Cool

image from damnitimvixen.com

To the essential questions of modern life -- paper or plastic; boxers or briefs; regular or decaf -- add this: fingers or palm? In what way, with which appendages of the hand, should one grasp a needle holder? I was chastised, during my formative years, for transgressions of either type; now, I feel strongly both ways.

Huey Lewis said it: "Cool is a rule." I doubt any student of surgery, from earliest medical school forward, failed to practice the technique of palming a surgical instrument. It is cool. Rather than putting fingers through the rings, the whole handle is placed in the palm, one side on the thenar eminence. The ring finger and/or the little one, when pressed onto the part of the handle that's not resting at the thumb, can be made to unlock the ratchet, and widening the palm makes the jaws separate. The index finger is laid along the shaft of the instrument, with the tip near the very end.

The index finger is really the most important thing, and it must be there no matter how the handle is held. The following picture, which amazingly enough is from the website of a university surgery program purporting to describe suturing techniques, demonstrates the worst of all possibilities (I suppose I shouldn't be surprised since in another section it refers to a pictured set of forceps by the name "Addison" instead of the correct "Adson." I'd bet my soul [a low-ball wager if ever there was one] that the piece was NOT written by a surgeon):

Here, the index finger looks bent and is not nearly close enough to the tip of the instrument. And no matter what the chosen method, no surgeon would ever stick his/her ring finger so far into the grip-ring. The object of the game is to achieve precise control, with the ability to make fine movements exactly the way your brain is suggesting. "Awkward" is the word that comes to mind when looking at that picture.

"God gave you fingers, so why not use them," said "Chatham Knell" (a pseudonymed teacher of mine), arguing for keeping the fingertips in the handle-holes. In my book I also referred to him as "Death" Knell.

In placing a suture, most of the action is in the supination of the wrist and hand. But fine adjustments can be made when the fingertips are in play; less so when the holder is palmed. On the other hand, when using a long instrument in a deep hole, one usually braces the hand in some way or another, taking fingertip control out of play. So here's what I think:

When placing fine sutures with a delicate instrument, hold the needle-holder with fingers in the handle-holes -- the TIPS of the fingers. When taking big bites or when necessarily using a large instrument, grip it with the palm, which confers strength.

And when you're using hairy-thin suture on fairy-fine needles, repairing nerves or patching small arteries, you use these beauties, the coolest of the cool, and it's fingertips all the way, baby:

News Flash

Ridge Lines

In no way is it false modesty to say that physicians are not healers. At best, what we do is to grease the way, to make conditions as favorable as possible for the body to heal itself. For without the body's amazing powers of defense and repair, nothing we do -- especially we surgeons -- would be lasting at all. The most immediate and palpable reminder of this is the process of sewing someone up, and watching what happens.

Wound healing is a wonderfully complex process, and it would be folly for me to attempt explanation in detail; mainly, because I've forgotten the pathways, the kinins and the prostaglandins involved. I'm not going to look it up again, but you can if you like. Anyone who's had an operation, from minor to a big deal, has had the opportunity to witness it. Maybe you were too sore to be in awe. But I always liked to point out the easy evidence to my patients.

I've gotten calls about red incisions (despite trying to explain it in advance.) Of course, it's necessary to separate the natural from the infected (digital photography and email have been known to save an office visit, for the technologically inclined); but all incisions get red for at least a few millimeters out from the cut. An inflammatory response, it's the process of bringing the building materials into the work site: capillaries dilate and proliferate, blood flow increases. That, and much more, goes on under the surface as well. Attracted by "injury chemicals," various cell types arrive and unload their cargo, set up lattice work, induce structural changes. The result of the influx is a gradual thickening and hardening of the area for an inch wide or more, and which carries the unofficial-official name "healing ridge." When the ridge isn't there, you know there's trouble ahead. In the very ill, in people on high-dose steroids, in the malnourished, a soft and non-pink incision is an unwelcome and unhappy harbinger.

As much as feeling the healing ridge can alarm the unexpecting, it's a sign of health, the indication that help is on the way, that work is going on to effect healing. I'd warn people. To hernia patients, I'd say, "In a few days it's going to feel like a sausage under there. You might think the hernia is back." Or, after removing a lump of some kind from some place, "In three weeks, you'll think I didn't remove it at all." It takes many weeks for the ridge to melt away. The zone of redness dims, but the incision itself gets increasingly red, and doesn't simmer down for a year or more. (It also fades after the application of vitamin E, of ear wax, and of snake-oil, singly or in combination.) It's a living monitor of how long healing is active. Given an explanation of what's going on, surgipatients get a ridge-id ringside seat from which to watch the body do its work. (A corollary is the tiredness that most everyone feels after surgery. There's lots of work going on, I'd tell them. While you're lying around feeling lazy, your body is doing the equivalent of walking around all day. Give yourself a break.)

Bleeder

Image from hippocritis.com

Like most training programs, mine had a weekly conference in which deaths and complications were displayed, discussed, and dissected (most are called "M and M" conferences, for Morbidity and Mortality. Standing for Death and Complications, ours was called "D and C." Given the scraping of the flesh until blood was drawn, it seems very descriptive.) In recent years there's been a trend, I think, toward deëmphasizing those meetings; despite the so-called "privileged" legal status of such discussions, time and litigation have caused people to fear exposure. Which is damnably bad, because those conferences are, in my opinion, indispensable to teaching and learning. But that's not my point today.

In the conference, take-backs for bleeding were not-infrequently addressed. In fact, the phrase "It was dry when we closed, Dr. Dunphy" (Dunphy was our chief, and usually he ran the sessions) was so common that one chief resident, when presenting such cases, took simply to saying "I-W-D-W-W-C, D-D." How can it be that a surgeon would have to re-operate for bleeding? What sort of incompetent idiot could have been so careless? I'll tell you: anyone.

