Almost famous

I was nearly famous. Coming this close to being on the PBS News Hour, I was fully prepared to receive love notes and hate mail, and probably would have. The subject was outpatient mastectomy, and I was for it. My patient made it on; I didn't.

Let's get this part out of the way right off the bat: there's no way I would EVER advocate that mastectomy should be considered an outpatient procedure in the sense that insurance companies would urge or require it. The default mode (as we computer-literate folk would say) is and ought always to be that it's done in the hospital. As with many things, I think that when there are options, women having the right to choose is a good thing. Having done many outpatient mastectomies, I can say with complete confidence that it's safe, amazingly well-tolerated, and, for some women, is better in all ways than being in the hospital. Especially in a hospital where the nurses are made to care for too many patients, or to rotate to specialty areas with which they aren't familiar.

First, some housekeeping basics. Clearly, for the woman having immediate reconstruction, outpatient mastectomy is not appropriate. Maybe in the near future I'll say why I have a mild bias in favor of deferring reconstruction ("mild" being the operative word -- it's a complicated matter which I don't want to get into now, but, as I think more about it, will definitely do so later.) And I'm painfully aware of how devastating the idea of mastectomy can be: even mentioning outpatient surgery as an option is something I've done very selectively. It's not for everyone. But physiologically speaking -- referring here to the impact on the body -- there are several operations that I'd consider more "severe," and which are quite often done as outpatient procedures: gallbladder surgery, gastric banding for obesity, various gynecological procedures.

Poking around inside the abdominal cavity has bigger implications than what is essentially a skin operation. OK: "skin operation" is a little glib. But really, the breast is a modified sweat gland. That lovely form, the symbol of femininity and the object of admiration by men and women alike, that most desirable (here I speak as a heterosexual male person and not as a physician!), soft and warm living poetry stinks like a locker room when you cut into it with an electrocautery device. And when you remove it, the operation is mainly on and under skin, leaving muscle -- where most of the pain comes from -- pretty much alone. The old days of removing the pectoralis major and/or minor, along with swaddling the patient in enormous restrictive dressings, are long gone. So, thankfully, are significant blood loss and hours of anesthesia.

Properly done, mastectomy ought not require blood use, and can be thoroughly carried out in well under an hour. My patients almost always woke up with no pain at all, because I had a way of injecting a long-acting local anesthetic into the field. But even when it wore off, most women were quite surprised at how comfortable they felt. (Nothing in medicine is 100%!) Of those that were hospitalized, the greatest number went home on the first day postop.

You get an idea when you see them: some women would rather not be in the hospital for any of a number of reasons. Privacy. Self-control. Whatever. And there was a time -- which is only marginally better today -- when nurses were so overworked and understaffed that patients didn't always get the sort of care they needed. Drains. Drove me crazy. Leave a drain or two in the area after mastectomy, expect them to be operated properly; otherwise, blood will build up (a "hematoma") and be a source of problems. I wanted them checked frequently and emptied properly; depending on the experience and workload of a given nurse, it might or might not happen. At home, with proper instruction, there was never a problem. So I did more than a few outpatient mastectomies, and neither I nor the women involved had reason to regret them.

In Connecticut, I think it was, a health insurance company is said to have announced it had designated mastectomy as an outpatient procedure. No reason it needed hospitalization; wouldn't pay for it in the hospital unless specifically excepted. People were, justifiably, outraged. There's some controversy as to whether it's actually true that the insurance company made the decision. But it's unquestioned that there has been an uproar, and that Congress has (huzzah) gotten involved, proposing legislation. "Drive-thru mastectomy" is what it came to be called, and it was a rallying cry for many advocacy groups. And, as happens when things get politicized, the truth got sort of swept away.

Once again, I'll say I fully agree: mastectomy has no place on the list of operations mandated as outpatient procedures. (Nor, in my opinion, does the one thing that is generally so mandated, and which is the most egregiously inappropriate: hemorrhoidectomy. Another topic, sometime.) But it absolutely can be done that way.

So, for some reason PBS got wind of it and of all places, it was in the Seattle area that they planned to do a segment on it, on the News Hour. And as luck would have it, the director of the surgery center at which I did most of my outpatient operations was contacted to see if she knew of anyone doing outpatient mastectomy. She gave them my name. I got a call and had a nice conversation with a producer of the show. Great, I thought. I could explain the realities; I made it clear to him that I thought it was very appropriate when the woman preferred it, but in no way should it be required. And, I figured, I'd get a chance to put in a plug for nurses: tell the country what the effect on quality care had been of the steady cuts in hospital reimbursement.

The man seemed quite sympathetic. What he wanted was to follow a woman through the whole thing: show a bit of the operation, film her at home. He needed someone within a fairly short time-frame, and although I saw several women with breast cancer -- as usual -- in the next couple of weeks, none was a candidate. I let the producer know, and asked if he'd like to talk to a patient who'd had it. He would. I contacted a couple of my patients and they were happy to offer themselves. If the piece was produced, I was assured, and if they included my patient, they'd schedule an interview with me, as well.

Time passed, silently vis a vis word from PBS. Until one day I got a call from someone telling me Mr. Producer wanted to let me know the show would be on tonight. What? No me? What about my three minutes of fame? My subsequent offers from Hollywood, the surge in my practice? Well, she said, it's on tonight.

It started well enough. The first patient profiled was mine, who said, among other things, that she'd had dental work that was a bigger deal. Her kids fought over who could empty her drain. She'd do it again in a heartbeat. Best decision she'd made. Like that. Then there were a couple of surgeons saying why it couldn't or shouldn't be done. Patients could never manage the bandages; things could happen that would lead to problems. It's a horrible and insensitive idea. Dangerous. And a couple of patients tearfully saying how they'd been hustled out of the hospital before they were ready. Had I been on, too, I suppose I'd have looked like an idiot. These docs were professors; I was just some country schmoe. And yet, they'd started with my patient saying what a breeze it was. Who, indeed, was the schmoe? If your patients can't handle a bandage, I thought, either you aren't instructing them well, or your bandages are too damn complicated. Bad things happen? Sure they do. But so they can with any outpatient procedure, or with brushing your teeth.

Surgeons -- myself included -- accept change with glacial speed. The things we were taught were pounded in with heavy hammers, and deviation was met with fire and spittle. To consider change is to face a nearly physical reaction and to hear your teachers shouting you down from the grave. It takes a conscious act -- an act of rebellion, really -- to consider the things you do and the instructions you give patients and to examine where they came from and the extent to which they actually make sense. "Don't lift more than ten pounds." Anyone do a study: this group, you lift five pounds; that group, you lift fifteen?

When I was in training there were a couple of old docs still practicing who'd been trained in the days when any person who'd had major abdominal surgery was required to stay in bed for two weeks. Pneumonia, pulmonary embolus -- they were just part of the deal. Get up, your guts'll fall out. Likewise, women who'd undergone mastectomy were told not to reach, not to lift, not to shower. Why, exactly? I was told -- very strenuously -- as a resident that everyone who underwent splenectomy needed a stomach tube for three days. Why? Because otherwise their stomach would dilate and pop the sutures off the short gastric veins. So that's what I did. Until I thought: wait a minute. I can tie a suture so it doesn't pop off. Do you suppose that it happened to one of his patients (or one of his teacher's -- or his teacher's teacher's) and led to a stone-carved rule?

My instructions to mastectomy patients -- no matter where they found themselves postop -- was to avoid things that hurt, and otherwise to do whatever they wanted. That simple. And, because I used a very small bandage covered in plastic, they could shower whenever they wanted. Yes, there was a drainage tube, connected to a bulb-like collection device. Hang it around your neck in the shower, like soap-on-a-rope, I'd say. And although I've seen the occasional hematoma develop in a hospitalized patient whose drain was ignored, it never happened in my outpatient people.

So what can we learn from all this? First, not everyone who speaks with confidence knows what the hell he/she is talking about. (This, of course, could just as well apply to me.) Second, health insurance companies -- no matter how soothing the music is in their TV ads -- are interested in the bottom line above all else and make decisions that are not necessarily in the interest of their subscribers. Third, doctors do lots of things because they were taught to do so and which have never been subjected to meaningful analysis to see if they actually make sense. Fourth, changing those things is incredibly difficult for lots of complicated reasons. Fifth, if -- and I hope you never are -- you are faced with the need for mastectomy and hate the idea of having to stay in the hospital, and your surgeon offers to do it as an outpatient, feel free!

Almost famous

I was nearly famous. Coming this close to being on the PBS News Hour, I was fully prepared to receive love notes and hate mail, and probably would have. The subject was outpatient mastectomy, and I was for it. My patient made it on. I didn't.

