Don't Worry, Heal Happy

On a pass through Kevin MD's website a while ago, I saw a reference to an article which reported a study on anger and healing. The report, at BBC online, said, in part:

"The Brain Behavior and Immunity study indicates stress has a major impact on the body's ability to repair itself. Nearly 100 participants were asked to rate how well they could control their temper, and the speed at which they recovered from a blister was monitored. Hotheads were more than four times likely to take more than four days to heal than mild-mannered counterparts.... The team at Ohio State University gave participants blisters on one of their arms and then monitored how the wound healed over the course of eight days. They were asked to fill in a questionnaire which looked at how anger was expressed - whether externally, by shouting at others, for instance, or internally, when one rages insides but keeps a cool exterior."

At the end of the article, there was this:

"Steve Bloom, professor of metabolic medicine at Imperial College, London, said stress was now increasingly recognized as a factor in recovery rates. "Your body prioritises and sorts one thing out at a time, so if you are stressed - angry in this case - your body works through that before it gets on with the process of healing. We've yet to see a study that categorically proves having an attentive, calming presence by your bedside actually speeds up your recovery, but the evidence is certainly pointing that way." (My emphasis.)"

Studies like these (judging emotion) are a little squishy, and one might well challenge the methodology, not to mention that "prioritises" deduction. But it sorta kinda rings true, off the top of my head. Naturally, I extrapolated. I think there's an important message; or at least there might be.

I often heard from nurses on the surgical floor that my patients were calm and positive when they arrived, and that they seemed to do better than those of other surgeons. (No, I can't say it wasn't just a way to ingratiate -- for all I know, they said it to every surgeon.) Of course, I loved hearing it; it went to a very specific aim and belief of mine. If their assessment was true -- and this is me saying it was -- it validates an overt effort on my part to achieve a sense of comfort and confidence, a positive attitude toward recovery. I've always thought it makes a difference. (I recognize the article in question doesn't draw an outright conclusion. "Pointing that way," is what it says.) (Nor, let it be said, am I talking about "cure." Just recovery from surgery.)

The antithesis is the doctor -- any type, really, but in this context a surgeon -- who makes hospital rounds, perfunctorily pokes and prods and leaves with little or no meaningful communication, ignoring obvious concerns. Having watched such behavior while visiting hospitalized friends and relatives, I can say it leaves the patient and family angry and frustrated, which, this info would suggest, is actually medically counterproductive. Doctors can't, of course, remain a "calming presence by the bedside" for more than a very few minutes at a time; but we can listen, explain, even sit down and look the patient in the eye. Not only is it the human and natural way to behave, if it produces the opposite of anger, it looks like it might actually be medicinal! Even grumpy docs give antibiotics when needed. In the same spirit, maybe they'll work to provide a decent dose of needed nice.

Res Ipsa Loquitur

Having nothing but time on his hands like any law student, esteemed reader Patrick sent me a link to a pdf containing the arbitration brief of a recent and widely publicized case. Far be it from me to beat a dead horse, but it seems a tidy argument for finding a way to provide health care without the need for dozens and scores of insurance companies. (And as an aside, a look at why, to some degree anyway, I've always been sort-of attracted to law as a profession: the orderliness, the linearity, the need for factual and logical thinking. Sometimes.)

The case is that of a woman who, despite having perfectly good health insurance, was approached by a (predatory?) guy wanting to sell her a less-expensive policy. Forms were filled out. She evidently thought it was going to be some sort of automatic transfer, rather than an application. At some point, the number for her weight had been changed on the form; the change was initialed by the agent, not by the woman. The form went forward, the insurance company reviewers noted the change but did not raise questions at the time, at least not to the woman. The old insurance dropped, the new policy established. Then she got breast cancer. Ostensibly because of the weight-change shenanigans, the insurance was canceled. Claims and counter-claims were made, and the case went to arbitration by a retired judge. (My dad was a judge, and when he retired, he was a much sought-after arbitrator.) (There's no real point to that interjection other than the fact that I always enjoyed hearing him discuss the process and the issues.) The result was a decision in favor of the woman, to the tune of several million dollars.

One might see the case as less about bad old insurers than about fine points of insurance law. In the brief, there was much about "due consideration" and "good faith" and various quite particular minutiae, from which one might or might not generalize. But one fact struck me as very important beyond the case at hand: employees of the insurer are paid, in part, based on how many claims they DENY; how much money they save for the company. They get bonuses for that. (Outrage mine.)

Just good business, some would say; and at some level they'd have a point. But that's exactly the problem. Having insurers sitting between providers and patients, taking money from both -- inserting the business of business and creating a whole profit-making/money-sucking ("non-profit" or not) enterprise that has nothing to do with providing actual care -- seems an obvious and unnecessary waste of health care dollars. Particularly when the business thus inserted clearly -- because its business is business, not healthcare -- has the aim of authorizing the least amount of care that is possible.

Most doctors hate the idea of a single-payer health care system, and for many good reasons, most of which have to do with concerns about loss of control. Of care decisions, of pay. I share them. But there can be no doubt that the system as now constructed in the US diverts huge amounts of dollars to companies that have nothing to do with actual care, and even -- as we see here -- to funding their efforts not to pay for it; and the amount is way more than would occur with a single payer and a single set of rules, aimed at paying for care rather than trying not to.

I've made it clear how disastrous I think is the trend, especially in Medicare and Medicaid, to pay providers less and less; how it will lead to huge access problems and changes in the sort of people who choose to become doctors. About that I have no illusions. But I don't think "single payer" and "cutting pay" and "onerous rules" need to be synonymous. For one, there'd be more money to work with. And it simply can't be totally impossible to find an operating model that would include providers in a meaningful way to set up and govern the execution. Improbable, maybe, but not impossible; unless politics as usual remains politics as usual.

You Are So Beautiful

Do you have any idea how beautiful you are? Well, okay; maybe for some it's were. Before you got a little thick in the middle, smoked, or even just breathed city air for enough years, or drank a little, or did a few drugs, there was a time -- and maybe it's still true -- when you were knock-down, take-your-breath-away gorgeous. Many times while operating inside a belly I've stopped working and just looked, and then said to the others in the room, "C'mere everyone, look at this. Look how beautiful it is." Because it's true. Really, you should see yourself.

Operating, as is our aim, on sick people, more often than not things aren't so pretty inside. Diabetic, or old, or overweight, or with concomitant diseases affecting various organs, typical surgical patients rarely retain the born-in beauty and peach-fuzz perfection with which they came into the world. But sometimes bad things happen to the well-kept or the young, and, in another of those paradoxical disconnects of the surgical mind, we are given a moment to find pleasure despite another's pain. Sometimes it's just all look-at-me laid out, not hidden in adipose, undistorted; the logic, the development, the relationships, the purity so bright as to be stupefying. Who gets to witness it, who's allowed at the window? Not many. Me, amazingly enough. Let me try to show you what I mean.

More often than not, when inside a belly what you see is this:

The grayish stuff is intestine. The yellow, of course, is fat, covering blood vessels and other structures you'd like to be able to identify. Here's another view:


If you know what you're looking at, you'd be able to tell what's underneath:

So you dissect, and scrape, and burrow through fat, and you find what you need, and deal with it. But sometimes, wonderfully, amazingly, it looks like this (the picture might not be of a human. The fact that I couldn't find a picture only underscores the rarity. But the point remains):

Imagine the joy! Not only is the operation immeasurably easier, it allows a look at the exquisite elegance of our bodies as they were meant to be. A basic principle of surgical technique is traction and counter-traction: elevating or spreading tissues and applying pressure in opposite directions to stretch things out, making dissection possible. When you pick up a loop of bowel to get that tension, most often there's much more work to do until you find the target vessels. But sometimes, like that picture above, it's all there. You can see right through it. If you like doing surgery, it's impossible not to be ecstatic. Like rounding a bend after a long climb and being able to see forever, you must stop and savor it. You can be precise and gentle; the tissues require no more, and deserve no less. There's something like sadness when the operation is over.

