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Showing posts from September, 2007

Names and Places, Pouches and Spaces

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It's always with wonderment that I consider the pioneers of medicine, of surgery, of anatomy. To conceive of a time when every thought was a new one, when discoveries abounded for those with imagination, boldness, and curiosity, is to be thrilled, jealous, and.... bemused. What could it have been like, opening the body and its mysteries to the world, engraving your name on the way out? As I let my mind jazz, thoughts fizz like a Sapphire tonic . When it takes some effort -- maybe a microscope or some really careful dissection -- to discover something, it seems reasonable that your name gets attached. Islets of Langerhans. Ampulla of Vater. Sphincter of Oddi. Valves of Heister . Crypts of Morgani (he got "columns," too.) But where's the cutoff? I don't get why Gabriele Falloppio got to name something as obvious and macroscopic as an oviduct. That's not discovering. That's noticing. We don't have the Colon of Powell, or the Heart of Palm. (I don't k

Pattern Recognition

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A physician-seamstress and plastic surgeon emailed an idea into my head, bringing up an amusing consequence of the dawn of the laparoscopic age: docs are required to infer a patient's history from a bunch of cat-scratches on the belly. Although it's not particularly rare that you point to a surgical scar on a patient and ask what the operation was, only to be told "I don't know," the more common situation is with a patient sick or injured enough to be unable to give a history at all. Finding surgical scars , we may need to make an educated guess about their past. Some scars tell their stories pretty well: long scar under and parallel to the right rib margin means gallbladder removal. Short one in the right lower quadrant: appendectomy. Flank scars likely mean kidney surgery. Some others that have a nearly singular signature: pyloromyotomy, umbilical hernia; splenectomy or sigmoidectomy if done in not-common ways. Others at least provide a short list: lower midli

Curses

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[This post is inspired by (though barely related to) one from that eminently readable medical blogger, Dr. Rob .] If I didn't know better, I'd say there's a curse: when a new surgeon arrives in town, he or she will have a very weird or embarrassing case within a short time, while all eyes are still upon him/her. I've seen it repeatedly. (With me, far as I can recall, it wasn't too terrible: my first operation after I moved to my final destination was a very routine hernia repair. I recall the anesthesia person mentioning something positive about how quick and smoothly it went. And his snarky smirk when, for the only time I can remember with an inguinal hernia repair, I had to bring him back an hour later because of bleeding.) One guy, even more arrogant than the typical surgeon, whom I came to dislike more and more over the years until he went elsewhere, began his career by leaving a sponge in an otherwise routine gallbladder patient. Another, whom I liked from the

Signs

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I mentioned signs in a recent post, at the time referring to those unofficial (as opposed, say, to Battle's Sign ) but somehow meaningful constructs we all get to know. To wit: The "O-Sign," signifying a level of coma such that the person's mouth is open. The "Q-Sign," meaning the same, with the tongue hanging out. More serious. The "Lipstick Sign," when a lady puts on makeup/lipstick after surgery or other illness, signifying recovery. I suppose a male equivalent is shaving. There are many others. ( Throckmorton's has already been done.) And I've seen a few compendia of abbreviations. Here, I'm thinking signs . It needn't be medical. Got any amusing or dead-on signs to add, relating to your profession? In particular, anyone ever come up with one of his/her own? I think I did. I used to refer to Schwab's sign (of imminent death): when the hematocrit and bilirubin cross. I think, in fact, it might also apply to hemoglobin /bi

Self Medic-ated

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It's considered a truism: if you have a doctor or nurse for a patient, it's gonna be a horror show. I'm not convinced, but to the extent that it could be true, the fault -- as Shakespeare probably said -- is in ourselves. The problem is the nearly irresistible pull to treat doctors and nurses differently than we do the rest of our patients: to abbreviate explanations, to avoid recommending things that are inconvenient, to bypass the ordinary steps taken to get from encounter to conclusion. In the formative days of this blog, I posted about operating on my partner when I was a very young pup. Any way you could look at it, it was a horrible experience; after removing a section of his bowel, he had a problem I'd never seen before, nor have ever again. Without question, had I closed his mesentery the way I'd always done (and still would do) instead of the way he liked to do it (I figured he'd be happy when I told him), I'm certain it never would have happened.

Word!

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[Credit to Judy for suggesting this picture.] I think it might be about 8,000. Or is it 12,000? Anyway, somewhere I've seen the number of new words people learn in medical school, and whatever the correct amount, it's impressive. Here and there in this blog, I've mentioned some words I really enjoy just for the saying: bezoar, inspissated. How about radiculopathy? (Sounds like a word that could be applied to most politicians, whether you pronounce it "rih-diculo... or "raa-diculo...) Neovascularization. Tachyarrythmia. Pancreaticoduodenectomy. Intussusception. Bezoar. Bee -zore. Say it like the taunting "air-ball" at a basketball game. (Digression: It's been shown that at every venue, whenever the chant is chunt, it's always in the same pitch, the same notes on the scale. F - D, matter of fact.) OK. The point I want to make is that in addition to the neo-vocabulary we learn, there is also a more

Sleeve (Up)