Let's get this part out of the way right off the bat: there's no way I would EVER advocate that mastectomy should be considered an outpatient procedure in the sense that insurance companies would urge or require it. The default mode (as we computer-literate folk would say) is and ought always to be that it's done in the hospital. As with many things, I think that when there are options, women having the right to choose is a good thing. Having done many outpatient mastectomies, I can say with complete confidence that it's safe, amazingly well-tolerated, and, for some women, is better in all ways than being in the hospital. Especially in a hospital where the nurses are made to care for too many patients, or to rotate to specialty areas with which they aren't familiar.

First, some housekeeping basics. Clearly, for the woman having immediate reconstruction, outpatient mastectomy is not appropriate. Maybe in the near future I'll say why I have a mild bias in favor of deferring reconstruction ("mild" being the operative word -- it's a complicated matter which I don't want to get into now, but, as I think more about it, will definitely do so later.) And I'm painfully aware of how devastating the idea of mastectomy can be: even mentioning outpatient surgery as an option is something I've done very selectively. It's not for everyone. But physiologically speaking -- referring here to the impact on the body -- there are several operations that I'd consider more "severe," and which are quite often done as outpatient procedures: gallbladder surgery, gastric banding for obesity, various gynecological procedures.

Poking around inside the abdominal cavity has bigger implications than what is essentially a skin operation. OK: "skin operation" is a little glib. But really, the breast is a modified sweat gland. That lovely form, the symbol of femininity and the object of admiration by men and women alike, that most desirable (here I speak as a heterosexual male person and not as a physician!), soft and warm living poetry stinks like a locker room when you cut into it with an electrocautery device. And when you remove it, the operation is mainly on and under skin, leaving muscle -- where most of the pain comes from -- pretty much alone. The old days of removing the pectoralis major and/or minor, along with swaddling the patient in enormous restrictive dressings, are long gone. So, thankfully, are significant blood loss and hours of anesthesia.

Properly done, mastectomy ought not require blood use, and can be thoroughly carried out in well under an hour. My patients almost always woke up with no pain at all, because I had a way of injecting a long-acting local anesthetic into the field. But even when it wore off, most women were quite surprised at how comfortable they felt. (Nothing in medicine is 100%!) Of those that were hospitalized, the greatest number went home on the first day postop.

You get an idea when you see them: some women would rather not be in the hospital for any of a number of reasons. Privacy. Self-control. Whatever. And there was a time -- which is only marginally better today -- when nurses were so overworked and understaffed that patients didn't always get the sort of care they needed. Drains. Drove me crazy. Leave a drain or two in the area after mastectomy, expect them to be operated properly; otherwise, blood will build up (a "hematoma") and be a source of problems. I wanted them checked frequently and emptied properly; depending on the experience and workload of a given nurse, it might or might not happen. At home, with proper instruction, there was never a problem. So I did more than a few outpatient mastectomies, and neither I nor the women involved had reason to regret them.

In Connecticut, I think it was, a health insurance company is said to have announced it had designated mastectomy as an outpatient procedure. No reason it needed hospitalization; wouldn't pay for it in the hospital unless specifically excepted. People were, justifiably, outraged. There's some controversy as to whether it's actually true that the insurance company made the decision. But it's unquestioned that there has been an uproar, and that Congress has (huzzah) gotten involved, proposing legislation. "Drive-thru mastectomy" is what it came to be called, and it was a rallying cry for many advocacy groups. And, as happens when things get politicized, the truth got sort of swept away.

Once again, I'll say I fully agree: mastectomy has no place on the list of operations mandated as outpatient procedures. (Nor, in my opinion, does the one thing that is generally so mandated, and which is the most egregiously inappropriate: hemorrhoidectomy. Another topic, sometime.) But it absolutely can be done that way.

So, for some reason PBS got wind of it and of all places, it was in the Seattle area that they planned to do a segment on it, on the News Hour. And as luck would have it, the director of the surgery center at which I did most of my outpatient operations was contacted to see if she knew of anyone doing outpatient mastectomy. She gave them my name. I got a call and had a nice conversation with a producer of the show. Great, I thought. I could explain the realities; I made it clear to him that I thought it was very appropriate when the woman preferred it, but in no way should it be required. And, I figured, I'd get a chance to put in a plug for nurses: tell the country what the effect on quality care had been of the steady cuts in hospital reimbursement.

The man seemed quite sympathetic. What he wanted was to follow a woman through the whole thing: show a bit of the operation, film her at home. He needed someone within a fairly short time-frame, and although I saw several women with breast cancer -- as usual -- in the next couple of weeks, none was a candidate. I let the producer know, and asked if he'd like to talk to a patient who'd had it. He would. I contacted a couple of my patients and they were happy to offer themselves. If the piece was produced, I was assured, and if they included my patient, they'd schedule an interview with me, as well.

Time passed, silently vis a vis word from PBS. Until one day I got a call from someone telling me Mr. Producer wanted to let me know the show would be on tonight. What? No me? What about my three minutes of fame? My subsequent offers from Hollywood, the surge in my practice? Well, she said, it's on tonight.

It started well enough. The first patient profiled was mine, who said, among other things, that she'd had dental work that was a bigger deal. Her kids fought over who could empty her drain. She'd do it again in a heartbeat. Best decision she'd made. Like that. Then there were a couple of surgeons saying why it couldn't or shouldn't be done. Patients could never manage the bandages; things could happen that would lead to problems. It's a horrible and insensitive idea. Dangerous. And a couple of patients tearfully saying how they'd been hustled out of the hospital before they were ready. Had I been on, too, I suppose I'd have looked like an idiot. These docs were professors; I was just some country schmoe. And yet, they'd started with my patient saying what a breeze it was. Who, indeed, was the schmoe? If your patients can't handle a bandage, I thought, either you aren't instructing them well, or your bandages are too damn complicated. Bad things happen? Sure they do. But so they can with any outpatient procedure, or with brushing your teeth.

Surgeons -- myself included -- accept change with glacial speed. The things we were taught were pounded in with heavy hammers, and deviation was met with fire and spittle. To consider change is to face a nearly physical reaction and to hear your teachers shouting you down from the grave. It takes a conscious act -- an act of rebellion, really -- to consider the things you do and the instructions you give patients and to examine where they came from and the extent to which they actually make sense. "Don't lift more than ten pounds." Anyone do a study: this group, you lift five pounds; that group, you lift fifteen?

When I was in training there were a couple of old docs still practicing who'd been trained in the days when any person who'd had major abdominal surgery was required to stay in bed for two weeks. Pneumonia, pulmonary embolus -- they were just part of the deal. Get up, your guts'll fall out. Likewise, women who'd undergone mastectomy were told not to reach, not to lift, not to shower. Why, exactly? I was told -- very strenuously -- as a resident that everyone who underwent splenectomy needed a stomach tube for three days. Why? Because otherwise their stomach would dilate and pop the sutures off the short gastric veins. So that's what I did. Until I thought: wait a minute. I can tie a suture so it doesn't pop off. Do you suppose that it happened to one of his patients (or one of his teacher's -- or his teacher's teacher's) and led to a stone-carved rule?

My instructions to mastectomy patients -- no matter where they found themselves postop -- was to avoid things that hurt, and otherwise to do whatever they wanted. That simple. And, because I used a very small bandage covered in plastic, they could shower whenever they wanted. Yes, there was a drainage tube, connected to a bulb-like collection device. Hang it around your neck in the shower, like soap-on-a-rope, I'd say. And although I've seen the occasional hematoma develop in a hospitalized patient whose drain was ignored, it never happened in my outpatient people.

So what can we learn from all this? First, not everyone who speaks with confidence knows what the hell he/she is talking about. (This, of course, could just as well apply to me.) Second, health insurance companies -- no matter how soothing the music is in their TV ads -- are interested in the bottom line above all else and make decisions that are not necessarily in the interest of their subscribers. Third, doctors do lots of things because they were taught to do so and which have never been subjected to meaningful analysis to see if they actually make sense. Fourth, changing those things is incredibly difficult for lots of complicated reasons. Fifth, if -- and I hope you never are -- you are faced with the need for mastectomy and hate the idea of having to stay in the hospital, and your surgeon offers to do it as an outpatient, feel free!

