of brick adorned incongruously with a sort of Gothic roofline and containing unexpected marble floors and carved wood banisters, "The County" -- as we called it -- served most of the destitute of the City-by-the-Bay, and provided trauma care to everyone of all walks of life, housing them in open wards, providing the most modern of care in the most ancient of settings. Containing surgical amphitheaters from the days of surgeons operating in suits in front of an open audience, in more recent times, just preceding my arrival, it had also been the living set of famous movies. Becoming Chief Resident on the Trauma Service was the pinnacle of years of training: the top of a steep and tall pyramid, the most demanding, the most exciting, the most responsible job there was. Having looked with awe at those chiefs as a lowly intern, working slowly and exhaustingly toward the goal over many years, finally finding oneself in that role was magical. Unbelievable. Both daunting and exhilarating. And you lived in a cool place. Deservedly, since being Chief Trauma Resident meant staying in the hospital, instantly available round the clock for sixty days straight.

It wasn't much, really, by most standards. Off a dark hallway on the second floor of the hospital was a small bedroom just large enough for a single cot and a bedside table, outside of which was a larger room where the senior residents slept (the trauma service consisted of two teams which alternated twenty-four hour shifts -- plus time required for joint rounds and finishing of work; more like thirty-plus hours on and twelve-plus off -- each headed by a senior resident, with a single chief of both teams, who stayed put.) Big enough to house the occasional liver rounds, that outer room also contained a chair or two, a bookcase, and a display of various items that had been extracted, over the years, from the recti of many clients... Despite being sparse and bare-walled, it was a cool place, if for no other reasons than throughout the hospital only the Chief Resident of the Trauma Service had access to such a room; and that so many generations of surgeons had occupied it, including some pretty big names in American surgery. When I moved in, I was very aware of the river of history that flowed through that suite and was deeply humbled by it. A storied nook in a fabled place. And I was the last ever to occupy it.

For much of the time I was there, a new hospital was being built -- modern, sterile, with private rooms, narrow corridors with none of those great and gloried ghosts walking them. It was while I was Chief Resident that the work was finished, and the move to the new facility made. (I did the first operation in the new operating room, it having been very important to the Chief of Surgery that the trauma team do so.) All we had for sleeping in the new place was an unused patient room, devoid of all that history. And having vacated, they took the wrecking ball to the old brick house. It put up a good fight; took much longer than had been planned, so sturdily constructed it was. (As opposed to the new place, wherein holes were punched into walls by door-handles within days of opening.)

I wrote about the mysteries of the old County in my book, and of the sense of loss as I moved out. JB read it and, because he'd felt the same way about that place, he wrote to me. He told me stories of many of the characters in my book, and said how much he'd loved reading mine. And he said he had a gift for me, something he'd had for many years and with which he'd always felt there'd come a time when he'd know what to do. Unaware of its impending ignoble end a decade later, he occupied that Chief Resident room with a sense of devotion and awe like mine, and when he left, he'd kept a little piece of it, which lay for forty years in a dresser drawer. He read my book, he retrieved the memento, made for it a proper repository, and gave it to me. A most wonderful thing. It is this:





Thanks, JB.

[Update, 2012: turns out the key isn't what I thought. In fact, I have no idea what it's for. I remembered the chief resident room was room 320, lovingly called "The 320 Club." It's all poetically appropriate, since it's turned out JB wasn't who I thought he was, either; namely, a true friend. But that's a long and sorry story, not worth repeating yet another time.]

Off Center

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 not. So I carry no grudges, bear no wounds, have no need for excuses. An observer only, I'm still working enough to see, from within, the workings of the process; enough, I think, to make comments based on experience. Thumbnail version: hypo-impressed.

For one thing, like a lot of other awards -- or like the boxing world last time I paid any attention -- there are lots of agencies and organizations handing out hardware; not only different ones for different types of care, but even within a given field. (And, of course, they charge for it. Some more than others.) Can't get one? Get another. Criteria? Variable. In addition -- as is true universally for such things -- it boils down, to a very large extent, to the filling of various boxes, the ticking off of a checklist, which may or may not reveal what really goes on in the delivery of care. Evaluators show up with a list of demands, such as having protocols printed out and available for review, folders with the credentials of participants, plans for gathering data. All of which can be assessed with feet up, smoking a cigar, sipping a nice port. (Nothing changes: when I was in the military our facility was evaluated regularly by any number of inspectors general from any number of command levels. It was always and only about buffing up the paperwork, period.) The depth of penetration, as it were, can depend on the individual with the clipboard, what kind of day they had, who knows whom. Meanwhile, the actual rendering of care, in the flesh -- because that's hard to measure and to evaluate on any meaningful and reproducible basis -- may get overlooked entirely or looked at only in the most superficial ways. Many have spoken up about inadequacies and inanities of the current P4P efforts ("pay for performance," ie tying reimbursement to the meeting of certain criteria).

I tread light-footed. As one neither directly affected by nor intimately involved in the details of the process, I don't want to say more than I know; nor, because of my once-removed level of insight, do I want to cast specific aspersions on specific institutions, neither the purveyors nor the receivers of evaluations. But in places with which I have at least a passing acquaintance and from organizations of which I have at least passing knowledge, I've seen COE designations received or withheld without any obvious correlation the the care people are actually receiving. In both directions: COE awarded to programs of questionable quality, denied to ones providing superb care because of some sort of bookkeeping glitch, and vice of all the versas. Moreover, since in some settings the COE designation is given to a program in a hospital and not to the physicians, all doctors who provide that particular care inside those walls can claim the mantle, no matter on which end of the spectrum they may fall, excellentologically. And spectra there are.