There are some situations in which a surgeon will look at a little oozing here or there and make the judgment that it's not a big deal, it'll stop, it's OK to close. Those are not the problem. The kind of bleeding that requires re-operation tends to be brisker: a little artery somewhere, pumping away, is typical. No surgeon would have seen that and said, screw it. So what happened? Simple: it wasn't bleeding when the operation ended. And this'll make you happy: the healthier you are, the more likely it could happen to you.

Within the walls of blood vessels are muscles. In response to various changes in blood volume and other factors, they tighten or loosen to maintain or adjust blood pressure. They also snap to attention when a vessel is cut. The younger and springier, the less enpipened with cholesterol are those vessels, the snappier is the response. With muscular integrity, a cut artery will retract and constrict, thereby lessening or stopping bleeding. It's a good thing, especially if you're facing a saber-toothed tiger in the woods. Less, though, in the context of today's story: a small artery can stop itself from bleeding intra-operatively. The effect may be amplified by the fact that blood pressure often runs a little low during surgery. On awakening, the blood pressure normalizes; the spasmotic reaction of the artery muscle relaxes; the fresh small clot that likely will have formed is easily washed away... The good news is this really doesn't happen all that often (our D and C conference included reports from several different surgical services at four different hospitals). Mostly we see vessels and unbleed them in advance. But things happen.

One of the more annoying of the frivolous lawsuits I've had, signaled as it was by the arrival in my waiting room of a sheriff's deputy waving a subpoena, was occasioned by a reoperation for bleeding. It had been a very low intensity situation; so low, in fact, that it wasn't until the next day that the need became evident. The surgery took only several minutes, delayed the man's departure by one day, and had no further consequences. At the time, things were fine between us.

On those rare occasions when I re-operated for such a thing, I didn't charge for it. Our anesthesia people coded their bills based upon the surgical diagnosis on mine. No bill, no code. So they winged it, and came up with a code that showed up on the bill as "Reöperation to repair artery," or something close to that. Which, hemi-understandably, suggested I'd done damage that I'd had to repair, which was not how I'd explained it to him at the time. Caught in a cover-up? The most cursory review of records -- not to mention a phone call -- would have disabused anyone of the misapprehension. Eventually it did, as it should, go away with its tale between its legs; although not without further erosion of my already tenuous gastric lining. I digress.

It's a safe bet that postoperative bleeding will never be entirely eradicated unless the time comes when the only people operated on are those with such hardened arteries that they can't retract back and tighten up, in which case all surgically caused bleeding will be evident instantly. That would be bad news, indeed.

The American Dream

[As I did for a past post, I begin with a warning: this is a political rant, so people who come here for surgical stuff should turn away now. But come back: tomorrow it'll be back to usual.]

News item: US Senate rejects measure to provide path to citizenship for children of illegal aliens, if they serve in the military or complete two years of higher education. By "reject," of course, it is meant that it received a majority of votes, but not the super-majority of 60 required to prevent filibuster. (Anyone remember when the Republicans were screaming over Democrats' use of the same ploy -- which is to say both sides are a bunch of shameless hypocrites.)

Personal item: Earlier this week I was a community volunteer, evaluating senior projects at a local high school. The first presentation was by a native-born Caucasian person, who did a lazy and entirely unimpressive job. The next was a young woman who was born in Iraq, sent to a refugee camp in Saudi Arabia, and finally found her way here. Her presentation was dazzling, brilliant. Wearing a hijab and a high-school sweatshirt, she spoke perfect English as she delivered a Powerpoint-backed speech.

One needn't take a stand on the way the US Senate works, or even on the details of immigration -- legal or otherwise -- to recognize this: to the extent that the "American Dream" is still alive, it's becoming apparent that it's more within the bosoms of the non native-born than otherwise. Look at who gets the scholarships, who wins the spelling bees, the science contests. It's not Jones and Jackson. It's Singh and Nguyen, Allawi and Ali, Kim and Yung. (For that matter, since this is a medical blog, look at the doctors being hired everywhere, and those entering med school. In my internship group, in 1970, we were eleven white US-born males, and one white US-born female. In one of the most recent groups, all but one were foreign born, and the one that wasn't was a first-generation immigrant. And I know the standards there haven't changed: it's about who can meet them.) (And if I need to say this to avoid one brand of comment, my point is not about white or male. It's about native vs. foreign born.)

As we are becoming a nation of people who -- for reasons, it seems to me, of resolving conflict in favor of religious belief over scientific fact -- reject evolution, global warming, and the fact that our Earth is older than twelve thousand years; of homeopaths and antivax; of people who would rather turn public schools into churches than training grounds for inquiry; who see open-minded education as a threat and who fail to see that democracy can only survive when the public is broadly educated and encouraged to question political leaders from all parties (and who fail to recognize that the greatest protection of religious freedom and the greatest tribute to its value is to keep it entirely separate from government, and that doing so has led this country to have a higher percentage of believers than any other Western nation) -- as all this is happening at increasing speed and with crescendoing decibels, it's clear to me that the future of America depends on the continuing influx of bright and motivated people from outside her borders. We are ceding greatness -- willfully and aggressively proud-as-hellfully -- to the rest of the world. Of the 70% or so who, in polls, say this country is headed in the wrong direction, I'd bet well over half think it's that we're not insular enough, not religious enough, not creationist-homophobic-unscientific-venomous enough.

There are plenty of great native-born kids. Mine, for one. And his friends. And cousins. And yours. Far be it from me to overstate anything. But as to trends? I'm worried. Really worried. It's not that "our" kids are inferior. It's that we're kissing them off, with a tax-cut and a hallelujah.

Illegal immigration is illegal, and although it appears our economy has depended on it in many ways, it needs to be addressed. But we discourage legal immigration at our peril. Unless the trends among "natives" reverses miraculously, people whose dreams still bring them here are our only hope. And we ought to do what we can to maintain America as (or return it to) a dream-worthy place.

Visual Fields

Check this out, then we'll talk:




OK. Aside from the fact that W.C. Fields was one of the funniest physical comedians we've had, there's a serious point to be made: laparoscopic surgery does not come naturally to everyone.

