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Showing posts from April, 2007

War Story

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"Doc, you gotta help me. I can't take it any more."  In the midst of the assorted humdrum and the occasional catastrophe, that was the complaint I heard the most when I served in Vietnam. And mind you, compared to the grunts, I had it way good. I, and the people for whom I was a doctor, lived on a base, not in the jungle. It was up north a ways, not far from the DMZ , and 160 mm rockets thumped (when far away) and crashed (when close) their way across the base pretty much every night. "Oh, Rocket City," was what people said when I told them where I'd been assigned. Still, by some measures, you could call it cushy. And that's my point. War, even at its edges, ravages people. The threat of random rockets dropping through the roof of your barracks can lead to "I can't take it any more." Think of the guys on patrol in Iraq and what their job does to them. A twenty-two year old Marine from my community -- he went to school in the district for wh

I've Seen Ghosts

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As a med student, I did a few circumcisions, in the free-hand style. Later, as an intern, on one occasion I had just finished a very well supervised hernia repair, along with which the adult patient had requested a circ. My attending couldn't have cared less about doing, helping with, or observing that part of the deal. "You can handle it, can't you?" Spoken through his back, and then through the door as he exited the OR, it wasn't really a question. Adult circumcision isn't the same, I discovered, as doing it on an infant. To my horror, I left the man's shaft looking on one side like a pink banana after some monkey had partly stripped back the first section of the peel. The feeling remained in the frontmost of my mind for the remainder of my training. When I helped, I stuck around. A reader asks what I think about "ghost surgery." Complicated answer: depending on terminology, I'm ok with it. Simple answer: it's complicated. First, the se

Plumbing the Depths

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Our shower has been acting up lately. It's happened before, but this behavior was different. Not wishing to hijack my own post, suffice it to say I came up with a clever solution. These little domestic victories, when they occur, find parallels in my mind with surgery. Finding solutions to unusual problems is very often what it's all about. Every once in a while I allow myself an inward smile, and tell myself I have a brain with certain kinds of software -- and feel surprise that I found my way to being a surgeon. It was, in the subject sense at least (and in others, not so much), a good fit. I'm able to figure certain kinds of things out with efficiency, and I think it's a talent not given to everyone. Not even every surgeon. It's not unique, of course, and I'm truly not trying to boast. It's just that I'm sometimes amazed at having wandered into surgery from a series of serendipitous situations, discovering after the fact that I can actually do it, th

Holes

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OK, so surgeons in New York pulled a lady's gallbladder out her vagina . There's a punch line in there somewhere. Anyhow, whereas that particular route is new, the concept of "natural orifice transluminal endoscopic surgery" (NOTES) is not. Or at least not as new. One has to wonder what is the motivation. According to those that advocate such things as pulling an appendix out a person's mouth or anus, the aim is to reduce pain and scarring for patients. I call bullshit. I think the motivation is "Hey, look at me!" See, we're already at a point where most operations done laparoscopically require holes around a quarter inch in size, with maybe one more, 'bout half an inch. Cosmetically, not a major problem. Pain-wise, pretty minimal, most of the time. So we're talking, according to the rationale, about lessening something already pretty minimal. Moreover, since it's literally impossible completely to sterilize the mouth, rectum, or vagina,

Booboo?

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Some would say I was asking for trouble. In my office practice, on any given day the plurality of patients were women with breast problems. Conservatively, fifteen hundred to two thousand a year. With a receptionist or two out front, in the work area it was only me and my medical assistant. She was a wonder of efficiency (me too!), but had lots to do: scheduling surgery and followup visits, talking to insurance companies, fielding calls from patients. Plus getting patients in and out of rooms. I helped: when necessary, cleaning rooms, bringing patients from the waiting room to the exam rooms, getting them settled and properly attired. There simply was no way Trish would have had time to chaperone while I did breast exams. So, with rare exceptions, I did it alone. We used to have nice cloth garments: like a mini-poncho, they'd slip over a woman's head and were, I think, comfortable. When it became cheaper to use disposable items (yes, I contributed to trash , too. Were it up to

Nice

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I suppose there's no point in mentioning it, since you're already reading this and therefore don't need enticements. Nevertheless, there's a nice little blurb about this here blog at OneBlogADay . And pay no attention to the picture. Not having one of myself, I gave them one of my elderly and slovenly great-grandfather.

Dirty Laundry

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Sharing many characteristics of humans, doctors can be assholes. Petty, venal, vengeful. Excessively political, and narrow-minded. I don't exclude myself. Here's how some of it goes. Went. In training there was a tradition of oil/water incompatibility between surgeons and medical types. It was reflexive, legendary, cultivated, part of the air we breathed. But also superficial: we said bad stuff about each other, yet -- no choice, of course -- interacted to the benefit of all. Like your embarrassing uncle: talk behind his back, but get along at family gatherings. In private practice, it's a different game: the animosities, it turns out, are real and impactful. It's not just surgeon - medical doc hostility: it's any doc on doc. Join the wrong clan, expect open hostility; damn the party-favor pretensions. It's real and serious, and deadly unpleasant. Pocketbook precludes pleasantry. When I arrived in town, young and naive, ready to become everyone's favorite s

On Death. Three.