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[This is another post that's been sitting around in draft form for a while. It might be obvious why I hadn't posted it. More cleaning of the attic -- or in this case, maybe the basement. It's conceivable that some day one person might find one thing useful.] In no particular order, and for no special reason, here's a few surgical "tricks." Most are amalgams of observations, teachings, and trial and error. Surgeons will shrug, non-medical types (and non-surgical medical types) will say "who cares." Credulous and ingenuous students might make note and tuck them away, against the possibility -- remote as it might be -- that they'd prove useful in a future life. Whatever. 1: In thyroidectomy, "walking" to the outer parts of the poles by sequentially placing suture-ligatures provides excellent traction for exposure -- much more wieldy than Leahy clamps, the sutures can be pulled any which-way as you work. 2: The same technique facilitates th

Hospitality

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My first encounter with the concept of the "hospitalist" was a sour one. As with many of my long-held medical beliefs, I eventually came to another way of thinking. (You may have read about my own gig as a surgical hospitalist, and about the fact that it was a period of unmitigated pleasure for me.) But that first time -- which involved the medical iteration of the concept -- was a bummer; not for what it was, but for what it wasn't. When the internal medicine department of my clinic announced they were moving to the hospitalist model, I considered it a terrible idea. Patients expect many things of their doctors; among them, that they'll be there in their hours of need. I understood the practicality: having docs at the hospital meant more immediate care for those housed therein, and it meant the rest of the internists could remain in their offices. Among other things, there's more money to be made by keeping up a schedule there than by running back and forth. Co

Thoughts on a Tragedy

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On the anniversary, I feel like writing something about 9/11. This will have nothing to do with surgery, or medicine. If political rants on a medical blog annoy you, please click away now. My brother was living in NYC at the time, and had colleagues in the World Trade Center. He went to some funerals, after. At first I watched the images and wondered if he was OK, unable to get through. Like virtually every American, I was dumbstruck and horrified. And I wondered about people who hate that much, who have a sort of faith that allows such a thing as mass murder by way of suicide. I felt the world change, and indeed it did. I had no reservations whatever about the correctness of going into Afghanistan. Aware of the Russians' failure there, and having a sense that it had at least some role in the later collapse of the Soviet Union (I'm no Russian scholar, but having studied the language for many years and traveled there in the apex of the Cold War, I have an interest), I wonde

Chickenshit

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Speaking of diverticulitis, I once operated on a nice little old lady with what seemed to be a classic case of it, with early perforation. On exploration, I was a little surprised to find the colon absent the typical thickening and redness of acute diverticulits; and more surprised on closer inspection to find something poking out of the middle of the sigmoid colon. What it was, was a chicken bone. Plucked it out (that's what we do to chickens, isn't it?), over-sewed the hole, left a drain for a while, and she did fine. That's when I learned something I'd never been told: chicken-bone perforations are not entirely rare in people with dentures. They don't get the roof-of-the-mouth feedback that there's something there, and they swallow the bone. If it goes down OK, no one would do anything about it. But with bad luck...

Ken's Colon

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Poor Ken Griffey, Jr . Seems like his body keeps letting him down, one thing after another. I was there at the beginning of his career in Seattle, and he was a joy to watch. Now [ I began this post a few months ago ] he's been having trouble with diverticulitis for the past several months. Guy his age? He's gonna need it out one of these days. Among the design flaws of the human body (the hemorrhoidal veins and pilonidal dimples are also on the list) is the fact that the blood supply to the colon travels on the outer surface, feeding the inner lining (the mucosa ) by sending little branches diving through the muscle layer to get there. Each hole-for-an-artery in the muscle represents a weak spot through which the mucosa can pooch outward, forming a pocket known as a diverticulum. In some people, it happens. In the US, more than a third -- maybe half -- of people over fifty have at least a few diverticula. Most never know it. For some, it becomes a problem. Unusual in so

Dead Man Wasting

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Even as I questioned the value of dog labs, I wonder still more about the most hallowed and time-honored tradition of medical school: the dissection of cadavers to which all first-year students are subjected. Because the bodies have been knowingly donated, it's not really an ethical issue, except to the extent that those who've made the gift might have a more exalted view of its value than is accurate. And before I say my piece, I must admit it's just one opinion, from a ways back. I'd hope more recent, and current, students might chime in and set me straight, if that's what is called for. I'd guess we've all seen classic paintings, like Rembrandt's " The Anatomy Lesson. " We've heard of grave-robbers hired on the sly to supply medical schools, of Michelangelo becoming one himself to facilitate his artistry; and we know the extent to which these dissections have been carried out, more or less in the exact way, for centuries. So in push

Thirty-Six Years, Today

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Puppy Love

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Looking back on med school, one thing crests the long list of second thoughts: dog labs. Growing up, I always had a dog. Having left home, when I returned to visit, a dog was always there. (From sublime to ridiculous: Buttons, my confidant, my purveyor of love when I felt otherwise, smarter than any; to Fred the disagreeable.) We recently returned from dog-sitting our grand-dog, a Chocolate Lab, the sweetest guy in the dog parks, Dutch the dog who has never known anger, doesn't even have it in his vocabulary, the luggiest of the big lugs. I love dogs. I approached my first dog lab with trepidation and discomfort. Smelling musty and slightly feculent, the room held around twenty lab tables of the old-fashioned kind: little sinks, taps, gas outlets suggesting that at some time they supported bunsen burners . On a dozen or more of the tables were dogs, lying on their sides, already anesthetized, looking peaceful and vulnerable. One or two had evacuated their bowels. (We'd been spa