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Showing posts from February, 2007

Stuck in the Middle

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Seem to be in a pattern here: post about something bad in the OR, then something cool. Here's another bad thing, based on a bad thing. Then maybe I'll get off it for a while. Getting stuck with a needle has never been fun, even before it could be fatal. I've had my share. Converted my hepatitis titer while I was in San Francisco, though I never got sick. If nothing else, sometimes it hurts like hell, right in the middle of a case. Methods to prevent getting nailed are in the category of the desirable. Great minds attend to it. Less than great minds appear to be the ones, so far, to have come up with solutions: And I couldn't even find a picture of the worst offender: probably got sold just before the sales force slunk out of town. The "safety" part looks like the back leg of a grasshopper, as it slides up and down the needle. Where I work, the hospital bought it by the pantload. Anyhow, the point is this: laudable as the concept might be, the "safety need

Very Cool

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Let's see if I can describe something. The scrub nurse for the case I was doing this morning has a very cool move he uses to hand us the towel for drying our hands. For comparison, the typical method is simply to open it up and hand it over, or drape it on an out-stretched hand. Efficient, classic really, but hardly noteworthy. This guy, he folds it into thirds length-wise, then rolls it up like a sleeping-bag or a jelly-roll . Holding the roll in his palm, he secures the end with his thumb, the rolled side up and facing away. This he's done while we're outside washing, and he's all ready when we walk in. A flick of the wrist, and the towel arcs toward us like a frog's tongue at a fly, like a back-hand yo-yo trick , the formerly inner end landing in our hands, after which he lets go of his end. I think had we both been ready, he'd have been able to do a simultaneous two-handed toss. He says he's been working on it for a while. Were I more blogompetant, I'

Floored!

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It happens sometimes: finished with a suture, you pass it back to the scrub-nurse, the needle contained in the jaws of the instrument, less than carefully locked. In placing it down on the sterile tray (the Mayo stand ), you might see the needle spring up as if alive, arcing across the table to land an impressive distance away, on the floor. Or they get laid down momentarily on the drapes; or transferred by hand, holding the thread, only to have it slip away. Needles, in other words, sometimes find their way out of the field and into the ethers. Incorrect needle counts being anathema, adding precious (and expensive) minutes to operating time, forcing several people to devote annoying amounts of time in the search, occasionally even requiring reopening of incisions, you'd think thought would be given to making the hunt as easy as possible. So why do the designers of operating rooms so often come up with Jackson Pollack patterns on the linoleum; and why do hospitals buy it? Only a f

a dusty trunk and a cardboard box

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Ten days before I was born, my father died. Three and a half years earlier, my mom had been a twenty-one year old bride, excited and optimistic, proud of marrying the brilliant young physician whose given name I bear, and whose family name is my middle. I know he was brilliant because over the years I've heard it from many of his former colleagues and patients, and because when he married he'd just finished work as Chief Medical Resident at Johns Hopkins Hospital. At that time, the position was highly selective and much sought: the plumbest of the plumbs. We're at our family home on the Oregon coast again, and my wife and I have been rummaging through old stuff, the contents of a trunk hiding in plain sight for many years. In it we found my mom's first bridal book (she married my adoptive dad when I was young enough that I have no real recollection of being fatherless. Their marriage lasted nearly sixty years, till my dad's death a little over a year ago.) Read

Beating The Spread

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If I could actually accomplish something with this blog, I'd like to put one notion forever to rest (I'm reminded of it by a commenter on a recent post.) There's an all-too-common conception out there; pernicious and pervasive, untrue as it can be, it's scared many prospective surgery patients nearly to death. In some cases, in believing it, it has quite literally done so. I've written the occasional humorous post: about this I'm deadly serious, so I'll say it very clearly: Surgery does NOT cause curable cancer to spread. I've heard the thought expressed a million times, and I have no doubt that every other surgeon has as well. "Doctor," they'll say, earnestly, fearfully, directly. "I heard that surgery makes cancer spread. Soon as they open your belly, when the air gets to it, it goes all over the place, and you die. I'm really scared to have an operation." Who wouldn't be, having heard such a thing? I think I know w

