Monday, July 30, 2007

Health care "solutions"

Ny Times from yesterday. The ridiculousness of the article is astounding. American doctors make more than doctors in other countries. Ergo, the health care crisis in the United States derives from exorbitant doctor salaries. Seems obvious, eh?

Never mind the fact that CEO's of major HMO's routinely pull down seven figure incomes. Never mind that health care is in the domain of private enterprise, completely funded and driven by private businesses. Never mind that doctors graduate from residency with close to $150,000 in student loans. It's simple. All we have to do is chop MD salaries from $200,000 to $90,000 and the solution will present itself.......

Friday, July 27, 2007

Experience = success?

What is the effect of surgeon experience on outcomes? It's a tricky issue to navigate. Conventional wisdom would seem to indicate that surgeons who do an operation frequently would have fewer complications than surgeons who perform said procedure less often. The classic paper from Hopkins describes this effect, with regards to pancreatic cancer. Conceptually it would seem to make sense. The whipple procedure is fraught with morbidity. Technically it can be quite challenging. Ergo, one should go to a major tertiary referral center for one's pancreaticoduodenectomy. Or should one? The paper, in all honesty, isn't a compelling piece of hard science. It compares results from Hopkins with results from all Whipples done at hospitals classified as "low volume". So some yahoo in Bethesda who kills three patients during hack job whipples gets lumped in with a technically brilliant surgeon at some community hospital outside Baltimore who does 5-8 whipples a year with morbidity/mortality numbers that are actually better than the national average. The numbers are going to be unfairly skewed when all comers are included. Moreover, plenty of papers have been published supporting the opposite conclusion; that complex gastrointestinal procedures can be done just as safely in community hospitals.

So what's the answer? I have no idea. There are academic surgeons at my residency training program that I wouldn't let come within 100 feet of my ampullary cancer, and there are surgeons here in my community hospital that I would feel very comfortable having operate on me. Finding the "right surgeon" isn't as simple as heading downtown to the big center where all the big names are. Surgery isn't set up like sports where the best in a field head the surgery departments at universities. There's no "Surgery Olympics" held every four years where surgeons compete for gold medals in "fastest, safest cholecystectomy" or "Best pancreatic anastomosis". Manual dexterity and technical excellence doesn't always correlate with whether you work in a communtiy hospital or an academic institution. Someone becomes Chairman of Surgery at Harvard because of an extensive, research-driven resume'; not because they can tie intracorporeal knots better than anyone on the east coast.

Given all that, here's when you should go to a tertiary referral center:
1. If your PCP recommends a specific surgeon for your procedure. If he/she just says, "I'll give you a number to the people downtown", you may end up with the junior attending on staff.
2. If you're comfortable with the idea of residents providing a significant chunk of the care.
3. If you live in Chicago; call Dr Doolas.
4. Inquire about night coverage at your community hospital. If physicians aren't in-house (hospitalists or house officers) consider going to the big center for your whipple or gastrectomy. Residents have saved many a life (and made mortality figures look better) at 3 in the morning.

If you need your gallbladder taken out or breast surgery or a hernia repaired, chances are you'll be able to get quality surgical care from your local General Surgeons. Ask around. Get references from other patients. Ask people who work in the hospital about Dr. So and So. Trust your PCP. Bottom line is, surgical excellence is very individualized. Some have it and some don't. Just because your surgeon's name tag says "Cleveland Clinic" or "Stanford", it doesn't necessarily guarantee a good outcome.

Tuesday, July 24, 2007

Katrina Doc

Good to see Dr. Pou will not be facing criminal charges for having the unholy gall to attempt to assuage the suffering of ICU patients abandoned by the United States government during the Katrina tragedy. Yet another attempt by right wing fascist America to politicize a very specific, personal act of bravery and compassion.

Listen, let's not be naive here. How do you think people die in ICU's? You really think the angel of God descends and gently lifts their soul from their earthly bodies, as they fall into the deep restful sleep of oblivion, a slight smile on blissfully parted lips? "Turning off the machines" and "pulling the plug" doesn't always lead to painless, comforting death. Often you watch them thrash, eyes go wide, muscles twitching, as they slowly suffocate. It's inhuman. No one should die like that. To have to go from being fully supported on a ventilator to having the machine flipped off, it's like someone pushing a pillow on your face. To not give any morphine or heavy sedation would be the unethical move. I had an ICU nurse who made me watch a patient die after I had written a DNR-CC order. It was the worst thing I've ever seen. Her eyes popping out of her head. The pain. Worse, the fear that seemed to seize her poor, wasted body. The nurse had 20mg of morphine in her hand. Give it, I stammered. All of it. She drifted off to sleep, death following shortly therafter. Granted, technically, you're euthanizing the patient; hastening the end. But it's the right thing to do, as far as I'm concerned.