The implications are great: not only is it important that the title of COE has meaning for people seeking care, there are trends toward insurers not paying for care rendered in a non-certificated place. So it is behoovenized that the process is meaningful. And here's the reason I bring it up now: A place at which I sometimes work recently was designated a COE, in a field of care with which I have familiarity. They'd previously been denied, having mostly to do with which three-ring binders were lying where. At its best, the care in question is indeed excellent. The difference in that care, comparing pre- and post-certification, in terms of the work going on where the latex meets the playtex, is zero. And the first time I worked there after the COE was announced, the scheduled OR crew consisted of people mostly unfamiliar with the work being done, necessitating the standing around at several points in the proceedings, while the proper instruments and equipment were scouted out. The outcome was fine, the patients as expected did well. But whatever that kind of support is -- adequate, satisfactory, safe, good enough -- it's not excellent. I'm just saying.

Bringing Down The House

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 Dr House once again barge into an operating room, hatless, maskless, gowned and gloved. The only way you can get gowned and gloved is if the scrub nurse helps you (ain't no sterile stuff like that sitting around outside the OR, at least not readily available), and no nurse would allow it. Not to mention the surgeons standing by dumbly while the guy reaches into their patient and pulls out a key in two seconds. Like Jack Horner. Like the surgeons were too dumb to have... Sigh.

It's not that I should care. But since reality is driving me crazy of late, it'd be nice if a simple attempt at escapism didn't make me want to slit my throat.

The Groening of Weight Loss Surgery

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. Weight loss surgery, I discovered, is a little like religion. Criticize gastric bypass in favor of lap-band, and expect serious flaming. When I predicted that, as the word got out, lap-band would replace gastric bypass as the procedure of choice, personal epithets were flung far, fast, and furious, as if I'd said Osama bin Laden ought to be president. The fact is that when most people think of bariatric surgery, gastric bypass is what comes to mind; and to date, it's what most have had (although the teeter is tottering). Good branding. Like MP3 player = iPod. But iPods don't kill 1.5% - 3% of their owners within days of purchase.

Disclosure: to the extent that I'm still a surgeon, it's only as a participant in the laparoscopic placement of lap-bands. Further disclosure: they pay me by the hour. Got no dog in the fight. Statement: if I were going to have a weight loss operation (and, depending on where I am on the sine-wave of my devotion to cycling and other factors, it's not inconceivable) there's no doubt I'd have the lap band. Why? Cheaper, safer, faster, doable as an outpatient procedure, quicker recovery, equal weight loss in the long run. More disclosure: not even all bariatric surgeons would agree with what I just said -- mainly the last phrase.

It's a strange world. Until pretty recently, those insurers who covered bariatric surgery (not many, for a long time) only paid for bypass, despite significantly higher initial cost and much more frequent (and very dangerous -- not to mention expensive) complications. In part, they claimed it was because (despite much world-wide experience with tens of thousands of patients) they considered the band "experimental." Cynical me: I think it's really because they figured that in covering only the more expensive and more dangerous operation, fewer people would choose to have it. Short sighted? Surprised?

Ain't no free (small) lunch. The main downside of lap band, as I see it, is that it affords less of having and eating your cake. Bypass works in significant measure by causing malabsorption of food. Stuff passes through. Although that often leads to diarrhea and nutritional problems for which the typical patient must take lots of supplements (as opposed to the typical band patient who needs none), some people are attracted to it because they may not be as restricted on intake. With a band, you can't eat as much, and you may need to give up certain things, like bread. On the other hand, a high percentage of people with a band in place find their appetite is wiped away like spilled crumbs in a white tablecloth restaurant. And there's this: the best results are with programs that are comprehensive and provide ongoing support. Some surgeons, of course, don't like that; which, I think, accounts for the disagreement amongst them. Cut and run, is what they prefer, and that's what they can more easily do with bypass patients. The people with whom I work set a very high standard of continuous followup.

Adjustability is another attraction of the band. There's a small "port" placed under the skin into which fluid can be injected, which fills a balloon on the inside of the ring. You can make it tighter or looser, depending on a patient's needs. Women who'd had trouble conceiving a baby while fat may get pregnant when thin, and need a little more room to eat for two. No problem.

Since there's none of the cutting of bowel and stomach that happens with bypass, there's practically no incidence of leakage or serious immediate surgical problems. Mortality rate is much lower (for the group with which I work, it's one (last I heard) in about three thousand.) The most irksome problem with the band is an incidence of "slip," wherein too much stomach ends up above the band, often requiring reöperation to reposition it. I think it's generally a misnomer, because in most cases it's not that the band has slipped, but that the originally small portion of stomach above the band has become stretched and dilated; which nearly always happens in people who go off the reservation, meaning people who force in too much food and end up vomiting a lot. Technical issues that might also be a factor are slowly being investigated and placement techniques have changed, which has lowered the incidence. That, of course, says that not all the problems are related to patient coöperation. (Love that ¨ thing, since I discovered how to do it recently.)

So. If you're like me and you get most of what you know about the world from watching the Simpsons, be of good cheer. As long as there are people around to correct the (very rare) occasional divergence from reality, you can keep watching with confidence. The internet is a wonderful thing.

