Proud to be an American!

This story is made me forget for a moment that we actually live in the 21st century. And it's shameful that Hillary Clinton has chosen this segment of the population (uneducated working class whites!) to pander to as a last ditch effort to salvage her failed campaign. Yeah Hillary, keep wearing that green John Deere hat when you crawl back to your fall sabbatical in the Hamptons.

Surgeon Tryouts

I'm not a huge fan of this drive to designate hospitals as a "Center of Excellence" in some surgical sub-specialty. Bariatrics was the first to champion the idea. On the surface it sounds super-duper. Center of Excellence! That's where i want my surgery! Obtaining such designation, however, usually requires jumping through multiple hoops and making sure all the boxes are checked on an application form. It doesn't hurt to be affiliated with an institution that that can afford to fund the added resources required to meet the prerequisites. The emphasis is less on outcome measures, more on program compliance. For instance, a bariatric program needs to documnet that they have nutritionists, weight loss specialists, specialized equipment for the operating room and afterwards, and other ancillary services available for potential patients.

It seems like a good idea but now we're starting to see a push for other kinds of surgery to be restricted to such designated "Centers of Excellence". Some surgeons (i.e. academic ivory tower big shots) would like to restrict operations like Whipples and advanced laparoscopic procedures (colon resections, Nissens) to the big tertiary referral centers. Isn't that nice. Let all the community surgeons handle the gallbladders and hernias and butt pus. We'll handle the big cases, they say. Despite the fact that volume actually correlates poorly with reduced morbidity in major operations like pancreatic resections. Other factors like quality of the individual surgeon, nursing staff, and chracteristics of the hospital where the surgery is performed contribute to outcomes as well. Volume is sometimes an arbitrary number.

Anyway, I do actually like this idea. (See page 7 of the link) General surgeons in the Boston area have agreed to take the Fundamentals in Laparoscopic Surgery (FLS) exam in order to maintain laparoscopic operating privileges at hospitals such as Massachusetts General and Beth Israel Deaconess. Basically you show up, take a written exam, and then have to perform a series of timed maneuvers using a laparoscopic training module. Meritocracy in the purest sense. If you have the goods, the skills, then you get to stay in the game. Doesn't matter whether you practice at a vaunted "Center of Excellence" or not. It's based entirely on individual performance and proficiency. Now there are some things I dont like about the FLS test. For instance, moving a bunch of rubber balls from one cup to another or being able to tie a knot in a piece of styrofoam does not necessarily translate into real life excellence. It's like drafting a quarterback based on how fast they can run the 40 yard dash and how many footballs they throw through a tire in a 60 second period. Surely we can do better than rubber balls and styrofoam bowels. Perhaps an in vivo exam on an animal would be a better indicator..... just don't tell PETA.

Sorry for the inconvenience

Sort of an amusing tale from the office last week. I removed an appendix a couple weeks ago from a young "au pair" here in the States from (let's say Paraguay) on a work visa. Very straight forward case. Laparoscopic appendectomy. Went home the next day. She works for a family in one of the foo-foo sections of the east Cleveland suburbs. I usually see post-op patients 10-20 days after discharge just to make sure everything has healed well and there aren't any further problems. I had to cancel this young woman's initial post op appointment because of an emergency that arose. Within minutes the "lady of the house" (LOTH) calls the office and is just outraged. How dare we cancel the appointment of her au pair. Didn't we realize that she was vital to the smooth functioning of the household? My office staff, as always, was quite apologetic and made arrangements for me to see her between cases the following day.

They arrived twenty minutes early the next day and I raced upstairs to see her between gallbladders. The patient looked fantastic; smiling, pain-free, completely back to normal. Her incisions had healed perfectly and I told her to remove her steri strips the next time she was in the shower. Standing in the corner, hovering almost, was the LOTH. She didn't acknowledge me when I said hello to her except with one of those dismissive upward turned arched eyebrows you give to someone you pass in the hallways. She stood next to the high end stroller shushing the cute baby during the exam. She looked to be about 30-35 years old. Not an ounce of fat on her. Prada bag dangling off her shoulder. Dolce Gabbana sunglasses perched atop her head. Dressed like a female correspondent on Fox News.

I gave the patient my usual spiel. No specific restrictions other than avoiding activities that caused pain. You're not going to hurt anything, but you may find certain activities make you uncomfortable (muscle soreness, scar tissue, etc). The young au pair smiled and thanked me. And it was "au pair". Not nanny. Not babysitter. Au pair. In Cleveland, Ohio.

That's not going to be good enough, the LOTH hissed at me. Excuse me, I asked? I need to have explicit instructions. If she can lift the baby, then you need to write that down. I have been trapped in my own house for two weeks doing all the things that we're paying her to do! I've missed yoga. I don't see my friends. I haven't been sleeping at night. And I have no recourse until we get clearance from the doctor. So if she doesn't have any restrictions, you need to make that clear in writing.

