Mitzvah

A year ago I wrote about the death of the son of some really good friends. He was at the Burning Man gathering in Nevada at the time, and this is the anniversary; the event is happening again now. Our friends are drawn to it, to see what it is that their son loved so much, as a way to connect to him. More than several decades beyond the demographic, they really want us to join them for some sort of mutual support. So we are. As some may already know, it takes place in the middle of Nowhere, Nevada, in a dry lake bed, where the soil is hard-baked and cracked, crunched into dust by the feet of tens of thousands of celebrants, and wind-blown into faces. Bring masks, they recommend. Be prepared for 105 degree heat, and for the fact that other than porta-potties, nothing is provided. For fifty-one weeks of the year, it's as empty and desolate as the moon. Not, I need to admit, my preferred milieu. We're only going for a day, having opted against tents or campers. The idea is just to get the feel of the place, to mingle with the crowd. Our friends are bringing some of their son's ashes.

So at the moment we're in San Francisco, our home for seven years (with a couple away for the Vietnam War) when I was in training, thirty years ago; it's the first time I've been back in a very long time. We've met our friends here, and will be driving to Reno for a night on either end, the hot spot in the middle. I'm expecting to be close enough to heat stroke and exhaustion that I'll not be able to appreciate the beautiful naked bodies that are a hallmark of the event. (If I'm wrong, I'll let you know.)

It's amazing how little the city by the bay has changed in the past thirty years. The downtown is different in places; and the street cars now traverse Market Street under ground, which is nice. But the neighborhoods look just the way we left them. Store fronts reside under different signage. Our favorite ice creamery is now a Thai restaurant. But the San Francisco streets and the homes thereon are as they have been and, seemingly, will always be. I loved it then, and do still. Near the med center we saw men and women walking around in scrubs; I felt a desire to approach to see if they were surgical residents, or OR people. To tell them I'd been there, too. I knew the place, I was like them. But I didn't.

Golden Gate Park is a treasure. Some of the buildings are different (notably, the de Young Museum is entirely new, and not particularly attractive: but it has a tower with a spectacular 360 degree view). The grounds, the roads, the trails -- much travelled by us in those days -- remain as they were, and beautiful. When we lived here (it pains me to say we actually bought the little house we'd been renting, and sold it when we left. If only.....) we had a guy come to help us clean up the unexpectedly deep and narrow back yard which included a tall cypress tree. Having cleared and pruned, we then maintained the yard as a personal refuge from the city and the fog as it often cat-footed to our front door, but didn't dog us in the back. Abutting a shoulder of "Tank Hill," which is an appendage of Twin Peaks, our yard looked onto a barren hillside, alone, and felt like an oasis plunked into Arizona. We had a pond into which I implanted a little fountain, aerating some goldfish and lily pads. The guy I mentioned was an old man -- twenty years older than I am now. We found him in the phone book under AA Landscaping. Good marketing plan. When much younger he'd actually worked under John MacLaren, the original landscaper of Golden Gate Park, helped plant the place. Chester Christiansen, his name was, and he tore through our overgrown place (the previous occupants had let it go, to say the least) like a helpful hurricane, discovering terraces and tiles, weed-hidden shrubs and plants. He even brought us some of his own flora, gratis. (Like everyone else, he was taken with my wife and her enthusiasm; not to mention her knowledge of the plants we had and wanted.)

I can't say the place feels like home any more: it's been too long. But I can capture the sense we had once, living here. Some big cities have a more friendly feel than small towns. Here, there are distinct and identifiable neighborhoods. We had one of our own, once, where we knew neighbors, merchants, and secrets.

The Lung Way Home

If you can imagine squeezing pink cotton candy, and if in your mind you can make it not sticky or sweet-smelling, you may have an idea of what a lung feels like. It's the coolest thing.

I found myself inside the chest more frequently in training than in practice, but it still happened often enough (almost always to work on the esophagus) to refresh my senses -- that airy texture; spongy and light. The way it conforms to a touch and molds itself, like a memory foam mattress; except in the case of the lung, the imprint becomes purple. And stays that way until the next breath.

When operating in the chest, not on the lung, we frequently impose upon the anesthesia person to use a special split breathing tube that can inflate one lung at a time, allowing the deflation of the one in the side of the chest in which one is working. It gets it out of the way very nicely. As it collapses (we may speed the process by pressing on it) the color of coral is replaced by that purple as it shrinks, leaving pink pockets here and there, looking empty and irregular. Later, watching the reinflation is the witnessing of a magical metamorphosis.

(Let me say here: a normal lung is fairy-tale pink, baby-cheek smooth -- a soft pillow and puffy. Clean, inspiring (pun intended), and as described, sadly rare. Even if a non-smoker, any city-dweller picks up enough crud from the air to deposit black spots throughout, changing that bubble-gum beauty into charcoal-pocked travesty. In a smoker: well, let's not even imagine it today. It's the opposite of beauty in the way steel wool is the opposite of creme brulee.)

It's when the critical part of the operation is over and the lung gets re-filled that the real thrill happens. Slowly and irregularly the lung expands, like a beaten fighter staggering to his feet, arms and legs not quite responding. Here and there the pink appears, pushing the purple crevices outward nearly randomly, erasing them, like strawberry milkshake bubbling up, filling them one by one, here, then there. As the anesthetist gives the breathing bag an extra long and extra forceful squeeze, you watch as the lung pops its way full: it's the opposite of crackling bubble-wrap. "OK, that's it," you say, and the breathing gets reverted to mechanical and regular. You can't resist touching the lung again, as it strains stiffly between the ribs; it both repels the touch and gives way, then refills the spot. If there were a soundtrack to the expansion, it would be like that of a wave receding over a gravelly shore.

Don't Try This At Home

In retrospect, I suppose it was stupid.

Deep vein thrombosis (DVT), meaning developing clots in the large veins of the legs which can break off and travel through the heart and into the lungs (pulmonary embolism -- PE --) is a risk of most major surgery. The general risk comes from the immobility of lying motionless on an operating table for a period of time (venous circulation in the legs depends much on muscular action, which milks blood north with the assist of one-way valves in the veins.) There was a time when such clots were an unrare complication of surgery; in fact, years ago I lost a couple of patients to it, despite doing everything we knew to do in those times. Now, because of several measures, the complication -- at least at a level where it's noticeable -- is quite rare. Those measures include much better peri-operative hydration, early ambulation after surgery, and the very common use of low-dose blood thinners before surgery along with pump devices on the legs during (and sometimes after) the operation. For certain orthopedic or pelvic operations, and with laparoscopy (which adds to risk by blowing up the belly and often tilting the patient head up, both of which tend to add to blood congestion in the legs), the risk is increased and these steps are virtually always taken nowadays. Which is a good thing. The last time I saw DVT with or without PE in a patient of mine was many years ago. I have, however, seen it quite close recently. Coulda killed me.