Snakes On A Pan

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 would drop into the duodenum (which heads to the right out of the stomach), it would occasionally occur that the tube -- draped in some way by the bed and hung to allow unravelling -- would take on a life of its own and begin disappearing into the person in question, slower than but not unlike a baited line that had been glugged by a fish. (After many years of use, studies were done which showed no difference in non-operative success using these tubes as opposed to the much more hassle-free ones that just went into the stomach. Which is why you don't see them much any more, except in museums.)

It's one of those stories you hear: not actually witnessed, but told by unimpeachable sources. I think it happened where I trained, when I was there. A woman had been treated with such a tube, and it had passed as hoped. She seemed to be improving: belly decompressing, cramps gone. But suddenly one day things took a turn. Her urine output dropped and the amount of drainage from the tube began to climb -- signs of recurrent obstruction. With diminished urine output, it could mean even more dire things. IV fluids were increased, labs were checked, and on paper at least things didn't seem scary. But the upped drainage and downed urination continued, flummoxing her caregivers and frustrating the patient. Until observation solved the mystery.

The long tube had passed through the lady's entire intestinal tract, and was hanging out her rectum. When she sat on a bedpan to pee, it sucked the urine up and away, draining into the bucket for collecting intestinal juices, turning her fluid accounting upside down.

Let's ignore a couple of obvious questions and just agree: it's a great story.

Veins and Ducts

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 wonder: clean and crisp and sparkling on the inside. There's something about these vessels and ducts that foster their own brand of amazement. Springy and soft, yet turgid and tough. Sewing a vein, unlike anything else, (as long as it's not during a mad rescue attempt) is almost meditative. It's quiet; maybe because the suture is finer, the instruments more delicate than with other kinds. And because it demands the perfection of needlepoint: even bites, close, careful and exact. There's rubbery resistance to the needle which gives way with a little recoil. There's no tissue quite like it. If creating, say, an arteriovenous fistula for dialysis, or if sewing a vein-patch onto an artery, you go through the vein first with the needle, and the textural difference is clear. Sometimes, you hold the slender suture between thumb and index finger of one hand, gently tugging upward to tent and approximate the edges, while suturing with the other. Very gently. The vein is more plastic, thinner, versatile. And, always, cleaner. When you release flow, the vein bulges, and holds.

Sometimes, it's the same with a bile duct: you might be closing a hole, sewing edge to edge. More often it's to make a connection between duct and bowel, and the two couldn't be more different. (Well, yes, they could. But if they were, you probably couldn't connect them at all.) Then, it's more of a puzzle: getting together two things of entirely different thickness and texture, one of gross and separating layers and another of imperceptible ones. It's a challenge and has its own rewards, but not the quiet kind that veins provide.

A vein, laid open but stilled of flow. A silky surface even when lying next to corporeal corruption. It's not a big thing, really; but seeing it time and again, is somehow reassuring. A signal that things might be made right. If one place in this person is still okay, maybe the rest can still get there.

No Alternative

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 arrived in the emergency department, acutely paraplegic. Her chiropractor had continued manipulating her increasing and unresponsive back pain until she became paralyzed. The "doctor" must have known about her history of breast cancer, because he was also her husband.

Until that time, because the theory behind chiropractic is so obviously loony, I'd assumed practitioners all knew it and were simply crooks who'd found a surefire way to separate the credulous from their money. (And yes, I acknowledge that manipulation has a place in certain specific anatomic disorders of the back itself. But using it to treat or prevent systemic disease is nothing but laughable. Except that it's not funny.) Stupid, careless, lacking judgment: yes, the man must have been all that. But unless he hated his wife, I had to conclude he believed in what he was doing.

I still haven't figured it out, and I'm sure I never will. Of what do the cerebral lacunae consist in these people? How can (some) otherwise intelligent people (givers and takers) become convinced of the efficacy of whatever woo they wish? Is truth just too hard to take? At some primordial level, is it just that we need to believe in silly stuff? What is it about humankind that pines for magic, for simplicity, for answers that pave over the painful? Why isn't inquisitiveness universal; doesn't skepticism confer survival benefit? Or would we all be jumping off cliffs if we didn't have mythology? Maybe that's it. Maybe too many skeptics have already jumped.

The frailty, the neediness of the human brain, when stacked against the obvious power of it -- the ability to create, to invent, to inquire -- is a probative paradox. It may be a stretch to write my way from anger about alternatives and chafing at chiropractic, to the death of skeptics and skepticism, but in my mind it's of a piece. I have a friend, a brilliant physician and much more of a scientist than most, who tells me he knows, based on his particular faith, exactly into which level of heaven he will enter; as if he's already done a mapquest search and downloaded the directions. Given that there are about six billion people on the planet who believe something else, and with just as much certainty, I find it amazing. And revelatory. It's a need. It's built in. It's human.

My conclusion is that the desire to believe in certain unprovable things at one time was good for us: when the dangers in the world were mostly external -- volcanoes and saber-tooth tigers -- and the need to organize and stay together was clear, supernatural beliefs were of obvious benefit. And now, as society has gotten impossibly complex, and the dangers are mostly human-generated, it's become a detriment. Rather than helping mankind to cleave together and help one another, magical beliefs -- whether on couches or in the clouds -- are causing us to fall upon one another in hate, in fear, in the unreason that comes from a mind blown by the awful realities we have brought upon ourselves.