Down the backside of the abdominal cavity runs all the plumbing: the aorta, bigger around than your thumb, carrying blood from the heart; the vena cava, bulging and blue, bringing it back; the ureters, carrying urine from the kidneys to the bladder. More often than not, they're hidden by fat. When you can see them -- the aorta, at least, and its branches -- they're often pocked and corroded, rusted and irregular. But just often enough to be a thrilling surprise, you can see them in all their orderly complexity; shiny and pristine, they ought to sizzle like high-tension wires.

Those big blue veins are both turgid and tender, scarily so. Their thinness speaks loudly of danger. Like a powerful waterfall, they call you closer, even as your knees feel weak. And the aorta, in the young and healthy, is a wonder. Its walls are strong and thick, but they bulge with each heartbeat. Retaining their natural elasticity (before inevitably giving it up to cholesterol) they throb and push against your fingers; simultaneously static and brimming with life. Knowing the power enclosed within (poke a hole and see what happens!), it's like standing at Kilauea and feeling tremors. Smaller branches, curlicued in the mesentery, lift and uncoil, stretching out and falling back, to the music of the heart monitor. It can be mesmerizing.

Much more than simple tubes, the ureters produce sensuous muscular waves, more subtle than gut peristalsis and less frequent, and therefore more pleasing. When unsure what you're looking at, rather than wait you can pinch with a forceps or give a flick with your finger: it'll respond with a lazy roll. Sometimes, just for the pleasure, I've done it more than once.

Funnyman

[Another weekend non-medical rant. Warning: may be offensive to some, but not all, believers, in that it is generally anti-religious. It does represent how I feel; questions I've asked myself and answered over the years. In the same way that my religious views never affected my practice, or devotion to my patients (except in those rare instances when people said they thought God was working through me and I responded, "I'll do my very best" or something similar) I hope readers will be able to separate this sort of post from my writings about surgery and medicine. Or will bail now before going further.]

I offer a comment on a TV show I didn't watch: having seen a preview is quite enough. The show "In God's Name" presents interviews with several heavy-hitting religious leaders, including the Pope, The Dali Lama (maybe it's unfair to lump him in, since Buddhism is about spirituality and not about deity), the Chief Rabbi of Somewhere, an Ayatollah, and a few others who aimed to address the problem of god and violence, and murder, and hatred. All were men, of course, and they spoke with the confident certitude that comes from being in direct contact with God, while likely ignoring the fact that the others were just as confident of their connection. In the preview I heard a quote from one of them which exploded inside my head and made my ears bleed.

"God must have a wonderful sense of humor," the guy said, grinning beatifically. It was in the context of someone becoming a religious spokesperson who'd formerly been a nay-sayer, or a bad person, or something. That a cleric -- or anyone, for that matter -- could look at the world and conclude that god is a jokester is what fried my brain. On the other hand, much religious thought -- especially the brands that we see becoming more and more a part of the political process -- is about seeing the world as it is not.

The mind reels. It's like walking into a crime scene, wading through body parts, and, because the perpetrator wrote "Hah hah" in blood on the wall, saying he must have a humorous streak.

God talked to George Bush and told him to invade Iraq, which has, among other hilarious things, led to the murder or displacement of most of the Christians there. Good one! He (God, not George) grants some prayers, which by definition means he chooses not to grant others. Because of him -- in his omnipotence he surely could have chosen otherwise -- children starve, or are maimed, or orphaned, by the thousands, every day, all over the world. (Stop me if you've heard this one.) He pits people against one another; he makes floods and tsunamis and earthquakes and wipes out innocents by the tens of thousands. Or, if they're not innocents, as we hear from the likes of Pat Robertson and Jerry Falwell (may peace be upon him), it can only be god the omni-powerful that made them that way, only to wipe them out. Then, we are told with certainty, he burns them in hell for a trillion billion gazillion years. Because, in addition to being a laugh-riot, nothing happen but that he wishes it so. (There is no logical middle ground: he chooses everything, or nothing.) Oh: but he loves us. That's the good news.

What a comedian! He makes mankind imperfect, sets up some rules to follow, knowing (by definition) that billions of people will be unable to follow them, and then sees to it that in their failure they suffer eternal punishment. Eternal. To infinity and beyond, hallelujah. (Although according to those who build the churches and collect the cash, you can live a life of sin and crime and have a deathbed conversion; or drop a dollar in a dish; or, like Jimmy Swaggart, weep and declaim, and be fine, poof, it goes away. On planet Earth some killers get off after a couple of decades. But god's "vengeance is mine" jones doesn't get satisfied after a million years or two? Pretty harsh.) And for what? Well, murder, I suppose, except when it's in his name; whacking off, I'm pretty sure; but for most, just not accepting him as their savior. Even if you live an exemplary life by all other measures, if you don't kiss his... ring, you boil and blister forever. FOREVER. Life is short, eternity is quite a bit longer. It's like giving a first-grader the SAT and jailing her for the rest of her life if she fails. This particular picture of god, which seems to place many beside themselves with self-satisfied delight -- by any reasonable criteria is one of a child abuser. If you heard of a guy who had a bunch of kids, starved them, and then threw them in a hole when they reached for food (god made rules he knows we'll break, gave us hungers he knows most can't resist), you'd call the cops for sure. Good for you, by the way. And even if you found cartoons on his hard drive, I'm thinking you wouldn't say with a chuckle (did I mention the chuckle in the preview?) what a funny guy he is.

Remember this post about a beautiful girl dying of cancer? Many honest and heartfelt and absolutely sincere comments indicated how god-loved and humbled people felt in her presence. But consider this scenario: A man tells his youngest child, "In your pain, the others will know my love. In your suffering, they will feel enriched. This honor I give to you." And then he breaks her leg. She screams in pain, but says "I know you love me, Daddy, and I know you'll stop." Then he breaks another. "I love you, Daddy," the girl shouts. "Your love is boundless, I must try to understand." And he cracks her arm. "Daddy," the girl cries, "I'll be better, your love is great, I'll always love you." The other arm goes. If you were to witness such a thing, what else would you call it but despicable and inexcusable? Wouldn't the girl's professed love pain you to your soul; make your heart break? Would you not rush in to rescue the her? Dial 911? Shoot the guy, lodge an axe in the back of his head? Surely you'd not feel privileged to have stumbled upon it; or blessed. You'd have nightmares for years. But isn't the situation exactly the same as with Gloria? Yet in the one, people are filled with love of God, and in the other -- quite properly -- they'd be enraged and sickened. Now there's a punchline!

No, whatever is true about the god of those men of god, a kidder he ain't, contumelious he is, if his hands are on the levers. Either that, or he's incompetent. Intelligent designer? Gimme a break! Cancer, diabetes, Crohn's disease, asthma. The heartbreak of psoriasis, cold sores. My mom's Alzheimer's. It would seem we're under the thumb of a pretty nasty and capricious guy, and I hope I'd have the moral fortitude to tell him so if I ever saw him. But if he's not calling those shots, then either he's disengaged, or a blunderer; in which case what are we doing worshiping him? "God works in mysterious ways," those scions say. But wait: wouldn't they agree he gave us brains? When some things are plainly nonsensical, ought we not feel empowered to say so? To find meaning and joy based on concepts that aren't contradictory and impossible on their face?