God of the Appendix: Of Truth And Worms

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[ OK, here I go, stepping off a cliff. Can't say why I want to, exactly. ] Of Design and Darwin, the appendix speaks to me. With my finger through a hole in the abdominal wall, I sense it, and at two in the morning it tells the truth. In the appendix, we have a thing within us of no demonstrable value, but which is capable of doing us great harm. People may argue at the edges, but there are two things we know with central certainty: the presence of the appendix kills a lot of people or makes them real sick, and its absence is of absolutely no consequence. Evidently, that's a threat to the concept of intelligent design/creationism, and in a sort of endearingly weak effort , Ken Ham, a major ID guru, once tried to explain it away. Believe it away. Faith it away. If you take a position in matters of science, says I, you need to keep at least one hand on the fact wall at all times; otherwise, you fall down. So whereas I'm not the first to address the appendix as religious

On My Honor

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So I received this thing in the mail the other day. Nearly threw it out along with the rest of the junk, but it was shaped like and had the heft of a possible CD of some sort, so I opened it. "Congratulations!" it grinned (or was it a wink?) "Your listing in the "Guide to America's Top Surgeons" is most impressive. You are among a select few..... Accomplishments like yours should be displayed proudly...." It went on to provide me with a number of options for flaunting my inclusion, from nicely framed, personalized and plaqued, to etched in glass. (Sadly, none carved in stone; but one of the glass panes is a proud erection on a faux marble base.) $149 to about $229. Included was a single small blue-tinted page, about four times the size of a post-it, evidently from the people who produce the actual book. "Consumers' Research Council of America is pleased to announce your inclusion in.... [that thing in the previous paragraph], 2007 Edition....

Liverly

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Ever soaped your sweetie in the shower? Or, to be less (so I've been told) disturbing: have you held a piece of hardwood, turned and sanded smooth as glass, oiled and rubbed until it's like hot ice; passed your hand over the surface, thrilled at its silkiness, its undulating shape? Did you find it stunningly beautiful? If so, you have an idea of what your liver feels like. But really, because it's warm and taut and alive, the first question conjures it more closely. In terms of touch. Surpassingly smooth, firm and full as a biker's buttock (I ride a Trek 5500 ), resolutely protected by the ribs and sealed snugly -- by surface tension and suction -- under the diaphragm, the liver releases itself with a certain reluctance. To explore it, you must make it come to you, but its barely-moist slipperiness resists exposure: you have to insinuate your latexed fingers gently between its lower edge and the underside of the ribcage, usually far to the left, while bending your w

Vibrations

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I consider surgery -- yes, even surgery -- to be grounded in science. Positing an idea, subjecting it to testing and peer scrutiny, healthy skepticism, constant re-evaluation: all those things, we do. Doctors are heirs to those who invented transistors, calculated moon-shots, figured out DNA. Still, it's not as if we're pure as snow, scientifically. I'm not, anyway. My gut -- which has metaphorically and metabolically grown over my career -- still plays a role. Here's one example, and I'd bet other surgeons (and to the extent that the concept applies to other docs, they too) would agree with this: you can tell who's going to do well as soon as you meet them. I doubt it's testable. For that matter, it may not even be true. But I'm saying there's a vibe about some people, good or bad, that can fill a room -- signaling strength or portending problems, making me light on my feet or feeling doomed. Demi-doomed, anyway. Wish I'd been able to bottle t

Windy Beneath the Wings

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People are strange. For the life of me, there's one thing (right: only one!) I could never figure out. As I said in a recent post, I made a major effort to gain patients' confidence, and to have them approach their operations with a positive attitude. With hardly an exception, they'd leave my office in a good frame of mind. Mostly, they'd show up for surgery the same way. But not always. There was that damn Uncle Joe, or the neighbor Alice, or good friend Betty. What the hell were they thinking? "Joe/Alice/Betty told me he/she/she knew someone who had (insert any operation you can think of) and (insert horror story here.)" Died. Couldn't walk. Woke up left-handed. Turned green. It's mystifying. Were they trying to help? To show off their knowledge? Were they deliberately trying to scare the shit out of them? What, ran out of small talk? Why would anyone do that to someone, right before they're going to the hospital? Nuts. And it's not at all

No Frickin' Way, Doc!