Quick to the Cut

The following is from my book. It might lead to some posts on trauma issues. Meanwhile, it's a passage I like, and it's handy:

Real men open chests in the emergency room. Every surgical resident wants to do it; it’s exciting, dramatic, life-saving, and a little bit showy. We’d do it for any of several reasons, especially when there’s massive bleeding in the belly: getting a clamp on the aorta via the chest can slow the leak of blood into the abdomen, without getting into a mess before you’re in the operating room. Opening a belly in the emergency room for any reason—but especially for bleeding—would be disastrous. Because the belly wall compresses bleeding to some extent, pressure drops precipitously when you open and take away that compression, and you need all the resources of an OR to handle it. More exciting, chests also get cracked for heart massage. When the heart is empty from exsanguination, pushing on the chest from the outside does no good, so we’d open chests directly to squeeze the heart until we could get the tank filled back up with blood and IV fluids. The desire to do it could be hard to resist. I stood watching, on one occasion, as the team was tuning up a
victim of multiple gunshot wounds. He was semi-conscious, struggling and mumbling, fighting back reflexively at the efforts to help. Just after I turned away to call the OR and the attending, the patient hollered out in pain. Having heard the nurse announce the blood pressure had dropped to zero, the ER resident had started a slash in the chest.
“Holy shit!” I shouted as I turned back to the scene. “What are you doing?”
“Zero blood pressure. Gotta open the chest,” he said, getting pumped up for the glory.
“Jesus Christ, man, the guy is awake!”
Reaching across the gurney, I fended off the attack before the scapel made it all the way in, leaving the resident to his own thoughts as we took the victim upstairs. No pulse, no blood pressure— the combination was often a ticket into the chest. But, c’mon, not in someone still talking and moving around! After a routine save in the operating room, stopping some bleeding, closing some holes, the man recovered without a problem. A couple of days after the surgery I casually asked him what he recalled about his time in the ER. Nothing.


There’s a trick to emergency thoracotomy (opening the chest): ribs spread apart with difficulty, even in the OR. In an emergency, you cut between the ribs and toward the front, then turn the knife upward, making the shape of a hockey stick. To the side of the sternum, the ribs are all cartilage and cut easily. Slicing vertically through three or four cartilages makes an ugly scar, but it works: you can flip up the front of the chest like a trapdoor and get where you want to go. The most dramatic reason for thoracotomy in the ER, which we all wanted like a notch on a gun, is a stab wound to the heart (gunshots were rarely salvageable). It may not happen right away: a small stab allows blood to leak into the pericardium beat by beat, and as the pressure builds up it compresses the heart gradually (tamponade, as you’ve learned). Showing the typical sign of bulging neck veins as the blood backs up into the vena cava, the patient might fade away slowly. There could be time to get to the OR before opening the chest, maybe by sucking some blood out of the pericardium with a needle stuck in through the chest wall. With no time, you open in the ER.


If surgeons have a God-complex, this could be why: split open a chest, slice into the pericardium, stick your finger into a hole in the heart, and the patient may wake up with your hand buried in him half-way to the elbow. I did that once. The patient gave a thumbs-up to his friends as we wheeled him to the OR, the hole in his heart sucking on my finger like a hungry baby. At SFGH there were no cardiac surgeons, no pump techs. But it was self-selecting: a heart injury that might need bypass would have never made it to the OR. The ones that did could be fixed directly, by us. Holding the heart in your hand, compressing the hole with your thumb, enough also to dampen the beats as you place sutures on either side, timing your moves with the beating, aiming to avoid the coronary arteries—that’s pretty cool. (Could it be cooler than scooping stool out of an abdomen?) When you place sutures into the heart muscle, it fires off a string of crazed beats, trying to jump out of your hand, not knowing you’re there to help.

Take Your Lumps

What to do with a patient referred for a finding that you can't interpret on a test you'd never have ordered? It's a tough one, and not as rare as you might think, especially in the area of breast lumps. As a topic for posting, the subject comes up in a roundabout way. A couple of other medical bloggers picked up on my mammorable patient" post, and a comment on Orac's site raised the issue of the morbidity of medical screening. It's a fruitful object of scrutiny: false positives, for example, (a finding that requires further evaluation, possibly invasively, that turns out to be nothing) add up on the other side of the ledger. If a person suffers harm -- or even death -- from investigation arising from some sort of routine screening (for whatever...), when the issue raised turns out to be harmless, well, that's not a good thing. There's lots to say about it. I won't, exactly, now. It's just that it reminded me of something that used to drive me crazy.

I could rant all day and into the night about evaluation of breast lumps and where I think the surgeon's role ought to begin. I had a sometimes friendly, sometimes antagonistic relationship with a number of radiologists over breast evaluation, and I tried over my whole career to educate (based on my own biases, of course) primary care docs in the matter of breast lumps. A dispassionate review would likely show I won the occasional battle, but lost the war.

In a nutshell, it comes down to this: when there's a lump you can feel, diagnostic imaging (Xrays, ultrasound, etc.) is a waste of time and money. OK, that's a bit over the top: you get needed information about the rest of the breast, and the other side, which will come into play at some point. But getting a bunch of studies -- particularly without the input of a surgeon -- as the initial step in working up a lump adds up to lots of unnecessary running around for the patient, distractions in the diagnostic process, and -- not rarely -- detours into side roads that never needed taking. Ain't nothing like a good physical exam by a person highly familiar with breast exams, followed, when indicated, by the quick poke of a needle. Don't get me wrong. I recognize that radiologists do good in this world. In fact, I'll admit that the occasional interventional radiologist has saved my bacon more than once, with a well-aimed drain into an abscess here or there. But as the evaluators of a palpable lump (emphasis: palpable. When you can't feel it, that's a whole different ball of wax), they either muddy or bloody the waters.

Mild to moderate disclaimer: ultrasound quality and interpretation is constantly improving. It probably has a role in the screening of breasts too dense for useful mammographic interpretation; and as specificity improves, it may become more reliable in the interpretation of solid lesions. But, basically, the value of ultrasound in the study of the breast is to determine if a thing is solid (which means a possible tumor in need of a biopsy, usually) or liquid (which means, almost always, a harmless cyst in need of no further investigation.) And when is it useful? When a thing shows on a mammogram, and when the thing can't be felt. Period. If you can feel the thing, poking a needle into it gives the same info and more; cheaper, quicker, and more definitive. If it's a cyst, the needle will produce fluid and can empty the cavity, which in most cases makes it go away permanently. So it's diagnostic and therapeutic. Or if the thing is solid, then with the knowledge of simple technique, a sample can be taken with the needle, smeared on a slide, and reviewed under the microscope; often giving a final answer. It makes me lunatic bonkers when the first stop for a woman with a lump is the radiologist's store.

She finds a lump in her breast: it's round, tender, and she's sure it wasn't there a month ago. Because it's the way things work, she sees her primary doc who -- because it's the way things work -- sends her for an ultrasound. Or, more likely, a mammogram and ultrasound. Or a mammogram, leading to an ultrasound which is hopefully done at the same time, but maybe requires a return visit. As expected, the finding is of a fluid-filled cavity consistent with a cyst. (Once in a while, the report will refer to some "debris" floating in the liquid, or some echoes that suggest some irregularity in the cyst wall, of uncertain significance. Now she's worried. My office gets a call: our patient is scared to death over her report. Can you work her in today? Even if there's not the fear element, she's coming to see me much later and lighter in the wallet than if I'd gotten a call about it in the first instance. So I see her, use my handy little needle, diagnose and disappear the cyst, talk to her about cystic breast problems. Depending on age, time since last one, I might have ordered a mammogram, if I'd seen her first. (There's another reason for holding off on it: why get a picture of a thing that'll be gone?)

But it gets more complicated: she gets her ultrasound, and it shows a simple harmless cyst, as expected. But of course the whole breast has been scanned, and wouldn't you know they saw a five millimeter (less than a quarter of an inch) something somewhere else, too small to characterize fully, can't rule out every bad thing on the planet. See, that's what I was talking about. What to do with something you can't interpret on a test you wouldn't have ordered, found in an area not even part of the original concern? Just to make it realistic -- and worse -- the radiologist who read the study has recommended ultrasound-guided biopsy of this tiny spot.

What I'd do is candidly tell the woman my feelings on the matter: that I think ultrasound is the least reliable and reproducible of the studies we do on a breast; that I'd not have ordered that test in this situation, and that whatever this incidental finding is, at that size it's most likely perfectly safe to leave it alone for now and repeat the test in a couple of months. And that based on my experience, if repeated in that time-frame, it's quite likely it will no longer be there. And, of course, I'd also explain that there's no way to be sure at this point and that if it'd drive her crazy to wait, we should arrange for a biopsy. (In several of such cases, the scheduled procedure was unsuccessful in finding the original lesion.)

In the case of large lumps in the breast, I've seen women sent for mammogram and then, per recommendation of the radiologist, undergo stereotactic biopsy. That procedure is intended for things seen on mammogram and not feelable: whether the recommendation was based on an unskilled exam or without an exam at all, it's an expensive and cumbersome way to handle tissue sampling when a simple office aspiration would have gotten the same info. I've seen infections from such biopsies which the radiologist feels uncomfortable in handling; so I see the patient ex post facto, having received an unnecessary procedure and now, salt in the wound, I'm to care for the complication.

