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Showing posts from August, 2007

Mitzvah

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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

The Lung Way Home

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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 shrin

Don't Try This At Home

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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 d

Farm Boy

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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 di

Fast Relief, and Simple

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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! Reduci

Kid Stuff

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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

New Rules

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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

See? P.R!

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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

Pride and Joy

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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.

Paper Trail

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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 explaine

Pain in the Ass

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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 invo

Pile O' Problems

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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 drugge

Thursday Thought

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One More Time

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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 t

Forest/Trees

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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 twen

Confessional

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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