After I sort of retired, I did some things I'd been meaning to do for a long time. Took an acting class. (Well, that ended quickly enough: in high school and college I had some leading roles in musicals, and had delusions...) Went on a trip up the Amazon River. Got back into shape and resumed bicycling, including a couple of several hundred mile rides. All of which, you'd think....

So anyway, at the height of my healthfulness, not long after finishing a long bike ride (and many months after flying to Peru and back), one day I began to notice I was shorter of breath on biking exertion than I'd been. Figured I must have a little respiratory infection, backed off a little but kept riding. A few days later I took my son to a basketball game, seated in a place with criminally minimal foot and leg-room (anyone been to Key Arena?) Shifting uncomfortably throughout the game, I complained of my left calf in particular. But I didn't think it related to anything but the cramped quarters. Until a day or so later when I noticed the calf was pretty big. Us biker guys gots big calves and nice quads. But they're supposed to be sort of equal, side to side. This wasn't.

Reluctantly, I saw my doc. (He's "mine" in the sense that I list him as such when asked to. I don't do the, y'know, regular checkup thing.) I have to say even he figured, "Naw, couldn't be... but let's get a doppler anyway..." Having driven to his office, I also drove to the lab, where the study showed a clot flapping its way right up to my groin, big as life. (The clot, not my groin. Sadly.) I drove back to his office.

"No way," I said when he ordered me to the hospital. "It's been going on for several days, I've been biking. If it was going to kill me, it already would have, wouldn't it?" I'm bigger than he is (bigger, not smarter), and somehow he agreed to outpatient treatment. So I got daily injections of fragmin while I waited for the coumadin to take effect, and spent most of my time on my recliner. Also, I figured if a big clot broke off at home, my chances of survival were approximately the same as if it happened in front of the cardiac team; but with less fuss. The outcome is pretty much binary: fatal clots are fatal, and survivable ones would generally allow time for a ride.

Faced with a similar patient with similar demands, I'd have insisted with everything I had that he go to the hospital for a few days and stay on complete bed rest until fully anticoagulated. Or had him sign something if he refused. I still haven't decided what I'll do if I really get sick sometime. As comfortable as I've been caring for the ill, as glad to help and gratified by it, the idea of being that dependent on other people -- the idea of one person (not one person: this person) taking up that much space in the order of things seems disproportionate and uncomfortable. Don't get me wrong: it's quite OK for you. I'm just not so sure about me. And what the heck. My recliner is pretty comfortable.

[Clarification: This incident occurred a couple of years ago. Other than mild post-phlebitic syndrome, I'm fine. Maybe it was the recliner reference in the last sentence that was confusing: I was just thinking ahead...]

Farm Boy

In the penprevious post I made mention of my past country life. It was the result of the coming together of a boyhood fantasy and a manhood failing. By which I mean this: I grew up in Oregon, left after high school for college, med school, surgery training, but held onto a vision of myself returning to live on acreage, milking horses and riding pigs, roping corn and being good 'ol Doc Schwab, country guy. (Other than a brief visit now and then, I'd never set foot to farm.) My wife, on the other hand, loved living in San Francisco for those years of my training; if we weren't going to stay there, her clear choice would have been the Puget Sound region, near Seattle, her folks, and her eight siblings. I was too much of an idiot to see or hear.

We did it my way. (It took me a few years to get where I am now, both in location and disposition. Which puts me in mind of one of my dad's favorite jokes: Two guys are shooting the breeze, one of them talking about women and how difficult they are to live with. The other guy says, "Well, I worked all that stuff out a long time ago, laid down the law. It's been great. I let my wife make the little decisions, and I make all the big ones." "Wow," says the first guy, "How does it work?" "Perfectly. She decides where we should live, what house to buy, whether to send the kids to private school, their religious upbringing, when it's time for a new car, which one to buy. I decide the big stuff: whether to recognize Red China, whether we're spending too much on the space program....")

It wasn't all bad. I got a nice offer from a small clinic in the Willamette Valley. The place we found had pre-existed in my dreams: seven acres, a home-made house surrounded by ancient oak trees. A hill for kite-flying in the summer and sledding in the winter. A barn. Our son was born shortly after we arrived, and as soon as he could walk he was toodling around in his Osh-Kosh b'Gosh dungarees. Sometimes with a sprig of tall grass in his mouth, exactly as imagined. Every Spring, a pond would appear just about when we thought of it again, complete with frogs and salamanders; we'd climb a fence to get to it, and bring some home for Mom.

About five minutes after moving in, I realized I had no idea what to do with all that land, and eventually worked out the perfect deal: our neighbor Les (a self-educated high school dropout, voracious reader of Oregon history, great guy) was happy to use it to pasture his horses and cows, and we could watch them kick up their heels (the horses) as they'd gallop past our house and up the hill when Les let them out every morning. We could toss them carrots, learn their names; Danny saw a horse being born.

I'd really gotten to know Les on the first freezing morning of our time there. New Year's Day, it was. No water when I turned the tap (to that point, the extent of my plumbing abilities). I knew we had a well out there, but had no idea where or how to service it. I trudged through snow to find Les in the fields, and imposed him back to my place, where he discovered, along with me, how poorly had the plumbing been done -- now thoroughly frozen in the ground and alongside the house. He jerry-rigged a bypass, and I kept the water running day and night through the winter. Embarrassed at having drug him over, revealing how little I knew about being a country boy, playing at it I guess, I apologized over and over and thanked him profusely. "Don't worry about it, Doc," said Les. "You retain it better this way."

The other neighbors weren't as welcoming. Damn city slicker doc thinkin' he's a cowboy, was what they saw, and they didn't return my waves as I drove by in my pickup. It might have been the fact that it was a Toyota mini-truck that turned them away. Probably, though, a big frickin' Ford wouldn'a done it, neither. Them's the ways.

What we did do was garden. I tilled a big patch right next to the house (got me a honkin' big roto-tiller), turned in manure from Les' barn, ferried it in my trucklet. It's a hot and fertile valley, is the Willamette. If you can't grow stuff there, you can't grow stuff. Rows of corn, berries, potatoes, tomatoes, all manner of greens. Dan would wander out and pick peas and berries, never getting them back into the house: eaten off the vines. To Les and Lorna's amusement, Judy planted a watermelon. Black plastic and lots of nurturing, and we served it to them a few months later. Grew a pumpkin big enough for Dan to crawl into while helping to clean it for Halloween.

The job wasn't right. My two surgical partners were great guys. I learned a lot from them, and our relationship in the OR -- especially with Keith -- was as close to perfection as it could be, whichever side of the table one or the other of us was on. I thought he was the best surgeon and assistant I'd ever seen: he reciprocated the feeling for me. But there wasn't enough work for three and they had first dibs. I happenstanced a reputation as a good surgical pancreatologist, but there wasn't much of that to do; work increased, but slowly. The clinic didn't get that we needed to increase our primary care base as the non-clinic docs in town tended less and less to refer there once specialists came to town outside the clinic. (The clinic had brought the first specialists of each type to town, and felt it could survive on that basis: as time passed and they weren't the only specialty providers, it didn't work. When I said my piece, they suggested I join the Rotary to get more business, and they hired a rheumatologist.) A young surgeon who's not as busy as he'd like to be is an unhappy one; and that ripples.