What's the point here? Not, despite appearances, to say that radiologists are the enemy. Rather, it's to say that with breast problems more than any "surgical" problem I can think of, coordination of care makes for better care; more economical, more efficient, less stressful. At worst, it can be fragmented into disconnected pieces, where doctors see the problem through a narrow lens, applying tools at their disposal no matter the alternatives. At best, it can come together in a true breast care center, dedicated to comprehensive and complete care. In the best of all possible worlds, surgeons, radiologists, pathologists, and oncologists are under the same roof and consult freely before diagnostic and therapeutic decisions are made. Such centers exist. They're not widespread; and, sad to say, there are some bogus outfits out there. I know of so-called "women's breast care centers" that imply broad-based care but which in reality are drop-in centers that encourage women to show up without referral, to have a cursory exam, mammogram, and quite often an unnecessary ultrasound. The results, rather than explained and followed up upon, are handed to the woman with instructions to see her doctor. It's a rip-off, not run by legitimate radiologists with honorable intentions, but by guys out to make a buck; some aren't even fully certified radiologists.

In most communities, women with breast problems have to start with their primary doc, and then follow a circuitous path to diagnosis and treatment. The end result is going to be good care, but it's hardly the most efficient journey. It's a microcosm of American healthcare: limited by the absence of agreed-upon protocols, complicated by varying levels of expertise, sullied sometimes by docs guided by self-interest (or at least a limited view), marked by wide variations in efficiencies and cooperation. And it showcases a central unclarity: is the best care delivered via good ol' Doc Jones, who knows and cares for the whole patient, or by taking certain body parts containing certain problems to a specialty center right off the bat? I guess if every doc in every area of practice were perfect, and had skills and knowledge equal to every other doc in their field, the question would be moot.

Opportunity lost

I've seen people reject mainstream (read: rational) treatment for alternative therapies, despite my attempts to shed light. When they came back with their cancers or other chronic diseases advanced far beyond where we started, I've not said anything. I've listened patiently to recitations of the value of what I've known to be useless approaches. I've encouraged my patients who wanted to, to supplement their recommended treatments with whatever herbs and potions they liked, as long as it was not in lieu of standard therapies. When I had nothing left to offer, I've not tried to take away the last straw for grasping, if I thought they had their eyes wide enough open.

And, of course, I've wondered how many of the purveyors of fraudulent care actually believe in what they're doing. But it's not often that I've lost a patient because of the success of mainstream therapy; which is why the case of Orchid bothers me so much.

She'd been having trouble getting food to go down and hadn't waited long to have it looked into. Cancer of the distal esophagus had been found, and it appeared wholly confined to within the esophagus: curable, best we could tell. I had a long visit with Orchid and her husband, during which I detailed the operation I proposed to do (described in previous posts: really, it's not the only operation I know): esophagogastrectomy. Removing the bottom half of the esophagus, the top half of the stomach, pulling the stomach into the chest and hooking the remaining ends together.

And I recommended an appointment with an oncologist ahead of time, because I thought her chances of cure would be enhanced by pre-operative chemo-radiation. The two of them were appropriately serious and worried, particularly about the operation. Ironically, they were living temporarily in the US; they were natives of Japan, the country wherein probably more such operations are done -- and done very well -- per capita than anywhere on Earth. In fact, I felt the need to point this out, and to raise the possibility that when it came time to have the operation they might want to return home where there are several surgeons with enormous experience. No, they said, they were committed to staying here.

Suffering very little of the possible side effects, Orchid went through her treatments without complaint, and noted quite early in the process that her symptoms were disappearing. By the time she returned to see me as planned, she was eating normally. Somewhat embarrassed, she said she didn't want to go through with the operation unless someone looked down her throat again to see if the tumor was still there. I pointed out the results wouldn't matter: even if visibly gone, the probability was high it wasn't fully eradicated by the treatments, and her high cure rate was predicated on going through the entire plan. She was insistent, respectfully. Her husband agreed, although he seemed less sure. So I contacted her original endoscopist, who repeated the study. Sure enough, there was no sign of the tumor.

As far as I was concerned, this was wonderful news and supported the optimism I had about her long-term outlook. I also, based on our conversations, knew it would make it nearly impossible to convince her to proceed. It was, in fact, completely impossible. She was convinced she was cured; and she was certain having the operation would be very difficult for her, with complications. It turns out she was well aware of the operation at home, and had heard stories.

No doctor wants to deceive a patient (no legitimate doctor). Much as I was convinced of her excellent prognosis, and confident as I was in my ability to do the operation well and with a very low likelihood of complications, I certainly could make no guarantees. "You'll be fine," I could have told her. "My patients do well and don't have problems," I might have said. "I know what it means to have a life in my hands, and I will do whatever it takes to cherish it. Please trust me. I can make it all right."

The most amazing thing about being a surgeon is that most people -- by far -- make that leap of faith without my having to say such things. (I don't -- I can't -- say them, of course.) I surely doubt it's because I'm overtly trustworthy. It's the situation: I hold all the cards, really. The patient hardly has a choice but to trust. As I've written elsewhere, "trust isn't given; it's taken."

Is there, in part, an acting job in my encounters? Do I, or must I, behave deliberately in certain ways to engender confidence? At some level, I suppose the answer is yes. There is an extent to which I see myself doing a sort of performance. Yet it's not deceitful. I want to gain trust: it's essential, I think, to get the best result.

And I believe in my ability. I would never falsely seek trust from a patient (I've sent people elsewhere when I think there's someone available with more experience in a particular area, even when I think I can do the procedure perfectly well.) Were there to be a complication, I'd have a hard time living with myself if I'd presented myself to the patient as equally qualified. Implicit in my "contract" with a patient is my belief that I can render the needed care as well as anyone. All surgeons feel that way, I guess. Perhaps you need to. But you also need to be reality-based. In the case of Orchid and her tumor, and the surgery necessary to deal with it, I felt fully able to speak with conviction.

I failed. I couldn't convince Orchid to have the operation; I couldn't overcome her fear of it, and neither could the other docs who'd been involved in her care. So away she went, husband in tow, looking back on his way out the door. Worried, he was. Unsure. Was he also disappointed in me, that I hadn't gotten her to say yes? He didn't say so. But they were both very respectful people. His silence felt incomplete, unconvincing.

In an album he made, posthumously, containing her letters, photos, her artwork, the words of her friends, he spoke eloquently and voluminously. Her whole life, page after page, rendered in perfect strokes, Japanese calligraphy, English used sparingly. No need. He sent me a copy. It was heartbreaking.

It took about nine months for the cancer to recur, presenting as before with swallowing trouble. Scans showed no evidence of spread, and now she agreed to have the operation. My sense that we'd lost our chance didn't keep me from going ahead. The surgery was more difficult than usual: had it been done on schedule, the changes from radiation wouldn't have been as "set." (Scarring occurs, but not right away.) Worst of all, the tumor had perforated, causing a small abscess. I gave it wide berth, but anatomy (heart, diaphragm, big vessels) mitigate against the generous swath you might take in another location. None of the things she feared about the post-op recovery came to pass.

Hospitalization was brief, she went home feeling strong; life, for a while -- until the invasion of her liver and spine -- was good. Her English was deeply accented, and halting, not easy. "Had I known....," she said with her lowered eyes. "Had I convinced you..." I said with mine.

Mammorable patient

It was so unusual that I wanted to write it up and send it to a journal for publication. But I didn't want to embarrass my colleague, who was a good guy. So I tell the story here for the first time.

When something shows up on a mammogram that warrants investigation, but can't be felt, you need to sample it using some form of Xray guidance. (If you can feel it, you can poke a needle into it in about two seconds, taking a sample for analysis. Or do a surgical biopsy. But when you can't feel it, there's no simple way to get at it in the office.) There are two main choices: wire localization, or sterotactic biopsy. In the former, the radiologist guides a wire to the area, and the surgeon then operates, following the wire to the target. In the latter, the radiologist does the whole procedure, with the woman lying prone, breast hanging down into a device which is aimed by Xray and then sends a biopsy-needle to the zone. There are, as usual, pros and cons of either method. Choosing one over the other depends on factors I might get around to some day. More and more, the stereotactic method is used; which is fine. In an ideal world, however, there'd be surgical input into the decision: coordinating diagnostic interventions in breast disease can eliminate a lot of unnecessary or duplicated testing. But I digress...

Marlene had had needle localization for a shadow on her mammogram. "Enormous" would be the word to describe the organ in which the shadow resided. The surgeon who did the procedure -- struggling, I'd imagine, in a very deep hole, following a flimsy wire into oblivion -- unfortunately cut the wire as he was working his way to the far end. As one might expect, gravity being what it is, the wire disappeared into the abyss. The surgeon spent a very long time trying to locate it and the target to which it pointed, and failed. He even transferred her from the surgicenter to the hospital across the street, where he used a mobile Xray machine (called a C-arm, for the shape of the business end which can be positioned to take live-action pictures on an operating table) without success. He gave up. Fully recovered and not a little pissed, Marlene came to see me for a second opinion.

