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.

Bugs, redugs

The previous post, on OR sterility, occasioned an email from a professor of surgery, who informed me of a study of which I hadn't been aware. I quote from his letter:

"I wanted to draw your attention to another surgical/OR dogma that has essentially been put to rest, the wearing of the surgical mask. The Karolinska Institute (and other groups) has evaluated wound infections in two groups, one in which the OR team wore surgical masks, the other without masks. The outcome, as you might predict, was that the infection rates are the same (4.7% with vs. 3.5% without). Here is one of the references: World J Surg. 1991 May-Jun;15(3):383-7; discussion 387-8."

Whereas, in this litigious society, I doubt you'll see anytime soon surgeons and scrub personnel eschewing their masks as a result of this study, I find it unsurprising; not to mention amusing and validating. Part of the inference to be drawn from my previous post is that some of what we do is not much more than ritual -- or, at least, it's unproven even if it makes intuitive sense.

In my earlier days, the ten-minute scrub (washing hands and arms before donning gloves and gown) was standard. So much so, that many ORs had timers above the sinks. Having never seen any studies comparing ten minutes with, oh, eight, or six, I can say I never scrubbed that long, unless someone was breathing down my neck. Later, studies were done: I was right.

Reading the email, I was reminded of a sort-of secret about my practice. For reasons of cost-saving, simplicity, and patient convenience, I did countless breast biopsies in my office, under local anesthesia. These were full-fledged surgical biopsies, not needle sampling (which I also did, in far greater numbers.) I had a small procedure room with a small OR table, a cautery unit (which I rarely used, preferring -- for cost saving, mostly -- the old fashioned suturing of bleeders), and I used instrument packs that we made up and cooked in an autoclave (eventually, after we built a surgery center in our building, we had them process the instruments.) Anyhow, my point is this: I painted the skin with antiseptic, used a small sterile drape, wore gloves and a clean cotton frock, short-sleeved and the size of a shirt. And no mask, unless I had a cold. I'm certain if some credentialing agency were to observe, I'd have been hauled off and boiled in oil. Yet, over a period of twenty-plus years, I never had a wound infection. Got a few hematomata, I'll admit, which I either drained or left alone, depending. But no infections.

I'm not -- repeat: NOT -- suggesting that sterile precautions are unnecessary. Quite the opposite; but I intuit there may well be a level of caution beyond which some measures are less important than we think. (As I said in the previous post, the extraordinary care taken in certain settings is vital.)

A related concept: skin prep. Sterilizing skin before operating is essential. But there are some parts of the process that have always amused me. To wit: it's expected that a reasonable zone of prepped skin will surround the area to be incised. Absolutely necessary and proper -- probably the most important of all the things we do. Yet I've watched with consternation as the prep is done for, say, an inguinal hernia. Unfailingly, the prep is carried all the way to the ribcage or beyond to the north, but only a couple of inches below the groin, where the actual incision will be. Similarly, unless I intervened, the prep for an upper abdominal incision went way down to the pubis or below, but only just above the xiphoid process, topside. I'm not aware (the cop-out that says I haven't looked it up) of studies that compare skin prep distances from incision. I'd guess there is a minimum necessary distance, and a point at the other end of the spectrum beyond which it doesn't matter (taking account of the possible need to extend or make a second incision.)

So what's the lesson? Nothing very important. It just happens to interest me that whereas it's best to err on the side of caution, it seems that much of what we do isn't necessarily grounded in science, nor makes sense. Does that surprise anyone?

Bugs

In commenting on my recent post about scrub clothing, Seaspray asked some good questions about operating room sterility. To give an excellent answer, I suppose I'd have to look up the latest studies. Fortunately for me, I'm quite willing to settle for anecdote and opinion, which is a heck of a lot easier. There's no doubt that maintaining sterility in the operating room is a prime directive. It's also true that, to a greater extent than might be expected, it's an illusion.