Malpractice insurance optional

I like this post from inside surgery. Funny how the plaintiff's attorney scurries away down his little hole when he discovers there's no money to be won.

On related note, poor charlie weis lost his lawsuit against the surgeons who peformed his gastric bypass. I guess he'll have to crawl back to his horribly compromised post operative life as COACH OF AN NFL TEAM!!!!!! What a joke that suit was.

Let's be honest. Gastric bypass is a dangerous operation. Patients with hypertension, diabetes, and borderline heart failure aren't ideal operative candidates to begin with. Throw in the fact they allow themselves to balloon to 350-400 lbs and you're talking about a ticking time bomb. What is your life expectancy when you weigh 400 lbs anyway? Gastric bypass represents a last ditch, albeit potentially life threatening, intervention to save and extend a patient's life. Complications are higher not because of surgeon "incompetence" but rather, because of patient demographics. If I did inguinal hernia repairs on nothing but 300 pounders, my recurrence/infection/hemorrhage rate would likely be twice the acceptable norm. Gastric bypass is major abdominal surgery and, when done laparoscopically, a very technically demanding procedure. It's a recipe for disaster. Granted, gross negligence does occur. But cowboy general surgeons aren't doing this procedure anymore. You have to be practicing in a facility that carries the "Center of Excellence" designation, or else reimbursements are scanty. Fellowship trained laparoscopists are performing most of these procedures in the major tertiary referral centers. It's all very standardized and legitimate. And yet bad outcomes will continue to haunt the specialty, at least as long as very very very fat people are the patients who require the procedure.

Saturday, July 21, 2007

dead bowel on a saturday morning

87 year old lady with a history of CABG, stroke, and peripheral vascular disease who came in two days ago with diarrhea, weakness, nothing too specific. I get called at 6:30 am today because she apparently decompensates overnight and now is intubated and on Levophed (a vasopressor). A CT was done which suggested the possibility of portal venous air. I show up and she's on 80mcg of levophed, has blue fingers, and a rigid, peritonitic abdomen. Her lactate is 13. Her pH is 7.20. She's cooked, experience tells me. Mortality for ischemic bowel remains around 70-85% even in the best of scenarios. And this lady is a disaster. The quintessential vasculopath. She has no chance. I know that. The nurses know it. The internist maybe knows it. But when I tell her daughter, the daughter who lives with her, cares for her, loves her, a daughter who can't imagine a life without her mother, well, she wants everything done. Even if she only has a 10% chance. Even if surgery will only likely increase her suffering. As young surgeon, I agree to explore her. We open in the midline. The subcutaneous fat barely bleeds, her vasculature so clamped down. Foul smelling acites spills into the field as I incise the peritoneum. And then the inevitable; blackened, necrotic small intestine pushes its way through the wound. The more I pull out, the worse it looks. Gangrenous bowel from ligament of trietz to terminal ileum. Likely superior mesenteric artery thrombosis. I look up, her pressure is 68/50, anesthesia frantically trying to push drugs, fluids, blood into her. Enough. Give me the #1 PDS. I close the skin only, like you would after a organ harvest on a cadaver. We take her back to the ICU. Morphine drip. Tell the daughter. She dies minutes after the family says goodbye. What did I do here today? Is this part of the job? To give family members the self satisfaction that "everything " was done? Maybe I should have refused. There's nothing to do.. Let your mom die in peace. The next case. But just you say no to some middle aged adult child crying, begging you to do something, anything to try and save their mom.

Friday, July 20, 2007


People don't have rugs anymore. They have wall to wall carpet and hardwood floors. Perhaps a doormat to wipe your filthy feet on when you come in from outside. Rug has become an ancient word. Like chanticleer, like cutlery, like agora. I like how rugs create a little island of existence in a room. You feel bad stepping off the defined limits of the rug, the floor creaking, groaning in rebellion. But sometimes it's nice to touch the walls. And get fingerprints all over those nice white suburban walls. The goddam rug. Trying to hem you in, trying to cramp your style.

Wednesday, July 18, 2007

Just a job?