Reviewing the Xrays led me to a couple of conclusions. First, uncomfortably: the shadow in question had, comparing mammograms taken regularly for several years, quite innocent characteristics (maybe fodder for another post, sometime) and -- more importantly -- had been unchanged for at least eight years. I, in other words, wouldn't have recommended biopsy in the first place. Second, the surgeon had given a pretty thorough effort to finding the wire, and I had no reason to think I'd be any more successful. We deliberately leave metal objects of all sorts in people; I didn't think the wire was in need of removal for its own sake. So I recommended watchful waiting, beginning with a repeat mammogram in a few months. If anything, Marlene seemed relieved. She's had enough plowing around in her breast for a while, thanks very much. She might have been a teensy bit annoyed at having undergone what may have been an unnecessary procedure, but we didn't dwell on that aspect. So when she reappeared in my office later, as planned, bearing the repeat Xray, we were both pleased to note that the shadow remained quite benign-appearing and absolutely stable. I was, however, a little puzzled to note that the wire was no longer there.

As usual, there are several types of wires from which to choose. Below is the kind I like:



It has a sharp backwards bend at the end, which discourages accidental dislodgment -- as can happen during the hubbub of transferring from the radiology area to the OR (not rarely involving a ride in a car) or during the operation itself. It also -- not relevant to the present tale, but giving credit to the inventor -- has a change in diameter near the end, which is helpful in pointing out that you're nearing the target as you dissect. It hadn't occurred to me until now (why would it have? It had never come up) that the characteristics of the hook could, with motion of the breast, allow for inching it forward. Guessing the wire had migrated itself to the periphery of the breast, outside the mammogram field, I ordered a regular chest Xray, and indeed it showed the wire. But not hardly where I'd expected it. Not hardly at all.

At the far edge of her right lung, is where it was. It had originally been in her left breast! And -- for you anatomists out there -- subsequent views showed it was definitely within the lung, not overlying it on the outside. Now, here's the hard part, because I'm not clever enough to be able to draw explanatory pictures and load them into this blog: the only way this could have happened is if the wire had humped itself directly down through the breast, through the chest wall, and into Marlene's heart: her right ventricle, to be precise, after which it was flushed out into the pulmonary artery and sent into the lung. The only other avenue was for the wire to have entered a vein in Marlene's breast -- or the big vein under her collarbone (the subclavian vein) and then gone to the heart. But the wire was at least two inches long. No way it could have made the twists and turns required of that circuit, starting its journey through a small vein.

"I've got some good news, and some bad news," I told Marlene. "The good news is that the shadow in your breast continues to look harmless, and safe to leave alone. The bad news is that the wire..... DRILLED A HOLE THROUGH YOUR FRIGGIN' HEART, PASSED RIGHT THROUGH IT AND STABBED ITSELF INTO YOUR LUNG. YOU'RE GONNA DIE!!!!!" OK, I didn't say that last part. But I figured that's what she'd hear, no matter what I said. Who wouldn't? I explained as mildly and as carefully as I could, drawing the sort of pictures I'd be doing now if I were clever enough, pointing out that if anything bad might happen, it'd already have occurred. I must have done alright, because Marlene remained seated calmly, as opposed to falling to the floor. I told her honestly that I'd neither seen nor heard of anything like it, and that I'd get consultations from cardiologists and chest surgeons; but that I thought the wire had done all the traveling it would ever do, and had come peacefully to rest where it would do no further harm. She liked that.

Catheter-wielding cardiologists and scalpel-wielding heart surgeons agreed: leave the damn thing alone. More damage was possible from trying to get it out than it could conceivably cause left in place. Subsequent Xrays over the next year confirmed it was happy where it was, and so was she. I'm pleased to say I'd never cut and lost a wire in a breast; but after meeting Marlene, I was even more careful with them than I'd been.

Arthur Of The Missing Stomach

Speaking of gastrectomy, as I was in the previous post, there's another patient I'd like you to know about. But first, a word regarding gastric surgery in general: it's fun. Unfortunately, it's much less common nowadays, because those doggone scientists have come up with excellent drugs to prevent and/or treat ulcers, which used to be by far the biggest reason for operating on stomachs. Too bad for me, good for you.

Anyhow, there are several things that make stomach surgery fun, uncommonness being high on the list. Also, richly endowed with blood supply, the stomach tends to heal well, no matter what you do to it. And, depending on how much stomach is removed, there are lots of ways to put things back together, each with its own nuance and technical challenges. Plus, you get to say the very cool surgical name, Billroth, when talking about a couple of those reconnections.

Christian Albert Theodor Billroth was one of the inventors of abdominal surgery. Born in the 1820s, he was working with a clean slate: everything he tried was the first time it had been done. My mind can hardly encompass what that must have been like, and not only in terms of technique. He had at his disposal the most minimal of anesthesia, few (and often home-made) tools, no IV fluids, no antibiotics. Not to mention an uncovered voluminous beard. It's amazing. And whereas it's true that (as my mentor said) the patient, ultimately, takes all the risk, still men such as he had a kind of bravery that I find astounding; not to mention provocative of envy.

After removing a portion of stomach it's necessary, of course, to reattach the remnant to the intestine. Among the choices shown in the above link, the amount of stomach remaining has much to do with selecting: the ideal is the Billroth 1,
because it is the most "natural," if you will. (I know I will.) But hooking to the duodenum is limited by the fact that it (the duodenum) is fairly-well fixed in place; so if the gastric remnant can't be pulled down there easily, you have to close off the duodenal stump and bring the closest bit of small intestine up to the stomach. That's a Billroth 2 operation:

It has more potential problems: duodenal stump leak, bile and pancreatic juices building up in the stump and/or periodically squirting too briskly into the stomach (bile and pancreatic juice drain into the first part of the duodenum, and the duct through which that happens is one reason the duodenum can't be moved much). If you take away the whole stomach, a whole lot of plumbing is necessary:


I get a kick out of that stuff. In fact, it's better than the illustration above: if you do it as shown, there's no reservoir for food. I like to bend the intestine around in the shape of a "P" and sew the top of the P to the esophagus. The loop of the P (which involves an extra suture-line to connect the bottom of the loop to the vertical part) makes a nice holding tank, and allows people, more often than not, to eat quite satisfactorily. That's what I proposed to do for Arthur, and it totally freaked out his wife.

Already slight and small, Arthur had been diagnosed with stomach cancer, in a location that demanded total gastrectomy. He was a "whatever-you-say-Doc" sort of guy, but his wife was literally beside herself. Vibrating in such a way as to appear to be two people must be how the "beside herself" expression came to be. That's what she was doing. "How can he live like that? He'll starve to death!! Look at him!! How can I feed him? What can he eat? I can't cook like that. What'll I do? What'll I do?"

It's certainly reasonable to be shocked at the idea of an absent stomach, but she was letting my words bounce off without sticking: I was telling her I thought he'd be able to eat whatever he wanted, maybe in smaller portions. There was no special diet. No instructions. He should eat whatever sounds good to him, and we can see how it all works out. Boing, boing, my words came back un-received. She was as refractory to input as a crashed hard-drive. But there wasn't much choice; and as our meetings continued, I managed -- calling upon my greatest communication skills -- to lower the vibratory amplitude. Calm, such as it was, prevailed.

The operation went fine, despite finding that the tumor had grown directly into the left lobe of the liver, requiring that I take the whole stomach and a pie-slice of liver as well. Arthur made an uneventful recovery and was ready for discharge in a few days. I stopped by his room for a final goodbye, to find his wife -- who'd relaxed a bit until then -- wide-eyed and pale-faced, vibrating anew as a dietician instructed her on a "gastrectomy diet." WTF?? Who requested that consult?

Delicately as possible, I invited the dietician to join me in the hall, where I explained that this was exactly what the woman did NOT need; I'd take care of the dietary management myself. Had anyone requested the visit? No, she said. She'd just noted that the man had had a gastrectomy, and had taken it upon herself -- per some protocol or other -- to make the connection. I explained the peculiarity of the situation, to which she smiled nicely, and returned to the room and took up where she'd left off, as Mrs. Arthur levitated to the ceiling.

It may not be a surprise to regular readers here that this event sat uncomfortably with me. Suffice it to say there were communications. It's my opinion that there are lots of very useful services provided by many professionals attached to a hospital. And they should be used. When invited.

Well, I managed figuratively to hose Mrs down. And how did Arthur do with his extensive cancer and large treatment? Two answers: first, about ten years later I took his gallbladder out. Second: around a year after the gastrectomy, my wife and I were eating at a local steak joint. Couple of tables away was Arthur, chowing down on a nice New York strip and a baked potato, as his wife, calm and cool, did likewise. They had dessert, too.