Having dragged my wife to a place for which she had not much initial enthusiasm, I eventually turned my eye northward, to where she'd liked to have gone in the first place. Ironically, by the time the right situation came up, she'd become happy in Oregon, and we left some good friends behind. Where we ended up, and have remained for twenty five years and counting, has been better. None of the siblings is much more than an hour away; whole-family gatherings occur as frequently as the tides on which we look. The job gave me the satisfaction I was looking for in breadth and depth of practice. If I hadn't done the country thing, even though it didn't work out, I'd have always regretted it, and wondered. Now I know.

A small glimpse of the view from our porch can be seen in the upper corner of this blog. Boats big and small chug or sail by. Somewhat ominously, our home-based aircraft carrier moves past a couple times a year, resolute on the out-going, celebrated by showering fire-boats on the return; at first we went outside to watch and listen every time. The weather changes the water's color and texture like a sorcerer; dazzling sunsets can be stupefying (for years I arose in the dark, and came home in the darker: now I luxuriate in what I'd been missing). We can't grow corn here (our rhodies bloom exuberantly, if briefly), but we can get the fresh stuff off the farms a few miles away. It's been pretty damn nice, mostly. For a farm boy.

Fast Relief, and Simple

In response to my recent "Pain in the Ass" post, in which the subject was a simple procedure bringing rapid and dramatic relief, commenters have mentioned other similar interventions. Seems like a fun topic. Here's a list I can think of (a couple of which are those mentioned in the comments, by readers.) Anyone want to chime in with others?

• Giving "Narcan" to an overdose patient: within seconds a moribund and blue, pin-point-pupilled addict is transformed to a yelling and screaming maniac.
• Similarly: Dextrose IV for hypoglycemia rapidly raises from unconsciousness to lucidity.
• Relieving a subungual hematoma with the red-hot tip of a straightened and heated paper clip. FZZZT, and the patient is happy!
• Draining any sort of painful abscess under local: pilonidal, perianal. The patient has arrived in abject pain, hardly able to walk, and leaves smiling and light on his feet.
  
• Releasing a tension pneumothorax with a needle. FZZZT, and the patient is happy!
• Reducing a dislocated shoulder: the water-bucket trick is rewardingly direct, low-tech, and effective. Pop >>> ahhh!
  
• Pulling back a too-far inserted endotracheal tube. The oximeter tone rises steadily.
• Untwisting a sigmoid volvulus with a scope. Stand back, or let someone else do it. Dramatic to all senses.
• Cricothyroidotomy. Too scary to be fun, it certainly qualifies as dramatic and effective, especially when done with nothing but a large IV catheter.
• Sticking a finger onto a major bleeding artery, the kind you can hear. It doesn't solve the problem but it sure as hell is a relief for the moment. When the natural instinct is to turn the head away, which some in the assemblage might do, it seems sort of heroic.
  
• Squeezing bags of fluid or blood with both hands, and seeing the blood pressure rise and pulse fall within moments.
  
• Carotid sinus massage: I actually did it once, for atrial flutter with syncope, absent readily available meds. I kept thinking I'd cause a stroke, and never had to do it again. Still, it's a nice maneuver based on medical school knowledge of cardiovascular physiology.
• Opening a chest and pericardium, of course, and poking a finger into a heart wound. Been there, done that. Not so simple, but uber-dramatic. Relieving pressure in a pericardium by whatever means can resurrect a person in an instant.
  
• Quickly accessing the subclavian vein. Simple. But often tricky enough that when you pop in the needle and get a nice flashback of blood in a couple of seconds, it feels pretty good.
  
• Inserting a suprapubic bladder catheter when you can't get a foley to pass.
• Apocryphal, perhaps? Everyone says it happened in their ER: giving sux to a hopelessly combative patient. Calms them right down.
• Administering valium for status epilepticus.
• Anyone perform/experience others?
  

Kid Stuff

The image is as burned into my mind as was the muffler into the little boy's back. Four years old -- same age as my son at the time -- living in the country, as did we, the boy had run to greet the mailman and had somehow darted in front of the truck and been run over. The mailman -- can you imagine his sense of dread? -- stopped and jumped out, finding the boy pinned under the truck. Its muffler, lined up exactly over the boy, pressed onto his back as if designed to do so: it burned a perfectly-placed rectangle vertically from his buttocks to his shoulders, literally cooking through skin and fat, down to muscle. It looked like tanned leather, like smoked meat; and it smelled like it. When I saw the child in the emergency room, he was lying on his tummy, not wanting to move even a twitch. And he whimpered for his mommy. I'm thankful we didn't have a burn unit; I don't think I could have stood caring for him. It was simply too close to home. As fast as I could, I got to a phone and got him transferred to the regional burn center. Faster still, as soon as the little boy left, I went home to see Danny.

I've gathered from the writings of others -- doctors, nurses, cops, firefighters, social workers -- that it's universal: the overwhelming desire, after caring for or being involved in some way with a sick or injured child, or one in danger, or mistreated, to be home with one's own child and hug him. Just hug the kid, whether he or she knows why or not.

It didn't bother me every time, taking care of kids who reminded me of my son. In fact, having a child made me much better able to do it, to get down to where they were and relate to them. Getting a frightened child to calm down; being able to soothe and cajole and manage a local anesthetic to clean and suture a cut was always a source of great pleasure. Meeting a kid in my office, trying in some acceptable way to explain a hernia, for example, ("See this little bump here? I know it doesn't hurt now, but when you get to be a big boy, the bump can start to hurt, so we're going to make it go away so it won't hurt when you grow up. Your mommy will bring you to a nice place with some nurses who really like kids like you, and it'll only take a few minutes, and we'll put a pretty bandaid on it -- maybe one with Snoopy on it, unless you like a different one. You be sure you bring your blankie or your favorite toy, will you?") was a pleasant little victory.

It's the hurt ones, the dangerously ill ones; those got to me because I was a dad, and it could be hard. I've said before that I could never be a pediatric surgeon because they keep the operating rooms too damn hot. But that's not the real reason. This is. Taking care of some kids requires overcoming a physical barrier, a nearly-irresistible desire to be somewhere else. At home, mostly. I don't know how pediatrician-parents do it.

New Rules

Interesting news:

"In one of the darker ironies in American health care, hospitals are often paid extra to treat the problems that arise when they make mistakes. Starting late next year, Medicare won’t pay for treatment for some conditions associated with screw-ups.

Under a little-noticed new rulebook that came down last week, Medicare will return the bill unpaid for care to solve these problems:

Bed-sores
Two kinds of catheter-associated infections
Air embolism, or bubbles of air or gas entering the bloodstream during medical procedures
Mediastinitis (infection of the area between the lungs) after coronary bypass surgery
Giving patients the wrong blood type
Leaving objects inside surgery patients
In-hospital falls
The government estimates its direct savings at about $20 million a year, and Medicare has said hospitals can’t turn around and stick patients with the tab. Other insurers are likely to follow suit, and hospitals may well do a better job for all patients, not just those on Medicare, say some advocates of the new rules.

