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Showing posts from May, 2007

Operation, Deconstructed. Eight: coming together

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Scenario one: "Hi Sid, this is Dave, calling about Patient Blahblah, pelvic sidewall. Is it OK to talk?" (Wondering if the patient is awake.) "Fire away." "Can you send me any more tissue?" "If I had to. Why, what's up?" "Well, I think it's just inflammation. Probably nothing, but I don't want to commit....yak yak yak..." "OK, OK, OK. I'll send you some more..." (Useless sonofabitch. I'da known he was there, I'da never sent a frozen...) Scenario two: "Room two? Dr. Schwab?" "Speaking." "Hi Sid. It's Ernie. Can I talk?... Patient Blahblah, date of birth yadayada, sigmoid resection, specimen pelvic sidewall?" "Right." "Nothing here but inflammatory cells. Histiocytes, neutrophils, fibroblasts, few eosinophils. Were you worried about something?" "Not really. Little more indurated than usual. I'm sure she has diverticulit

Operation, Deconstructed. Seven: resection, finally

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Would you know what I mean if I describe whistling without whistling? Barely pursing the lips, making little quasi-audible windy sounds while inhaling and exhaling, in tune yet nearly silent? Unless there's music playing, that's what I do when I operate. And for reasons about which I have absolutely no clue, I nearly always "whistle" The Caisson Song. I've always wondered if anyone in the room noticed. Joanie? I suppose if anyone did, they'd eventually recognize it as a sign of contentment. "Over hill, over dale, looks like things are going well...." So it's "hi hi hee" to cut the colon free. I grasp the sigmoid again, and pull it upward then downward, looking to see where the bottoms of the loop fall, determining how much looser I need to make it before removing the damaged portion. Having mobility not unlike that of the sigmoid, the rectum can be made to stand up and out of the pelvis with a few judicious snips of its surrounding

Operation, Deconstructed. Six: sticky stuff

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Let's make it easy on ourselves. I haven't yet established why -- other than liking the particular operation -- we're removing this nice person's colon. So since our patient has agreed to remain exposed and to do so for all to see, I declare s/he has diverticulitis. (I'm planning a post about that entity in the near future, so for now I'll ignore the details.) (Were it cancer, the operation would be largely the same, taking a bit more out.) Most likely there have been a few prior episodes of infection which resolved with antibiotics, but we've agreed the time has come to do a little preventative work. There's unlikely to be even the slightest adverse consequence of losing this portion of the colon; and it should ensure that the attacks will end. So let's backtrack a few steps. Because of the prior infections, it's likely that there are some adhesions with which to deal: that means that a few loops of small intestine are stuck to the sigmoid co

Operation, Deconstructed. Five: getting to the nitty-gritty

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There's a reason for the cliche' -- surgeon barks out the name of an instrument, scrub nurse whacks it into the hand. The reason is this: when you are focused on a particular area -- especially if it's one in which danger lies -- you don't want to look away. If you need to change instruments you lay down the one you're using, open your hand toward the scrub while keeping your eyes on the object of your effort, and want that new tool placed quickly and firmly. So you know where it is without having to fumble. So you can feel it through your glove which, when your palm is open, makes a little trampoline between the bases of your thumb and pinkie. Mobilizing the sigmoid colon from its attachments along the left side of the pelvis is one of those areas. Behind the sigmoid colon passes the left ureter (the tube carrying urine from the kidney to the bladder); causing it harm while working on the colon is a major transgression. Unless the area is distorted by infection or

Operation, Deconstructed. Four: packing for the trip

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Inside the belly, everything is slippery. The peritoneum is a glistening layer of self-moistening plastic wrap, enveloping the surfaces of all the organs, and the inner aspect of the abdominal wall. Undisturbed, the intestines coil and slither, reptilian. Watching waves of peristalsis makes me smile: there's something always entertaining about those moving contractions, following one upon another, gurgling, surprisingly tight bands of tension moving along the length of the bowel in a wonderful concert of muscle action. Like those gifted prestidigitators and their moving coins . Exposure -- providing excellent view of what you're doing at all times -- being a sine qua non of efficient and safe surgery, that slipperiness isn't necessarily your friend, amusing as it may be. Having taken three posts to get to the peritoneum, it's now time to pass through it. In some people you can tell before opening it that things will be OK: the membrane is translucent and you can s