Magical thinking is who we are, I guess. If it were only that it serves to enrich some at the expense of others, maybe even make some people feel better, what the hell. If they're only hurting themselves, or the willingly deceived, should I let it go? But they are hurting people, and it's pretty clear that eventually it will hurt me. When I see this mainstreaming of stupid, I can't keep myself from thinking of the other side of the same coin: people flying into buildings, blaming hurricanes on gays, invading the wrong countries, laughing as we pee in the pool. The need for crazy-stupid is great; if straws they be, still grasp at them we must. We've gone from flivvers to Ferraris in a sigh and a gasp; from Kitty Hawk fields to the seas of the moon in the eye of a bat; Allan Pinkerton's shoes to spies in the skies: the power of scientific method is obvious to the most casual glance. Yet despite -- or is it because of -- the amazing progress we've seen at the hands of science in less than a lifetime, people willfully and seemingly in increasing numbers simply ignore it at their convenience. Need to ignore it. Demand to ignore it. Demand that I ignore it.

I don't think you should get to pick and choose. Don't believe in evolution? OK, then don't get on an airplane. Earth is twelve thousand years old? Fine. Take back your laptop. Homeopathy makes sense to you? No problem. Put down that cellphone, never avail yourself of GPS. Because if man and dinosaur occupied the same space and the same time, if carbon-dating is bogus, atomic clocks don't work and transplants are impossible. If vaccines cause autism, Rovers aren't on Mars and nothing will happen when I push the button to post this.

I Could Clean Up

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 the FDA...") an infusion of natural derivatives that integrate with and chemo-analyze feces and, depending on what toxins are present, transform into the proper natural substance which is then absorbed via your most delicate membranes (which happen to have special immune powers due to their critical location, as anyone could naturally infer) in exactly the right mixture to restore the body's proper balance. Straightens bent shakras, directs qi into the perfect meridian, which superluxes the spine. And it's soft and gentle.

I'm working on the advertising campaign;









Still needs work.

Que Ball, Side Pocket

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 speeding up when physical activity increases, of being interrogated by telephone, adjusted non-operatively. Many of them pace both chambers of the heart. Wiggly wires have replaced the rigid ones. Safer. And harder to position.

To the newbie go the onerous jobs. By the time I came to town, cardiologists were placing the wires for pacemakers, but they still wanted surgeons to make the pockets. Some of them also liked to cede the poking of the subclavian vein. Nor were they comfortable with the production of a thorough local anesthetic. So for the typical two-team job, I'd meet the patient for the first time in pre-op, introduce myself as the pocketmeister, prep and drape, inject local anesthetic, and make an incision through the skin, which I'd deepen to the chest wall and then, with my fingers, nooger a space big enough to fit the battery. In some cases, I'd also slide a guide-wire into the vein. On a good day, that whole thing would take five minutes. On a bad day, six. And then, I'd stand. Because when the electrode was safe and sound, I had to hook the wires to the box, insert it into the pocket, and sew it up. Took about two minutes. Tried. How I tried to get them to learn to do it; that thumb-in-ass standing around was a gargantuan waste of time.

Many factors dictate the ease and speed with which the wire placement occurs. Certainly, skill of the cardiologist ranks well above the bottom of the list. I worked with several, and one of them usually drove me nuts. Not only did he frequently show up late ("communication problems" with the OR), so did the pacemaker rep, who brought the requested device ("communication problems" with the office). Not rarely, the wrong kind had been ordered ("communication problems" with the doctor). To the extent that I could plan my time around these procedures, it made a big difference whether one or two leads were to be placed. Plans, with this guy, were fantasy.

He was actually very nice. Reminded me of Mr. Rogers. Which, of course, made it even harder: how do you explode at someone who always smiles? But it was forever the same. Head-hurting delays while everyone showed up and the right equipment was assembled. Doing my five-minute thing and then, in the case of this person, invariably standing around for a looonnnggg time while he got the wires where he wanted them. A loooooonnnnngggggg time. How long? Let me tell you.

On one occasion I had injudiciously (optimistically. Necessarily, because of patient needs) scheduled a mastectomy to be done after completing the pacemaker procedure (on another patient, if that wasn't clear, in another room.) I figured the first job at an hour and a half, as I recall. As the time to start the mastectomy approached with no end in sight to the first case, I got increasingly annoyed. I'm pacing, the machine is not. My assistant arrived (the able Joanie, RNFA, mentioned in my book and here). My own patient was foundering in the pre-pre-op area. Finally, I could stand it no more. (I've written about how much I hate being late.) I had Joanie -- more than capable of stitching -- wait for the cardiologist, managed to wangle another nurse to help me, and had them send for my patient. When she arrived in pre-op, I left Dr. Mrrogers, greeted my patient, talked to her and her family, escorted her to the OR, made ready to and performed a modified radical mastectomy, applied bandages, helped move her to the gurney, went to the waiting room to talk again to her family, came back to write orders and speak with my patient, returned to the pacemaker room, excused Joanie, waited another half-hour or so, and sewed up the pocket.





And the picture is...

Once More, With Peeling

(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 say that because I haven't heard from the publisher in a while...) Include in the email your postal address, which I promise I'll trash as soon as I mail your inscription, and will use it for no other purpose. Email me at sid dot schwab at gmail dot com (or, my profile at the right has a direct link) and title it "book inscription" or something even more clever.