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Among many, many who've needed it and accepted it, I've had two patients who refused colostomy . One is dead, the other alive and well. More than that: both eventually had colostomies, and each said, nearly identically, "If I'd known how easy it is, I'd never have refused." No one likes the idea of a colostomy . When talking to a patient who needs one, I try to point out that there's nothing -- NOTHING -- a person who has one can't do. I list a few famous people who've had them, talk about the various ways to handle it. With enough education -- which, unless there's no time, always includes a visit ahead of time with an ostomy nurse -- people generally accept the idea and we move ahead. Not these guys, no frickin' way. I tried. I really did. Step one in curing colon cancer is removing the portion of bowel that contains it, with some room on either side to be sure you're not leaving any tumor behind. Fairly early in my surgical life, it

Age of Consent

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"Whatever you say, doc." "Just tell me what you're going to do, and forget about all the rest." Once in a while, you still hear that sort of thing. There are times when "informed consent" isn't all it's cracked up to be. Don't get me wrong (not that no one ever would, or could, or has!): I believe in full disclosure, think an informed patient is a good patient, and in fact I always took pride in my ability (and willingness!) to take plenty of time to explain things clearly. And yet... I also think instilling confidence and a positive attitude facilitates smooth recovery. Nurses regularly told me that my patients always seemed calm and confident when they were admitted, and I considered that a very good thing, and high praise indeed. So I hated, at the end of a conference with a patient and family wherein I explained the plan and tried to alleviate fear, to whip out a consent form and ask them to put their name on a shopping list of horrors.

For Bongi: mini - steps

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Bongi, whose blog "Other things amanzi" is truly amazing and should be read by everyone for its look into a world most of us can't imagine, mentioned in a comment that he'd like to know details of how I did my mini-gallbladder operation. In his hospital in South Africa, they don't have laparoscopic equipment: for his situation, the "mini" makes enormous sense. So this post is specifically (but not exclusively) for him; I suppose I could have posted it in a comment on his blog, but I thought maybe others will find it of passing interest, for their own dark reasons. Bongi: my only advice would be to work your way slowly, over several patients, down to a really small incision. And don't hesitate to enlarge a very small one when you feel uncomfortable: it's amazing how much difference even a half-inch makes. The following is a snippet from something I wrote when I first "retired," having in mind a booklet of tricks and tips for surgeons j

It's Complicated: part three

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The idea behind surgery is a really simple one: you come to me with a specific problem, I fix it, you go away happy. And when you come back, you're still happy. What's so wrong with that? If I wanted to be miserable, I'd have gone into primary care. When a surgeon screws up, his/her role is clear: admit it, make it better, or as good as possible, and stick with it as long as it takes. (Comments on the first two posts in this series indicate that it's not so clear for some surgeons, and it's depressing to realize it.) But what about when you don't screw up, and the patient is still unhappy? As I indicated last time, in some ways that's the most difficult situation of all. Once again, it's complicated: there are bad outcomes or side-effects that result from well-thought-out and well-carried-out surgery; and there are, well, who knows exactly what they are... As an example of the first sort: it's possible nowadays, with certain beautifully engineered

It's Complicated: part two

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Speaking only for myself (but guessing I'm not alone), I can say when a patient develops post-op problems, there's a strong tendency to deny it: not to deny there's something wrong; not to dismiss the patient's concerns or symptoms. Just to grasp first at the less dire set of possible explanations. Maybe it's just the flu, constipation, drug reaction. That sort of thing. It's not about blowing it off -- because I never did. It's about hoping against hope, both for the patient's sake, and mine. Rationalization is a powerful instinct. In reading various forums and blogs and seeing innumerable patient complaints that their doctors took a long time to take them seriously, I'd guess that in many instances the desire to believe you didn't screw up is at work. That doesn't excuse it: maybe it explains it to a degree. For better or worse, doctors are human. I know I am. When I saw my patient in the Emergency Room, her abdomen was distended, she had a