That's not to say that maintaining proper technique is unimportant, or that breaks in such technique aren't to be avoided like, well, the plague. It's just that there are inconsistencies that might seem strange, but which don't seem to matter all that much, mostly.

I recall a study that was reported when I was in training. I don't remember where it was done -- it could have been there, for all I know. In it, some sort of stuff was placed on the gloves of surgeons and scrub nurses, detectable in some way -- I think it was by Wood's Light. In the course of routine operations, it showed, touches went to places they shouldn't have: the top of the ether screen, IV poles, face-masks, parts of drapes that were close to the floor. (I assume the stuff was applied after all the draping was done, otherwise it would have been meaningless.) From that report I took a couple of messages: one, we could do a hell of a lot better; and two, it might not be as important as we think. Clean is important. Sterile, maybe not so much. After all, at least in the sort of surgery I did, nearly all wound infections (which -- despite what you may be wrongly concluding is a cavalier attitude -- were vanishingly rare in my practice) occur from the patients' bugs, not the OR's.

Don't misunderstand: my point is not that sterility is unnecessary. It's that, other than cooking instruments and using properly packaged attire, there's much that goes on in the OR that falls short of exemplary. But it's also that whereas it's impossible to achieve perfection, you should take heart: it'll be okay. Under most circumstances, being plenty clean and taking various other precautions (such as proper and judicious use of antibiotics) does just fine.

[OK, let me dispense with one situation: when prosthetic joints are implanted, extraordinary steps are taken, and well they should. Often the scheduled room is specially cleaned the night before surgery, and is then shut down. Rooms have laminar airflow, to minimize the raising of dust; surgeons and scrub nurses wear special all-encompassing gowns, along with full head-gear. Traffic in and out of the room is prohibited. This is because when bugs come in contact with implanted foreign material, they are extremely hard to eradicate. And whereas such steps would probably reduce wound infection in any operation, the incidence in routine operations is so low, and the implications so much less ominous, that following such protocols universally surely would not be cost-effective. (I use the word "surely" in the spirit of my opening paragraph.)]

Between cases, floors are mopped, some equipment in the room is wiped down. But people come and go. Some wear shoes that they keep in their lockers only for OR use; but they aren't cleaned, and if shoe covers are used, they may not be changed for days. Gurneys are wheeled in and out. During some operations, despite the claimed water-proofing on gowns, fluids may leak through to one's non-sterile scrubs, or to one's skin. Also, one must presume, back again. And the operating lights? Don't ask! So. Operating rooms simply are never completely sterile, nor, after a time, are most surgical fields.

Once again, we can only marvel at the wonders of the human organism. I've said in the past that were it not for the ability of a body to heal itself, surgery would be impossible. Surgeons are not healers; we are tippers of the balance, setters of the stage. Likewise, if there were no intrinsic ability to repel bugs, we could never safely enter, because we'll never reduce the load to zero. I've always believed that what goes on under the skin is more important that what we do outside it, surgically speaking. Strangulated tissues don't heal, nor resist infection. Brutalized, they can harbor infection. Carelessly handled, bacteria-bearing organs can be made to seed others. Surgical technique matters, at least as much as the pre-incision measures.

Overload

(Here's another of the posts I wrote a while back, and didn't publish, in my "why bother" phase.)

Once again (it seems this keeps being reported, about annually) we have a report which states that doctors (especially surgeons) are doing a poor job of informing women about reconstruction options after mastectomy. I'm at a loss; I simply don't know what to make of it. My mind is filled with conflicting thoughts.

The first thing that comes to mind is a question: is it true? And: if so, how can it be? And: if it's not true, what's up with the report? And the ones before it. And before those.

I've written about what a complicated and difficult mission it is properly to explain breast cancer treatment to patients. And it's not just because the subject is complicated, with many components to treatment and options within those components; it's also that such a discussion takes place in the context of a mind near to or beyond blowing, enwrapped and nearly erased by fear and shock. There's only so much that can be absorbed.