[Aside: in college I put on a W.C. Fields film fest as a fund raiser. His stuff is timeless; his short films are classic. I've repeated the "Honest John" story, and demonstrated with a pool cue, off and on for the last forty years. If you can find "The Barbershop" (or is it "The Barber"?), watch it, although it could ruin your concept of shaving and of puppy-dogs forever. And, of course, in addition to the physical comedy, Bill left behind some of the best lines ever uttered...]

Watching the ol' curmudgeon's struggles to control his pool cue is an exact replication of observing (some) neophytes in their first attempts at laparoscopy. Newly-minted surgeons have had the advantage of training in laparoscopy over time, in labs. Perhaps more importantly, they grew up playing video games, which really do prepare one's brain for making the wiring changes needed to accomplish a three-dimensional operation while observing on a two-dimensional screen. Old as I am, I was well into my surgical life, three dimensions to the wind, when laparoscopy came on the scene. So I had to take a couple of crash courses. I found, I'm happy to say, the transition both easy (compared to some, that is: it does take time to gain fluidity) and fun. I was NOT one who was waving instruments around like a Fieldsian pool cue. (In other words, the reasons I continued doing my mini-gallbladder operation were unrelated to skill, but to practicality.) To the extent that I'm still doing surgery (I've semi-retired into assisting, of late) it's only of the laparoscopic kind, and I like it.

The process is an interesting one. I think that getting good at laparoscopy is a matter of learning to read motion digitally, to break down tiny quanta of visual cues as they happen. Instead of watching the sweep of actions, you get to a point where, unconsciously, you discern depth by reading increments of changing relationships; it's a sort of visual echolocation. Like this: if you took a series of pictures of your finger as it moved toward you, and then looked at them one at a time, you'd have -- while looking at any one -- no sense of motion. But if you looked at them in order, you'd be able to tell the direction the finger was moving, by its size relative to the other things in the picture. In one sequence, it'd be moving toward you; in reverse order, it'd be moving away. So when doing laparoscopic surgery, you are constantly processing the changing screen-size of the instruments you are using, relative to the organs and structures surrounding them. Your brain translates it into real-time 3-D. Neat! Based on observations of my fellow course-takers, I'd say that ability is not equally distributed among us.

Technology marches on. It should surprise no one that 3-D video has come to the operating room. I hate it.

Wearing a helmet containing a separate small video screen in front of each eye, you form a 3-D image from a scope with two parallel and slightly off-set lenses. The biggest problem is that the lenses are, necessarily, not far apart; so unlike what we see with our comparatively wide-set eyes, the sense of depth is pretty minimal. And strangely -- at least for me -- there's something slightly disorienting, or at minimum disquieting, about having the same image in front of you no matter where you move your head. Ain't natcherel. Finally -- and I suppose I could have it better adjusted -- the strap holding the apparatus in place gives me a damn headache. Unpleasant, unhelpful: without doubt, it adds up to a negative number. The equipment used to reside in the room in which I work. Haven't seen it in several months.

Sissy

The term "running the bowel" is one I've used before. Not to be confused with this, it refers to the process of inspecting the intestine from one end to the other, looking for trouble. Often it's done by pulling the bowel with one hand, through the gently closed fingers of the other. As the bowel is slippery-moist, it glides greasily over rubber gloves. Sometimes it slips the grip, requiring starting over nearly at the top, since the whorled loops retract gloppily into a pile, in a way that erases traces of where one was, quickly. It's very slithery.

While performing the task on one occasion, on a person whose background was justifiably in question -- the less-than-innocent victim of a sharp object or missile of some sort -- my fingers found a circular object within the man's gut, the size and texture of which made me think it was a condom. Or possibly a balloon. My conclusion was that the punctured person was a drug-runner, since ingesting condoms and balloons filled with heroin is a known way of crossing borders (and an explanation of why so many addicts got such horrendous infections where they ultimately injected the stuff, after the, uh, passage of, uh, time).

My next conclusion was that it was time to release the bowel, which I did with a notably unprofessional and sissified shriek and a rapid and uncontrolled unclenching of my grip and yanking away of my hand, arm and much of the rest of myself, as the "condom" unfurled and wiggled under my fingers. "YEAHHGGGGUHH!!!" The startled crew jumped in unison in response to a likely unprecedented display of wimpishness. But that's what worms'll do to you (to me, anyway) when they show up unexpected.

Layers

The body comes in layers. I've written here and at least one other venue about the need for surgeons to find the planes between those layers, and to work within them. Having used the technique to prolong a few lives over the years, I can now say I've done it to prolong my own.

My wife is the oldest of nine siblings, all of whom live within (amplified) shouting distance of Puget Sound; and their parents do, too. Family gatherings are frequent, and for special occasions (which occur only once or twice a week) the entire clan collects at my in-laws' place, the northernmost homestead, nestled dramatically at the water's edge (of a lake, not the Sound). This weekend, the raison d'etre is their mother's eightieth birthday. Hilarity, lubricated and well-fed, will undoubtedly ensue. A damper has been narrowly avoided.

It was delegated to me to pick up the special-ordered cake, produced in a fabled Danish bakery in Seattle; and I did. I'll accept only part of the blame: the guy who handed me the cake, and the extra goodies I free-lanced, did so with the after-mentioned goodies piled on the cake-box. His fault. But I failed to compute the danger. My wife, when I got home, looked stricken as she surveyed the stack, and the tell-tale stains on the boxtop when I removed the bags. Frail flimsy frosting flowers, flattened. F-f-f-fuck.

Ready to drive the twenty-five miles back to the bakery to convince them that their shared blame should occasion the re-frosting of the flowers, I figured I should at least attempt a cure. So, taking a nice little knife in hand, I tried to discern the now-distorted layers of faux petals, using my most well-learned control to turn the blade within the flowers, recreating a sense of the smashed strata of pinks and blues and yellows.

It turned out OK. Not, I admit, perfect. But judged acceptable by my wife. As I've said about surgery, second go-arounds are rarely as good as something done well the first time. Even when working in layers.

