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Showing posts from October, 2007

Cool

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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 im

News Flash

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Ridge Lines

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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,

Bleeder

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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 deƫmphasizing 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 res

The American Dream

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[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 fin

Visual Fields

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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

Sissy

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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 ballo

Layers

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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 bl

Podcast

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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

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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

... And A Pink Carnation*

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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

An Opinion Opinion

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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, respectfu

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 t

I'm Aware

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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 ni

It Sent Me Up a Wall

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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

Brittle Beauty

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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

Speaking of...

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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

A Post In Vain

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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." " t he 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 forgivin

The Student Prints

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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 n

Smooth Move

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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 anatomica