There are two corollaries: one is that there's a tendency to compress the info, especially during the first encounter. The other is that -- and I know it well, having witnessed it time and again -- even the most careful discussions can be misunderstood, partially forgotten, or misconstrued in the horror chamber that is that initial consultation. Which is why I wrote a booklet recapitulating the information I shared, and personally handed it to each of my breast cancer patients. Even then -- and this really bugged me, because I prided myself in my commitment and ability to explain things to my patients -- I'd get the rare call from a pre-op nurse saying my patient hadn't signed the permit because she said I never explained things to her.

So what I'm saying is this: before swallowing the data without chewing, I'd think there's some number of people who actually did get informed but who zoned it out. Far be it from me to defend surgeons. I know the category includes many who are jerks, who can't be bothered to do much more than cut and run. But to the extent that the data are true -- and I question it -- it may not be entirely layable at the feet of the cutters. And it may also be the case that some surgeons practice in an environment where most of the counseling and decision-making is done with primary docs or oncologists, wherein the patient shows up at the surgeon's door with mind already made up. Or polluted. I absolutely rejected that style; in fact, I agitated to get involved as early as possible. But other approaches are not always unreasonable.

Without doubt surgeons could, as a group, do a much better job of talking to patients. But when someone says he or she was never told this or that, it ain't necessarily so. And when it is, shame on us.

Life Saver

In response to a post from long ago, about death, I recently received the following (in part) comment:

"July '03, I was dying in a hospital bed at the moment my doctor came in to check on me. I saw his face and I knew in that moment that if I let go, he would blame himself for the rest of his life--when it absolutely wasn't his fault. I saw in his face how deeply he cared about me, and I knew I couldn't do that to him....he needed me to live so much, and I needed so much for him not to be in pain for the rest of his life over my death, that that gave me the strength and will to live, gave me the emotion to hang on that I needed, pulled me through that horrendous night."

The more I think about it, the more amazing I find those words to be. I've been there. Much as I always tried to establish a relationship of trust and caring, much as I believe in the value of attitude in recovery from surgery (the writer had not, in fact, had an operation, as she told me in a later email; in addition, the doctor was not even the one treating her at that moment), I'd never have thought of it in exactly those terms. Living because of one's relationship to one's doctor. I'm still not sure how to process it. But it has made me think, once again, about the concept of "saving a life." What does it mean, really, and what are the relationships? Isn't it, at some level, hyperbole?

In one sense, perhaps every operation could be considered life-saving: fix a hernia, prevent strangulation and the death that can sometimes follow it. More clearly, doing a curative operation for, say, colon cancer, pretty inarguably fends off certain demise. Having done thousands of cancer operations, I guess I could say I've saved that many lives. But if there's anything at all to the term, in my mind the concept of saving a life suggests something most immediate. Rescuing someone from a fatal condition, right now, right here, with no time to lose. I've written about a few of those: here, here, and here. Oh yeah: and here.

I've been thanked directly for saving a patient's life. I've gotten cards, annually, on the anniversary of the event. When writing a check at some store or another, my wife (she has control of the checkbook) has been told, "Oh, Dr. Schwab is your husband? He saved my life." It makes me feel weird. I happened to be there at the right time, is all. And I'd learned enough to manage the situation. Whatever else it might be, it's not as heroic as the term -- saving a life -- suggests. There is, of course, another side to the coin. If I can save a life, what is it when I fail to do so?

When thanked for saving a life I always felt uncomfortable, and mumbled something to decompress the situation; to shorten the distance between us; to get us back on equal footing. One human being ought not be in that position with another, so it seems to me. Not a doctor, anyway. And yet, when being unable to save a life (as I described here), I've often felt so bad as to want never to pick up a knife again. And in those rare cases when I've wondered if I had erred... well, it's unspeakable. So maybe my attitude that it's less a big deal than it would seem is tied to my desire not to bear the burden of the opposite; even though I do.