Podcast

Still searching for better ways to get audio connected here, I've just set up a podcast site. I recorded another few pages of my book, and invite you to go there and have a listen. And this request: hang in there through the first minute or so. It gets better.

The link is here.

The BFH

A while ago I wrote about choosing a surgeon. Related is the decision to have care (surgery, of course, would be the subject here) in a community hospital, as opposed to the famous medical center. A commenter on a recent post referred to the BHD, the "big hospital downtown." I'll call it the BFH and let you figure out what I mean.

Like everyone else during training, when I was at a BFH learning to be a surgeon, I basked in the belief that I was at the only place a person could go to get good care. I thought derisively of the silly referring docs; so did my confreres. I even wondered how I'd be able to care for my patients when I didn't have a retinue of people following me around happily (or not) doing whatever I asked, as I did when Chief Resident. It took a minute or two in practice to disabuse myself of the mythology.

Think about it: if those BFH's are so wonderful -- and in many ways they really are -- ought it not be the case that the people they train to go out into the world are also pretty damn good? Is it only within the great walls that folks have mystical powers? Powers that poof when passing the portals on the path to private practice?

Wisdom may be generated in the BFHs but the whole idea is for it to flow outward. Most treatments for most diseases have been pretty well worked out, and the information is readily available. And as it evolves, the news spreads. If it were really the case that the only people who know what they're doing reside within a BFH, wouldn't that mean that they'd failed in their central mission? That they'd created incompetents and loosed them upon the populace?

The fact is that when I began my practice, I felt I'd been very well trained; nor was it self-delusion (trust me, I'm a doctor). And, by golly, I found it was easier to get things done, to provide personal and expeditious care when all the BF accouterments were stripped away. With academic largess come layers, complexities, and, yes, arrogance. The most stunning thing in the comment I referenced above was the demand by the BFH that care be transferred up front, sight unseen. While I doubt such a thing is universal, it's revelatory.

It's decidedly NOT my position that people should avoid the BFH. Were that to happen, the system would grind to a halt in half a generation. And clearly, for very specialized care -- transplants, for example -- such places are the only places to be. It's just that for most care, given a little time to check out the local folk, I believe strongly -- based on years of observation and participation -- that excellent care is available in most community hospitals; people should feel good about that. (So as not to upset anyone, I'll stop short of saying that for the commonplace, care is better in the community hospitals; but that's what I believe. Given the right players.)

[In re-reading my earlier post, linked via the fifth word of this one, I realize I've said much the same, in different words, previously. This means two things to me: 1) it's tempting to re-write a lot of what I've written in this blog, and 2) I'm starting to bang against the bottom of my brain. It bodes ill, futuristorically.]

... And A Pink Carnation*

Before arriving in town to begin life as a practicing surgeon, I got a call from my pre-assigned medical assistant, asking what size and style white coat I'd prefer. Well, I thought, these guys think of everything. This private practice stuff might be cool. But then I wondered, who says I have to -- or even want to -- wear a white coat? Having spent the past ten years or so wearing the white coats of learning, and despite thinking those thigh-length ones that some of the professors wore looked pretty spiffy, I couldn't wait to get out of them. I'd also noted that in the teaching hospitals at which I'd spent all my time, the full-time professors were generally the only ones who wore white coats. The private guys mostly didn't. Not that I was emulating one or the other. But it said there was a choice, and I went nolo-alba.

I've only owned a couple of suits in my life, but I do have a few sport coats, and that's what I wore in practice. Always, back then, with a tie. Gathering dust in my closet are a couple of racks of generally garish and outlandish ties which, for some reason, I chose to wear for several years.

Ahead of my time (recent reports have, disgustingly, showed the amount of bacteria lugged from room to room on doctors' ties), I long ago ditched the ties. Within a couple more years, it was shirt and slacks sans coat, and that's where it stayed for the rest of my time in practice (now, as an assistant, I show up in jeans and whatever.)

Without any data or real basis for it, I'd always felt that white coats were off-putting; a barrier, of sorts. There is, after all, the white coat syndrome. But it really wasn't a plan, or even an overtly thoughful decision. I just didn't feel right in a white coat in my office, and the subsequent divestments were simply a matter of comfort. The only time I got negative feedback was when my mother asked my wife why she couldn't get me to dress better. A generational thing, on several levels.

It changed when I did my surgical hospitalist gig. Then, it was a considered decision. I figured it most practical if I were to spend the day wearing scrubs, and whereas there are usually available some scruboid cover gowns for running out from the OR to the floors, I figured a little decorum was called for. In particular, since I'd be seeing patients only in a hospital setting, people acutely ill having a surgeon thrust upon them cold, I thought some visual cues would be good. So I ordered, for the first time in about twenty-five years, some of those nice patrician thigh-length jobbies. With my name, MD, and Department of Surgery embroidered thereon.

Funny thing. I really liked wearing them. And it wasn't just because of the capacious pockets (I'm a surgeon: the stethoscope does NOT go around the neck. Plus, there's note cards, several rolls of paper tape, couple of gauze pads...) As I frequently lacked the time to establish rapport which the office setting tends to afford, that coat was an anthropomorphic business card. This guy's legit, it said. To a potential patient already in tough shape and low on time to think things over, that's good. Worn with scrubs, it was a way to be comfortable and appear serious. Looking back, I suppose I could have been wrong all those years.

*Only old people and/or dorky ones will get the musical reference.

An Opinion Opinion

My para-previous post mentioned getting second opinions. I think it's a concept worthy of separate rumination; and because I'm not entirely coherent on the subject, I'll be interested to read what I have to say.

So it doesn't get lost in the morass, let me be totally clear: whenever a patient wants a second opinion, for whatever reason, s/he ought to get it, and I'd never ever discourage or disparage it. Being comfortable with whatever medical intervention is at hand is essential, and if the first doctor resists it or gets huffy, well, that's probably confirmation of the need. But it has always bugged me when the reason is a requirement by some insurer or another, or when it's because someone (an agenda-driven talking head; a relative; a BFF) has made the patient feel guilty or inadequate if they don't demand it. It's possible -- and I always made a hell of an effort -- to establish a relationship of trust based on being fully informed, respectfully addressed, and carefully listened to without the need to run off.