[Image source]

Memorable Patients: Part seven

I'm certain that if I hadn't been just finishing a midnight appendectomy, Daphne would have died. Not fully balancing all the bad luck in her life, she fortuitously chose to exsanguinate when a surgeon and OR staff were immediately available. Nevertheless, vomiting all that blood, she damn near died before she got to the hospital.

Niceties like passing a scope to find the source go out the window when someone is bleeding to death from her stomach. When I'd gotten the call, I was writing orders for the previous patient. I let the OR know they'd be getting someone in a big hurry, flew down the stairs to the ER, and met Daphne, who wasn't in a position to be sociable. In shock, confused, continuing to vomit blood, she was also very obese and showed obvious signs of Cushing's syndrome: side effects of high dose steroids. Whatever I might find and do, healing would be severely limited by those drugs. And you can't stop them for surgery: it would cause general collapse. Daphne's husband had ridden along in the ambulance. Compared to her, he was a tiny wisp of a guy, looking appropriately worried. I told him -- no surprise -- that she needed immediate surgery, and we'd see what we'd find, and do what we could. It was a very critical situation, I said. Blood had been drawn for cross-match, and I ordered a bunch of O-negative blood, started a couple of big IVs, told the OR we were on our way, talked to the anesthesiologist, and drove the gurney myself, pointed the way to the waiting area for her husband.

One thing about operating on the hypercritically ill: when you start from zero, there's no downside: clearly, she's going to die unless I can do something. No decision there; and, at some level, no pressure, in a perverse sort of way. Which is not to say I'm cavalier about it: I know that I'm the only hope she has. But unless I make a horrible judgment, or a monster technical error, a bad outcome is the default situation: I can't make it worse. I think.

In the middle of the belly wall, the rectus muscles (the six-pack muscles, in the fine and fit) are separated by a fibrous band, called the linea alba, or "white line." It's pretty bloodless, and what you aim for in making a midline vertical incision. Off to either side, it can get bloody. But in the very fat, it can be hard to find rapidly. There's a trick, for those of you trying this at home: after cutting through the skin, if you and your assistant pull the edges away from each other, hard, the fat splits apart like the Red Sea (the yellow Red Sea), right down to the white line, fast and smack on. Then you can split the linea sharply, fastly, and get in there.

What you'd expect, based on the odds, is a bleeding duodenal ulcer, the surgical approach to which is generally quick and easy: make an incision through the pylorus, place a couple of well-aimed sutures, and it's all over but the closing. Cut a couple of vagus nerves for good measure (it reduces acid secretion). But Daphne was anything but routine: she had two enormous ulcers, huge, encompassing much of the middle of her stomach, front and back; one of which had eroded through the wall of the stomach and into the splenic artery. No wonder she was bleeding so massively: that's a really big one, and I'd never seen it be the source of gastric hemorrhage. Having eventually made a large incision in the front of the stomach, the next thing I did -- once I realized the source -- was to put my finger in the hole in the artery to stanch the flow and give the anesthesia team a chance to catch up on volume replacement. That took a few minutes, during which there was nothing for me to do but stand there, a warm-blooded cork. Several pints of blood and bags of saline later, I placed sutures on either side of my finger, and warily pulled it out of the hole. Dryness, welcome dryness. (A professor of mine once said, "You don't need to worry about bleeding, Doc, unless you can hear it." Ha ha. This bleeding, I actually had heard and it's scary as hell. A hiss, a jet, a roar, hauling life with it, like a raft in a river.)

Even when it's necessary, operating on someone in shock is not a good thing: it unavoidably adds to the trauma, even as it seeks to reverse it. The least you can do is the best you can do. Get in, get out. But Daphne was in a hell of a fix: these ulcers of hers took up over half her stomach; plus, I'd probably just killed her spleen. I actually tried to save some of her stomach, not wanting to do a total gastrectomy for myriad reasons, but it was clear the remnant wouldn't survive. So, despite everything that would be ideal in a dire emergency, I removed her entire stomach and her spleen, and fashioned a sort of stomach-substitute reservoir out of intestine, and stapled it to the end of her esophagus. Too much surgery, really, for such a sick and medically depleted lady.

In a book I could tell you about if you were interested, I mentioned the generally competitive and uncooperative relationship between surgeons and medical docs in training. In practice, happily, it's the opposite. I worked with a sensational group of intensive care specialists, and between the two of us we pulled a few people out of the fires over the years. Daphne was one. In fact, I picked up her chart in the ICU one day to see a note from her primary doc -- pretty much out of the picture at this point -- saying, "I stand in awe of the excellent care being rendered to my patient by Drs Schwab and OConnor." Never saw anything like that at San Francisco General Hospital.

Despite my having told the family to expect, at best, a long and complicated stay in intensive care, Daphne actually recovered on a semi-straight path. (Secret to caring for surgical patients on high-dose steroids: lower the dose as much as possible, give supplemental oxygen, intravenous multi-vitamins and extra vitamin C.) Her life was tough: she lived in a half-hovel, to which I made many house-calls over the years. Her kids -- whom she'd named after cartoon characters -- struggled in school; her husband rarely worked. Unlike most patients with a total gastrectomy, she had a hard time nutritionally (other than a need for injected vitamin B12 on a monthly basis, many actually eat fairly normally and do well.) It had, in part, to do with the mysterious disease for which she'd been put on steroids in the first place: she sort of wasted away over the next several years. But every Christmas I got a card from her, thanking me for another year of life she'd not have had, had we not met. Once in a while she'd call with some concern or another and, since it was hard for her to get around, I'd go see her and do what I could.

Several years later, she underwent a total cystectomy for a chronic bladder infection: an ill-advisedly (in my opinion) big semi-elective operation for a woman in her shape, and once again she damn near died. This time, it was from MRSA. Not directly involved, but feeling responsible, I visited her in the ICU and painted a pretty grim picture to her family. Yeah yeah, they seemed to say. Heard it all before. She'll be fine. And darned if she didn't make it, again. She had healing problems this time around, and I became the default home-health aide, debriding her wound for months at her sorry little home. I guess I didn't want those Christmas cards to stop. They did, eventually, but not for a few more years.

Tales From the Right Lower Quadrant, Part four

I used to have certain prejudices, one of which was that people who'd attended college were smart. I'd managed to hold onto that one for several years, until I met George, in the emergency room. He'd been sick a few days, getting more feverish, vomiting, suffering increasing pain in his right lower belly, putting up with it long enough for his appendix to rupture and form a quite impressive abscess, easily detectable on exam. That's not the un-smart part; I'll get to that eventually.

There are several ways to handle an appendiceal abscess, most of which don't involve removing the appendix right away. Since the body has, in forming the abscess, managed to keep the infection from spreading all over the place, it's generally a good thing to keep the barriers in place; rooting around within the abscess cavity in order to find and remove the appendix can tear down the wall (Mr Gorbachev) and spread infection around. So quite often, treatment consists of draining the abscess, surgically or by placing drainage catheters into it with Xray guidance. Typically this leads to rapid resolution of the immediate problem, but leaves on the table the question of how -- or whether -- to deal with the offending appendix in the future. But before we get to that, let's talk a bit about draining that abscess.

Mainly risking incredulity and recommending finding another surgeon by the patients' friends, I've on a couple of occasions treated small abscesses only with antibiotics. When a person comes into the office complaining of a month's worth of somewhat annoying illness, and the workup shows mostly swelling in the appendix's homeland with only a small fluid collection, it's seemed reasonable to take a pretty conservative approach. But in most cases, the patient is sicker than that, and the abscess is bigger, so drainage is best. Of course, I've always leaned toward the surgical approach, because it's the most definitive: especially for a large and loculated collection. You can get big drains in there, wiggle your finger around in the hole to break down the septations, and get it done all at once. Radiologists are getting better and braver at approaching intra-abdominal fluid collections, and it's become the preferred approach in lots of situations. The one area that until fairly recently many of them like to avoid, however, is a deep pelvic abscess. I liked it, if the anatomy was just right, because even in busy operating rooms, it seems I could always surprise a person or two with how I did it. Guess it must be an old-timer thing.

When the appendix is long and low-lying, and its tip sits way down in the pelvis, it's not rare for it to rupture by the time its particular form of appendicitis is figured out. That's in large measure because it tends to present with diarrhea, as opposed to most cases, in which bowel shut-down is the norm. The abscess that forms sits on the front of the rectum and bulges inward into it. You can put the victim up in stirrups, spread open the anus, confirm you can reach the abscess, poke a little needle through the rectal wall to prove the pus is there, and then, grossly, ram a clamp through the same point, through the entire thickness of the rectal wall and into the cavity. Pus ensues; fragrant, copious, gratifying pus. Guide a rubber drain into the area, and you're done: no skin incision, no consequences. You'd think poking a hole through the rectal wall into the abdominal cavity would lead to disaster; but it's well walled-off, it drains, it heals, and everyone is happy. The drain falls out in short order.