Operation, Deconstructed. Three: parting the curtain

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Traction and counter-traction: along with maintaining excellent exposure, that is one of the fundamental principles of operating. It's Newtonian : equal and opposite. In nearly all forms of surgical dissection, there's a need for some pull in the opposing direction: tissues that are a little stretched-out, that are under some tension, fall open more easily when dissected. Plus, it's a form of stabilization, another obligatory component of safe and precise work. One of the great pleasures of operating is having an assistant who understands, so that actions are coordinated and balanced. Constantly in motion, it's an ever-changing dance, as if we were tethered together by a silk cord, leaning slightly away, each move I initiate perfectly mirrored, keeping the cord perfectly taut, no matter where I choose to go. Ideally, it happens in a constant flow, with no words needed, part of the music of surgery well-done. In fact, when the orchestra is at full throat, my assistant kn

Operation, Deconstructed. Two: cutting in

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The preliminaries are over. Sponges, needles, and instruments have been counted and checked, their number recorded on a whiteboard on the wall, as well as a clipboard. The checkoff is a comforting hum of words; the tuned machinery of the workplace. As the bottle of local is opened and poured into a sterile bowl on the back table, the expiration date is read aloud. "January, Two Thousand Ten." "We'll be done by then," I say, as usual. I look over the ether screen and ask the anesthesiologist, "OK to start?" "Dig in," he says. Scalpel blades come in myriad sizes and shapes. #15 for a delicate cut, needing controlled curvature, like around the edge of an areola. With those little pokes for insertion of laparoscopy tools, it's #11 . This being the real deal, I use a #10 blade , for its deep and long belly; a serious cutting device, but wieldy. There are bigger knives. The act of incising human flesh is one of moment, never light, nev

Operation, Deconstructed. One: preamble

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With as much detail as is useful, and as descriptively as I can manage, I'd like to relate what it's like to do an operation, from before laying knife on skin to after placing the bandage. I'm a general surgeon, so I choose sigmoid colectomy as my prototype; it's always been one of my favorites, although the particular operation isn't the point. The idea is to let the reader into the operating room as much as possible. I figure it'll be several parts. Let's see how it goes. First stop: the pre-op holding area, where my patient -- and most often family -- and I exchange greetings minutes before the operation. If I've done my office-job well, the patient is likely to be relatively calm and optimistic. I touch a hand, a knee, a belly, say something like "Seems like a great day for a colon resection." To the oft-said "Hope you're not hung over, Doc," I respond with a raised hand, deliberately shaking, saying "Steady as a ro

Personal Paradox

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If there's such a thing as mild OCD , I think I have it. For a surgeon, I'd say that's generally a good thing. In my practice, I was pretty obsessive over making sure everything was as it should be: the right instruments available, all lab and paperwork hand-carried to the OR the night before surgery. I liked the look of putting sutures in perfectly spaced, each bight the same size as the last. I took certain stairs, walked the hospital halls in ways that required the least amount of retracing steps, achieving maximumfficiency. Back stairs to the top floor, down a particular hall where the first patients were, then to the nurses' station, then another hall, down the front stairs to the next floor. Like that. The down side is that I often over-reacted if things weren't just so: if during the thousandth time I was doing a particular case, the suture (for example) that I always used wasn't readily available, it could drive me nuts. Less in terms of going ballistic