As I've said in other posts, I've witnessed as a physician the ability of belief to give comfort. (For the reasons above, it's hard to understand how the prevalent -- or at least most publicly preached -- view of god provides comfort, but belief is rarely about consistency.) In the privacy of one's thoughts, when religion assuages that "sickness unto death," I don't doubt it's a good thing. But for too many, in order to protect those impossible beliefs from being shaken, there's a need to demonize -- not to mention murder and maim -- those who don't share them. Sadly, it's the religious of that sort who are on the world stage, here and abroad.

If religion has value, I'd think it ought to be central that it maintains some connection to reality. Allows one to deal with life as it is, to give flight to our spirituality without the need simply to make stuff up and ignore the contradictions. If it gets you to look at the world and chortle at what a wiseacre god is, it's leading you too far into unreality. Religion requires one to believe in things that are disbelieved by billions of other-believers (and not to find that fact at all disquieting.) But why must it also require one to reject that which is known to be true? Like, oh, the age of the earth. Carbon dating. Science, evolution. Stuff like that.

Did It Again

Sorry, those of you on a RSS feed or something. I had another episode of premature epublijacation, and took it down. It'll appear, as intended, this weekend.

Ripoffs or Reticence?

Couple of months ago I read an article about a guy who did a three or four simple un-fixes to his Subaru, took it to a bunch of repair places, and reported the results. Bottom line: only about twenty percent found the problems and provided the appropriate and easy repairs. The others suggested all manner of unneeded and very expensive work, and missed some things. Not a surprise.

The article analogized to medical care: experts who have a stake in providing the care and charging for it may not always be trusted to give the best advice. It's not an entirely specious proposition. I was reminded of it recently.

I get ongoing comments on posts from long ago; most particularly the gallbladder series. "I'm so glad to have found your blog," they say, and then proceed to tell me their saga of problematic diagnoses and/or recommendations, and they ask my advice. At some level it's flattering, until I realize they're probably pretty desperate to trust some guy on the other side of their computer whom they don't know from a bag of groceries.

Anyhow, I try to help when I can, within the parameters of my disclaimer over there on the right. Recently there was a description of a symptom complex that was quite typical of gallbladder pain, with confirmatory ultrasound which even showed some thickening of the organ's walls -- pretty much diagnostic of active problems. Her gastroenterologist had her scheduled to have upper endoscopy to "rule out ulcer," and then she'd be sent to a surgeon. Her question was less about the need for the scoping than about how to approach the upcoming surgical consult. (The preceding link is worth checking out, by the way, because the doc appears to be using an invisible scope and looking at a lampshade.)

So here's where it gets complicated. Unlike a Subaru, the human body doesn't have a shop manual. Doctors sort through incomplete, conflicting, and inadequate data (because all of our tests are fallible) in order to come up with a diagnosis and recommendations. On the one hand, I can't judge from afar the need, in this case, for endoscopy; on the other, from the little info I had, it seemed a waste of time and money, with at least a small amount of risk.

I didn't say anything.

In my series on the appendix, I told the story of a call I got from a family doc, asking me to see a young man he suspected of having appendicitis. A twenty year old with a day and a half of abdominal pain, starting near his belly-button, moving to his right lower quadrant, he now had point tenderness, associated with loss of appetite, nausea, fever, and an elevated white blood count. Which did I want ordered, I was asked: ultrasound, or CT scan? If ever there was an appendicitisoid duck ("if it walks like a duck, quacks like a duck, has feathers and feet like a duck, it's a duck"), this was it. But here's the point: in this case, the doc had no financial stake at all in the imaging studies he'd have ordered. (I operated with no further tests, removed a hot appendix, and the guy lived happily ever after.) So yeah, it's complicated: it's not just about self-interest, at least in the purely financial sense.

I've been referred many patients over the years, all teed up by their docs and expecting an operation. For a variety of reasons, it wasn't an intergalactic rarity for me to tell them it wasn't needed or advisable. I can say with near certainty that I never did an operation where I let monetary considerations tip the scale. But I'm sure nearly all docs would say the same thing about any procedure, even the ones that did. Is it conceivable that an ulcer could cause severe colicky right, upper abdominal pain, intermittent, radiating to the shoulder blade, and not be related to the proven gallstones and gallbladder wall-thickening? I guess it is, although she might also have been struck by lightning on her way to the test.

If the patient were seeing his/her family doc instead of a gastroenterologist, would s/he have been referred first for endoscopy before an appointment to a surgeon? I'm guessing not. If the patient were seeing a surgeon who did endoscopy, would that procedure more likely be done, pre-operatively, than if it was a surgeon who referred such patients to a gastroenterologist? And if not, would there be any back-scratching involved? I'll defend my profession vigorously, and I'll argue as hard as possible that caring for humans will never be subject to binary decision making. But in this I can't claim we, as a group, are pure as a virgin's smile.

I am.

Were it possible, liability-wise, and avoiding-being-burned-at-the-stake-wise, it'd be interesting to consider an on-line business wherein one provided prospective (as opposed to working for lawyers) second opinions or general guidance through a problem. Obvious preclusive limitations and dangers and presumptions aside, I bet it'd be eye-opening.

Where You Find It

Enlarging on a footnote in my book, I share the story of a magical picnic:

Toward the end of my year in Vietnam, as the North Vietnamese Army marched ever more successfully downhill toward Danang, we had to bug out to Thailand. We shuttled to a barely re-opened base at which our "hospital" consisted at first of cots and bare walls, and where my office was furnished with boxes. My arrival was met with delight by a fully-trained surgeon who had not been allowed to leave until I (having had only a surgical internship's worth of training) got there. When he left, the portable OR and the anesthetist went with him: such was the logic of the military.

There was a small town nearby, which grew rapidly, putting up bars and other establishments more quickly than we fixed up our facilities. One of my fellow docs found himself a Thai girlfriend, with whom he moved in, part-time at least, downtown and in short order. My friend thought her an amazing young woman, and wanted me to meet her. The first visit was to her (their) little hut near town, where she made us a memorable meal. On a little cookstove, while telling us the story of her life (another time, maybe) she whipped up some stir-fry, leaving out the hot sauce which she reserved for herself, saying the stuff she made us was so mild she could barely taste it. My lips and tongue burned for a week.

Several days later, she took us on a picnic. Riding in the back of a tiny pickup truck she'd hired, we bounced our way through the countryside, eventually pulling up to a marble stairway which led partway up an abruptly rising mountainette. Yes, a marble stairway in the middle of nowhere, up which we lugged the bounty she'd brought: a hibachi, bags of fruits and meats and breads. And other material of a horticultural nature.

At the top of the stairs was a monastery. Shaved-head men in citrus robes took no note as we followed Banjit down a path and into a cave, at the back of which was a dark wooden platform with airily carved sides, supporting several statues of the Buddha, incense, and a monk in prayer. Behind it was a handmade ladder, rungs tied with rough cords, up which we climbed through a hole at the top of the cave, handing our bags up to one another, coming out to find another path, seemingly leading to a different planet. On the truck we'd traveled through flatlands, rice paddies, all horizon and open space. Now we were in a green grotto, rocky and steep, softened by banana trees, huge ferns and palms. The air was hot and humid, smelled like a prom corsage. We sat on chunky rocks, looking down on the monastery and up at cliffs, while Banjit fired up the hibachi and handed out the previously-referenced, subtly-mentioned, vegetable-based, mood-enhancers. Not that the mood needed enhancing.

There was papaya, banana, and the most honey-succulent pineapple I've ever tasted. She cooked satay, passed around mango juice, and we lay back on the rocks and took it all in. As much as we could. Then, Banjit climbed a tree and began shaking its limbs and chanting.

"What you do?" I asked her.

"I call monkey."

"How you know monkey come?"

"Monkey come."

"You be here before?"

"No, not be here."

