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Showing posts from March, 2007

It's Galling: diagnostic dilemmas and the gallbladder

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I finished the previous post with the sad story of my patient, illustrating diagnostic difficulties at the fringes of biliary disease. And I began the series by stating that the vast majority of gallbladder problems are straightforward, with surgery leaving patients happy and symptom-free. In the time it's taken me to write these things, I haven't changed my mind: surgery on the gallbladder is typically gratifying all the way around. But a few patients defy understanding and can end up miserable. Doctors have a few diagnostic categories that, in my opinion, are over-called, and under-stood. Fibromyalgia. Chronic fatigue syndrome. And, in the current context, biliary dyskinesia and sphincter of Oddi dysfunction. I'm not a primary care doc, so I include the first two on the list in this sense: I know it's nice to have a fancy name to toss out when you have no idea what's going on. Having a disease or two up your sleeve the diagnosis of which is fuzzy, the descrip

Slippery Stones: more about the gallbladder

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"If you don't have a pretty good idea what's going on with your patient after a thorough history and physical," I was told in medical school, "you probably never will." It's a wise -- if a little dated -- statement. Most of the time, diagnosis isn't all that hard. Rare things are rare. Common things are common : another med-school pearl of wisdom. Figuring out the problem in those outlier situations can be frustrating on each side of the white coat and, in the case of surgery, can lead to errors in both directions: doing operations that don't help, or deferring ones that otherwise might. The gallbladder has been the source of more than its share of such scenarii. Delicate and robin's-egg blue , the normal gallbladder is startlingly beautiful. Out of place among the muted earthiness of the rest of the abdominal anatomy, it peeks above the lower edge of the right lobe of the liver, demure, nearly luminous; typically you see only the top of it,

Tony Snow. And a story.

I'm interrupting the gallbladder series for a moment, at the news of Tony Snow 's discovered metatstatic colon cancer in his liver. As I said about Elizabeth Edwards a couple of posts back, when famous people get sick, it's an opportunity to learn. If nothing else. In the case of colon cancer which has spread to the liver, the outlook is not good. On average, survival is in the range of six months (as with all cancers, there are variations in both directions). There are exceptional circumstances, for instance when it appears that only one tumor nodule is growing in the liver, in which case removing it and giving chemotherapy may prolong life. Unfortunately that's rare: in most cases when it's discovered, it's widespread. Response to drugs is usually brief. Some data suggest improved response when the drugs are infused directly into the artery to the liver (in the linked diagram, the images are of experiments in rats. The one on the right is sort of like what

Rocks in a Bag: what I know about gallbladders

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Finally I'm getting around to writing about the gallbladder. Don't know what took me so long, seeing as how, next to hernias it's the thing upon which I operated most (if you don't count breast biopsies). And I liked it. When a person came to see me with a clear-cut gallbladder problem -- which was the case at least 90% of the time -- I could be quite confident that I was going to make him or her happy and, most likely, have a little fun while doing it. But there's the rub: it's not always a Tenantoid "slam dunk," nor is it always fun. A mysterious little bugger is that bag of bile: perhaps more than any other organ it's able to elude or confound diagnosis despite such apparent simplicity. And more than any other category, I sent people home from my office without surgery despite being referred with the idea of separating them from their gallbladders. Rocks get in your head. First, some basics. Among the many functions your liver performs for you (

Thinking About Elizabeth

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Reading about Elizabeth Edwards' breast cancer recurrence brings my own patients to mind. On any given day in my practice, the greatest number of office visits were women (and the occasional man) with breast problems. The majority of those who saw me for cancer appear to have been cured, but many weren't. It took a long time for me not to see them as personal failures, and in some sense I think I still do. For everyone involved, there's enough pain to go around. My patients came to me wanting cure, expecting it. My hope was to be a part of that. Yet no matter how expeditiously, how skillfully I did my job, cure did not always result. That it wasn't my fault (had I delayed diagnosis, done the wrong operation, failed to coordinate surgery with other needed treatments, it would have been) didn't change the fact that I saw myself -- and assumed the patient did, too -- as having let them down. When such a public figure deals with serious illness, people learn a lot. One