At some level, when a patient requested a second opinion I felt like a failure. Drawing diagrams, writing booklets, soliciting questions, I succeeded nearly always. Many is the time my patients told me they'd never had a doctor explain so thoroughly and understandably. So to me -- ever self-critical -- a request for a second opinion said, somewhere in my lizard brain, that I'd not done something well enough. I recognize that many people simply see it as due diligence: taking control of one's health includes exhausting every avenue to information. But in that evanescent and impossible best-of-all-worlds, that fantasyland, I like to think doctors could be good enough, and patients open enough, to justify the idea that one opinion can suffice.

Patients have the right to feel right. They are entitled to full disclosure, to thorough explanations, and to complete answers to all their questions. And people have senses. If they feel uncertain or dissatisfied; if there are warning bells ringing in their heads; if for whatever reason they are left uncomfortable with a physician encounter, they should absolutely positively get another opinion and/or another doctor. But what's wrong with feeling OK in the first instance? If what you hear makes sense, if you think the doctor in front of you is being honest and thorough, must you be made to feel like an idiot for standing pat? Some people show up broadcasting distrust from before the first hello; or bring someone who glares dares from the co-pilot seat. It ices the wings of the encounter before it ever gets off the ground. That attitude comes from giving too much credence to crap. Don't cheat yourself, says I. Don't close the barn door before the horses are in. Or something.

Of course, it's not always simple, and doctors are imperfect. I'll examplify.

There was a time when, because of insurance demands, I saw lots of people in need of second opinions before hernia repair; and had to send them for same, as well. (After looking at a few years of predictable data, most companies have dropped most such requirements.) Usually it's a no-brainer: you can see the hernia as the pants are coming down. But I've had a couple of people in whom, for the life of me, I couldn't confirm the hernia for which they were scheduled to be operated. It's uncomfortable. Often, because the mandated need for a second opinion was realized at the last minute, I'd be seeing the person within a day or so of the operation. In part, it (the non-finding) happens because you can't always feel a hernia, even when it's there. They don't always pop out on command, with office maneuvers. I'd explain that to the patient, and tell them the fact that I can't feel it doesn't mean it's not there.... Unpleasant, mutually. When the patient had symptoms, and described what surely must have been a hernia, I always explained that it was a probably a safe assumption. But sometimes it was a person in whom the "hernia" had been found on a physical exam, and there'd been no signs or symptoms at all. When such a person was sent to me directly from the primary doc, I'd generally recommend against surgery until things were more clear, trying also to avoid any implication that their doc was wrong. But what to do when it's a second opinion referral from a surgeon who had them on the dotted line?

With breast cancer, some aspects of treatment are extremely complex, and changing nearly daily. Along with the good information available, there's lots of bad, sometimes leading to distrust as the default position going in, which makes the job of explaining even harder than it already is. I still get upset when I think of my patient who went for a second opinion and died a couple of years later, very possibly as a result. She had a very large cancer in her breast, and for several important reasons I told her she ought to have mastectomy despite her hope for breast preservation. She accepted what I said and why I said it, but saw another surgeon anyway. A young guy fresh out of training, sure he knew way more than the old guy, he told her she could safely have lumpectomy and radiation. He convinced her, signed her up, and went ahead. As I was sure would happen, he ended up cutting through tumor at all edges of his large lumpectomy, operated again unsuccessfully, and not very much later, operated once more to do a mastectomy. I can't say with certainty she would have been saved if she'd had it at the outset, but cutting through tumor that extensively may well cause direct seeding into the bloodstream, if it hadn't already happened; and three major operations on incompletely treated tumor seems less propitious than having only one.

So there you have it. Second opinions aren't necessary except when they are, and they're good for you except when they aren't. Have a nice day.

Reading

After nearly a year of quiescence, I did a reading of my book a few days ago, to an audience of about a hundred local ladies. A great time, I think, was had by all. Public performance is a personal pleasure, having done it many times, starting in grade school and carrying through college and beyond. Jud Frye in Oklahoma; Sir Joseph Porter, KCB, in HMS Pinafore, Conrad Birdie in Bye Bye Birdie. The Wolf, in Little Red Riding Hood)

So, buoyed by enthusiasm, I decided to record myself reading a couple of pages, for blogload, and being a clever surgeon, I figured out a way to manage it. (Blogger supports video upload, but not audio.) Using the tiny, invisible microphone which is somewhere on my laptop (and which provides pretty crappy sound), I used Garageband for the voice recording, then uploaded it to iTunes, then to iPhoto where I used it as the background for a slideshow (if you can call a single photo of the study in my parents' beach house a slideshow), which I imported to iDVD and made it into a movie, then to my desktop, from which I uploaded it here. A long way around the barn; maybe there's a simpler way. After all that, it's an admittedly poor effort, but it's a start. In my performance days, I'd have rehearsed it.

Here it is:

I'm Aware

Since it's Breast Cancer Awareness Month, I should point out that I've done a series here about breast cancer and related issues (one, two, three, four, five; and this about breast lumps.) My "memorable patient" series included this lady with advanced breast cancer; and there was a post about Elizabeth Edwards and her recurrence. I've admitted some outdated views on immediate reconstruction, and lamented my near miss with national notice regarding outpatient mastectomy. None of it does justice, perhaps, to the fact that over my career, by far the greatest number of patients I saw was women with breast problems. In fact, I'd have to say that one factor in my eventual burnout was the increasing number of young women with breast cancer that I was seeing; those office encounters are much worse for the woman and her family, of course. But they took a heavy toll on me as well, time and again, nearly daily.