They came. Small, grayish, timid, a group of maybe ten or twelve monkeys appeared out of the undergrowth, looking wary, as if worried why they'd been summoned. We tossed pieces of fruit their way. Never taking their nervous eyes off us, they reached suspiciously, clearly not tame like park-squirrels, grabbing morsels and retreating to eat them, entirely, with care, licking their fingers when finished. Ants, I was thinking. I've been on picnics with ants, but this... Banjit stayed in the tree, laughing. It was beyond ecstasy.

Suddenly the monkeys scattered in fear, as if a shot had been fired, eyes directed up the mountain. Down strode who could only have been the king monkey, half again as tall, walking on hind legs intently, commandingly, boom, boom, boom, hands fisted. His testes looked as big as the other monkey's heads. Drilling us in our eyes with his, he grabbed up a slice of papaya, chomped off a bite or two, and tossed it away. Then another, the same way. No nibbler; not this primal padrone. He glared at us as if to say, "That's all you got?" then spun around and marched back whence he came, and, as his remarkable presence ebbed, slow, like a setting sun, returning the place to us, the monkey-flock reappeared, gingerly taking up his leftovers, picking them clean.

Banjit spoke from the tree.

"I think, before, man, monkey, same-same."

"You mean," I asked, "Man, monkey, live same-same?"

"No. Man. Monkey. Same-same."

There. Evolution. Obvious to anyone with eyes open, in the jungle, sitting in a tree.

* * * * * * *

Oh, and what of the place where this magic occurs? As happens in Southeast Asia, the sky darkened before we knew it, and when we did, we saw a monsoon on its way. Grabbing what we could while Banjit called, "Go now, go now," we couldn't get everything together even though there was now less of it.

"Time go now, big rain come."

"No, no, have to get stove."

"Come now," Banjit cried. "Leave stove. We come back, it be here. Not be here, be in temple, wait for us."

Pleasin' Squeezin'

From my prior comments about my love for bowel surgery and for the old-fashion method of hooking the ends together, one might draw the erroneous conclusion that I eschew all forms of operative shortcuts. Untrue. While not the top priority, speed is an issue, and I've written about that, too. My reasons for preferring hand-sewing over staples -- aesthetics, cost savings, connection to the history of surgery -- don't apply when it comes to clamping and tying blood vessels. Surgical clips, particularly the old-style individually loaded ones (as opposed to the fancy disposable multi-fire guns) are cheap as dirt, simple as hell, and save lots of time.

For the first thousand years or so, surgical clips were made of stainless steel. More recently, and mainly because of concerns about clips being pulled off by MRI machines, they come in titanium or, most lately, are made of absorbable material. Whatever the composition, the idea is straightforward: shaped like the marriage-bed issue of a V and a U and grasped in the jaws of whatever instrument, the open part is slid across a vessel or duct, the holder-handles are squeezed, and the clip flattens into two legs tightly pressing the tubular structure in question and rendering it closed. Depending on size, pressure, and tightness of one's own sphincter, more than one clip might be closed onto the business end before cutting. Either way, it saves several seconds over clamping and tying; over a long operation with need for many ligatures, it adds up.

Blessedly uncommon, one teensy problem can occur: if the jaws of the applier are out of alignment, instead of bringing the "legs" of the clip properly together, they may overlap in such a way as to turn it into a scissor, cutting when the intent had been the opposite. Depending on where and what, it can fall anywhere along that line which connects "nuisance" with "disaster."

Practically every patient who's had his/her gallbladder out in recent years will have had two little clips placed, one on the artery to the gallbladder, and one on the duct that drains from it into the main bile duct. By the pattern and location, you can tell a person has had the operation just looking at a plain belly Xray. Consequently, I've had many patients return to me upset because their chiropracter took one of their infamous whole-body Xrays and told them that those clips near their spine are causing all sorts of problems, likely requiring monthly manipulations for the rest of their life. I'm guessing the regular reader will not have to wonder what I think of that. It did, however, lead me to be sure to inform everyone in advance, pointing out that we leave chunks of steel the size of doorknobs in hip sockets, and pacemakers aplenty, big as a pocket watch and housed happily.

Mother of all general surgical operations, the Whipple procedure (about which I've written here and in my book) affords many opportunities for applying clips, and I've always done so liberally. One such patient brought me an amazing story, which I'd never heard before and haven't since.

Other than being the color of a daffodil, when I met him he was a very healthy and vigorous man, in his sixties and in need of a Whipple, which I did promptly, slick and quick. His recovery was rapid (much more so than indicated in the preceding link) and he returned in short order to his major pleasure, golf. One day, several weeks after the operation, golfing as usual and on a dog-leg left, long par four, he explained, he felt a strange tickling sensation on his belly. Lifting his shirt and looking down, he noticed some activity at the small and previously healed scar from where I'd placed, and left for a few days, a drainage tube. He got his hand to the area in time to catch a whole series -- fourteen, to be exact -- of steel clips exiting out the former hole in single file like little tin soldiers, blip, blip, plop, plop. He brought them to me in a baggie.

Good One!

My political rants have gotten a mixture of comments, as well they should. Clicking on the name of one of my commenters led to the discovery of the following cartoon. Although it doesn't reflect any plans of mine, at least for now, it's definitely worth sharing:

Sad Times

[This post is another of my forewarned weekend rants, written in part a while ago, during my outage.]


The New York Times recently ran an article that hits home. For a variety of reasons, I've been feeling pretty depressed; if you put my mood on a pie-chart, the state of our nation and world occupies a large part of the dark areas. The rest, well, it's just who I am, and not worth sharing.

If anything, the article doesn't plumb deeply enough. The world IS depressing; and to the extent that some people don't see it that way, well, that's depressing, too. Where to start? OK, how about the war in Iraq?

I accept that some don't see it as the worst mistake ever made by a US president since the beginning of the Republic. It most certainly was, but that not everyone agrees isn't what disturbs me. What does, is that the argument for ending the war is characterized by all the Republican candidates as "surrender," as a great victory for al Queda. But it seems so obvious: our being there in the first place is an enormous victory for AQ. If you were a bunch of guys living in a cave, who had no army, no means on their own to take down this country, wouldn't it be perfect to sucker us into an endless war, depleting our military, our treasure, and our standing in the world, while providing them with a steady stream of recruits? In order to avoid "waving the white flag," as McCain et al like to put it, we must keep doing exactly what those cave-dwellers want: stay there forever, bleeding ourselves to death, and blatantly disregarding everything we've always stood for; not to mention ignoring the things that really might make us safer. On their own, terrorists could hurt but have no means to destroy us, yet it seems they inveigled us very possibly to have done it to ourselves. I'm not arguing that we have no obligation to the Iraqis whose country we so carelessly invaded, nor that leaving wouldn't potentially lead to big trouble within Iraq and beyond. I'm just saying that Bush's war is a win-win for al Queda, and a lose-lose for us. To frame the argument as "white flag" versus "love America" is depressing political bullshit. And stupidity. In his culminating project, ending his string of flip-flops du jour, Romney said, in effect, that voting for a Democrat is "surrendering to terror." How venal is that? How completely despicable!

"Stay on offense." "Strong on terror." What the hell does that mean? Invade another few countries? Of course we need to be intensely vigilant and to intervene when it makes sense. That requires the gathering intelligence; doing so, among other things, depends on having friends around the world who'll help provide it. Which is why it's so important to be respected and admired, rather than hated. Or laughed at. Mitt wanted to "double Guantanamo." If we are so insecure about the ability of democracy and our Constitution to deal with such an enemy, then what the hell are we doing trying to export such a system to the rest of the world?