Hard Fact

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In my para-previous post, I referred to an injury to my medial digital nerve. Because our bodies are movable, it's necessary to have standard terminology in reference to positions; when your hand is palm up, medial and lateral are the opposite of when it's palm down. Thus, the "Anatomic Position," the reference posture by which, among other things, medial and lateral are determined. This guy is in it. And here's something amusing. In addition to medial/lateral we refer to "dorsal" and "ventral." In the anatomic position, ventral is the front, and dorsal is the back. We're seeing this guy's ventral surfaces. So what? Well, there are these things called the dorsal veins of the penis . And whaddya know? In the specimen standing there at the top of this post, we're looking at the surface on which those veins run. But it's ventral! So there's only one explanation: in the anatomic position, the penis is erect! Those anatomists! W

Comment, Alley-view

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Damn. I screwed up. I was wondering why, for the first time, my previous post had garnered zero comments. Was it something I said? And then I noticed: somehow the post was marked "don't allow comments." Too late, I fear, but I fixed it. So, if anyone had anything to say, it's now possible. Doggone it, anyway!

Swan Thing or Another

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I played rugby in college; that's me in the picture. We were a damn good team -- East Coast Champions a few times, played in tournaments in the Bahamas over Spring Break (yes, we did play.) The only time I got hurt was when I returned to Amherst during my freshman year in med school. It was a rugby weekend, and the opposing team was short one man, so I played for them, against my former team. Bad karma, I guess: in a desperation tackle, I collared a guy and my grip was stronger than the flexor digitorum profundis tendon on my right ring finger. After the game, when I tried to make a fist, the finger wouldn't flex. Bummer. Especially for a future surgeon. So I had it operated on. Stupidly, rather than seeking out a hand surgeon (there were a couple there of great renown, including one with a fabulous name: Kingsbury Heiple. During one of our orthopedic exams, one of the students had written on the blackboard "Kingsbury Heiple is not a flavor of ice-cream.") I went

Knot Really

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Of all the strongly-held beliefs imparted to me in training (and the list is long, indeed), using which suture under what circumstance may be at the top of the list. Emphasis on "strongly" as the operative criterion. That various surgeons had widely divergent views on the matter didn't diminish the near religious intensity of those beliefs. Woe be to the trainee who even questioned it: and forget about actually making up your own mind. If you were working with Doctor X, you used his/her preferred suture. At some point, it's likely you'd hear each one's reasons. Everyone had an understandable basis, I suppose. It's just that it turns out most of them were wrong. Some stuff never really made any sense; other things changed as materials improved, so I guess the old guys should get a pass. Before getting to the meat of the matter (I could make it a pretty long and ultimately boring post if I enumerated all the examples), here's one thing I'd bet each s

Focus

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Referring to the idea that, like athletes, surgeons are engaged in demanding physical work, I wrote recently about having an "off-day." Another side of the same coin is having a tough day: as distinguished from not being on one's game, here I mean to describe what it's like to face an exceedingly difficult and danger-filled situation. Notwithstanding having one's faculties and wits gathered and finely honed, as in command of yourself as you can possibly be, it may test and demand everything you can bring to bear. All the antiperspirant in the world wouldn't suffice. I've been in war, when I feared daily for my life. It's not pleasant, but in some way you can get used to it. In my situation, at least, the odds were with me, so it wasn't too hard to ignore. Fearing for the life of someone in my charge, having to forge ahead knowing the next move could literally be fatal, while knowing I have no personal risk at all -- that's unique at least ins

Walk and Water

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Ambulation and hydration; the most important parts of post-operative care. Time was, people were kept flat in bed for a couple of weeks after major abdominal surgery. I've always assumed it was because in the days of crummy suture material, there was fear of people tripping over their guts if they got up. I can see where that'd be counterproductive. Send the wrong signal, as they say. In any case, pneumonia and blood clots -- the handmaidens of bed rest -- were just part of the deal for those subjected to it, and they claimed a lot of lives in the surgical patients of yore. I'm old enough that in my training there was at least one surgeon old enough to require his patients to stay supine for days on end (he's the one, in my book, over whom I fantasized about a beating in the parking lot. He was so frail I think I could have taken him.) Anyhow, I obsessed over getting people up and watering them down. On the one hand, I thoroughly believe it played a major role in the f

Fielder's Choice

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I watched a bit of the Pac - 10 tournament final the other day. A player for the Duckies was so "in the zone" it seemed anything he threw up went in. It was simply magical; I'd guess even some USC fans were mesmerized by what they were watching. You've seen something like it, I'm sure. A no-hitter where the pitcher has such control that he can do anything he wants with the ball; a running back who seems to move through the opposition as if they were paper posters; the gymnast who scores 10 after 10. A diver; a swimmer. It's another of those things that probably can't be studied, but it seems pretty clear: on some days for some people in some situations, there's a coming together of mind and body in such a way that leads to a level of control far beyond the ordinary -- even when "ordinary" for these extraordinary athletes is beyond anything the rest of us could even dream of. And, likely as not, another day not soon thereafter, those same