Or maybe it's about "heroism." I've saved lives, whatever that means, but I'm no hero. (I also allow adequate spacing when driving on the freeway, and I've slammed on my brakes when someone made a stupid move.) First of all, the term is so over-used nowadays as to be nearly meaningless. Doctors don't risk their own lives (well, I've operated on lots of people with AIDS and hepatitis C); we don't run into burning buildings, or jump into rivers. Sometimes it falls into our laps to do a thing for which we've been trained, about which we've learned a few more things after training, and we do it successfully, when the chips are down. It alters the trajectory of another's life. I don't know why, but I just don't feel right about referring to it as life-saving. It puts me on a different level from my patients, and I never felt that way. Plus, if my commenter's words are true, it might even be the other way around.

A Step Forward

(This is one of several posts I wrote in the last few weeks, but never published, for a variety of reasons.)

In an ideal world (or, it could be said, a well-designed one) there'd be no cancer. Failing that, we'd have perfect treatment: one that destroyed every bit of cancer with no damage at all to normal cells and organs. That is at least imaginable at some point in the future. Even the not-too-impossibly-distant future. Meanwhile, we're stuck with imperfect treatments and we lack the ability accurately to determine who needs how much; who will get along just fine without extensive treatment (and, for that matter, who will succumb even with maximal therapy.) Recently there was news about some progress on that front.

As a surgeon who dealt extensively with breast cancer, I can say one of the most frustrating categories has been the entity known as DCIS, or "ductal-carcinoma-in-situ." It refers to the earliest possible form of breast cancer, wherein the abnormal cells are confined to the inside of the milk-ducts; as such, because it hasn't invaded across any blood or lymph vessels, it presents no danger at all, as long as it stays in that stage. A very rare diagnosis only a few decades ago, it's become increasingly discovered as mammography is more widely done and is of better and better quality. And it's become a therapeutic dilemma: how much treatment -- and what sort -- is necessary for this entity, not dangerous in itself but which has the potential to become so? As DCIS has been more and more frequently dealt with, it's become apparent that not all forms are of equal potential: some women who have it will never develop invasive cancer; others will. And whereas it's still not universally agreed what treatments are indicated for which types of DCIS in what sort of women, it looks like there's progress toward figuring out which women need treatment, and which don't. That's a good thing.

At a national meeting in San Antonio, a recently published paper was reported (by researchers at UCSF, where I learned to be a surgeon) showing that molecular markers have been discovered which can be used to predict when a given woman with DCIS will go on to develop invasive cancer, and which won't. As is the case with early results, confirmation is needed and the testing is not yet widely available. Still, it strikes me as a really significant finding -- one which will lead to much more precise decision-making, conferring confidence on both sides of the equation. Women who need treatment will really need it, and those that don't can safely be excluded. I hope it turns out to be the case; and I wish I'd had such testing available when I saw all those women, all those years.

Scrub Club

I've just received an email from a designer, in New York City. She's addressing the issue of surgical scrubs and related attire, and asks for my input. (I love the unexpected connections that have arisen from blogging -- and state once again that it wasn't falling out of love that led to my abloggia. Or the current hypobloggia.) I imagine her contact was a scatter-shot towards all the surgeon-bloggers she could google; still, I'm both flattered and intrigued. And it seems a good topic for a post. Writing about a thing, after all, is the best way to figure out what one thinks.

Simple and entirely functional, scrubs are nonetheless among the most recognizable of uniforms, and make an easily understood statement of authority. And not a little edginess: "I work in an OR. I know things you don't, and never will (unless you read Surgeonsblog.)" Assuming the wearer is legit, which more and more is less and less the case.

I think there are phases of scrub-wearing: at first, as a student, you feel entirely a pretender. But you like it. If you select surgery as your future, when you wear them it feels like a commitment; before long, they become comfortable and practical, and wearing them is a matter of convenience (and saving money on laundry.) Somewhere along the line they become a badge of honor; and, eventually, it's all of those at once. I'm most aware of them, self-consciously and proudly, when I'm talking with family members immediately after completing surgery on their loved one. Which means, among other things, that one wants them neither dorky nor unclean.