Walk of Life

[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. No gurneys, no wheelchairs. You walk, we'll carry the IV bag (or wait till you're in there to start it.) Being well into my career by that time, and having worked in a few previous surgery centers -- not to mention oodles of ORs of the olden ouvre -- I was surprised. Weirded out, even. Likewise, I figured, our prospective patients. On several levels, I was wrong. It is, after all, ambulatory surgery.

Outpatient surgery is all about the "out." To wake up quickly, and to be clear-headed when doing so, the less extraneous drugs the better. Sedation of the pre-op variety can add to time in the recovery room. If you're marching, you're not medicated. There's more to it, though. Walking to the OR sends a homey message: it's like coming into someone's house. Hi there, welcome. I'm Cindy, and this is Jane. It's unthreatening; there's some retention of control, of doing instead of being done to. And best of all, it gives those veins in the legs a final squeeze at the best time: right before lying motionless for a while and going all thrombogenic.

In medicine, involving, as it does, humans, nothing is 100%. The stroll is not for everyone. Some people, medically or emotionally, need that sedation going in. And to make it a tolerable trek, you need to attend to certain potential gaps in coverage. Still, I rapidly came around to liking everything about walking to the room. And with a nice robe, a few smiles on arrival, and a quick and comfortable exit, it's my perception that the patients did, too. I can't count how many times I heard from patients on their post-op visit, within a couple of words of verbatim, "I never thought I'd say this about having surgery, but that was a wonderful experience." A great facility and a superb staff had, of course, much to do with it (as did receiving a perfect operation!) But the walk, I think, played a part. And the rose petals we strewed along the path.

Selling Out

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.

Cool

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 important thing, and it must be there no matter how the handle is held. The following picture, which amazingly enough is from the website of a university surgery program purporting to describe suturing techniques, demonstrates the worst of all possibilities (I suppose I shouldn't be surprised since in another section it refers to a pictured set of forceps by the name "Addison" instead of the correct "Adson." I'd bet my soul [a low-ball wager if ever there was one] that the piece was NOT written by a surgeon):

Here, the index finger looks bent and is not nearly close enough to the tip of the instrument. And no matter what the chosen method, no surgeon would ever stick his/her ring finger so far into the grip-ring. The object of the game is to achieve precise control, with the ability to make fine movements exactly the way your brain is suggesting. "Awkward" is the word that comes to mind when looking at that picture.

"God gave you fingers, so why not use them," said "Chatham Knell" (a pseudonymed teacher of mine), arguing for keeping the fingertips in the handle-holes. In my book I also referred to him as "Death" Knell.

In placing a suture, most of the action is in the supination of the wrist and hand. But fine adjustments can be made when the fingertips are in play; less so when the holder is palmed. On the other hand, when using a long instrument in a deep hole, one usually braces the hand in some way or another, taking fingertip control out of play. So here's what I think:

When placing fine sutures with a delicate instrument, hold the needle-holder with fingers in the handle-holes -- the TIPS of the fingers. When taking big bites or when necessarily using a large instrument, grip it with the palm, which confers strength.

And when you're using hairy-thin suture on fairy-fine needles, repairing nerves or patching small arteries, you use these beauties, the coolest of the cool, and it's fingertips all the way, baby:

News Flash

Ridge Lines

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, it's necessary to separate the natural from the infected (digital photography and email have been known to save an office visit, for the technologically inclined); but all incisions get red for at least a few millimeters out from the cut. An inflammatory response, it's the process of bringing the building materials into the work site: capillaries dilate and proliferate, blood flow increases. That, and much more, goes on under the surface as well. Attracted by "injury chemicals," various cell types arrive and unload their cargo, set up lattice work, induce structural changes. The result of the influx is a gradual thickening and hardening of the area for an inch wide or more, and which carries the unofficial-official name "healing ridge." When the ridge isn't there, you know there's trouble ahead. In the very ill, in people on high-dose steroids, in the malnourished, a soft and non-pink incision is an unwelcome and unhappy harbinger.

As much as feeling the healing ridge can alarm the unexpecting, it's a sign of health, the indication that help is on the way, that work is going on to effect healing. I'd warn people. To hernia patients, I'd say, "In a few days it's going to feel like a sausage under there. You might think the hernia is back." Or, after removing a lump of some kind from some place, "In three weeks, you'll think I didn't remove it at all." It takes many weeks for the ridge to melt away. The zone of redness dims, but the incision itself gets increasingly red, and doesn't simmer down for a year or more. (It also fades after the application of vitamin E, of ear wax, and of snake-oil, singly or in combination.) It's a living monitor of how long healing is active. Given an explanation of what's going on, surgipatients get a ridge-id ringside seat from which to watch the body do its work. (A corollary is the tiredness that most everyone feels after surgery. There's lots of work going on, I'd tell them. While you're lying around feeling lazy, your body is doing the equivalent of walking around all day. Give yourself a break.)

Bleeder

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 resident, when presenting such cases, took simply to saying "I-W-D-W-W-C, D-D." How can it be that a surgeon would have to re-operate for bleeding? What sort of incompetent idiot could have been so careless? I'll tell you: anyone.

There are some situations in which a surgeon will look at a little oozing here or there and make the judgment that it's not a big deal, it'll stop, it's OK to close. Those are not the problem. The kind of bleeding that requires re-operation tends to be brisker: a little artery somewhere, pumping away, is typical. No surgeon would have seen that and said, screw it. So what happened? Simple: it wasn't bleeding when the operation ended. And this'll make you happy: the healthier you are, the more likely it could happen to you.