The American Hospital Association had proposed a narrower list, saying some bedsores and hospital-acquired infections occur even with top-notch care. The trade group wanted only “never events” — such as air embolism, blood incompatibility and leaving objects inside patients — unreimbursed.

Consumers Union, which has been campaigning for better control of hospital infections, generally applauded the new rules. “We think it’s going to be a very powerful incentive for hospitals to improve care, and also a way to contain costs,” spokesman Michael McCauley told the Health Blog."

Article printed from Health Blog: http://blogs.wsj.com/health

URL to article: http://blogs.wsj.com/health/2007/08/08/medicare-wont-pay-hospitals-to-remedy-flubs/

As one who's gone on record as supporting single-payer health care, this is the sort of thing that makes the position a little hard to defend. It's not that I entirely disagree with the concept. For one thing, I never (nor do most surgeons, far as I know) charged for a re-operation, even if it wasn't for an obvious error. Plus, I have advocated greater efforts to identify measures that some doctors take to get better outcomes, and to encourage them. So this sort of thing -- in theory -- is not unwarranted. The devilment is in the details. Some items on the list are inarguable; but not all. In particular, my ears up-pricked with the inclusion on the above list of mediastinitis. That happens, in this context, to be a particularly devastating infection that can occur after open heart surgery. If survived, the costs are likely to be huge. But here's the thing: there are steps we all take to prevent surgical infection; and we know that nothing is 100% effective. (The same can be said for certain kinds of air embolism.)

I can't say for sure, based on the articles I've read, but I infer these decisions will apply even if all appropriate steps were taken. Maybe there'll be fine print by which decisions can be appealed, but surely the bureaucracy will be daunting. I'm no heart surgeon; but wound infections can occur in any circumstances, despite the most scrupulous efforts to prevent them. What will be next? Orthopedic appliance infections (artificial knees, hips, etc) are awful occurances. Typical operating rooms in which they are implanted are cathedrals of carefulness: the operating teams can look like astronauts repairing the Hubble. Should a hospital that has gone to the expense of providing such a level of sterile isolation be penalized for the inevitable rare failure? Certainly, the patient will have suffered many consequences, and financial ones ought not be on the list. But hospitals have a hard enough time hanging in there financially already.

Without question, steps are needed to contain costs, and pressure to produce the highest possible levels of safety are justifiable -- more than that: they're required. It's one thing to penalize when failure to follow proper protocols occur. My concern is for events that happen when everything has been done right: there's simply no way to eliminate it completely. My prediction: once this policy is in place, we'll hear many examples of excellent care being penalized; and we'll see the list steadily expanded. It seems like the most fertile of soil in which to plant the seeds of unintended consequences. Time will tell.

[Unrelated statement: this blog seems to be experiencing an outflow problem. I'm of that age, of course; but I'm not sure the obstruction is amenable to the sorts of things a urologist might suggest. I could shove some Flomax up my nose, or into my ears, or sleep with it under my pillow. But I'm not optimistic. Just so you know.]

See? P.R!

If you watch medical shows on TV -- and who doesn't? -- you can be excused if you think CPR regularly raises people from the dead. What could be more dramatic? All those close-ups of concerned (and uniformly handsome/beautiful) doctors, nurses, medics, heroically pounding on chests, turning to look at a monitor as it suddenly changes from flat-line to perfect wave-forms. Like nothing had happened. Sadly, it doesn't work that way very often. On the other hand, surgeons have a better crack at it than most, literally.

I've written before, so I won't again now, about the drama of cracking a chest in the ER, clamping the aorta or putting a finger in a hole in the heart. Take a young person with cardiopulmonary collapse from a non cardiopulmonary cause (like exsanguination from an injury), or from just the right cardiac injury, and make the circumstances perfect -- like arrival quickly at a well-run and properly equipped ER -- and you can be part of something memorable. A person in profound shock from sepsis: with the help of many people -- intensivists, nephrologists, ICU nurses -- a well-timed operation can be a part of a heroic rescue of a life that was nearly lost. These things are a part of surgery, and can be exhilarating in the looking back. In my case, it's hardly a high-five'n sort of thing. It's about being in the right place at the right time to be involved under the right set of circumstances in doing the right thing. As opposed to how it usually goes. Which is why "heroic" really means "lucky." A reader asked about what it's like to resuscitate someone. I hope she won't be disappointed.

"Code Blue, room 326; Code Blue room 326; Code Blue room 326...." My first response is to run the room number through my mind to figure if it could be my patient. And whether it could be, or clearly isn't, it's always a sense of dread and doom at what I'll find. Being painfully honest here, I'll also admit that if it's a medical floor my response is slower: I figure there'll be plenty of people more capable than I at running the show, and I may sidle up slowly to see if they need something mindless like inserting some sort of tube or access line... "Oh boy!!" is the last thing I -- or anyone but maybe a student -- think when I hear the call. Odds are, it's not going to end well. In fact, various particulars aside, one can get pretty good mental image of what will be found, based on many repetitions of the same thing.

Chaotic and crowded, the room will be full of people and machinery; a "crash cart" with drawers gaping open in disarray, popped vials strewn on top. A couple of nurses with clipboards, documenting. Possibly three or more docs, one at the head of the bed; likely having run up from the ER. Pharmacist, respiratory therapist. Students, maybe (in my situation, only nursing students). Thrilled; and horrified at being thrilled. Shocked, too; wondering if this is really what they'd had in mind. Disorganized from the broad view, there's usually in fact an overall calm in the principals, deriving in part from the fact that those responding most immediately have done it many times before; and maybe also from a realistic sense of the inevitable.

Remember this: people who arrest in the hospital must already be pretty damn sick. When they fail despite whatever it is that's being done for them, there's already been a stark selection.

Some things are nearly constant: protruding from under the patient is a polished board, maybe maple or oak. Cut-out handles visible at the edges; tubes, sheets, maybe bloodied, draped crazily. Someone kneels on the bed or leans over the edge (backs of knees aching within moments), hunching, with elbows locked, onto a bare chest (in the frail and old, the feel of ribs breaking, sternum cracking are among the more sickening sensations I've ever had). With each compression, the patient's arms flail a little, the belly shakes, the legs shudder. Looking at the feet, one sees ominous blue mottling, heading up the calves. The thighs are webbed with blue veins, as if spidery Death has been there, laying claim, marking territory. The more tubes already there, the worse the outcome. A bandage on the belly is like an address label to the morgue. The defibrillator is no Trekkian transporter. If it works, it bespeaks a particular set of circumstances. And you might be surprised to know this: the word "clear" is said, all right. But unlike those TV shows, it's not a shout. It's a question.