It's depressing to hear the Republican candidates promise to be like George Bush only more so. McCain: more war, lower taxes. Giuliani wanted even bigger tax cuts. At their debates, they elbowed each other out of the way to exhume the corpse of Ronald Reagan. How many examples do we need before we agree that Reaganomics doesn't work? Reagan instituted tax cuts, everyone felt great, while the deficits mushroomed. It doomed George's dad, who followed him. Clinton raised taxes, Tom Delay and Newt Gingrich screamed, but it brought the budget into balance, the economy roared back; then Bush cut taxes, the Republicans felt great, the deficit once again skyrocketed, and the economy is crashing like the house of cards that it obviously was. And yet... all we hear from the right is a return to Reagan (who also, by the way, reversed all of Carter's initiatives to reduce oil consumption -- and look where that's gotten us.)

"George Bush has kept us safe." Reminds me of the guy falling off the Empire State Building who says, as he passes the thirtieth floor, "So far, so good." The things that HAVE kept us safe, any president would have done: airport security (anyone remember what a fiasco it was at first, because of Bush's insistence -- or was it Cheney's? -- that it be privatized); surveillance (any reason why it couldn't have been done legally; change the law if needed?) The centerpiece, the central front -- ie, Iraq -- has by no reality-based measure made us safer. The opposite is undeniably true. And the list of remaining needs is long.

Some things seem so obvious that they ought to transcend politics. Why is it only Republicans who deny global warming? Why do the people who believe Earth is six thousand years old (or is it twelve?), who want evolution out of school curricula and creationism in, come from the right wing? As the current government overtly tries to redact and ignore science, why isn't everyone screaming bloody murder?!!

How can anyone argue that the institution of marriage is threatened if people of the same sex who love each other have access to it? If your religion doesn't allow it, fine. No church ought to perform marriages of which it doesn't approve. But why prevent another from doing it? Why amend the Constitution? Where's the harm? I've been married thirty-six years. I feel not the slightest threat to my marriage if gays join together in love. Moreover, it's clear that sexual preference is for the most part genetically determined. Like claiming the age of the Earth is a few thousand years, arguing that homosexuality is some sort of abomination in the eyes of God is to ignore fact; at the very least, he has seen to it that there are gays in every culture, in every religion, in every age of man. If it's a perversion, who's the pervert? Clearly the fear-based need to cleave to certain beliefs trumps common sense and common decency.

Democrats, the hollerers spew, "blame America first." What crap!! There are those of us who know the transformative power this country can and has shown, who have seen its greatness, and who long for its return. To lament the last seven years is not to hate America, but to pine for lost love. I was in college when JFK was president; only two weeks before his assassination he spoke at my college, and I was there. His vision and his rhetoric, his wit and intelligence -- even his good looks -- were, to a young person like me (idealist, maybe, but not naive), inspiring and energizing. I hear echoes. But not from the right. From them (from their candidates and radio and TV hosts at least), I hear the peddling of fear, of divisiveness, of exclusion. To the extent that there's hope of harnessing the power of the diverse opinions and skills in this country and bringing it again to greatness of the positive kind, that hope resides not Rovian divide-and-conquer politics, but in imagining much more. From another website: "The reason Obama is winning and will win is so simple. Americans want to believe in themselves again." I think it's true for more than Democrats. But is it possible?

As a veteran, I find it depressing that for most Americans, "support our troops" seems to mean sticking a magnet on the back of their vehicle (well, I admit I have one: but it's this); that patriotism is defined only by loving the war in Iraq. When I was in Vietnam, my wife was working for George McGovern, and I felt supported as hell. How many nowadays would park their yellow-ribboned gas-guzzling SUV and agree to a tax surcharge to pay for the war and its long-lingering needs for our vets? Show of hands?

Ever since Ronald Reagan declared the US was once again "walking tall" after we (wow, successfully!!) invaded that super-power known as Grenada, keeping the world safe for people who couldn't get into American medical schools, there are some that are only proud of this country when it's "kicking ass." That form of patriotism is good for selling flags and ribbons and bumper stickers, but for not much else.

The people who would label me an America-hater and an infidel want to believe in fantasy, to live on borrowed money, to let another generation deal with the mess our politicians (and those who elected them) have made. Unfortunately, they may well have been successful to the point of no return. I'd like to think Barack Obama is right, that there is hope. In the thirst to be proud of this county again, and to be inspired one more time before senescence, I'm willing to risk disappointment. But I think it's too late. We're screwed, and we've done it to ourselves; by succumbing to fear and superstition, by twice electing a president who clearly does not believe in what has, until recently, made our country great. Respect: given and received. Laws: made and followed. Discourse: valued and encouraged. Reason: sought and produced. Power: respected and reserved.

Other than that, I'm feeling pretty good. And believe it or not, I edited a lot of stuff out before I posted this.

Doing God's Work

In response to outbreaks of MRSA and c.difficile, hospitals in England have instituted various hygiene policies, including the need for medical staff to have bare arms, which they must wash to the elbows. Muslim female medical students are refusing, on grounds of immodesty inconsistent with Muslim law. When mentioned on the website Pharyngula, among the comments thereon was this:

Many moons ago I lived with a Bedouin hill tribe near Petra in Jordan. One winter I got terribly sick with pneumonia and had to receive treatment by a Muslim doctor in Petra. Whilst he was a lovely man and their training is first rate he still had to adhere to the silly requirements of his religion. As such, sick as a dog, I could only be examined from the other side of a sheet held up by his two giggling nurses. I explained that it didn't worry me to be examined and to go ahead, lift up my top and listen to my lungs, but no, still had to have that damn sheet. I was in that clinic for a week and all I remember in my delerium is that...sheet.

Some time ago, in another context I wrote about the very regal and imposing matriarch of an immigrant Muslim family on whom I operated. Seeing her in my office, I was forbidden, in no uncertain terms, from exposing her in any way when I examined her; I thumped, prodded and auscultated through her black coverings. When she came for surgery we brought her fully clothed in her religious garb into the OR, and I left it on during the whole operation, sliding it up (while keeping her lower body covered) only after she was asleep. Both the office exam and the OR proceedings broke a few rules of thoroughness, but I really didn't have a problem with it. I made some non-critical compromises to accommodate her beliefs; I assume (but don't know) that under other circumstances -- like evaluating her in critical shape after a car wreck -- her family would have allowed whatever uncovering was necessary.

In refusing for religious reasons to allow a full exam, my patient was the one taking the risk, however small, of forcing me to be incomplete: her religion, her problem. Had I thought it dangerous, I'd either have insisted otherwise, or if unsuccessful, I suppose, refused to provide care (since it was elective.) But the situation in England (and in Petra, for that matter) is different: in following their covenants the medics are putting others at risk. People have right to practice their religion freely (in most Western countries, anyway.) But isn't a line being crossed here? If your religion prohibits you from doing certain things, professionally, that are in the interest of others, ought you not opt out of that particular profession?

Well, of course. And in the US, there are pharmacists who refuse to dispense "morning after" pills for similar reasons. What's next? Young-earth firefighters not rescuing a married gay couple?

Sesqui Semimillionaire

Blogging a little over one and a half years, it seems I recently passed the half-million mark in page views (small potatoes by the standards of the big boys; but to me, significant.) I discovered the joys and perversions and obsessions of site counters only after having been doing it for a while, but the arithmetic would seem correct. I find it amazing. As time has passed there's been an increasing sense that I'm blogging not just for myself; and whereas that could be considered overly self-important, I mean to say that it's gratifying and thrilling that people actually read my tappings from a laptop situated in a small town in a small corner of the planet. And find use for them! As I said on Dr A's radio show, I hadn't considered when I started, nor was even aware of the many unexpected and entirely pleasant ramifications of blogging. It's very cool.

