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Showing posts from January, 2007

It's Complicated: part one

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One of the hardest things about being a surgeon is the inevitability of complications. It's true for any doctor; but with surgery, it's as if they are lit in neon and given a soundtrack. At least to me. Aiming for perfection (as do we all) and beating myself up (more than healthier people) when I miss the mark, I found bad outcomes of nearly any magnitude deeply disturbing. The big ones are there for lots of people to see: nurses on the surgical floor or ICU, operating room personnel when you have to re-operate. And of course, the patient. The family. My family, for that matter. Smaller problems might just be between me and the patient; but they still are painful. Carrying the responsibility for having done harm to people who gave me their trust can be nearly too much to bear. Thankfully rare, it's never been easy. Nor should it be. I don't know the extent that I speak for other surgeons in this matter. I actually believe I took it too hard, and too personally; so what

Local Hero

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I said in a recent post that I liked doing office surgery, somewhat parenthetically implying as well that I could do a mean local anesthetic. It's true, of course. More than just lumps and bumps, I did lots of breast biopsies in my office under local, revised mastectomy skin flaps, took off a few humongous lipomas, excised gynecomastia; and I did more than a couple of simple mastectomies under local in frail ladies (not in the office.) (Also not in the office, I repaired many a hernia under local.) Per a request from a commenter on that post, I hereby share some tricks of the trade. None, I'd say, is original; but I'm not sure that by the time one finishes training, all of these pearls -- if that's what they are -- have been assembled in the same part of every graduate's brain. Realizing it's the ultimate in surgical esoterica, I hope non-medical readers might also find it interesting, if in a useless sort of way. "Vocal anesthesia" is the term for

Mini Me

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"Big surgeons make big incisions," said the visiting professor at our Saturday morning conference on deaths and complications. He could also have chosen to say "incisions heal side-to-side, not end-to-end," which was another aphorism professors liked to repeat, with the same implication: for safety's sake, the bigger the incision the better. In a training program -- especially in the ancient times in which I trained -- the point was made often. When open incisions were the only game in town, and when a young surgeon-in-training found him- or herself in difficulty, the first thing the attending was likely to do was to enlarge the cut. And, as I said in a post a while back, there's nothing quite like stepping up to the table and making a bold and generous incision; especially when carrying it through skin and fat and fascia in one glorious and heraldic (if medieval) stroke. By contrast, poking little holes in a belly for inserting scopes is like peeing sitting

Foxy Me

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(picture from yerf.com) Hey, welcome to readers who drop by from the Fox News site! Just saw the article myself. I hope you'll wade into the archives to get a feel for the place. To make it easy, a couple of oldies but goodies are here, here, here, here, and here. I'm more than pleased to have been noticed, and welcome a look around. There's lots more. Some of it gory, some a bit raunchy, some, I'd like to think, informative.... and occasionally moving.

Taking my Lumps

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One day when I was in college, when my hand was near my lower abdominal wall for reasons I don't entirely remember, I felt a lump. Off to the right, a little below my belly-button, and just under the skin, it was firm, smooth, and moveable, sort of ovoid in shape. Maybe a half-inch in size. It scared the crap out of me. Mine was a very small college, just over a thousand in the entire student body, and all male, which narrowed the health care needs quite a bit. So the student health service -- such as it was -- was sort of a mom and pop operation, literally. A doc and his nurse wife, housed in a small one-story building, with a tiny lobby, couple of chairs and magazines, maybe two exam rooms. In the back was the infirmary: the size of some people's bedroom, it held about three beds, meant mostly for guys who didn't feel like going to class that day. No one very sick could stay there, if he planned to see the next sunrise. Mister Brown the doctor, is what we called him. Not

Speaking of Grand Rounds...