I drained silly George, and he got well promptly. He followed up as suggested, in the office, and I told him (as I had in the hospital) that I recommended he have his appendix removed after an appropriate amount of time had passed for healing. It's become controversial -- more now than a few years ago. The concern is that left in there, appendicitis will eventually happen again, and it's one of those things passed down from generation to generation of surgeons. It's only quite recently that studies have been done that raise questions about the need (these are all "retrospective" studies, meaning analyses of existing data, rather than "prospective" studies, meaning randomizing current patient to groups who'd have it done and who'd not have it done, and seeing what happens. Prospective studies are better. None have been done; but the papers have, rightly, gotten the attention of surgeons.)

Trained in the dark ages, I've done quite a few "interval appendectomies," and it's interesting how they have varied: in some cases it's as if the person had never had appendicitis. Everything normal, easy as pie. In others, the worm has been plastered to various entrails and exceedingly difficult to remove. Once or twice, it had been so fried by the original infection that there was nothing left but a thread; clearly incapable of causing further trouble. One time the pathology report came back "acute appendicitis with rupture," months after the actual event. But the need for the surgery was not what troubled George. He was worried about having his appendix removed, fearing the loss of it would lead to some sort of future health consequences.

That's not an unreasonable concern, and it's been addressed in many ways. I liked to refer to a study done by the Mayo Clinic (can't find it now. Didn't try real hard.) that compared around 4000 people who'd had appendectomy with the same number of ones that hadn't, similar in all other ways, and found no difference in incidence of health problems over many years of observation. But George brought an article, published in a journal of alternative medicine. It had actual photomicrographs of the appendix, showing lymphoid tissue (well-known.) The article pointed out the appendix's location between the small and large intestine (close enough) and stated that given the location and the lymphoid tissue, it clearly had an immune-surveillance function. There were no data, no studies. Just a conclusion out of thin air. Now this is not really a big deal, and I don't mean to hijack my own post. But it was the first time I'd seen an educated person show a complete lack of ability to judge data. Pretty picture, shiny paper = conclusion must be correct. Imagine. George rejecting reams of scientific and peer-reviewed data in favor of pseudo-data that served his purposes...

I'll finish this series (for now) with another prejudice, for the heck of it: I'm not a big lover of laparoscopic appendectomy. I think laparoscopy is a fabulous innovation, and there are several operations for which the laparoscopic approach is clearly superior to the open one. Appy, in my opinion, ain't one of them. Why? Properly done, an open appy takes fifteen or twenty minutes, uses a small incision that isn't very painful (much less so than the original disease was!) and from which the patient recovers rapidly; often in the hospital only a day or so postop. Admittedly, this isn't always so: appendectomy can be an extremely difficult operation. But we're talking typical, here. Come in to do an appy in the middle of the night, get a crew not so familiar with all the laparoscopic tools of the trade, and you've turned a simple thing into a time- and money-consuming circus. But tool-makers are very talented at marketing (there are some great technologies out there, just waiting for a disease.) High profile, big-ticket lasers gather dust in OR hallways as we speak. But that's for another post, another time.

Tales From the Right Lower Quadrant, Part three

She was among the sickest kids I've ever seen: as close to death as any who eventually made it. And I never figured out if her parents were just incredibly clueless, or criminally negligent. When I saw her in the ER, her pulse was thready, barely palpable, and slow -- as in nearly agonal. Undoubtedly, a day or two ago it had been rapid, a desperate staccato plea for help. She moaned a little to deep stimulation, but her eyes -- like a doll's, like a pathetic imitation of some cliched cartoon -- were rolled up with only the whites showing. Instead of flushed and hot, as would be consistent with the rigid abdomen that told me her likely diagnosis, she was dusky and cool. Temperature below normal, heart slowing down. Jesus Christ!!! This little girl is dying of a ruptured appendix. I was as shocked and angry as I was scared I couldn't save her.

It had started over a week ago, her parents said: upset stomach, vomiting, fever. They put her to bed, figuring, they said, it was the flu. They just planned on waiting it out, as she got more and more lethargic. OK, yeah, kids get sick, they get a bug; don't call the doc for every sniffle. But vomiting for a week, becoming unresponsive: this is cult-worshipping craziness. You have to be nuts, or a committed conspiracy theorist -- a believer that doctors plot to make people sick, a snake-oil consumer -- to ignore all that for so long. Their daughter was no more than hours from death.

Cleverly called "the policeman of the abdomen," the omentum is there for a reason: it hangs down in front of the intestines like an apron, sliding around looking for trouble. If it finds it, in the form of an infection or inflammation, it sticks to the area, sealing it off with its layer of fat, richly endowed with lymphocytes and fibroblasts. Plug holes, send in the repel and repair crews. It works quite well when it works quite well. I mentioned previously that rupture leads either to pus all over the place, or to an abscess. Which one, depends largely on the omentum. If it finds the appendix early in the process and sticks to it -- and if in the process the nearby intestines close in as well -- the area gets effectively walled off. In kids, the omentum is thin and can be small. In the case of this little girl, for whatever reason it didn't do the job: she had a belly as full of pus as I've ever seen. And see it I did.

With warm IV fluids, heating blankets, and having given broad-spectrum antibiotics and medications to improve heart function, we got her in shape to handle an operation. I made an incision in her pretty little belly, up and down, in the middle. It would be there as long as she'd be there. I never cared too much about putting a belly-scar on an adult: whatever the indication, they'd know it was worth it. But cutting into a child's belly always bothered me a lot, no matter the reason. The bigger the cut, the worse I felt. The thrill of being the cavalry, riding to the rescue, was and is absent. That perfect skin, the vulnerable little child.

It was as if someone had taken a gallon jug of ugly gruel and poured it in: her insides were literally afloat in it. Raw and red, her intestines bobbed in pus. Her liver and spleen, surrounded. Sickly consistent, the same soup in her pelvis, the lateral gutters (that's the term for the area to the right of the ascending colon, and to the left of the descending. Never more appropriate), under her diaphragms. I sucked it out with catheters, and irrigated and irrigated, flooded her over and over again with liter after liter of warm and clean saline. Lastly, with antiseptic-laden solution. Assuring an un-cosmetic scar, of necessity I left the edges of her skin apart, lest she get infection in her wound.

Oxygen has antibiotic powers, and I kept her on it postop, to the (only slight) consternation of the pediatrician, since her measured oxygen levels were fine without it. The irrigations, the antibiotics and oxygen, her youth and who-knows-what other factors combined to give her a remarkably easy recovery. I was even able to tape her skin edges together, and her scar wasn't, as these things go, too bad after all.

Miracle? Not to me. The miracle would have been giving her parents who'd not let it happen in the first place.

Speaking of God, at the opposite end of the spectrum of parental involvement was a girl of similar age I was asked to see after she'd been in the hospital for three or four days with abdominal pain and not much else. No fever, no vomiting, no abnormal blood tests (the white blood cell count, a reflector of infection under usual circumstances, is nearly always elevated in appendicitis), Xrays, tea-leaves all OK. Was an operation indicated, I was asked? Look around, see if it's her appendix or something else surgical? I reviewed all the data, examined the child, and was as certain as I've ever been that it was neither appendicitis nor any other surgical situation. "That's what they told us about my other daughter, in Colorado," her mother said. "And she had a ruptured appendix and nearly died." I told her I understood how scary it was, that I couldn't comment on how that situation might have differed from this, but I was as sure as I could be that her daughter didn't have appendicitis, and I didn't think surgery would be of value. I told her I'd keep seeing her daughter every few hours to be sure, and moved toward the door. At which point the mom took that other daughter by the arm, and they both knelt and prayed at the child's bedside.

I was young then. I don't know if it was wise or not, but then and there I decided the little girl would never be really well -- never free of her mom's fear -- until her appendix was removed. So I did. When I told the mom I'd go ahead, her relief filled the room like fresh air; she looked as if she'd sprout wings and fly. And here's the amazing thing: in the face of my certainty, the normal lab work, the Xrays, the repeated exams, when I got in there it was as obvious as could be: her appendix, that mysterious little worm, that innocent little stripe-cum-killer, was.... entirely, amazingly, completely..... normal and pure as the first snow.

I've got a few more of 'em....

Tales From the Right Lower Quadrant: appendixes I have known. Part two.

"Get a crew ready!! Guy coming in with a ruptured splenic artery aneurysm!! Order blood and a cutdown tray, be there in the ER. He's arriving by medevac in five minutes!!!"