I've gotten only a few insults, and more than a lot of really nice comments; even a little outside notice, once or twice. And I feel I've made actual friends (as opposed to entirely "virtual." They seem pretty real.) Thanks.

ZAP

Not many surgeons nowadays would want t0 operate without an electrosurgery unit, but it wasn't all that many years ago that everyone did. In fact, when dinosaurs roamed the earth and I was still in training, a couple of my teachers refused to use it at all. So I learned both ways. Cutting only with a knife, and controlling bleeding only with clamps and ties and sutures has a certain elegance; grace, even, as tying a small vessel requires gentleness and coordination of the fingers so as not to avulse the knot from the bleeder. But it can also be tedious. I wear size 8 1/2 or 9 gloves.

An electrician or physicist I'm not, so I can only say that electrosurgery refers to any of several devices that provide the surgeon with a pencil-like hand unit, connected to some sort of magic box which sends little electrons or something to that hand unit, which then arc to the patient in at least two different modes: one that's best suited for cutting, and one that serves to cauterize; ie, cook tissue to make it stop bleeding ("dead meat don't bleed," a colleague liked to say). I guess the first such devices, widely available only in the last fifty years or so, were those invented by a guy named Bovie. That name has become like Kleenex to facial tissue -- pretty much used generally and generically to refer to any unit, which I assume must annoy the other manufacturers. "Bovie," the surgeon says, and he or she receives a hand-unit most likely made by someone else.

In those days of yore (or mine) the Bovie looked like something from a B-grade science fiction movie, with knobs and buttons and dials; having a fat handle and foot pedals to operate it. "Turn the coag to sixty," the orthopedist would say when encountering bleeding, and the dial would be rotated far to the right, the surgeon would step on the left-hand pedal (there was one each, for cutting current and for coagulating current). Spzzziiiiit the arc sounded, while the floor unit emitted a low-pitched and disquieting hum. Now, we have tidy little boxes with digital readouts, buttons marked ">" and "<" and spiffy hand units with a rocker switch to go from cut to coag, with no need for a pedal. (Most surgeons, I think, like to dance their index finger on that switch -- or buttons, which some "pencils" have -- but I preferred the side of my thumb, which I could rock back and forth without changing my grip.)

I didn't much use electro surgery for cutting, except for going through muscle, preferring the lesser tissue-trauma and greater speed of a knife, cauterizing as needed. You can scald directly, by touching the bleeder with the tip of the unit and firing away. More precise is to clasp the vessel with fine forceps, then touch the blade of the pencil to the metal of the forcep. "Buzz me," is what I'd say after forceptualizing the bleeding point; my assistant would touch the bovie to my instrument and activate it, and I could let go of the tissue at the instant I was happy. Excellent control. Cautery is great for (some kinds of) bleeding from the liver. The old units had a ball-ended option: turn the phaser to stun or kill, press the ball into the wetness, and blast away. It would, of course, smell exactly like grilling liver, and smoke would rise, white, profuse, acrid. (Concerns have been raised and remain, regarding health hazards to the team inhaling that stuff.) "Turn up the coag," I'd request, "and get us some sterile onions."

Sometimes, when it's cranked way up, you can see little lightning bolts running away from the point, for a few millimeters, within the tissues. Spidery sparks, singeing. A charcoal-like coagulum of tissue and baked black blood forms; depending on the nature of the bleeding, blood may continue to ooze from underneath and around, making the field look like an evil-staring eye. Pulling away the cautery unit, stuck like a grill on steak, sometimes also pulls away the char, and you have to start again.

Since sliced bread, the greatest invention is "spray mode" cautery. Using some electromagical manipulations, these new units can be adjusted to provide a white and sizzling rivulet which leaps as if from a Van de Graaf generator, lighting the space between tissue and tip, covering a relatively broad field of fire, cooking without the need for touching. Excellent! No avulsion of clot. Perfect on liver or spleen, where suturing is tricky.

Gathering dust in many an OR are uber-expensive laser units, once sold to hospitals as the next wave, the future of surgical cutting. Better than electric current, and what the public is demanding, they were told. Half-right. For most operations with which I'm familiar, laser offers absolutely no advantage other than marketing. (It has a rightful place in eye surgery, various skin procedures...) In laparoscopic surgery (where laser was predicted to be the ne plus ultra and isn't), there are cleverly conceived devices that combine in one wand, cautery, suction, and irrigation. In the early years of laparoscopy, that was precisely what I thought was needed, and, by golly, here it is. When scissors are added, a lot of annoying motion (taking one instrument out, inserting another, back and forth) will be eliminated. Surgeons nowadays are deeply beholden to engineers.

Penultimate Gift

In my local newspaper there was recently a letter to the editor, the gist of which was that people who indicate they'd be an organ donor (we have a place on our driver's license to do so) ought to go to the head of the waiting list were they ever to need one; and conversely, those that don't so indicate go to the back of the line. It would, he said, go a long way toward solving the shortage of available organs. And so it might.

It's been many years since I was involved in a very busy transplant program. Way back then, there were, in some localities, committees set up to decide the relative worthiness of potential recipients. Doctors, nurses, social workers, clergy, lay people met to hash it out, to prioritize recipients of those scarce bits of flesh based on highly subjective considerations of people's relative value. To someone. Far as I know, such deliberations no longer occur. The ideal, of course, is that one's place on the list is determined only by medical need and appropriateness, and the urgency thereof (Mickey Mantle and other celebrities notwithstanding.) The letter writer's suggestion, it seems to me, is a step backward. I've indicated that I'm a donor; if I were given an option, I wouldn't specify that it should only go to another person so inclined, nor would I want it to be legislated that way. And, I'm pretty sure, I wouldn't place a lesser value on the life of a person who, for reasons unknown to me, chose not to be a donor.

Such were my thoughts as I read the letter, and I was surprised to see that it came from a person who identified himself as executive director of an organization involved in promoting organ donation. Surely it's a worthy goal to increase organ donation among the population. (We're talking about post-mortem donation here; living donors are self-directed, as they should be.) As it now stands, there's no self-interest in checking that box -- other than feeling good about oneself, and, of course, the hope that it might cancel out a life of dissolution and get one a ticket to heaven.

I'm not certain about this. The letter writer is more involved than I am. Maybe it's a smart idea, especially as society becomes more self-centered and less generous. Maybe "what's in it for me?" ought to be the motivator, as it is in so much else. Could such a system be gamed? After all, most people who indicate their willingness don't end up being a donor. And, I wonder, how many cadaver donors come from that checked box, without input from family? Conversely, how many potential donors are "wasted" (if that's a proper term) because of a lack of advanced directive? In my experience the decision is generally made at the time of disaster, by the family, regardless of prior indications. These questions are part of why I'm uncertain. The rest, I guess, is philosophical. Tenuous territory for a surgeon.

For the time being, organ donation is a gift with no strings; an act of generosity and grace and, often, a way forward for the bereaved. (I refer the reader to a post of mine from a while ago.) The better part of me (that vanishingly small nut-like nubbin, ever more withered and battered) says it ought to stay that way. The pragmatist and cynical (ever growing, especially that last part) says, given what we are become, maybe the guy is onto something.

Tortured Logic

[I can't help myself: I write political posts, but more often than not, I haven't posted them. But what the heck. There are some things I believe strongly, and in these most consequential of political times, where, as far as I'm concerned, the existence of the US is literally in the balance, I'm gonna post them. It's not like it'll make any difference, other than pissing off some of my readers; which is decidedly NOT what I want to do. So, as a compromise, I've decided that from now on when I post these screeds, I'll do it on weekends, when not as many people drop by. It's in no way my intention to turn this into a political blog: my goal remains to provide insight, information and hopefully some humor as it relates to the practice of surgery. But on some things, I can't hold my tongue.]