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... during training, Grand Rounds were a big deal. Whereas our weekly conference on deaths and complications that had occurred throughout the surgical services was the most informative -- and entertaining -- Grand Rounds were the stately and intellectual reminder that we were at a major academic institution. Held monthly and theoretically directed at the whole spectrum of people in the institution, they'd usually involve a presentation by one of the honcho/professors, speaking about some cutting-edge (as opposed to cutting-error) research. More often than not, the lecturer had briefly emerged into the light, from the medical or PhD side of the mysterious and removed laboratory wing, behind the hospital. Kinetics of messenger RNA. Membrane potentials in sciatic nerves of thymectomized rats. Conflated uranian hopflotsch in HLA reduced amoflatric cell tramiphones. I didn't go on a regular basis. About a year after he'd finished training, one of the stellar medical chief resid

Rounding Off

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I was in a fraternity in college. (Where I went to college, housing depended on fraternities: there weren't anywhere near enough dorms to handle it on their own. Also, there were rules such that everyone who wanted to be in one, was guaranteed to do so. I say this because people who know me might not consider me a frat-guy.) It was a national fraternity, but on our campus the rules and mumbo-jumbo went out the window. Literally, in some cases. Anyhow, we'd occasionally get visits from some grownups in the national organization. Among other things, it struck me as an entirely useless job: an organization whose purpose was to promote the organization. A self-perpetuating loop of meaninglessness. Which brings me to Grand Rounds. I'm getting a little annoyed over here. In the last few weeks, the whole raison d'etre seems to have changed. Instead of being a collation of the medblogosphere's current writings, it's become a theme-park at the direction of the current h

Give Peace a Chance

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"Peace of mind." In the previous post, that's exactly (as a commenter pointed out) what the ad is all about: trying to create peace of mind as a new reason for having a defibrillator implanted. Get people to dread Sudden Cardiac Arrest, maybe they'll try to talk their doctors into the procedure, even as the typical cardiac indications don't exist. And, when you think about it, it could happen: Doc, if you don't give me one, and I die of cardiac arrest (don't we all, eventually?), I'll see to it that my family sues you for everything you have.... These ads, and many like them, are about creating a cure for a problem that doesn't exist -- at least not to the degree that the makers would like you to believe. Haven't heard much about "social anxiety disorder" for a while? Maybe it's because it turned out the acronym was already taken. (OK, I'm no psychiatrist: I'm sure the condition exists, or could well exist. But the ads cle

Ads Up

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OK, it's official: what little is left of my mind is now totally blown. In today's New York Times is a full page ad for ICDs ( implantable cardiac defibrillator ), and it's aimed straight at the consumer. I've gotten used to the ubiquitous ads for every prescription medication in the book; which is not to say they don't annoy me anymore. It's just that I've descended into a sort of overload that allows me to ignore them. Plus, in my bailiwick of the medical barnyard, it's rare to have a patient request a particular medication (other than the "this pain medicine yer givin me ain't fer shit" trope.) But this, this really is something. "532 Candlelight Dinners; 4,354 Blissful Moments; 687 Walks in the Rain," it lists. Never mind that it sounds like a pathetic ad in the personals section of a book review mag (not that I read them.) It goes on to say "...ICD can give you more time to do the things you love with the people you love

House Doc (Not "House, Doc")

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I received a request recently to share my thoughts about the future of surgery; specifically, I was asked about the concept of the "acute care specialist." About the future, as I've implied in some earlier posts, I have concerns. Despite my occasional wistful posts about the good old days, my worries are less about the people choosing to enter the field (I've indeed expressed concerns about how various factors are converging to select people with different expectations and perhaps a lower commitment level -- not entirely negative, in terms of a surgeon's self-preservation) than about the milieu in which they'll be practicing. I've also said here and elsewhere that whereas surgeons may have brass balls, they don't have crystal ones. So my predictive powers are diminutive at best. Nevertheless, because I see a continuing trend toward needing to work more to receive less, and an undeniable trend toward making the choice of surgery less appealing which is

Guts. Glory.