The call at three in the morning: "Dr Schwab, your patient Mr Jones is coding." "What, who, what's.... Nevermind, I'll be right there." I got into the habit of hanging next day's clothes on a hook, to save time rummaging, and to avoid turning on a light and waking my wife, because on a typical day, I left in the dark. It's useful for this situation, too. Holding the clothes in my hand, squirting a finger-tip of toothpaste and sticking it into my mouth, heading downstairs, dressing in the hall. Running possibilities over in my mind on the drive in. I always figured if flashed down by a cop I'd hang my stethoscope out the window and keep going; it never happened.

The feeling is horrible: it's a rarity, really, because most people do well. Or if they don't it's not unexpected. But on those awful occasions when there'd been no reason to expect it, it feels like you're driving with a boulder in your lap. When you get there -- from phone to floor it was give or take twenty minutes -- and enter the room a scene not unlike the above, eyes all turn your way. "What happened, how long has it been?" you say. "Anyone have any idea what's going on? Who's his nurse tonight?" She gives a review of the preceding events. A call like this, out of the blue, is extraordinary. If things had been changing, there'd have been contact; I'd likely have already come in. So this is a catastrophic event -- a stroke, a heart attack, a major blood clot in the lungs. You get a sense of the air in the room, the time. Feel the belly -- because that's what you do -- look at the pupils. Glazed and fogged, pupils black and wide as pools. Lips purple. Ears, too. Purple ears. "Anyone want to keep going? Any suggestions?.... OK then. Let's call it."

Sometimes it's not so bad: it's loss of blood pressure with a persisting heartbeat. A post-op bleed, some sort of infection. Then you can slam in a couple of extra lines, tilt the bed head down, squeeze bags of fluid or blood, watch parts pink up. See the eyes come open, feel feet get warm. Not to mention sense your own heart slow down, your armpits dry a little. It'll be OK. This time, it'll be OK.

Pride and Joy

I hinted at it in my para-previous post: if there are things I can look back on with pride, near the top of the list is my involvement in establishing the surgery center in the clinic for which I worked. It was -- and is -- among the best of the best; and I think I can honestly take credit for some of it.

It was controversial at the time. There were, of course, politics involving the hospital as well as another local center. In fact, that local center was the one I'd been using, and I loved it. I knew that in building our own, we'd be hurting that one, and I felt bad about it. (In fact, I was later told, of all my fellow clinic docs, I was the only one that told them so. Among other things, I wrote them a letter stating the reasons -- purely selfish, at the bottom line -- and that I wished the reality weren't such that we felt we needed to do it. I still went over there frequently to say hello; eventually, we ended up assimilating them and many ended up working there still...) More difficult was convincing the rest of the partners that such a thing made sense. It was a big investment, and, to the non-surgical docs, a huge risk. To me, from the beginning, it was a no-brainer: the only question -- outside consultants to the contrary -- was whether we were thinking big enough. (They thought our design would satisfy our needs for nearly ever; I thought we'd fill it up in a hurry. The aforementioned "assimilation" indicates who was right.)

In several ways, the stars were aligned just right. At a time when physician reimbursement was being cut left and right, there was a trend to encourage outpatient surgery; so facility fees were still paid at a reasonable rate. And it was ideal for those patients who were on a capitated plan (meaning one that paid us a fixed annual amount to care for patients). Also, in my town the two hospitals had recently merged, and for many reasons there was a lot of frustration and dissatisfaction among the nursing staffs of both former entities. While they were being told by administration to shut up and stop complaining, we were hiring with the premise that we wanted the best and needed their input in setting things up. Getting good people was not a problem. At the top of the list was the woman -- let's call her Helen -- who'd headed up one of the former hospital's OR and was the best ever, anywhere: smart, efficient, knowledgeable, a problem-solver, and -- most importantly -- loved like crazy by everyone who worked with her. Fun was a priority with her. In a last-ditch effort to stave off financial collapse, her hospital had, before the merger, summarily axed its longest-tenured, highest paid (and best) nurses; Helen, included.

I can't claim to be the only one, but I trumpeted Helen most loudly and made it clear that hiring her to run the place would be a coup of the highest order. Administration, having held open auditions, had others on their list as well. To my everlasting credit, I (and some others) prevailed. Then, she went about hiring people to set up the various sections: pre-op, OR, recovery. Finding a place where their ideas were welcome, they came.

Meanwhile, our planning committee was addressing nuts-and-bolts issues: number of ORs, size, layout. Colors, even. And here's where I'm most proud: to that point, our clinic had been sort of industrial-efficient. Ugly, in other words. Cheap. The initial plans had a cramped waiting room, and a broom-closet for a staff lounge. I insisted that one of the keys to success for an out-patient center was patient comfort and satisfaction: it needed to provide a better experience than a hospital. Likewise, staff morale was an indispensable ingredient. Having Helen would go a long way; but the lounge is the heart from which the pulse is generated. A comfortable gathering place, with essential appliances and plenty of room for cookies -- that's what it takes.

On my first walk-through, I was floored. Literally. The floors said it all: beautiful patterns in the halls, a carpet in the family area which had soothing tones and elegant style. Our main building had never looked like that. Plus, there was nice lighting, comfortable furniture, elbow room. The ORs were bigger than some at the hospital, equipped with the good stuff. And the staff.... the staff were nothing but smiles and skills. To say the attitude differed there from that of the hospital is to understate titanically. And damn! It was mine! Operating there was heaven: what can we do to make it work for you and your patients? (And here's what you can do to make it work for us...) Patients -- literally without exception -- raved. One after another, they'd come to my office post operatively and say things like, "I never thought I'd say this about surgery, but that was a wonderful experience!" Or, "You have a fabulous staff there..." How great is that? (As a bonus, the wave of success and satisfaction swept over the rest of the clinic, which was steadily re-done in the image of the surgery center.)

Turnover time (the time between the end of one operation and the start of the next) can be the bane of a surgeon's existence. There, it was so fast I had to streamline my routine or I wouldn't have time to dictate, write orders, talk to the next patient and the previous family. In my four-hour blocks, working with the same great people over and over, I could do four gallbladders (with Xray!) or eight hernias. The ENT folk did tonsils by the pound. Every day in the lounge there was another dozen or more patient evaluation forms on the wall, raving. And, of course, pictures of staff pets, families, announcements of a picnic or a party. And food. Deliciously unhealthy food. I always brought cookies.

None of this is truly unique: surgery centers in general have an ethic of excellence and esprit de corps. It's just that this one was "mine," and was as good as it gets. I work in one now, and I like it. But that place... I miss it the most. When I left, I wrote to them that they were "an island of excellence in a sea of despair." At the time, that said it all.

[As an afterthought: it's one of the most amazing changes in the last couple of decades. When I trained, surgery centers didn't exist. When they started, it was very controversial: could or should general anesthesia be done in such a place? What sort of operations? Is it safe -- even ethical -- to send people home after "real" surgery? At first, it was mostly local anesthesia, and small operations. Doing hernias was a big step: when I was an intern, we kept hernia patients in the hospital for three days or more. I caused a stir, in practice, when I started sending them home the day after the operation. And we on the West Coast seemed to lead the pack. While we were doing bigger and bigger operations there, in the Midwest and East, they were still holding back. Now, there's almost no limit, everywhere: gallbladders, hysterectomy, ACL repair. Mastectomy. Lap-band in 400-pounders. Who'da thunk it?]