President Bush told the world, "The United States does not torture." (I did NOT..Have..Abusive... Relations...with that prisoner... Mister Zubayda...) The CIA now admits to waterboarding at least three prisoners. So there are two possibilites: Bush is a liar, or the US has undefined waterboarding as torture. Either way, it only adds to the degradation of our image in the world.

After WW II, the US prosecuted Japanese soldiers for waterboarding our own. During the Vietnam War, a GI was convicted in a court martial for waterboarding a Vietnamese prisoner. It's a technique used by the Khmer Rouge, the North Vietnamese, in Chad, and in the Spanish Inquisition. And, it should be noted, its purpose was to get people to confess to things they hadn't done. Like being witches, or pawns of the criminal US government (as in the case of North Vietnam.) Not, in other words, to get at the truth. Under such torture, it's said, people will say anything. It's not a lie detector. Except, evidently, in the US.

But that's neither here nor there. The point is this: waterboarding is torture, and has been so designated by the UN Convention Against Torture, not to mention the US's own standards. Until now. So. Who do you think we are, George Bush? If you want to argue, like Jack Bauer, that torture works and is justified, then do so and make your case. Does it, in fact, produce reliable information? Is it the best or only way? Is it in our long-term interest to be known as a nation that tortures? To survive, must a democracy be as bad as the baddest? People so argue. Man up, as they say, and give us your best shot. Just don't lie to us, or insult us by saying black is white. There's already more than enough bullshit to go around.

And, for the record, I happen to think that becoming like our enemies, in the case of Islamic terrorism, is exactly the wrong way to win the war, which, in the most final of final analyses, is a war of ideas. I think our ideas have transformative power, which is, in part, why Osama, et al, keep convincing George Bush to piss all over them. Is what I think.

How I Spent My Day

I went to an Obamarama today: he spoke in Seattle, at Key Arena, which is where concerts are held and where the Sonics play. Yesterday Hillary spoke to about five thousand people. Today when we arrived the line stretched for countless blocks; holding seventeen thousand, the place was filled and doors were closed while thousands of us remained in line. The media said it was three thousand who stayed to hear the speeches piped out to us; it looked like more, and it was after thousands left as soon as the news came that the place was full (it was cold and windy and a little rainy.)

Obama arrived after quite a wait, but when he did, he stopped before going in and addressed us lockedoutenfolk, which was thoughtful. In his speech he said all the things a candidate for whom I'd vote would have needed to say, and many others. It was worth the wait, even if I received some negative feedback from my bladder.

But here's the kicker: I'd been contacted recently by the woman who runs Washington Veterans for Obama. Turns out her father was in the Air Force in Vietnam at the same time I was, and was shot down, survived in the jungle and maintained radio contact for eleven days before he went silent, never to be heard from again. I remember hearing about it while I was there: we were waiting for word and possible rescue, but it never happened. She said they wanted some veterans on stage today, behind the Senator, and to call her when I was there; she might make it happen. So when we arrived I called her cellphone, but was only able to leave a message. I checked my phone a while later, and there was a voice mail: she had a VIP ticket waiting for me; I should leave the line and go right to the entrance.

By the time I got the message, it was too late.

Damn.

Post Talk, Propter Talk

I thoroughly enjoyed myself on last night's radio show. Listening later, I cringed a couple of times, and wished I'd stammered a little less, and said "y'know" more infrequently. Still, it was great fun. Most particularly, I appreciated the people who honored me with their calls: bongi, Rob, Enrico, Seaspray, Eric. How great to talk to you all! And when I say honored, I really mean it!

The chat room was populated with lots of my cyberfriends and was, according to my wife who watched the scrolling words, lively and highly entertaining. I wish THAT were archived!

Most of all, I'm grateful to the inventive Dr Anonymous, who has pioneered that aspect of the blogosphere, for having me on. This whole blogging thing is quite amazing: the connections around the world being at the top of the list of the unexpected pleasures. Thanks, everyone.

For anyone who missed it and has an hour to waste, it's archived here.

That'd Be Up The Butt, Bob

[If you don't get the reference, I ain't explaining.]


I have some memories of the first time I did a rectal exam as a student. I even seem to recall that we were made to do it to each other, before inserting ourselves into the affairs of patients. Embarrassing, to be sure, there was also a sense of gratitude and bemusement that people would agree to such a thing, while surely knowing it was of no benefit to them. They allowed students, overtly unsure and explicitly unskilled, to prod them for the sake of furthering education.

Much maligned, and stereotyped as a physician's perverted pleasure; the (obvious word here) of comedians' jokes, rectal exam is in fact an important intervention. Especially, I'd propose, for surgeons. Like a Swiss Army Knife, it's an all-purpose tool. Many things in one. E probicus, unum. (Not that anyone would put a Swiss...) For most doctors, it's a matter of poking around for a little stool to test for blood, and, half the time, to make a pass over the prostate. For a surgeon, it's diagnostic, therapeutic, and a means of making plans.

It's impossible for me to be unaware of the inequities inherent in the fact of one person having his finger up the hindmost of another. Of the things we do, on an awake patient at least, it's arguably the strangest, and I've always wondered how it seems to the recipient. Like some sort of ritual? A rite of passage? (Passageway?) Something akin to what witch doctors do; a sacred privilege given only to them? An assumption that there's some special divining going on, the mysteries of which are learned in secret? In any case, it behooves one fully to explain exactly the reasons for such a transgression. So here are some:

• In evaluating a patient with bowel obstruction, it's useful to determine if there's air in the rectal vault.
• By revealing localized pain on the right, it can help in the diagnosis of appendicitis.
• With a pelvic abscess from any source, it can determine the feasibility of trans-rectal drainage. (Yes, it's possible to do it without a radiologist, and there's still a place for it.) In fact, under some unusual circumstances, such an abscess, followed for "ripening," can be drained digitally and yuckally, right there in the bed.
• Rectal exam can stimulate the bowels to move, in a post-op patient (hopefully not in an instantaneous fashion.)
• Among the most important: it predicts successful resection of rectal cancer with the ability to re-connect the colon without colostomy. (If I can feel the tumor on rectal exam, I won't be able to resect with a margin safe for anastomosis.)
• The exam helps to judge how extensive a rectal tumor is; how large, and how fixed in position. The need for pre-op radiation is determined, in part, this way.
  
• When that very low stapled anastomosis becomes too tight (which they sometimes do), it can be permanently fixed with a single digital dilatation.
• Some anal fistulae track up into areas that can be felt and mapped out by a rectal exam.
• In addition to routine evaluation of the prostate, there are some circumstances wherein prostate massage is therapy.

I'm sure I'm missing some.

Despite the fact that my own doc liked to do the exams from behind, with me standing up and leaning onto the exam table, I always felt (perhaps from that very experience*) that the most gentle and least humiliating way to do a rectal exam is with the patient curled up on his/her side, and covered except for the target orifice.

I've been told that some clinicians of the older school (but within my lifetime) insisted on doing rectal exams ungloved, for maximum sensitivity. Hopefully, someone was jerking my chain. For me: properly fitting glove, plenty of lube, and thoughtfully trimmed nails.


*And from thinking of the apocryphal story of the military doc (it would have to be military) who had some patients bend over and would then put his left hand on their left shoulder, his right index finger in the anus, and then have a hidden corpsman sneak out and put his right hand on the victim's right shoulder...

Tonight's The Night

As previously announced, I'll be on Dr Anonymous' blog talk radio show tonight. I'll try not to embarrass myself (I have a cold, which will either make my voice sexy, or absent). Join in if you can, here. The show starts at 9 pm Eastern, but the chat room (requires a simple and free login) will get going a little before that. On the website is a number for calling in, which anyone can do. Be there, or be... sensible. (The shows are archived there, so if you wake up tomorrow and smack your head in a V-8 sort of way, you can still hear it, non-participat-orally.)