It was the appearance on NBC news, a couple of nights ago, of a person who has annoyed the hell out of me in the past that reminded me of my recent silence on the subject (which is only because I think I've said most of what I have to say.) This love-ly person is mentioned in one of the above-linked posts. She'd gotten early fame by appearing on various shows claiming that the only reason mastectomy was invented is because men like to mutilate women. Sigh. It's hardly worth responding to something like that. Upping the ante, she also liked to say that if your doctor tells you you need a mastectomy, find another doctor, because no woman ever needs one. Complete and utter bullshit, then and even now. I'd like to believe she wasn't dumb enough actually to have believed it, but was just trying disingenuously to get attention. I do give her credit for having written a quite good "breast book," and I've seen her, more recently, being generally reasonable. But last night she did it again: questioned by Brian Williams about the most important thing a woman can do regarding breast cancer, her answer was always to get a second opinion before embarking on treatment.

I have no problem with the idea of second opinions: when there's any reason at all for uncertainty, I encourage them. ("Always" is a little dogmatic, though.) But what got me was her reasoning. As complicated as the field has become, she said, it's impossible for any one doctor to "keep up." So see two? Like if no one person knows enough to be trusted, getting another will magically fill in the holes? Two wrongs make a... what? I question the math. Anyhow, it's not really a big deal. Getting a second opinion is perfectly sensible, no matter the issue at hand. It's just that, after those years of listening to the woman's crazy rants back then, I have a hard time giving her much credence now. Even when she's right.

It Sent Me Up a Wall

A post by the always entertaining and often profound bongi reminded me of an amusing occurrence from the recent past.

At a free-standing surgery center where I sometimes work, I arrived in the usual wee hours of the morning ready to do battle. The center occupies the main floor of a multi-use building, so there's an outer door to a lobby, and another inside providing access to the work spot. On this occasion, for some reason, the outer door was locked, and whereas both doors are windowed generously, I could not make myself seen by anyone at the reception desk. In retrospect, this may have been because there was no one at the reception desk.

The side doors are windowless and hostile; also, locked. I went around the corner to where the operating room is, and studied the situation. It has a long horizontal window, narrow, running across the top of the room, around eight feet off the ground. (One cool fact -- irrelevant, I'll admit, to the issue at hand -- is that the window has a motorized shade, so that when operating and ready to view the screen for the laparoscopic part, the shade comes down at the touch of a switch, darkening the room. Nice.) Not really considering how it might be received by the people on the inside, I began tossing bits of gravel at the window. The response, if any, was not evident from the outside. Certainly it didn't open any doors.

I noted a tiny decorative brick ledge around the building, a couple of feet off the ground, protruding less than two inches. I'm an ex-football/rugby player (defensive line/second row scrum) with size 14 feet (48, +/-, European), reasonably strong but demonstrably ungraceful. Taking off my floppy sandals (yes, that's what I wear in the OR: Birkenstocks. They have great arch support -- but don't climb walls worth a shit), I toed my way onto that ledge, grasping at essentially ungraspable spaces between bricks with my surgeon's fingers. Managing a few seconds of upheaving myself, I got to the point of being able to knock on the window, once, before I fell back down. From the inside, a knuckle might have been visible, but not me. (At this point, I was later told, the nurse setting up the room was beginning to get frightened, trying to remember the number for 911.) Seeing the doors remaining closed, I wall-climbed once more and managed enough purchase to get my face up to the window, affording a brief view of the nurse, evidently startled to see a head bobbing disembodied eight feet above the floor; but enough to see a hint of recognition crossing her face before my fingers went the way of my toes, and I again had to fruzzle back to Earth.

Many times I've tried to picture how it could have looked to someone who had passed by at that hazy hour: a large individual, stocking-footed, clinging ungainly to a wall, like the glomulous opposite of Spiderman; releasing so quickly that the passer-by might have wondered if (or hoped that) it was only imagined.

I heard my name called from around the corner, where I hobbled to find an open door and a couple of nurses showing a mixture of bemusement, uncertainty, and hilarity. It took several weeks of broken promises, and I finally was given a key.

Brittle Beauty

Image from triggison.com

I think my first real amazement in med school may have been learning about the nephron. Don't ask me to recount it in detail; that part of my brain has long since been emptied and refilled with concern about fiber and bladder trabeculations (another good med-school word.) Looking at it one way (a perverse way?) the essence of medical school is the building of a sense of wonder at the complexity and beauty of the human body, and the essence of becoming a surgeon is the realization of how breakable and disposable it all is.

If you follow the link I made to the word (I sometimes hesitate to link to Wikipedia, given its, er, vulnerabilities, but this one seems OK), you can see what a marvel the nephron is: tubules coming and going, membranes, feedback loops, regulatory perfection. It's but a small example. The brain and its corpora and olives; the endocrinata. Muscles and mitochondria. And wow: the liver. It's simply astounding. Whereas the amount of new information raining down during those years is more than enough to swamp even the most absorbent mind (and notwithstanding the sense of dooming of the looming), it's impossible not to be thrilled and exhuberated by the glimpses you get of the wondrous workings of the human body.

And then you're in an operating room, staring deep into a stellate smash of livid liver. It oozes discontinuous destruction. Fragments of hepatic mush are strewn and coddled among clots of blood, stained with bile and mixed with stool. The beauty of the enzyme pathways is nowhere to be seen; Dr. Krebs is not in the building. Weak indeed is the capsule holding it all in, split apart like broiled bratwurst. How little it takes!

Grey bits of brain on a stretcher in no way reflect the neatness of neurotransmitters, or of ions flashing across axons. A hand, with its marvelous pulleys and cables, when rent apart by a saw or a slash, looks frail and helpless and pathetically flimsy.

There are times, when driving, or riding my bike, when wielding a knife in or out of the operating room -- or just breathing! -- that I suddenly think of how tenuous it all is, how easily smashed and torn apart is this wonderful work of nature in which we find ourselves. It's gelatin; it's a paper bag. I don't suppose the thought is unique to surgeons, or even health-folk in general. But we get a damnably intimate view, and there are times when it haunts me.

Cinch your seatbelt, tighten the shoulder harness, keep two hands on the wheel. Wear a helmet. And for God's sake, look both ways when you cross the street.

Speaking of...