Paper Trail

An unused bedroom is full of old papers -- among much else. Today, my wife was doing some excavation therein, and found some weathering evaluation forms, from a few years back. My clinic began a process some time ago, which (I think) it continues, whereby for every physician every year (now numbering well over 200), a random 100 patients are sent questionnaires, asking about various aspects of their ecounters with that doctor. All docs got summaries; overall, I'd say it was an extremely useful thing. The batch my wife found brought back long-forgotten memories.

Most were unsigned. One was neatly typed, the others hand-written in style varying from scrawl to neat and grandmotherly. Some brief, some overflowing the alloted spaces. The ages were indicated, and they ranged from 5 (in a mother's hand) to 85. Without exception, what they said was really nice, every last one of them. "You made me feel so comfortable." "You really seemed to care." "You explained everything clearly and thorougly." "I've never had a doctor who came to see me twice a day. I really appreciated it." "I was scared, and you took the time to make me feel comfortable." "Well, you didn't tell me how great I'd feel." "I wish you were my regular doctor."

And here's the thing: while I was reading them, I felt warm and good. Now, I feel really bad. I tossed them in the garbage. (No, not the garbage of course: the recycling bag.) I think it's a Woody Allen sort of thing.

Pain in the Ass

I suppose the greatest satisfaction for a surgeon is taking on a big and challenging case, carrying it out perfectly even when encountering difficulties, and having it turn out well. Saving a life in the process -- understood. And yet it might be that the most grateful patients I've ever had are those on whom I performed an embarrassingly simple operation -- one that takes only a minute or two. These patients, often, came (or were helped) into my office crying, begging, "Doc, if you can't help me, could you please kill me?"

In my previous post I suggested the anus could stand a little re-design. How nice it would be to download (as it were) version 2.0. Maybe it could come with a user's guide, too; and not just for the owners (it could be brief: Fiber. And lube. But I digress). A shop manual would be nice, because it's actually surprisingly misunderstood by lots of primary docs. (Also brief: hemorrhoids protrude, and bleed. If there's lots of pain involved, it's something else.) (Oh, yeah: "thrombosed hemorrhoid" -- which can indeed hurt like hell -- is another of those misnomers. "Peri-anal hematoma" is more apt. But that's not what I'm talking about.)

I'd guess most people (maybe not vegetarians) have had one of those bowel movements that brings tears to the eyes. A small tear of the skin overlying the sphincter muscle (control muscle) may occur on such an occasion. When it does, then things go in one of two directions: with time and luck and perfection of stoolage, it heals. Or it doesn't. The tear deepens, exposing the muscle underneath. Which leads to a vicious cycle of pain, spasm, tearing, more pain, more spasm, more tearing. And then you have an anal fissure. Ouch. No, seriously: ouch! Grab the walls, yell and cry ouch.

Most fissures heal, one way or another, without surgery. Hot soaks, stool softeners, various ointments or suppositories, injections. But some resist all that, leaving that patient asking for cure or death, whichever can be accomplished the quickest. Such patients, I treated as an emergency, imploring the surgery center to find a spot in a hurry (I had one of the three or four best centers on the planet one floor below my office. I say three or four because I accept the possibility that others could be as good. But, really, I doubt it.)

The operation is totally simple (lateral sphincterotomy). The idea is to break that cycle of spasm; so you make a cut in the muscle, off to the side -- forced relaxation. Applying a little pull while doing it, you can feel it release, like a rubber band. (There are two sphincter muscles there: cutting the most superficial, and smaller one rarely leads to control issues.) You can also just stretch the muscle, without cutting it. Personally, I don't think it's as effective. That release is like a bugle call: ta da. In rides the rescuer, swooping up the patient into heroic arms and riding off in glory. "Oh my god, doc," says the patient when it's over. "I love you. You're my hero. My kingdom, my gold: it's all yours." "Happy to help," I say, humbly, while walking off with at least some of the gold.

IMPORTANT NOTE (added 12/09): I'm beginning to think this post must be linked to some sort of forum on anal problems, because I'm getting a steady diet of questions lately. I'm truly delighted that my blog continues to be a source of information for people; that was, most certainly, one of my goals. On the other hand, I hope it's evident from my posts in general, and from my responses here in particular, that I'm not comfortable making specific diagnoses or treatment recommendations. I'd like to, really. But the problem is there's no way I can ever know for sure what's going on, and the last thing I want to do is substitute for or supersede in any way the input of a physician actually able to assess the situation directly. My aim has been to provide general information. Because my recommendations, absent direct involvement, might be wrong, and because it might delay a person from contacting their own doctor, I simply don't feel right about doing it.

SECOND IMPORTANT NOTE (added 10/10): I'm closing comments in this thread. The last four or five comments will demonstrate why. It ended badly, and I'm sorry for that. I must be getting crotchety in my old age. On the other hand, I'm pretty confident that any information I'd have to pass on to future commenters is already available in the original post and in my many, many responses to questions I've received. And the point of the first update still applies.

THIRD IMPORTANT NOTE (added 4/13): I recently did a series of interviews for a website. Here is a link to what I had to say, in the brief time allotted, about anal fissures.

Pile O' Problems

Many years ago, a friend of mine told a story that, at the time, I thought was hilarious. He'd been hospitalized -- I forget why -- and his roommate was a fellow young man who'd undergone surgery for a pilonidal cyst. The operation had involved the placing of wires, which had been tied down over buttons (the technique -- not always involving buttons and wires -- is called "marsupialization," although I didn't know it at the time.) One evening the man felt a pop and pain. He called the nurse who, after having a look, placed an urgent call for the man's surgeon. On arrival, the doctor (resident? the man's actual surgeon?) felt it necessary rapidly to dig in to retrieve the wire, and did so with a clamp, without any attempt at anesthesia. My friend was horrified by the screams of his roommate, and began yelling at the doctor and nurse to do something. "Knock him out, knock him out," he demanded. (In telling the story, he described his own drugged state, painting a bizarre picture of confusion, paranoia, and semi-stupor. And I'd be pretty sure prodigious profanity of Shakespearean quality was involved.) Seeing no attempt on anyone's part to reduce the pain of his neighbor, he finally starting throwing things at the man's head, trying in his own way to knock him out. First some books, then the phone, and finally an IV bottle. (I must interject that my friend happened to be one of the funniest people on Earth, and could have elicited helpless laughter in the reading of a water-meter. Plus, this being a long time ago, I can't say with certainty that the mood was not enhanced in any way.)

Well, it was funny back then. Now, it's a pretty horrible story on many levels. Forgetting about the brutality of the surgeon and the indelicate approach to the initial problem, it does illustrate one thing: pilonidal disease can be a bitch. If people were cars, along with the anus the tailbone area would be subject to recall and redesign. (Maybe this time it could be intelligent?)