F*ck 'Em

Or help 'em. Those, it seems, are the philosophical options in the funding of health care nowadays. In order to balance the budget, George Bush wants major cuts in Medicare and Medicaid. Primarily, his plan is to cut back on payments to hospitals and nursing homes. There is also on the table a pending cut of ten percent in reimbursements to physicians, but I'll not make this post about that except to say the obvious: there's only so much blood in that turnip. Somewhere there's a floor below which doctors can't and won't go. We're there, in my opinion. Care will become less available. But I'm out of the provider loop nowadays. So let's talk about recipients.

What do you do with people who can't, for whatever reason, afford medical care? You either bar the door, or you let them in. F*ck 'em, in other words, or help 'em. And if you help them, but don't pay hospitals enough to cover the costs, then in order to stay afloat, hospitals must shift the burden to those who do have coverage. Our politicians may be cool with deficit spending, but hospitals aren't, and can't be.

Controlling Medicare and Medicaid costs mainly by cutting reimbursement is, to use a sophisticated economic term, moronic. Unless the plan is to ration care by putting a bunch of hospitals out of business. I'm all for accountability and for the eliminating of waste in the system and for promoting best practices. But, as I've said previously, at some point this country will have to face the fundamental question: how much can we spend on health care, and how will we divvy it up? If we choose to ration care, or to have different levels of care for those that can pay and for those that can't, then let's just stand up and say it, rather than slither around it.

The problem with the (conservative) view that people ought to bear responsibility for their health care and retirement costs is that not everyone can. Many people count on Social Security -- anathema to so many on the right -- and retirees are expected by their former places of work to have Medicare to cover their medical needs at some point. It makes sense to me to index premiums and payouts based on a person's ability to pay. But the scattershot approach of continually lowering reimbursement to providers is chickenshit: it begs the question, and hides the real philosophical differences at work. Picking up corpses is cheaper than paying for care (if they smell bad, we could have illegal aliens do it). So would it be to send those who can't afford care to some place where they can do their damn duty and die. But if that's abhorrent, and if we choose to provide care, then cutting the payments for it simply shifts costs to businesses and rich people -- the very constituency Bush is trying to protect in choosing to pay less rather than to increase revenue. Isn't it cleaner and more transparent to adjust taxes to cover expenses (while doing everything possible to reduce costs)? Maybe the upcoming election will clarify where, as a country, we stand. F*ck 'em, or help 'em. Time to make the call.

Oh, and George's budget also has significant cuts in funding for medical research, as well as a 400 billion dollar deficit. So fuck us all.

Never Mind

Brief note to those who, seeing a couple of posts disappear of late, including one that was up for three seconds a few minutes ago: I haven't lost my mind. A few minutes ago I hit the "publish" button instead of "save" for a post not yet ready. And the others a couple of days ago involved the posting of a moving video (OK, it was about Barack Obama) which kept getting made unavailabe so I gave up. It's (probably) still available here.

Surgeons and Sex

Well, here's a new one: it's reported that women who have lumpectomy for breast cancer are more likely to have radiation therapy afterwards if their surgeon is female. Once again, I'm stumped. As a surgeon of the scrotumnal sort, I'm trying to figure it out. In the article, you'd see the differences weren't huge; and that there were other independent characteristics which seemed to matter at about the same level: that the surgeon was an MD, and that s/he was US-trained. (Chauvinistic in ways other than sexual, I'm not surprised by those two.)

It's hard to imagine any properly-trained surgeon who doesn't know of the need for adjunctive breast irradiation after lumpectomy. As always, there's room for some judgment: from a few very elderly and frail women I've removed a cancerous lump under local anesthesia and elected -- fully consulting with patient and family about options -- simply to follow along with no other treatment except, for some, hormone therapy. But the study is said to have controlled for age and other factors. So what can it mean? Are female surgeons more interested in saving the lives of their patients than males? Is it that we males prefer the feel and look of uncooked and unbrowned breasts (truth be told, I've heard it said more than a few times that the irradiated breast is preferred by its owner, because of youthful firmness)? After a night of carousing and piggish behavior, did the menfolk sleep through the lecture on complete breast treatment?

Maybe it's patient self-direction: women who don't want "all that fuss" (ie, radiation) gravitate toward male surgeons. It could even be, I suppose, that males are more open to modifying treatment for the frail and very elderly to whom I referred above. Or maybe it's about the age of surgeons: could older ones not be up to date? I doubt it; but if it's true, there are a lot more old male surgeons than female ones, since the demographics have only somewhat recently shifted toward the ovarian model.

At the end of the article it's stated that more work is needed to figure it all out. Meanwhile, it has me mystified. In most ways I think women are more admirable than males. Still, I'd hate to have to hang my nuts on a nail to practice my craft.

Juggling Brains

The always amazing bongi (I could also characterize him as shiftless, but not everyone would get it) has a post that led me to think about how doctors juggle patients in their brains, and how bizarre it is. The need to switch gears rapidly and completely among clients, customers, or patrons of one sort or another surely isn't unique to physicians. It's just that, given the stakes, with docs it might be the most jarring and otherworldly.

I've always tried to be mindful of -- and here I'm just making up a term -- "disproportionate impression." I walk into a patient's hospital room, or see someone in my office, and it may well be the most important and impactful minutes of that person's day. For me, it's one of many similar encounters, some pretty routine, others of horrendous import. I'm the only surgeon each patient has; each is but one of many for me. My words and reactions likely reverberate in each room for hours or days; but I must move on and reset my brain in a blink. Therein is the unworldly aspect of it: I can't, but I do. I mustn't, and I must.

"Minor surgery," it's said, "is surgery done on someone else." Seeing a surgeon is a big deal, whether for removing a harmless lump, fixing a hernia, or taking out half an esophagus. Everyone deserves a full measure of my attention. If I'm despondent over a patient dying in the ICU, or have a bunch of operations pending later, or am feeling like God's gift to surgery because of some tricky procedure done well, I have to attend properly to the person in front of me. To give a young woman news of her cancer, as bongi wrote, and only a moment later to see a routine post-op, or speak hernia. I guess that's what is meant by "compartmentalizing." I can't quite figure out if it's a good or a bad thing to be able to do it.

In my book, I wrote:

"There are times when I’ve thought that having been inside people’s bellies, touching them more intimately than they’ve ever been touched, knowing things about them that they’ll never know themselves—seeing their liver ferchrissakes!—I ought to stay at their bedside for every minute of every day they remain the hospital. Maybe take them home with me..."

I wasn't kidding. It's such a cataclysmic thing, operating. How can you operate on a person and just move on to the next case? It seems, to paraphrase and borrow from myself, "disproportionate attention." But it's obvious we need to; and somehow, in the process, we must not shortchange anyone. Including ourselves. I can handle it during the day. I just wish it could be turned off when pulling up the covers for the night, which is when the compartments seem to break down.


[P.S: For those of you who noticed and are wondering, I put up a video twice this weekend, and finally took it down because the video, about Barack Obama, kept becoming "unavailable." No hidden meaning to the disappearance, other than frustration.]

Radiohead

Far as I know, I'm scheduled to be on Dr. Anonymous' internet radio show next week, Thursday February 7. It's at 9 pm Eastern. In addition to listening -- a good way to waste an hour -- people can call in. I'd love to hear the voices of some of the regulars around here. Also, there's a live chat-room associated with the show. That requires a free log-in, but listening doesn't. Calling in is not toll-free. The shows are archived, for those who don't make it live.

Information is here. I'll put up another reminder as the time approaches, since, from what I've heard, you're pretty busy.