Her cold steely gaze was one of pure contempt. I was incredulous. The poor Paraguayan girl was blushing silently on her chair. The baby started whimpering.

What I just said is what I'm going to write, I told her, slowly, standing from my stool. She may have pain when she does certain activities. If that happens she should stop what she's doing. Most of the time, people don't have any problems after appendix surgery. But I have to prepare her for the possibilities. It would be prudent for you to give her a little leeway and empathy in this matter.

Fine, she hissed. Are we done?

Yes, we were done. Amazing. Hopefully the poor girl is only there on a one year contract. And hopefully the LOTH has no plans to add to her brood. I should have written "no lifting anything heavier than toilet paper for 6 months".

Fournier's Gangrene

It has been a while since I've seen a case like this one. An 83 year old diabetic male presented over the weekend with perianal pain, fevers, and a leukocytosis to 28,000. The surgeon on call performed an incisional drainage of a large abscess at bedside and intially he seemed to do well. WBC came down to 15 and fever curve improved. However, when I saw him this morning he seemed somnolent and his white count had bumped to 20k. Exam revealed several ominous pathonogmonic findings including a wide area of bruising and ecchymosis involving most of the gluteal skin, crepitus, and some skin changes over the base of the scrotum. I spoke to the surgeon from the weekend and apparently all these findings were new.

Fournier's Gangrene is a specific form of necrotizing fasciitis that afflicts the perineum. Classically, it involves the penis and scrotum and is usually described in textbooks as a "urological emergency". Jean Fournier was the eponymous French scientist who first described the disease in 1883. Nowadays, general surgeons get involved in more complicated Fournier's because often the underlying cause is related to a perianal/ischiorectal abscess gone wild. The tissue planes in the perineum and groin are all connected and the aggressive agents of destruction in necrotizing infections tend to spread along these planes unabated.

This is not a diagnosis you want. Not unless you're someone who would look forward to the idea of having your penis skinned as primary treatment. Because that's what often ensues. These patients all need to be in the OR as soon as you suspect it. The fundamentals of the surgery are quite simple: wide, extensive debridement of all non-viable or infected skin, fat, fascia, and muscle. The patient is usually left with large, gruesome wounds that can be very difficult to care for post-operatively.

My poor guy had one of the more extensive cases of Fournier's I've seen. Basically, the entire ischiorectal fossa (horseshoe abscess) was full of pus, deep to the necrotic skin and fat. Furthermore, the infectious process extended down into the scrotum and the right testicle was non-viable. Literally pounds of flesh were debrided and an orchiectomy was performed. I also had to excise most of the skin covering the scrotum and penis. Just a hideous, awful surgery. Finally, we turned him over so I could do a loop sigmoid colostomy to divert fecal contents away from the raw, exposed wound. It's going to be a long haul to get him through it all. Tomorrow I take him back for a second look, further debridement, lavage, etc.....

Jackson-Pratt

I must admit I have a Jackson-Pratt fetish. No, it isn't as sordid as it sounds. I just love leaving these babies inside the human body (in the appropriate clinical scenario, of course). Nothing helps a frazzled general surgeon sleep better at night after a tough, dicey case than knowing you've left a drain behind.

What's a Jackson-Pratt (JP)?
A closed suction, silastic tube with multiple perforations on the flat part that resides in the body. You can attach it to a bulb which applies a constant negative pressure to the intracorporeal portion of the tubing.

What purpose do they serve?
Helps evacuate fluid/blood/pus from spaces in the body.

When do you decide to leave one?
-Lap appy for perforated/gangrenous appendicitis
-Nasty gallbladders with spillage of foul bile during a lap chole
-If there are common duct stones seen on a cholangiogram and I can't clear the duct laparoscopically; higher risk of the clips coming off from elevated ductal pressure.
-Emergency lap chole on a patient on plavix/aspirin, or even if the liver bed looks a little "oozy". Gives you an idea of any "bright red" blood loss.
-Next to low colorectal anastomoses
-Most pancreatic surgery
-Patients who present with peritonitis and massive fecal contamination
-After mastectomies/axillary dissections
-After excision of large lipomas (dead space can fill with serous fluid)
-Under the flaps after a large open ventral hernia repair
-Groin dissections
-Those cases where I just sorta feel like it.....

Now you don't want to stick a JP in the belly after every case. They provide a route for skin bacteria to enter the abdomen and cause abscesses. The closed suction design makes this less likely compared to say, the Penrose drain, but you have to be careful nonetheless. There is good literature to suggest that leaving a drain in after splenectomy will lead to higher rates of infectious complications. Also, you have to be careful leaving drains in too long around a fresh anastomosis. Sometimes the JP can erode into healing bowel and cause a fistula. I've even had a patient yank at the JP and snap it off flush at the skin surface, and have to go back in to retrieve the tip laparoscopically.