Within the walls of blood vessels are muscles. In response to various changes in blood volume and other factors, they tighten or loosen to maintain or adjust blood pressure. They also snap to attention when a vessel is cut. The younger and springier, the less enpipened with cholesterol are those vessels, the snappier is the response. With muscular integrity, a cut artery will retract and constrict, thereby lessening or stopping bleeding. It's a good thing, especially if you're facing a saber-toothed tiger in the woods. Less, though, in the context of today's story: a small artery can stop itself from bleeding intra-operatively. The effect may be amplified by the fact that blood pressure often runs a little low during surgery. On awakening, the blood pressure normalizes; the spasmotic reaction of the artery muscle relaxes; the fresh small clot that likely will have formed is easily washed away... The good news is this really doesn't happen all that often (our D and C conference included reports from several different surgical services at four different hospitals). Mostly we see vessels and unbleed them in advance. But things happen.

One of the more annoying of the frivolous lawsuits I've had, signaled as it was by the arrival in my waiting room of a sheriff's deputy waving a subpoena, was occasioned by a reoperation for bleeding. It had been a very low intensity situation; so low, in fact, that it wasn't until the next day that the need became evident. The surgery took only several minutes, delayed the man's departure by one day, and had no further consequences. At the time, things were fine between us.

On those rare occasions when I re-operated for such a thing, I didn't charge for it. Our anesthesia people coded their bills based upon the surgical diagnosis on mine. No bill, no code. So they winged it, and came up with a code that showed up on the bill as "Reöperation to repair artery," or something close to that. Which, hemi-understandably, suggested I'd done damage that I'd had to repair, which was not how I'd explained it to him at the time. Caught in a cover-up? The most cursory review of records -- not to mention a phone call -- would have disabused anyone of the misapprehension. Eventually it did, as it should, go away with its tale between its legs; although not without further erosion of my already tenuous gastric lining. I digress.

It's a safe bet that postoperative bleeding will never be entirely eradicated unless the time comes when the only people operated on are those with such hardened arteries that they can't retract back and tighten up, in which case all surgically caused bleeding will be evident instantly. That would be bad news, indeed.

The American Dream

[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 finally found her way here. Her presentation was dazzling, brilliant. Wearing a hijab and a high-school sweatshirt, she spoke perfect English as she delivered a Powerpoint-backed speech.

One needn't take a stand on the way the US Senate works, or even on the details of immigration -- legal or otherwise -- to recognize this: to the extent that the "American Dream" is still alive, it's becoming apparent that it's more within the bosoms of the non native-born than otherwise. Look at who gets the scholarships, who wins the spelling bees, the science contests. It's not Jones and Jackson. It's Singh and Nguyen, Allawi and Ali, Kim and Yung. (For that matter, since this is a medical blog, look at the doctors being hired everywhere, and those entering med school. In my internship group, in 1970, we were eleven white US-born males, and one white US-born female. In one of the most recent groups, all but one were foreign born, and the one that wasn't was a first-generation immigrant. And I know the standards there haven't changed: it's about who can meet them.) (And if I need to say this to avoid one brand of comment, my point is not about white or male. It's about native vs. foreign born.)

As we are becoming a nation of people who -- for reasons, it seems to me, of resolving conflict in favor of religious belief over scientific fact -- reject evolution, global warming, and the fact that our Earth is older than twelve thousand years; of homeopaths and antivax; of people who would rather turn public schools into churches than training grounds for inquiry; who see open-minded education as a threat and who fail to see that democracy can only survive when the public is broadly educated and encouraged to question political leaders from all parties (and who fail to recognize that the greatest protection of religious freedom and the greatest tribute to its value is to keep it entirely separate from government, and that doing so has led this country to have a higher percentage of believers than any other Western nation) -- as all this is happening at increasing speed and with crescendoing decibels, it's clear to me that the future of America depends on the continuing influx of bright and motivated people from outside her borders. We are ceding greatness -- willfully and aggressively proud-as-hellfully -- to the rest of the world. Of the 70% or so who, in polls, say this country is headed in the wrong direction, I'd bet well over half think it's that we're not insular enough, not religious enough, not creationist-homophobic-unscientific-venomous enough.

There are plenty of great native-born kids. Mine, for one. And his friends. And cousins. And yours. Far be it from me to overstate anything. But as to trends? I'm worried. Really worried. It's not that "our" kids are inferior. It's that we're kissing them off, with a tax-cut and a hallelujah.

Illegal immigration is illegal, and although it appears our economy has depended on it in many ways, it needs to be addressed. But we discourage legal immigration at our peril. Unless the trends among "natives" reverses miraculously, people whose dreams still bring them here are our only hope. And we ought to do what we can to maintain America as (or return it to) a dream-worthy place.

Visual Fields

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, in labs. Perhaps more importantly, they grew up playing video games, which really do prepare one's brain for making the wiring changes needed to accomplish a three-dimensional operation while observing on a two-dimensional screen. Old as I am, I was well into my surgical life, three dimensions to the wind, when laparoscopy came on the scene. So I had to take a couple of crash courses. I found, I'm happy to say, the transition both easy (compared to some, that is: it does take time to gain fluidity) and fun. I was NOT one who was waving instruments around like a Fieldsian pool cue. (In other words, the reasons I continued doing my mini-gallbladder operation were unrelated to skill, but to practicality.) To the extent that I'm still doing surgery (I've semi-retired into assisting, of late) it's only of the laparoscopic kind, and I like it.