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Before there was hospice , there were house calls. As ought to be obvious, I'm old enough that I've practiced surgery through many changes. Early on, when I could, I had to be my own hospice, sort of. Having observed families dealing with death, both in my practice and in my personal life, I came to believe that there was great benefit from keeping a patient at home as long as possible, even to the end. As exhausting and draining as it often is, the family members who did it seemed to gain a palpable measure of comfort themselves, a deep sense of... satisfaction. (Can we agree forever to ban the word "closure?" What a load of new-age crap that is! In the death of a loved one, there's no such thing. Acceptance, finding a way to live with it: yes. But closure, like it's over, like going through a door and shutting it behind? Please. ) I realize it's a tricky subject: not everyone is able -- for a huge number of absolutely important reasons -- to manage it; n

On Death. Two.

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We went to New York a few years ago, mainly to see a production of "The Iceman Cometh." Expecting to be impressed by Kevin Spacey in the lead role (we were!), I was blown away by Paul Giamatti's portrayal of Jimmy Tomorrow. Near the end he gave a soliloquy of such pain, his emotions naked and raw, that I was moved to tears. So was he. Afterwards, among other things I was left to ponder was what it must be like -- how is it possible? -- to do that night after night, to tap into those feelings so deeply as to move himself to tears, repeatedly. Is it just acting, or is he there each time? Is it as cathartic to him as it was to me? Can he move others so, without moving himself? Is it exhilarating, or exhausting? Could it be neither? As an analogy, perhaps it's a bit off; yet that's what came to my mind in thinking of my role in the death of a patient. It's not that it's an act -- for me at least, it is anything but. Yet if there are courses in talking to pati

On Death. One.

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I've been asked to review a book for Medscape. As it happens, its central subject is a theme about which I'd been planning to post at some point, and the reading has jogged me into it. After the review is posted, I think I'll mention more about the book. Meanwhile, some thoughts on death and doctors. To a physician, death rarely comes unannounced. Because of what we know, we can see it coming before others do. That doesn't make the arrival any easier; in fact, because our essential aim is to cure or prevent disease, death is a repudiation -- perhaps even a humiliation. The author of the book I'm reading sees it as wrapped up in physicians' fear of death, in their need to convince themselves of their own immortality. I don't happen to buy that. But I do agree that, for complicated (because humans are complicated) reasons, we tend to turn away from our dying patients. Willing to do almost anything to stave it off, when death becomes inevitable in those under o

Judging Judgment

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I remember a party my folks had when I was in high school. A couple of their doctor friends were talking -- a general surgeon and an orthopedist -- and the subject was whether, given the choice, they'd like to have more brains or more brawn. At the time, their answers impressed me: surgery was such a physical enterprise, they both agreed, that they'd want more strength, more endurance. Back then, I think I thought "wow, what a tough job." Now, I think "wow, what bullshit!" What makes a good surgeon is judgment. A strong back? Useful, no doubt. Deft hands? Sure. But -- stereotype to the contrary -- surgery is a thinking person's sport, one where thoughts have immediate and profound consequences. In retrospect, maybe those guys were kidding or otherwise off-point. My dad made a mean gin and tonic. Since I've been writing I've been thinking a lot about the concept of judgment -- surgical in particular, but also medical in general. From where does it

Risky Business

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By way of introducing the subject of surgical risk, as requested a while back by a reader, I present a couple of noteworthy patients: Harry was a crusty old fart, mid eighties, wiry and wheezy. Grizzled about the muzzle, straightforward in speech and unrepentantly profane, he'd been admitted with a touch of pneumonia, following upon an episode of aspiration . Burdened for years with severe symptoms from a hiatal hernia with reflux (wherein the stomach slips up into the chest and its upper valve loses the ability to keep stomach content from backing up the esophagus), he'd been rejected in the past as a surgical candidate by at least two surgeons before I was asked to see him. Harry's heart, it was felt, was too precarious to withstand a major operation. It was a little puny, all right -- a dollop of a-fib , question of congestive failure in the past (although that had been at the time of a previous episode of aspiration) -- but far from the worst I'd seen in someone c

Junkies

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A while back, a reader brought up the environmental impact of surgery, suggesting that it ought to be a consideration when planning an operation. Whereas I don't think that's possible in an individual sense (one can try to use as much re-usable material as possible, but you have to take what's available at the moment), it raises a valid point: operating rooms produce a horrendous amount of trash, much of it non-biodegradable and painfully wasteful. It started, I think, because of medicare madness, insurance insensibility, payor pettiness and egregious economics. Time was, we re-used a lot of stuff: cloth was cooked, needles were nuked, staplers were sterilized. But as cost-control became a priority and payers were looking for ways to be non-payers, operating room expenses came under close scrutiny. And it came to pass that hospitals couldn't pass expenses related to re-processing materials. They could, however, charge -- including some sort of reasonable (whatever that

Stones and Knives

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No chemist I, unable to explain solubility constants or crystal formation, I can only note and admire: gallstones come in all sizes, shapes, and textures. Hard and shiny like agates, faceted like emeralds, crumbly like clay. Mulberry-shaped, round, uniform or uneven; surfaces determined by their neighbor, or identically shaped as if manufactured. Green, black, bright yellow, fecaloid. They can occur by the hundreds in a single gallbladder, or fill up an entire bag in the form of one gigantic rock. Feeling like a magician, I liked to save a few from the lab and present them to their owners, more amazed than if I'd pulled a quarter from behind their ear. I always enjoyed looking at gallstones. Unless they were oozing out of a gooey gallbladder in the middle of an operation, like cockroaches from a garbage bin. Learning surgical technique is an incremental process. The student may be allowed to cut some sutures, maybe even tie a few. Simple as that is, it allows a sense of tissue ten