"Pilo" means hair. "Nidus" derives from the Latin word for nest, and generally means the area in which a thing forms. In essence, pilonidal disease arises from the fact that some people have little dimples -- deep and narrow pits, really -- over their tailbones. Not always a problem, they can be a starting place for infection in many owners thereof -- particularly hairy people. Those pits are an indrawing of skin, along with the usual players in the skin: bugs, hair, etc. Although people of any body habitus can have problems, big hairy guys are the poster-children of the disease. It's a gigantic case of ingrown hair; and once infected, it's impossible permanently to eradicate it without some sort of surgery. Sometimes the amount of hair in there can be truly stupefying. Trust me, you don't wanna know. Tempting as it might be, had I a picture, I'd not link it. And that's saying something, as many readers know. But not all pilonidal infections have hair in them.

It's a surgical truism: when there are lots of widely varying operations to accomplish a thing, the perfect one remains undiscovered. And so it is with pilonidal disease. In part, that derives from the fact that it manifests itself in myriad ways. The rest is due to the fact that if you were to compile a list of ideal conditions to promote post-operative healing, the tail bone area is the antithesis, right down the line. Dark, moist, self-contaminating (being discreet here), and subject to tension which tries to pull an incision apart.

About the only straightforward decision is when a patient shows up miserable with a big pilonidal abscess. You drain the damn thing, and the patient will be immediately grateful (once again, the ancient and honorable and most basic tool of the surgeon: draining pus. Break out the air-freshener, Trish. I stunk up another exam room.) Other than that, who knows? Antibiotics alone for a little mild discomfort? Only remove the dimples? Simple excision of the "cyst?" (Cyst, by the way, is something of a misnomer, strictly speaking. It's a collection of infected gunk. "Cyst" implies an obstructed and filled-up gland, which is not what pilonidal disease is.) Leave open? Close?

It's my experience that once you get to the point of an abscess that needs draining, you'll need some sort of surgical eradication or it will be a recurring problem. And it can be worse than an abscess: infection can track impressively under the skin, making a tunnel and popping up nearly anywhere else in the area (a pilonidal sinus.) If it surfaces vertically in the midline, you may get away with a fairly simple operation. The more off to the side, and the more tracks, the more likely it is you'll need some sort of complicated operation, widely to excise the area with creation of flaps to bring it all together again. When it's uncomplicated disease, as with an abscess having been drained, once it's healed a fairly small operation to excise the dimple and the formerly infected tissues underneath, with simple closure may do the trick. But slow healing, with an open wound requiring regular cleansing and shaving of the area, is a pretty common sequence of events.

All in all, an annoying and frustrating array of approaches for what seems a simple problem. We can transplant livers; we haven't figured out the best care for a tiny hole by the tailbone. My advice: if you're hairy and have a dimple "down there" but haven't yet had problems, keep the area shaved (it requires a sympathetic significant other) or invest in a depilatory creme. If you're a peach-skinned person, keep the area clean and dry (no powders) and your fingers crossed.


[Some time ago, a reader asked me about pilonidal disease, so this has been sitting around for a while. You'd be right in thinking I'm cleaning out the attic...]

Thursday Thought

One More Time

When I was "interviewed" for a website recently, one of the questions was if another blogger and I had stopped feuding. Not that I know of, was what I said. I'm not sure if there's been a feud, for one thing. For another, I feel teensy bad that many moons ago I did make some (possibly inappropriately) snide comments about his chosen field. The reason I bring it up now is that there've been a lot of articles lately that suggest that lots of people have no idea what it really means to be a doctor. Crazy stuff, some of it.

In the formative days of this blog, I wrote once about shortcomings I saw in family practice docs coming right out of training. (I find many of my older posts embarrassingly bad, so I'm not even going to look for and quote myself.) What I hope I said was along these lines: worse than a doctor who doesn't know stuff is a doctor who doesn't know s/he doesn't know stuff. Compared to specialty training -- in which it seems half the time is spent reminding (putting it nicely) trainees how little they know -- it was my impression that (at least at one time) the opposite seemed true of family practice. I probably didn't acknowledge that it's nearly an impossible task: teaching people a smattering of everything -- enough to know both what they're doing and to recognize when they don't. Still, the FPs I worked with who were freshly minted knew much less than they thought they did about the topics with which we dealt in common: breast lumps, breast cancer. Gallbladder problems, hernias, hemorrhoids. Colon things. Various stuff. (I put on some seminars, which helped.) And yet they happily (because, I assume, they weren't taught any differently) took on issues with no sense of discomfort or of a need for input. It may be intangible: but a doctor simply MUST know his/her limits. The shorter the training, the less intense (maybe, even, the kinder and gentler), the more poorly is that goal met. Now, in all specialties, that appears to be exactly where we're headed.

I think I also said -- and if I didn't, I should have -- that the FPs I knew who'd been around awhile were excellent docs. It just seemed to take a while to assimilate the sense of limits (not to mention to broaden the limits outward); and I think that's not as true of most specialty-trained docs. Acknowledging once more that many doctors share much in common with human beings, it's true that within any subset there are exceptions to the left, and to the right.

So why am I picking this scab again? Because of my recent post in response to an article in the NYT decrying doctors' incomes, and the comments thereon, as well as several related posts and comments in the recent medical blogosphere. Still more: I got an email from an excellent young medblogger asking my opinion about a post by some sort of health/fitness blogger in which he claimed that it should take way less time to train doctors; that you ought to be able to learn surgery in a couple of years. Procedures, he said, are often taught nowadays by reps from instrument companies, so how hard can it be?

Related is the concept bandied about by commenters here and elsewhere that all our health care money problems will be solved simply by cutting what doctors are paid and by cranking out way more docs. Perhaps the best of all was the prediction that any gaps in physician availability would be happily made up by women who want to be part-time docs and moms.

Still another connected issue is the on-going discussion among other bloggers regarding the 80-hour work week, and how us old farts who trained in the days of much longer hours simply haven't a clue about how clueless we are. These generally include tirades at how particularly egregious is surgical training and the arrogance of those within -- more the teachers than the teachees. But them, too.

And finally, my blog and those of others are rife with comments by people who've been treated egregiously by doctors. Truly. Egregiously. I'm embarrassed just to read some of the stuff; particularly as it reveals complete lack of communication skills, compassion, and empathy on the part of those doctors.

OK. I probably have neither the will nor the skill to do justice to bringing together all of these themes. Except to say this: there seems to be a very schizophrenic attitude about physicians. People want more knowledgeable doctors, ones that will listen better and explain more clearly. Docs that will fully enumerate and carefully explain all the issues and choices for any situation; who will be sensitive to their individual needs, who will both guide them but let them make all their own decisions. And, of course, doctors with comprehensively flawless knowledge and impeccably perfect skills. People criticize doctors -- surgeons especially -- for having a god-complex, but they want god-like perfection. To achieve it, they suggest flooding the market with doctors and spending less time training them. And, of course, after people flock to become these perfect doctors, to pay them less and less for their efforts. Highly qualified, well-motivated folks with altruism aplenty will fight their way to the front of the line.