Twist and Shout

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The more senior of my two partners when I first went into practice was old school in the very best sense of the words. The most general of general surgeons, he still did the occasional orthopedic procedure, yanked out uteri (indeed, that operation is more of a "yank," in terms of non-anatomic dissection, than most), didn't mind drilling a burr-hole or two if called upon to do it. I'm sure he'd have been happy to deliver a baby on the proverbial kitchen table; in fact, I think he did, back a ways. Many of his patients were people for whom he provided complete care as their family doctor. Blood pressure, diabetes, pneumonia -- he managed them all. And well, far as I could see. Gentle and soft-spoken, self-deprecating, Hume was welcoming to me from the start, and set an admirable example. When he assisted me, or I him, I always learned something. And, I'm happy to say, I showed him a few things as well. If it was mutual admiration, it was lop-sided in the way of

Pigs in Shit

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Reading the comments on another blog recently (the blog of the world's most dastardly lurker) I was reminded of a thing that always drove me crazy. No matter where I was, in the locker room of every OR and surgical center in which I've worked, there were guys who left their scrub clothes and towels on the floor. And their caps and shoe covers, often within an arm's reach of the receptacles into which they could easily be placed. Moreover, whereas I never risked the perversion-alert of hanging around long enough to check, I'd be willing to bet my (admittedly depreciated) left nut it was exclusively the surgeons -- as opposed to the various techs and nurses -- who behaved that way. It annoyed the hell out of me. Embarrassed me. I actually went around picking all the stuff up and putting it in the hampers, because I hated to imagine the housekeepers having to do it, surely thinking what a bunch of spoiled assholes those doctors were -- and including me in their scorn. I al

Burnout: Quenching the Fire?

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In two ways, I'm feeling a little guilty. First, I doubt I've provided any new insights in this burnout mini-series. And second, since I began by saying I'd heard from a few people that I've gotten them interested in a career in surgery, I don't want to have turned them off or discouraged them. So let's see what I can do about that. In my core, I always loved doing surgery, and being surgeon to my patients. As I hope I've made clear in this blog, I was always amazed that I was allowed to do it, and awed at the mysterious beauty of it all. As much of a responsibility as it is, it's also an inexplicably wondrous honor and privilege. Those words aren't lightly written. But in a diabolical combination of being constitutionally unable to cut back, being hyper-demanding of perfection in myself and only slightly less so in those who touched my patients, mixed with a certain degree of paranoia which made me see any imperfection as an accusation, I got to a

Burnout: Fanning the Flames

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In trying to understand my own burnout, "control" (or lack thereof) is a dominant theme. This is nothing new. In fact, I doubt I'm unearthing bones not already thoroughly analyzed. But I can give instructive personal examples. For a while I was on the board of directors of my clinic, which was then and is even more so now one of the most successful doctor-owned and -managed in the US. During my tenure, we were deeply in the thrall of the managed care model as the guarantor of our future. My feelings about it were, diplomatically, mixed. If I may be allowed to say it for the ten thousandth time, providing cost-effective care has always been as much a part of me as the Krebs Cycle. I've never needed anyone to remind me of it. Nor -- take my word for it -- have I ever been a trigger-happy surgeon: many is the patient sent to me for an operation, returned to his/her referring doc with a note pinned to the shirt saying "Please excuse Johhny from surgery today. He doe

Burnout: Embers

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The medical director of my clinic once gave me a book on burnout. I never read it. Didn't have the time or energy. Because a young reader considering a career in surgery referred to stories he's heard of depressed and disappointed surgeons and asked for my thoughts, I'll try to address it. Parenthetically, I've heard from more than a few readers that my blog and/or book has inspired them to consider surgery as a career. Don't know whether to smile proudly, or shoot myself. I quit my practice much younger than I'd have predicted when I went into it. In thinking about the reasons, not all of which can I distill, I can't make the claim that one ought to generalize: I speak only for myself. In some things, the themes are universal; in others, maybe more particular to me than my colleagues. As with many others, it's true that my love for my work diminished over the course of my career: yet at its core, the rewards and pleasures remained. It's just that it