The process is an interesting one. I think that getting good at laparoscopy is a matter of learning to read motion digitally, to break down tiny quanta of visual cues as they happen. Instead of watching the sweep of actions, you get to a point where, unconsciously, you discern depth by reading increments of changing relationships; it's a sort of visual echolocation. Like this: if you took a series of pictures of your finger as it moved toward you, and then looked at them one at a time, you'd have -- while looking at any one -- no sense of motion. But if you looked at them in order, you'd be able to tell the direction the finger was moving, by its size relative to the other things in the picture. In one sequence, it'd be moving toward you; in reverse order, it'd be moving away. So when doing laparoscopic surgery, you are constantly processing the changing screen-size of the instruments you are using, relative to the organs and structures surrounding them. Your brain translates it into real-time 3-D. Neat! Based on observations of my fellow course-takers, I'd say that ability is not equally distributed among us.

Technology marches on. It should surprise no one that 3-D video has come to the operating room. I hate it.

Wearing a helmet containing a separate small video screen in front of each eye, you form a 3-D image from a scope with two parallel and slightly off-set lenses. The biggest problem is that the lenses are, necessarily, not far apart; so unlike what we see with our comparatively wide-set eyes, the sense of depth is pretty minimal. And strangely -- at least for me -- there's something slightly disorienting, or at minimum disquieting, about having the same image in front of you no matter where you move your head. Ain't natcherel. Finally -- and I suppose I could have it better adjusted -- the strap holding the apparatus in place gives me a damn headache. Unpleasant, unhelpful: without doubt, it adds up to a negative number. The equipment used to reside in the room in which I work. Haven't seen it in several months.

Sissy

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 balloons filled with heroin is a known way of crossing borders (and an explanation of why so many addicts got such horrendous infections where they ultimately injected the stuff, after the, uh, passage of, uh, time).

My next conclusion was that it was time to release the bowel, which I did with a notably unprofessional and sissified shriek and a rapid and uncontrolled unclenching of my grip and yanking away of my hand, arm and much of the rest of myself, as the "condom" unfurled and wiggled under my fingers. "YEAHHGGGGUHH!!!" The startled crew jumped in unison in response to a likely unprecedented display of wimpishness. But that's what worms'll do to you (to me, anyway) when they show up unexpected.

Layers

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 blame: the guy who handed me the cake, and the extra goodies I free-lanced, did so with the after-mentioned goodies piled on the cake-box. His fault. But I failed to compute the danger. My wife, when I got home, looked stricken as she surveyed the stack, and the tell-tale stains on the boxtop when I removed the bags. Frail flimsy frosting flowers, flattened. F-f-f-fuck.

Ready to drive the twenty-five miles back to the bakery to convince them that their shared blame should occasion the re-frosting of the flowers, I figured I should at least attempt a cure. So, taking a nice little knife in hand, I tried to discern the now-distorted layers of faux petals, using my most well-learned control to turn the blade within the flowers, recreating a sense of the smashed strata of pinks and blues and yellows.

It turned out OK. Not, I admit, perfect. But judged acceptable by my wife. As I've said about surgery, second go-arounds are rarely as good as something done well the first time. Even when working in layers.

Podcast

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.

The BFH

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 to go out into the world are also pretty damn good? Is it only within the great walls that folks have mystical powers? Powers that poof when passing the portals on the path to private practice?

Wisdom may be generated in the BFHs but the whole idea is for it to flow outward. Most treatments for most diseases have been pretty well worked out, and the information is readily available. And as it evolves, the news spreads. If it were really the case that the only people who know what they're doing reside within a BFH, wouldn't that mean that they'd failed in their central mission? That they'd created incompetents and loosed them upon the populace?

The fact is that when I began my practice, I felt I'd been very well trained; nor was it self-delusion (trust me, I'm a doctor). And, by golly, I found it was easier to get things done, to provide personal and expeditious care when all the BF accouterments were stripped away. With academic largess come layers, complexities, and, yes, arrogance. The most stunning thing in the comment I referenced above was the demand by the BFH that care be transferred up front, sight unseen. While I doubt such a thing is universal, it's revelatory.

It's decidedly NOT my position that people should avoid the BFH. Were that to happen, the system would grind to a halt in half a generation. And clearly, for very specialized care -- transplants, for example -- such places are the only places to be. It's just that for most care, given a little time to check out the local folk, I believe strongly -- based on years of observation and participation -- that excellent care is available in most community hospitals; people should feel good about that. (So as not to upset anyone, I'll stop short of saying that for the commonplace, care is better in the community hospitals; but that's what I believe. Given the right players.)

[In re-reading my earlier post, linked via the fifth word of this one, I realize I've said much the same, in different words, previously. This means two things to me: 1) it's tempting to re-write a lot of what I've written in this blog, and 2) I'm starting to bang against the bottom of my brain. It bodes ill, futuristorically.]

... And A Pink Carnation*

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 a tie. Gathering dust in my closet are a couple of racks of generally garish and outlandish ties which, for some reason, I chose to wear for several years.

Ahead of my time (recent reports have, disgustingly, showed the amount of bacteria lugged from room to room on doctors' ties), I long ago ditched the ties. Within a couple more years, it was shirt and slacks sans coat, and that's where it stayed for the rest of my time in practice (now, as an assistant, I show up in jeans and whatever.)