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I've said it before: I love sewing bowel. Nothing, it seems to me, represents what the general surgeon does more than that. It makes me feel connected to and a part of the chain of daring and innovative people who braved the terrain and blazed the path for us all, a century and a half ago; done right, it can be beautiful. Yes, guts: beautiful. Done wrong, it can kill. Even unopened, intestine has a faintly unpleasant odor. Not repellant; certainly easy to ignore. In fact, the smell is like a musty greeting, of sorts: here we are now, in the belly, what's next? In a virgin abdomen, where they are free to slither and slide unbound by scars of previous surgery or from disease, grabbed by a hand gloved in latex, the bowels are slippery and smooth, and the sensation of holding them is like warm pudding flowing. When you need to push them out of the way, to expose a particular area, they stream around either side of your hand, slurpily wanting back in. The classic method of sewing to

Self-Service

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I never wore a white coat. Sleeves rolled up, open collared is how I dressed in my office. (Well, early on, I not only wore a [non-white] coat, for some reason I presented myself with a collection of the most garish ties imaginable. "Oh yeah," people would say when I was mentioned. "The guy with the ties." Somewhere along the line, I got tired of it, and opted for comfortable. Meanwhile, I developed a small lipoma on my left arm, which never bothered me but which, as time went on, I realized people were noticing. I'd be sitting in front of a patient, gesturing this way and that as I explained (beautifully and patiently, I might add) some surgical subject or other, and I'd notice a distracted glance at my arm. Surgeon with some sort of growth, a tumor, not the guy for me.... So I took it off. Laid out all the stuff I'd need, sat on a chair resting my arm on the bed in one of my exam rooms, painted it up (my arm, not the bed) with betadine, stuck on a st

Rationale

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I've written in this blog, and in a certain book I've been known to hype, about the pleasures of doing an operation when it all comes together. I've compared it to music: the transcendent feeling that derives from the sense that the team is flowing together, from being able to ply the craft with no distractions. No need to wait for an instrument, to ask for something you always use; having people assembled who know you, and what your intent is and who can nearly wordlessly join the orchestration of effort, uplifted by the knowledge that you have been invited into the essence of another human being. Because, for many reasons, it's rare to work with the same team over and over, achieving that kind of soaring synergy is uncommon -- when it happens it's invigorating beyond words. When it doesn't, the lack is ruefully noted at best; deeply disturbing at worst. That an operation is carried out by a team is an understatement, which brings me to the off-the-wall point

Spike

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Among life's insignificant but grating annoyances are certain celebrations by athletes when they do whatever it is they were supposed to do. Linebacker sacks the quarterback, gets up and struts around, flexing his muscles, shaking his head, looking to me like an idiot. Guy dunks the basketball over another, gets in his face, prances in front of the audience beating his chest. C'mon man: you didn't just cure cancer. You put a ball in a hole. On the other hand (there's always another hand), I can relate. Some operations become so hard that when they're successfully over, I feel like there ought to be a gallery watching, doing the wave. In fact, I've done a couple of celebrations myself. I've not hid the fact that I'm sort of an old-timer. Many operations I used to do regularly have all but disappeared. Common duct exploration , poking around in the tube that carries bile from the liver to the gut -- usually to extract a stone that's passed into it from

Revelation (or, Why Surgeons Shouldn't Think)

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Let's see if I can explain something I no longer understand. I'll preface by saying there are about three things I recall from studying neurosciences in med school. First, one neuroanatomist could draw perfect slices of the brain using both hands at once, holding more than one colored chalk in each. Second, studying I-don't-remember-what, a patient was presented who'd had a stroke which left him with a sort of aphasia . The professor held up some keys and asked the man what they were. The man said, "well, you know, you open doors...." "What's it called?" the professor asked. "It's, uh, it's what you use to start the car... It's..." Finally, after the same sort of back and forth, the prof tossed the keys to the man. As soon as he caught them, he said "Keys!" The story has no relevance to this post: it's just that it made an impression. It's the third vaguely remembered -- and no longer understood -- concept