I'm about to do a reading of my book, which I haven't done for nearly a year. Having looked it over for the first in a long time, I find these paragraphs from the "afterword" relevant to my recent post about student blogs, and the comments that resulted. So, for those of you who haven't read THE BOOK (I find it all but unthinkable), I re-print them here:

"When I left Judy at Travis Air Force Base and headed off to Vietnam, I surprised myself by sobbing like I’d never stop. Three decades later, I’m glad I went. It was the seminal event of my generation; I know it from a perspective held by few of my friends. The analogy to surgical training is imperfect; I chose to be a surgeon, and didn’t cry on my way to San Francisco. But it was a tough slog, through a system set up by people over whom I had no control, and with whose conduct within that system I didn’t always agree. Nevertheless, I was among the last participants in an era now over for good. I felt part of an unbroken chain of teachers and learners tempered in that same cauldron, walking through the same halls, awake through the same nights, going back for much more than a century. Across the country, the old county hospitals are gone, and the residents are getting a little sleep. I won’t argue that it was better then; in fact, it probably wasn’t. But my training, which informed the lives of generations of surgeons, in many ways brutal and inhumane, is an experience I feel privileged to have had before it disappeared forever.

I wonder if Dr. Dunphy and his WW II buddies, and those before them, actually had thought it out like this, as they fashioned the modern rules of training surgeons: beat them down, overwork them, hold back the rewards, so that only those who really love it, who find being a surgeon irresistible—like surrendering to a disease—will push on into the senior years of residency. If people burn up and drop out, good riddance. Take their mistakes and wave them like semaphores, visible for miles. There are no brighter lights than those in an operating room. You’d better get used to it, because there’s no separating from the pleasure of dramatic success the misery of abject failure.

Fear of failure is the surgeon’s safety net, and his dead weight. If you haven’t had driven into your essence the sweaty recognition that failure is just around the corner, you ought never pick up a knife. But if you aren’t the kind to overlook that fear and plow ahead believing you’re prepared, you’ll never get out of bed in the morning, much less in the middle of the night."

It goes on from there, in other directions, and perhaps a little too long. But the above is a good crystalization of my thoughts about the inherent (and, to a significant extent, disappearing) toughness of surgical training. For what it's worth. Nor do I mean to belabor the point. I just came across the words again and found them relevant to the recent post. In addition to which, as readers will see, I'm running low on ideas...

Oh, and the book is a lot funnier than those paragraphs suggest. And entertaining.

A Post In Vain

An oft-used literary cliche´ has something coursing in someone's veins:


"The adrenaline coursing in his veins merged each moment..."

"... the palpable high coursing in his veins..."

"The blood coursing in his veins felt thick and sluggish."

"With his own blood coursing in his veins, the characteristics..."

" music was always coursing in his veins."

"the milk of human kindness was now coursing in his veins..."

"...even then the poison which Selima has secretly administered -recalling the murderous act of Voltaire's Mohammed-is coursing in his veins..."

"pomposity coursing in his veins like steroids through an Olympic athlete..."

"he felt “the old fire of 1848” coursing in his veins."

"for the music coursing in his veins had chased it out."

"..and the wine of life was coursing in his veins."

"the assassin coursing in his veins was less forgiving than the cocaine..."

"a chill having nothing to do with the venom coursing in his veins."

"The thrill of making the next biggest profit of all time was always coursing in his veins."

"Wine and desire coursing in his veins like the raging fires..."

"As for Puff the Magic Diaz, I’m pretty sure the boxing lesson and the gogo weren’t because of the THC coursing in his veins."


Omigod! It's worse than I thought. Somebody stop me!! [The above lines -- all of them -- came from a search for the term. Don't blame me. And there were lots more.]

So anyhow, here's the thing: blood in the veins is the depleted, the metabolized stuff. Oxidized, alkylated, detoxified, it's the left-overs. The good stuff, potent and active, is in the arteries. So how is it that writers -- those many, varied, and sometimes-awful writers -- came to see the veins as the carriers of, of... whatever, when clearly it should be the arteries? I'm not going to lose sleep, but really, someone ought to look into it.

The Student Prints

I like med-student blogs. They remind me of the excitement, the frustration, foreboding, and fun of those times. More than that, from the quality of the writing and the depth of the thoughts expressed, it gives me hope that when I'm sick there may still be doctors out there interested in taking care of me in the way I'd have taken care of them. On the other hand, some of what I read is disturbing.

It's a predictable pattern: someone writes about her/his surgery rotation, and -- if not perfectly word-for-word -- certain statements will be made, and an inevitable array of comments will follow. The cast of characters is always the same: the asshole resident, the overbearing and brutish professor, the student who hates everything about it, sometimes with one or two who love it (and whose motives and sanity will likely be challenged.) Rarely, there might be a supportive resident or two. The behaviors described recur time and again. Berating, humiliation; a senior attending who not only treats the students and residents like shit, but his patients as well. The author, and the commenters, in the most vituperative and unforgiving of terms, validate their owns similar experiences and roundly condemn the surgeons and their method of teaching.

Keep your fingers off the keypads for a minute, kids: I'm with you. The reason this is disturbing is that it's true, and I hate hearing it. By far the worst thing to read -- and I've read it in commentary by patients as well -- is the description of a doctor (any doctor, but particularly a surgeon, because they seem to be the most frequent offenders, in these fora, anyway) being disrespectful and uncaring toward a patient. For that, there's no excuse, ever. And whereas I don't think for a minute that it's limited to academe, I believe -- from observation -- that such behavior is more common within the ivory walls than outside. Maybe it's tenure; maybe it's the academic rat-race; or maybe it's slop-over from the anti-Socratic method of discourse that's become embedded in surgery training like dogshit in a Doc Martens.

The operative phrase is "shit runs downhill." Profs dump on the chief resident, who dumps on the senior resident, who dumps.... But it needn't be like that. I wasn't like that.