Wow! This was a big deal. The only intern on the vascular surgery service, I was already swamped with work, but this was going to be an amazing case. As I sort-of knew, the splenic artery is a pretty big one, heading from a take-off point on the upper part of the abdominal aorta, across to the left behind the stomach and on the upper edge of the pancreas, to the spleen, which lies in the left upper abdomen. (Since I now have a search box on this blog, and since I'm sure you've read all my previous posts, in which I've mentioned those organs now and then, I'll assume you don't need hot-links to all of them. Gets a little showy, I suppose.) Splenic artery aneurysms are pretty uncommon: once in a blue moon you'll see an ovoid rim of calcification in the right spot on an Xray that clues you in that a person has one. In most cases, they're silent unless they burst. When that happens, you'd expect sudden onset of pain in the mid or leftish upper abdomen, and, most likely, the rapid descent into shock: clammy, rapid pulse, low blood pressure, mentally out of it.

Which is exactly the story behind this man's arrival: he'd been ambulanced to an ER across the Bay, where an Xray had shown the typical calcification pattern, and he'd been fired off to us, one of the pre-eminent vascular surgery departments in the country. Dr. Wylie himself, chief of service and famous, who rarely came in for emergencies, was on his way. (He was pretty much the guy who'd invented repair of abdominal aneurysms, and pioneered much of the modern world of vascular surgery. He didn't have to take call!) We got the man well-resuscitated and into the OR in short order. Bags of blood at the ready (strangely, he didn't show signs of much blood loss, although he definitely was in shock...), extra anesthesia personnel in the room to help if he crashed further, with the patient shaved from stem to stern, special vascular clamps shiny and in easy reach of the scrub nurse's hand, Wylie got the nod from the north end of the ether screen and opened the man up with his usual dexterity, despite lacking the tip of his index finger (boating accident.) Expecting to find blood filling the lesser sac, everyone was more than a little surprised to find the cecum rotated up to and plastered on top of the stomach and spleen, forming the front wall of an abscess cavity, central in which was a ruptured appendix. "I'll be goddammed," said Dr. Wylie as he walked out of the OR, leaving the disposition to the resident team. The shock, it turns out, had been due to sepsis, not blood loss.

Malrotation of the gut is moderately uncommon, and usually presents with obstruction of the bowel due to twisting on itself. That can be very serious; in fact a case of it early in my practice was my virgin entre' into the medico-legal system (sounds like a fruitful subject of a future post!) Presenting as a dislocated case of appendicitis is not common; especially when also associated with a previously-undiagnosed splenic artery aneurysm -- which the man did indeed have. The patient did fine. Dr. Wylie had to take some gleeful guff at weekly complication conference for an error in diagnosis and for venturing out of vascular surgery into general surgery.

It wasn't the only time in my experience that a floppy cecum fooled me: I once operated on a man with a diagnosis of strangulated left inguinal hernia. (Yes. Left!) He had a hernia, all right. But what was contained in it was not dead bowel but his appendix: infected and ruptured. He also did just fine, thanks. But it's one more instance in which I remembered that Dr. Dunphy (previous post) was a wise man. And hardly the only time I was impressed by the power of the appendix....

Tales From the Right Lower Quadrant: appendixes I have known. Part one.

Dr. Dunphy (J. Englebert "Bert" Dunphy, Chairman of the Surgery Dep't, UCSF, RIP) used to tell us: when evaluating abdominal pain, never have appendicitis lower than second on your differential. It's a good thought to keep close: whereas classic appendicitis is most often a fairly straightforward bedside-makeable diagnosis, it can do pretty strange things, and be a major diagnostic challenge. Not to mention being the cause of a few good stories.

First, some background: the appendix -- its spanking name is appendix vermiformis, which means wormlike thingy -- looks, in its normal state, like a little worm, 'bout half a night-crawler. Doing nothing that any (reliable) research has ever identified, it hangs down from the cecum like a sad little rat-tail in the right lower part of your belly. Most people never have any reason to know it's there. When they do, in by far the most of cases, it's because it becomes infected: infection of the appendix is called appendicitis.

Your mom may have told you if you swallow cherry pits you'll get appendicits. I know your mom: she wasn't wrong often, but this is one of the times. That rumor may have gotten started because of an item called an appendicolith, which means a stone in the appendix. ("I gave my love a cherry, without a stone... I gave my love a chicken...." etc.) The other, less impressive, name is fecalith. What it is is a piece of stool that got stuck in there and become so inspissated it's like stone. This is one presumed cause of appendicitis; it also can lead to a rare situation of recurring appendicits (more, later.) But the fact is, in most cases there's not an identifiable reason when it happens; and in the vast majority of instances, it's a one-time deal. (I always made a point of telling kids with appendicitis, and their parents, that it's no one's fault: it's nothing they ate, nothing they did. It just happened.)

The gut doesn't have a large trick-bag; meaning, it only has a few ways it can respond to illness, and it doesn't have the sort of pain nerves that allow localization. If I pinch you on your skin, you'd know exactly where, with your eyes closed. Pinch a spot on your intestines, and you'd likely only muster a "yuck." So the early signs of infection or inflammation of one part of the gut have a way of sounding like and feeling like those in another. When appendicitis starts, therefore, it's usually with a vague yucky feeling, loss of appetite, nausea. Pain is hard to put a finger on, at first. It's only when the inflammation progresses to the point that it involves surrounding tissues -- specifically, the parietal peritoneum, which has LOTS of nerves, of the kind the brain can pinpoint -- that the pain begins to localize where the appendix is (or is supposed to "is"), in the right lower abdomen. Typically it takes a half a day or a day for the symptoms to localize. Appendicitis can happen at any age, but is significantly more common in kids (around five years old to teenage, and there's another spike of frequency in us senior citizens.) Luckily, it's rare in babies, which is good: it's hard as hell to diagnose early in them.

As the infection evolves, the appendix gets red and swollen, going from worm-size to -- sometimes -- finger-size. And left to its own devices, the infection eventually rots away all or part of the appendix (gangrenous appendicitis) and it falls apart, allowing the pus inside to leak out. Ruptured appendix, as you've no doubt heard. When that happens, things generally go in one of two ways, depending on several factors, including the location of the tip-end of the appendix: either pus flows all over the place, causing generalized peritonitis, or it gets walled off into an abscess. In the former case, you'll get sick as hell; in the latter, you won't feel great but it's possible to limp along without disaster.

The cecum is always the starting point, anatomically, of the appendix, and the cecum is nearly always situated in the right lower part of the abdomen. But the tip of the appendix can be in a lot of places, depending on its length, and resting place. Some far ends of the thing are way down in the pelvis; some are across to the left, or aiming north. Quite a few take off from the cecum and run backwards behind it, and can go as high as the liver in that "retro cecal" orientation. Major bummer for the victim and his/her surgeon.

OK. So now, assuming you didn't already, you have a background for a few stories I'm going to tell.

The memo, at last

THE BOARD OF TRUSTEES IS PLEASED TO ANNOUNCE
A NO-HOST BARBECUE TO CELEBRATE THE OPENING OF OUR NEW BURN UNIT
ALL STAFF INVITED. BRING YOUR OWN BUNS

We are delighted to announce the immediate opening of the Catherine O'Leary Burn Unit. As this project may not have been well-known to all, there follow herein some details, in a question-and-answer format, designed to show our sensitivity and desire for thorough -- albeit ex post facto input.

Q: Burn Unit?? Where the hell is it going to be?
A: Patients will be housed on the surgical floors.

Q: Aren't those floors already at capacity?
A: Data have shown that on weekends, there are quite often available beds, and it is on weekends that people typically ignite.

Q: Who will be taking care of the patients?
A: The plastic surgeons.

Q: Uh, what do they say about it?
A: What possible difference does that make???

Q: Aren't there only two of them?
A:Yes. And that's the beauty of it: there's nothing they can do about it.

Q: Well, what facilities have been put in place to deal with the patients?
A: As we speak, finishing touches are being put on a large sign that says "Burn Unit," to be placed at the entrance to the ER.

Q: Isn't there a world-class burn unit just a few miles away with lots of experience and excellent results? Why on earth would we want to open one here?
A: Listen, you smart-ass son of a...... Sorry. Excellent question. It's why we do everything, It's about the effort we are making on behalf of the hospital. It's our new mission: Market Share.

Q: Burn patients require a great deal of nursing care. Will more nurses be hired, and will they be experienced?
A: You can be sure we have looked into it. And while we're on the subject, let us remind you that most nurses are women, and women have plenty of experience scraping crust off of burned toast. In life, things overlap.

Q: I have a bad feeling about this. If our patients do badly, what shall we tell their families?
A: Tell them "Nobody Cares More."



That's it. I think the original was longer, but as usual I can't find it. This is pretty close.


Followup number one: the hospital is still designated at level three for trauma care.

Followup number two: the hospital now, several years later, has a cardiac surgery program consistently ranked in the country's top 100, and the hospital has been so ranked as well. It's building a whole new plant. Actual "state of the art." Go there with confidence. Times change. Sometimes -- who knows why? -- for the better.