In surgery, we wear gowns of some sort over the scrubs. Claims of imperviousness to the contrary, they often allow, uh, fluids to penetrate and stain our scrubs. (I wrote about some implications of that fact here.) And, permeable gowns or not, when an operation is fluidiferous the cuffs of one's pants and the shoes or the covers on them bear witness. It behooves, in other words, a scrub-survey before heading to the waiting room. (I know of one curmudgeonly and generally embittered surgeon who liked to talk to families still engowned -- the bloodier, the better.)

Having checked for nastiness and changed, if needed, into clean scrubs, I nearly always donned some sort of cover before going to the families. Since I eschewed a white coat until the latter part of practice, for many years that meant grabbing a cover gown: color-matched but generally untidy and sloppy-looking. It's only in retrospect that I see the get-up as unimpressive. Functional, efficient, but inelegant. I absolutely don't think that the clothes matter much; but when I began wearing a spiffy thigh-length white coat, I found I liked much better the appearance of a clean and pressed lab coat over scrubs. And I took off my surgical hat, too. I hate how I look in hats, and, having fairly long hair, I always wore a bouffant cap anyway. If there's anything to presenting a nice image, that pretty much tears it.

I worked in one surgery center that provided pink scrubs. Having no choice, I wore them.

And now, let me get to the central issue of scrub-wearing, as it applies to the male of the species. Here, I'll let you in on one of the best-kept secrets of the club. I'll begin with an aphorism known to males of any occupation: "No matter how you shake and dance, the last few drops go down your pants." I trust I needn't explain any further. Whatever else it might be, when wearing normal pants drippage isn't a, uh, cosmetic issue. But thin light scrub pants -- well, a spot is easily spotted. That may play into the controversy of tucking one's scrubs in or not; walking back into the OR having taken a break between cases, there may be, on occasion, reason for self-consciousness. Particularly if the stock of clean scrubs is low.

A friend -- my favorite anesthesiologist -- handled it best. Before returning after relieving himself, he'd put a drop of water on his fingertip, and dab it on his scrub pants, down at about knee level.


P.S: what the heck are those people in the title picture doing, anyway?

Flush

It's gratifying that despite my absent posting for many weeks, this blog still gets over five hundred visits and more than a thousand page views daily. This I attribute to the fact that some of my stuff comes up on searches for medical information, which makes me feel as if, whether or not I regain my enthusiasm for bloggery, my work will have been of use. (Or maybe it's just that people like coming by when I'm not around so they don't have to worry about running into me.)

Anyhow, I still get comments and questions; quite frequently on the subject of gallstones, about which I wrote a series (one, two, three, four) of posts many months ago. A recent visitor asked some good questions about non-operative management of gallstones, and I was surprised and disappointed to discover that I hadn't really covered it in my prior series. So this is an attempt to rectify (a term which I used in a punny context -- and one which gets hits now and again, from the perverted and/or the easily amused, ever since -- here, and here.)

Let's start with a gentle statement of fact:

OF ALL THE BOGUS, DISHONEST, DISINGENUOUS AND STUPID BULLSHIT THAT MASQUERADES AS ALTERNATIVE MEDICAL METHODOLOGY, "GALLBLADDER FLUSH" IS AT THE TOP OF THE LIST. THE PURVEYORS OF IT ARE, AT BEST, CREDULOUS; AT WORST, THEY ARE CHARLATANS AND (LITERAL) SNAKE-OIL SALESMEN WHO WILLFULLY DECEIVE AND STEAL FROM THE SICK AND THE VULNERABLE, AND ARE TO BE COUNTED AMONG THE SCUM OF THE EARTH.

OK, let me tell you what I really feel.