Without any data or real basis for it, I'd always felt that white coats were off-putting; a barrier, of sorts. There is, after all, the white coat syndrome. But it really wasn't a plan, or even an overtly thoughful decision. I just didn't feel right in a white coat in my office, and the subsequent divestments were simply a matter of comfort. The only time I got negative feedback was when my mother asked my wife why she couldn't get me to dress better. A generational thing, on several levels.

It changed when I did my surgical hospitalist gig. Then, it was a considered decision. I figured it most practical if I were to spend the day wearing scrubs, and whereas there are usually available some scruboid cover gowns for running out from the OR to the floors, I figured a little decorum was called for. In particular, since I'd be seeing patients only in a hospital setting, people acutely ill having a surgeon thrust upon them cold, I thought some visual cues would be good. So I ordered, for the first time in about twenty-five years, some of those nice patrician thigh-length jobbies. With my name, MD, and Department of Surgery embroidered thereon.

Funny thing. I really liked wearing them. And it wasn't just because of the capacious pockets (I'm a surgeon: the stethoscope does NOT go around the neck. Plus, there's note cards, several rolls of paper tape, couple of gauze pads...) As I frequently lacked the time to establish rapport which the office setting tends to afford, that coat was an anthropomorphic business card. This guy's legit, it said. To a potential patient already in tough shape and low on time to think things over, that's good. Worn with scrubs, it was a way to be comfortable and appear serious. Looking back, I suppose I could have been wrong all those years.

*Only old people and/or dorky ones will get the musical reference.

An Opinion Opinion

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, respectfully addressed, and carefully listened to without the need to run off.

At some level, when a patient requested a second opinion I felt like a failure. Drawing diagrams, writing booklets, soliciting questions, I succeeded nearly always. Many is the time my patients told me they'd never had a doctor explain so thoroughly and understandably. So to me -- ever self-critical -- a request for a second opinion said, somewhere in my lizard brain, that I'd not done something well enough. I recognize that many people simply see it as due diligence: taking control of one's health includes exhausting every avenue to information. But in that evanescent and impossible best-of-all-worlds, that fantasyland, I like to think doctors could be good enough, and patients open enough, to justify the idea that one opinion can suffice.

Patients have the right to feel right. They are entitled to full disclosure, to thorough explanations, and to complete answers to all their questions. And people have senses. If they feel uncertain or dissatisfied; if there are warning bells ringing in their heads; if for whatever reason they are left uncomfortable with a physician encounter, they should absolutely positively get another opinion and/or another doctor. But what's wrong with feeling OK in the first instance? If what you hear makes sense, if you think the doctor in front of you is being honest and thorough, must you be made to feel like an idiot for standing pat? Some people show up broadcasting distrust from before the first hello; or bring someone who glares dares from the co-pilot seat. It ices the wings of the encounter before it ever gets off the ground. That attitude comes from giving too much credence to crap. Don't cheat yourself, says I. Don't close the barn door before the horses are in. Or something.

Of course, it's not always simple, and doctors are imperfect. I'll examplify.

There was a time when, because of insurance demands, I saw lots of people in need of second opinions before hernia repair; and had to send them for same, as well. (After looking at a few years of predictable data, most companies have dropped most such requirements.) Usually it's a no-brainer: you can see the hernia as the pants are coming down. But I've had a couple of people in whom, for the life of me, I couldn't confirm the hernia for which they were scheduled to be operated. It's uncomfortable. Often, because the mandated need for a second opinion was realized at the last minute, I'd be seeing the person within a day or so of the operation. In part, it (the non-finding) happens because you can't always feel a hernia, even when it's there. They don't always pop out on command, with office maneuvers. I'd explain that to the patient, and tell them the fact that I can't feel it doesn't mean it's not there.... Unpleasant, mutually. When the patient had symptoms, and described what surely must have been a hernia, I always explained that it was a probably a safe assumption. But sometimes it was a person in whom the "hernia" had been found on a physical exam, and there'd been no signs or symptoms at all. When such a person was sent to me directly from the primary doc, I'd generally recommend against surgery until things were more clear, trying also to avoid any implication that their doc was wrong. But what to do when it's a second opinion referral from a surgeon who had them on the dotted line?

With breast cancer, some aspects of treatment are extremely complex, and changing nearly daily. Along with the good information available, there's lots of bad, sometimes leading to distrust as the default position going in, which makes the job of explaining even harder than it already is. I still get upset when I think of my patient who went for a second opinion and died a couple of years later, very possibly as a result. She had a very large cancer in her breast, and for several important reasons I told her she ought to have mastectomy despite her hope for breast preservation. She accepted what I said and why I said it, but saw another surgeon anyway. A young guy fresh out of training, sure he knew way more than the old guy, he told her she could safely have lumpectomy and radiation. He convinced her, signed her up, and went ahead. As I was sure would happen, he ended up cutting through tumor at all edges of his large lumpectomy, operated again unsuccessfully, and not very much later, operated once more to do a mastectomy. I can't say with certainty she would have been saved if she'd had it at the outset, but cutting through tumor that extensively may well cause direct seeding into the bloodstream, if it hadn't already happened; and three major operations on incompletely treated tumor seems less propitious than having only one.

So there you have it. Second opinions aren't necessary except when they are, and they're good for you except when they aren't. Have a nice day.