When do you take out a JP?
Depends. Breast drains I leave in until daily outputs are consistently less than 30cc a day. Most JP's left in after gallbladder surgery come out the next day unless I'm waiting for an ERCP to be done. Drains left after complicated cases of perforated appendicitis usually come out in a day or two. It's a judgment call for the most part.

Does it hurt?
A bit. Usually not much at all, and it comes out fast.

Going home with a JP happens occasionally, especially in breast and pancreatic surgery. They're not too difficult to care for; patients receive teaching from nursing staff and me prior to discharge, and are instructed to measure daily outputs. I usually send them home with a JP instruction packet, something like this.

Odds and ends

1) From the American College of Surgeons "Surgery News" April edition: Future Surgeon Shortage Predicted. Interesting. But is it valid? Where exactly in America are we anticipating a "shortage"? Topeka, Kansas? Fargo, North Dakota? Truly, there will never be a shortage of general surgeons in places like Chicago and New York and San Francisco. Never. Guys are clawing each others eyes out to get every last gallbladder and hernia they can. Moreover, there's another study from the JACS in April which studied workforce projections for hepato-pancreato-biliary surgery. According to this study, the current levels of fellowship training will result in an excess of subspecialists in that field by 2020. What does that tell you? More and more chief residents (over 50%) are opting to pursue further fellowship training prior to embarking on a career. Training more surgeons, expanding residencies, or building more medical schools is not the answer to the so-called shortage. You can train all the residents you want, but if most of them ultimately decide to become vascular surgeons, or CT surgeons, or plastic surgeons, or "laparoscopists", then you aren't doing society any favors. We're trying to sub-specialize general surgery to death. That won't be a problem in the large metropolitan areas with multiple academic institutions because you'll have your colorectal guy, your foregut guy, your bariatric guy, and your hernia man, but in the rural and semi-rural communities across America, it's going to be a gigantic problem. The general surgeon who can do breast and bowel and endocrine and advanced laparoscopy is going to be in great demand. If American residency programs don't provide them, be assured that hospitals will seek qualified surgeons from somewhere (the foreign talent pool).

2) Any reason why GI needs to be consulted on a bowel obstruction? Yeah, I don't know either. Good way to drive up costs. If I'm wrong, please let me know in what way. You don't need two specialists to come by, examine a belly, put in a nasogastric tube, check abdominal films, and decide whether or not the patient needs an operation and when. Especially when one of the specialties doesn't actually do operations...

3) The controversy over "never events". Cigna recently published a revised list of "potentially non-reimbursable" events that has the medical blogosphere all aflutter. Me included. Apparently, urinary tract infections from indwelling Foley catheters ought NEVER to happen. Nor is it conceivable that the little old lady on the floor one week after abdominal surgery could lose her balance, fall and break a hip. And central lines aren't allowed to get infected anymore. Decubitus ulcers in demented nursing home invalids who swing by the ICU for a short stay will no longer be accepted. The sickening thing is that this is all done under the guise of "improving patient care". In reality it's about controlling costs. So I don't get paid when I get consulted to debride a rancid sacral ulcer that's been there for probably a year? ID doesn't get paid for their consultation on an elderly patient with urosepsis?

4) Go Cavs. Deshawn Stevenson maybe ought to re-think the wisdom of calling Lebron "overrated".

5) The Tribe can't hit. CC Sabathia can't find the plate. Could be a long season for the Indians..... so glad I got a ticket package.

Mission....... Possible

Lovely case last week. 99 year old lady (yeah, that's right) came in with abdominal distention, pain and dehydration. She was a pretty sharp old broad, though. Knew what was going on and lived independently. CT scan showed evidence of a large bowel obstruction, transition point somewhere in the rectosigmoid area. Flexible sigmoidoscopy was unable to maneuver the scope past the narrowed area, but it didn't look like a mass. I saw her and she had focal peritoneal signs and feculent matter coming out her NG. Her daughter was there and we went through the options. Option one: Do nothing, make her comfortable, with the understanding that she probably wouldn't survive much longer. Option two: Big operation, bowel resection, likely colostomy, with significant risk of perioperative complications.

They went for option #2. My mission, which I accepted, was to try and get this lady to her centennial birthday. She turns 100 in the middle of May. Lot of pressure, no?

Basically, she had a diverticular stricture with a mass of small bowel matted to the inflammatory process. Tough operation but she tolerated it rather well, even extubated at the end. Today she goes to a rehab facility. I still have to get her through the next 4 weeks, but I'm starting to like our chances.

Operating on the extreme elderly is starting to become commonplace as our society ages. I'm sure in ten years residents will be competing to fill fellowship slots in the highly lucrative sub-specialty of "Geriatric Surgery" but that's a topic for another day......