Over the years, particularly after the dawn of that series of tubes called the internet, patients have asked me about "gallbladder flush" as a method of eliminating gallstones. They've handed me recipes (which commonly include some sort of oil and something acidic like lemon-juice, with a few plants thrown in), and, in some cases, have proudly presented me with little cartons of their stool, containing what they are certain are stones they have pooped out as a result of drinking their herbalicious and natural remedies. 
Fortunately, as a surgeon, I'm well-used to staring at excrement in its many forms, both within and without the confines of the viscera generally expected to contain it. What I saw was curds. I know stones, and I know curds. These was curds, is what they was. Evidently, if you drink some kinds of oils and chase it with certain acidic substances, what you get is curds in your turds. What you don't get -- and trust me, I've seen the proof in pre- and post-glugging ultrasounds -- is change one in the number and nature of stones in your gallbladder.

As with most other forms of medical woo, the pharaohs of phlushes toss around terms like "toxins", and "weak liver," and "detoxify." They make extravagant claims with no proof. Potions of prevention, like methods that keep the elephants away, are hard to disprove. If my writings over the past couple of years confer me with any credibility at all, please trust me: it simply doesn't work, and the proof -- when there actually are stones -- is easy to obtain. If you really believe it, do it. And then get another ultrasound.

There are, of course, those who push these flushes onto the healthy, onto those with no gallbladder problems at all. Generally those are the ones who have something to sell, and, sad to say, they easily manage to separate the credulous from their cash. Like chiropractic on healthy kids and homeopathy on anyone, it most often does no harm, other than to one's economic well-being, and in the situations wherein it delays needed and actual treatment.

A truism: people who produce the kind of bile that can precipitate crystals will, as long as they have a gallbladder (which is where the crystallization occurs), form gallstones. A corollary: treatments that eliminate stones but retain the gallbladder are generally followed by the return of the stones.

Indeed there are pills that can dissolve gallstones. I've prescribed them, for people who really, really want to try everything to avoid surgery, or for people in whom I've thought the surgery would not be tolerated. The main problems are with side-effects (nausea, cramps, diarrhea typically), and the fact that success depends on the nature of the stones (big ones are unlikely to dissolve, as are ones that contain calcium), as well as the tendency for stones to come back again, eventually. Also, it takes months for the stones to dissolve. But since -- as opposed to flushes -- they may work, such pills are an option, and should be part of the discussion for people facing surgery.

You can also smash gallstones. Twenty years ago, extra-corporeal shockwave lithotripsy (ESWL) got a fair hearing, if for no other reason than it was cool to say the phrase. Results have been predictably disappointing. (My hospital contracted a privately owned, trailer-borne machine to occupy the physicians' parking lot once or twice a month, into which the gallstone-bearing were rolled and pounded. I was told -- by the owners, not the hospital -- I could accompany my patients into the unit and sit there while the technicians did all the aiming and calibrating, and then I could push a button and charge a grand or so. I demurred.)

Similarly, you can guide a catheter directly into a gallbladder and irrigate with a form of ether which, in addition to giving you weird breath for a while, has a chance of dissolving stones comparatively instantly. Long-term, the results are as expected. Short-term, there may be the really rare situation in which it could make sense.

Of all the things a person can do to live non-operatively with gallstones, dietary changes make the most sense. Typically, gallbladder attacks happen after eating a fatty meal, so, theoretically, modifying one's diet to avoid fat and any other personal triggers makes sense. Theoretically. In some people it's a very linear relationship: eat fat, have attack. Don't eat fat, don't have attack. But for many, the attacks come in no relation to eating.

On the other hand, by far the majority of people with gallstones who have symptoms (NB: not everyone with stones has problems from them. I was among those surgeons who leaned away from operating in the absence of symptoms) don't go on to have the really serious complications that can occur with gallstones. So for the average person, absent risk factors that could make complications more serious were they to occur (diabetes being high on the list), and absent a crystal ball, trying to live without surgery by judicious dietary behavior -- and, for some, trying pills -- is not entirely unsensible. Just, in the name of all that's holy -- or unholy, if you prefer -- don't waste your time, or your money, or your self-respect, on flushes. Really. It's the poster-child, the sine qua non, the Platonic ideal, the Mona Lisa of quack.