Especially moms.

Talked to the tooth fairy lately?

Forest/Trees

Sometimes it's hard to see in front of your face.

When I started in practice here, I took over for an older surgeon who was retiring, and inherited most of his long-term patients. One was a woman with a pretty amazing surgical history, beginning with a rare tumor in her pelvis, slow-growing but difficult to eradicate. She'd had several increasingly difficult operations, and with her last recurrence she was told she'd need a hemipelvectomy to have any sort of chance of control. Facing such a thing was too much for her -- in her twenties at the time -- and she refused. Somewhere along the line, she'd had a transverse colostomy, the most unpleasant of all to manage: the output is semi-liquid, bags don't fit well. A mess, often. When it had been done, it was because of impending colon obstruction from tumor. Suboptimal for a permanent stoma, the transverse location had been chosen in order to avoid operating close to the pelvis. When I first met the lady, it was twenty years later.

Now in her late forties, an advertising exec from out of town, she'd been coming for yearly checkups ever since. Who knows? Maybe it was the last-ditch irradiation or the not-much-chance chemo. Perhaps her immune system finally figured out how to recognize the tumor and gobbled it up. Whatever the reason, year after year her exams turned up nothing, and she felt fine. She lived an active life, putting up with the occasional leak, the sometimes smells, and kept on keepin' on.

It didn't dawn on me until after seeing her a couple of times, doing a physical exam, a pelvic, getting a couple of blood tests, as had been done regularly by my predecessor ad nearly infinitum. Had anyone ever raised the idea of closing her colostomy? Was there a reason why she still had it, all these years later? No, she said. She just assumed that's the way it was, and no one had ever suggested anything different. Well, I offered, let's think about it. How 'bout we check things out?

A barium exam of her distal colon showed it to be anatomically normal. On a CT scan there were post-surgical changes but nothing to raise flags of concern. The only thing was, I'd never heard of closing a transverse colostomy so many years later, and I wondered if somehow or other the long-defunctionalized bowel had lost its ability to do what it does; namely, to absorb liquid to produce formed stool. Not to mention keeping continent. The high-tech "squeeze my finger" test confirmed a functioning -- if pretty tight -- sphincter.

Calling around, I talked to a couple of my old profs. No one had any experience to bring to bear, but none thought there'd be a problem. Worse coming to worst: it could always be re-colostomized. She was more than willing to give it a try.

Closing a colostomy is one of those operations that can be fairly easy, or a frustrating nightmare. Not usually, however, a transverse colostomy. The area hasn't been much disturbed, both ends are right there (in this case, differing from the linked diagram above, it was a loop colostomy: potentially messier to live with, but a slick little operation to close up and drop back inside. Which is what I did. And, having reminded myself often enough that I started telling me to shut up, I remembered, while she was asleep, to dilate her anus manually.)

Long story medium-long: she did great. I'd told her to expect she might have diarrhea with or without control issues for a while, pending her colon getting up to speed, as it were. She didn't. Delighted is an understatement. Imagine getting rid of that thing after twenty years! I saw her once or twice more and we both started wondering why: she came from a ways away for the visits, and had a doctor at home. Never saw her again, but for a few more years she sent me Christmas cards. Hardly a surgical tour-de-force, nor a journal-worthy case; not a diagnosis for the ages or an ovation-inducing operative save. But I felt good about it. A slap on the forehead moment. A look at what hadn't been seen, making a nice lady's life a little better. Sometimes it doesn't take much.

Confessional

There's something irresistibly horrifying about doing an amputation. I did several during training, and a few in practice, before eventually turning such cases over to people who did it more. In a way, it's a microcosm of the perversity and beauty of surgery; of the screaming contradiction that one must somehow accept to be a surgeon. Removing a limb is so many things: failure, tragedy, cataclysm, life-saver, life-ruiner. Gratifying.

Stark and sudden, an above-knee amputation done in the "guillotine" fashion for infection is shocking. But, if you're a surgeon, you can -- maybe you must -- find pleasure in it; and I don't mean some poetic sense of helping one's fellow man. I mean in the actual act of doing it. Which is why I say it's a microcosm. Some things we do are terrible. And yet, within walled-off portions of the mind, divorced from the suffering of the patient, there's a place to go wherein satisfaction comes from the the work itself; the physicality, the artistry, even the transgressive brutality.

The foot, dying, has been wrapped in towels and covered in a sterile plastic bag. The leg, painted in iodine, protruding through a paper drape with a rubberized hole in it, is all you can see of the patient. With the knee bent, you place the covered foot on the table, and it holds itself in place. Holding in your hand the rough handle of a huge amputation knife, you reach as far as you can under the thigh and bend your arm back over the top toward yourself, curling the knife blade around and under the thigh as much as possible. Can you see what's going to happen? You're going to uncurl your hand and arm, drawing the knife, as deeply as you can, completely around the thigh; slashing -- if it works -- in a single circular motion all the way down to and around the femur.

If there were normal circulation, you probably wouldn't be doing this; so there's often not much bleeding. Still, you need to be aware of the femoral artery and be ready to clamp it quickly. Maybe you've placed a tourniquet of some sort above; or maybe you have a strong and big-gripped assistant who's squeezing the leg between both hands. In any case, once the bone is visible around its entire circumference, you reach for the Gigli saw -- that's what's pictured at the top of this post.

And, while someone holds the leg down, you place the wire under the femur, grab the handles between the middle and ring fingers of each hand, and stretch the saw nearly straight. Back and forth, fast as you can, making the toothed snake rise through the bone, which it does with surprising ease. It's a whirring sound, more than grinding -- high-pitched, err err err err. White until you get to the marrow, the fragments coming off are like gruel. And then the wire springs up with a flap and a splatter as it rises out the top. Start to finish, it's been only a couple of minutes. (Somewhere I read of the fastest such amputation, done in a few seconds, including the removing of a couple of the assistant's fingers.)

It's awkward lifting the leg off the table and handing it away. The balance point is hard to find. There's an awareness of mutual discomfort in this act -- in the giving and the receiving. (A gallbladder plops into a pan, free of emotion. Handing one person the leg of another: that's an exchange for which there are no words.) It's a relief to return gaze to the stump: concentric and clean. White bone, red muscle, brown skin. The anatomy is there, on end: hamstrings, quadriceps, neurovascular bundles. It's not a commonly seen slice.

Before the operation, there's been pain -- physical and emotional. There've been sad talks, bargaining. Nothing to feel good about, for anyone. After, there's the stark realization, the encouraging words that ring hollow. The relief -- mine -- of turning much of it over to rehab specialists, prosthetists. But there, for that few moments in the operating room, there's a separate, private, and possibly unspeakable pleasure. (And I must say the same can be said about other amputations I did throughout my career, hundreds and hundreds of times, as a breast cancer surgeon.) The dissociative and dramatic doing. The fact that, for an instant, I can remove from my consciousness the horror and find enjoyment in my craft, can see beauty even here -- that's something almost too terrible to admit, even now.