In training, as I worked up the ladder, I was a good and patient teacher (or so I'm saying!) I had interns and junior residents over for dinner; I made jokes on rounds, and pitched in on the scutwork. I relished showing technique and explaining reasons for things. I rarely -- if ever -- grilled, and when I did, it was to get somewhere rather than to debase. It can be done. I don't recall chewing someone out, ever. But when I became a real doc, bearing all the responsibility myself, some things changed. I NEVER treated my patients with anything less than respect and empathy. But I know I could be hard on the nursing staff, and even referring docs, when I thought something had been done less perfectly than I demanded of myself. Believe it or don't, I was much harder on me than on anyone else if anything diverged from my view of excellence, but I make no excuse (OK, I do: it was based on hyper-perfectionism and not arrogance): things can be said in less off-putting ways. (In fact, in my second incarnation, after brief retirement and time to relax and reflect, as a surgical hospitalist I had an entirely different attitude. Nurses who'd known me before said they'd never seen me so happy. I think it partly had to do with sleep. And, yeah: being old and beat up enough to let some things go.) But there's a point here.

Not everyone will buy it without offense, yet it's true: surgery is the court of last resort. A surgeon is judge, jury, and -- God forbid -- executioner. Every other doctor can punt, and they do. Often. A surgeon can't, especially in the OR. And so, whereas it needn't be as punitive and degrading as it is in some places, surgery training will always be long, and hard, and demanding. I accepted a certain amount of misery when I went through it (and worked hours far more brutal than now) because I felt urgency and necessity. I thought then, and still do, that surgery training does more than the others to inculcate a sense of responsibility, the knowing of one's limits, and a commitment to perfection; and it must, because there are no hiding places in an operating room. If some students are put off by it, it's not entirely a bad thing. They will, and should, make another choice.

I read a student blog the other day. The writer said she hadn't read up on the operation in which she'd be participating, and was taken to task by the operating surgeon. With relish, evidently. Her post was followed by lots of comments deriding the attending in particular and all surgeons in general. There was an echoing chorus of animus: they're dehumanizing, bunch of egomaniacs, surgeons are terrorists. But along with the cringe of embarrassment for being associated with the evident scum of the earth, there was a twinge of an opposite thought: if I were to show up to an operation unprepared, someone might die, or be maimed forever. I'd hope that people who choose to become surgeons are the sort that don't need reminding, and are, in fact, the kind that wouldn't show up unprepared in the first place. But in training, some do. And they don't last. If they don't respond to whatever method the attendings or the senior residents bring to bear to point out and correct their failing, they get tossed. As they should. And, as someone who might some day lie on a table in the most vulnerable position you'll ever be in, aren't you glad to know that?

Smooth Move

On a Nobel Prize website, in reference to Theodor Kocher, recipient of the Prize in Medicine in 1909, it says, among other things, "The influence of a devoted mother and later the loving care of a selfsacrificing wife enabled him to pass without interruption through the continuous strait of secondary school and University, and he obtained his doctorate in 1865." Some things, I guess, don't change all that much; in others, he was unique.

In surgical lore, Emil Theodor Kocher is known for many things, as is the case with all those greats of old: innovation, invention, vision. Clarity. Viewers, they were, of the empty spaces between knowledge and action, and seers of ways to fill them. Despite my cognizance of the breadth of his influence, when I think of Kocher three main things come to mind: a big honkin' surgical clamp (curved or straight), the classical gallbladder incision, and his discovery of how to mobilize the duodenum; another of those simple and anatomically-correct tricks that gives the surgeon entry into secret places, and makes a hard job easier. The Kocher Maneuver. What a great thing to have named after oneself. A maneuver.

It's as if the duodenum is the command module of the belly: riding high and hanging back, daunting (one might assume) to the lesser organs, it receives input from the stomach, the liver, the pancreas and distributes it all downstream.

With many life-sustaining tubes draining into it, and with as many big and scary blood vessels passing behind, beside, and around it, surgery of the duodenum is tricky, and requires most of the skills a surgeon must have acquired. The simple snip Dr Kocher invented makes the work a little cleaner, and is essential to working on that part of the intestine, on the pancreas, and for much of the surgery of the stomach.

In one sense, it's no big deal at all: just a few seconds of scissoring along an imaginary line. In another, it's amazing that there's one person to whom the move is attributed, since it seems anyone working there would see the need to do it. Which makes it all the more noteworthy: when the Kochmeister was poking around in bellies, many of even the most basic concepts were yet to be deduced.

I can barely imagine what it must have been like to be a surgeon in those times. Scary, exhilarating, deflating, rewarding. Those guys must have lain awake many nights as their brains buzzed and glowed with ideas. ("Teddy," his wife might have sighed, "Can you stuff a cork in your ear? The light is keeping me awake.") Would they have been barely able to keep from getting up and running to the lab to enflesh their latest inspiration?

I guess you could say there was no downside to what those trailblazers attempted: the conditions against which they were struggling had, until then, only bad outcomes. Either they found new ways, or the patients died as usual. Depending on how you look at it: either unbearably pressure-filled, or completely liberating.

The duodenum is plastic-wrapped to the backside of the abdominal cavity, covered as it is by the posterior parietal peritoneum for most of its length. Looking at the picture above, you can see that after connecting to the stomach, it descends downward and then curves hard to its owner's left. That curve is called the C-loop (or the "second portion," or the "descending duodenum.") The Kocher Maneuver is the process of cutting the C-loop loose, by incising the peritoneum covering its lateral edge. Made a verb, the term is "Kocherize," as in dictating "the duodenum was Kocherized..."

Doing so gives just enough mobility to be able to tug the duodenum upward to join the stomach if you happen to have cut part of it (the stomach) away (only so far: the duodenum is, ultimately, tightly tethered by the aforementioned tubes and vessels); or more easily to open the duodenum across the pylorus for any of several reasons. And, most exquisitely, to gain access for your finger to nooger behind the duodenum and pancreas together, all the way to the superior mesenteric vein, after which, among other things, you can extend the Kocher Maneuver downward and to the left. Then you really have the meat of the belly in your hand. Awesome.

On the other hand, maybe you have to be there...