Hair's the Deal

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Among my duties as an intern, back in those dark days and nights, was to order (and, not rarely, to do) the pre-op shave on patients. "Nipples to knees" was the typical order for vascular surgery patients. (Might be a good name for my next book, or for a rock group.) In addition to shaving hyper-extensively, we also generally did it the night before surgery -- now shown to be a bad idea, because the inevitable nicks became little soup bowls for bugs. The closer to the time of an operation the shave is done, the lower the incidence of wound infection from skin organisms. In fact, evidence suggests shaving not at all might be the best idea, even in the Tony Sopranoesque . Once in a while, in my practice, I had a guy (always a guy) show up for a hernia repair having hacked himself way more extensively than necessary, even into the, uh, saccular parts, leaving terrible tracks. Claiming only the wish to help, I guessed it was a matter of not wanting just anybody mucking about &quo

Expert

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Speaking of physical diagnosis -- and I just was -- I'll never forget one guy at whose feet I sat as a med student on my pediatrics rotation. Double boarded in radiology and peds, he used to come up to Cleveland from Akron to hold forth on rounds, periodically. The ritual was that after he'd given a talk of some sort, the staff would pop up a few Xrays for his analysis. Cold. On one occasion, we had a child admitted with acute glomerulonephritis , an inflammation of the kidneys, in kids typically due to strep and potentially very serious. What was shown to the doc was just a chest Xray. "Watch this," the peds resident said as she leaned over to me. "Bet he gets it." To me, it was an absolutely normal Xray. "OK," he said. "Looks like a male, about eight years old.' [It was.] "The vascular markings are a little prominent [to me, they were perfectly normal], like early heart failure. The heart is slightly enlarged [in my eye, it wasn

Soft Touch

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They told me in medical school that the diagnosticians of old could thump on a chest and detect a tumor as small as a centimeter. I'm not sure I ever believed it, but I've always had a love for the art of physical diagnosis -- of touching, feeling, listening to the body, and coming to an understanding. As technology invades and pervades, that art is becoming almost (not quite) superfluous and antiquated; an amusing throwback. Look at that old guy, touching his patient. Sweet, really, if a little creepy. Hasn't he heard of ultrasound? Actually, I have. A realist, I've ordered a ton of 'em. Still, I think that more than anything else what makes a doctor a physician is the ability to use the senses to figure out what's going on. It's a wonderful combination of book-learning and the accumulation of experience, of sensory attunement to another person. It's very cool. In med school, things are revealed one or two at a time, and each finding seems like a little

Four Minutes of Fame

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When our local NPR station has its (barely tolerable) fund-drive, one of the gifts you can choose is a license plate cover that says "I'm not laughing at you, I'm listening to Car Talk on KPLU." It's true: it's one of the rare shows on any medium that makes me laugh out loud. I've listened for years. So the other day, I have a little problem with this beater Bronco I have and it occurs to me.... Small fantasy fulfilled. Having gone to their website, dialed and redailed many times; having finally got a recorded message and left an account of the issue; having waited through a couple of weeks of silence, I recently got an email from a familiar (to listeners) name: Louie Cronin. "We're interested," is the gist. There followed a couple of phone-tag attempts at connection, and eventually we were talking. Louie, it turns out, is a girl. Mary-Lou, she said. I'd always assumed it was some cigar-chomper in a green eye shade. Come to think of it, I

Suds and Buttons

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Without question, the best way to sanitize an operative field before making an incision is with a mixture of iodine and alcohol. (Barring allergy, dose related burns, stains, etc.) I have my reasons. It's fast. Easy to see where it is and isn't on the skin. Kills on contact, no scrubbing required. One layer is fine (although most OR folk can't seem to be convinced of that.) All of the preceding points are true, but unimportant. It's about drama and belly-buttons, in that order. Ritual is comforting. It grounds us, connects us; going through certain motions consolidates attention, funnels us toward a specific task, strips away the extraneous as it sharpens our focus on the moment. Unlike ritual, which also suggests creaky and forgotten reasoning, what we do at the start of an operation has obvious purpose. Still, it's a literal (and perhaps a figurative ?) cleansing ritual. Hands upward as if blessing , we enter the operating theater . (There's a reason: if held