A couple of interesting posts in DB Rants and Panda Bear recently regarding the nature of what it means to be a doctor. Specifically in the DB piece, I was surprised by the vehement responses from medical students and residents defending lifestyle and monetary compensation as legitimate guides to specialty choice. Now mind you, most of these posts were well written and carefully thought out. Diminishing reimbursement, long hours, and lack of respect were all cited as sources of disillusionment and justification for younger physicians to pursue opportunities in fields more conducive to a) better earning power and b) more flexible hours and improved lifestyle. Applications to primary care and internal medicine have tailed off. General surgery became a much less competitive field over the past ten years as numbers of interested fourth year students decreased (attenuated somewhat by the recent implementation of work hour reform). The best and brightest of our medical students, the AOA bunch, are gravitating toward specialties like dermatology and radiology and I wonder if this is something to be concerned about. There is a sense of entitlement found in recent medical graduates that I find a little shocking. The thinking goes, "I busted my ass, got the top grades, made AOA, racked up $150,000 in debt, now it's time for a little retribution. Why should I slave away as a 'provider' for some mega-corporation HMO that seemingly randomly denies payment for this or that procedure/admission/test?" Compelling argument indeed. But an important detail is conveniently omitted; no one forces anyone to be a doctor. There's plenty of ways to make a bundle of money and have weekends off. Manage a fund. Become a broker. Run a 4.2 40 meter dash. I don't think medicine is supposed to necessarily be a default pathway for "really smart" kids who happen get high scores on MCAT's. We live in a meritocratic society, I understand that. But I think you compromise a core principle of medicine when practitioners see the job more as a reward for high achievement, rather than a privilege to be treated with humility and respect. A classic quote that killed me: "Ultimately, medicine is a job." If medicine is simply a job, a way to kill some time between the hours of 8 and 5, then I think we're all in trouble.

The whole concept of "just a job" fascinates me. It used to be, man's identity was intimately tied up in his caste or profession. Warrior classes, the clergy, the nobility, merchants, even the peasant classes. As a surgeon who trained just before the era of work hour reform, I'm a little biased, but truly, how can I honestly separate what I do every day, all day, the rest of my life, from who I am? I am a surgeon. It's a big part of who I am. I spent almost twenty years in school training for this. I spend the bulk of my waking hours thinking and doing surgery, taking care of patients. Not that I'm a one dimensional automaton. I have a wife. I read voraciously. I watch too much sports. I work out. I mean, I live a pretty regular life. But if one's self identity isn't dependent to some extent on what one does for a living, I don't know what else is left. Are you "that guy who's married and has two kids"? Or the woman who "likes to paint reprints of Cezanne on the weekends"? I think a cursory review of human history demonstrates that only recently have we considered those who "define themselves by the work they do" as somehow pathologic and subhuman. "It's just a job" denigrates all those conscious hours one expends during the day as mere frippery, an unessential, meaningless experience. One reason for this may be the way the workforce has changed. Factory jobs are gone. Agriculture long ago ceased to be a viable occupation for the average person. Most people are employed in the service industry, or involved in sales/marketing of mass-produced merchandise that they really could care less about. Is it any surprise that someone who sits in a halogen soaked cubicle all day hawking widgets would rather define his or herself by something other than "paeon of giant corporate conglomeration"? As a surgeon, as any physician, that isn't an issue. I'm lucky enough to be involved in an occupation that allows me to help people directly, every single day. It isn't "just a job". To consider it as such would be disrespectful to all the patients who come to me seeking to be made well again.

Saturday, July 14, 2007

Pulling organs out your vagina

We're always pushing the envelope in Surgery. How can I do it faster and easier, with less pain, less invasiveness. The first laparoscopic cholecystectomy was performed in 1985 in Germany. The first series of lap choles in America were done in 1989. But it wasn't until the 90's that the technique took off. Nowadays, if you aren't taking gallbladders out laparoscopically, you might as well start slapping leeches on patients who come in with CHF. The technique of laparoscopic cholecystectomy has been perfected to the point where it now takes 15-40 minutes skin to skin, with four small incisions, and most patients return home later that same day. Outpatient surgery for a procedure that used to result in a one week hospitalization with significant post operative pain. It represented the apotheosis of the fusion of surgical expertise with technological innovation. Laparoscopy was then expanded to other procedures. Laparoscopic Nissen Fundiplication for GERD/hiatal hernia. Laparoscopic appendectomy. Inguinal and ventral hernias are now being addressed minimally invasively. And of course laparoscopic colectomies are being done routinely for benign and malignant disease.

And now we have the Next Big Thing: Natural Orifice Transluminal Endoscopic Surgery, or N.O.T.E.S. Incidentally, can we please place a moratorium on stupid acronyms in the medical field? NOTES? Are you kidding? That's not even a cool word, like NATO or LASER. It's terrible. In fact, I'm not even going to call it that anymore. For now on, it will be known as POOV (pulling organs out vagina). That's it. It's settled.

So what is it, I'm sure you're wondering. Well, we'll start with the good. It's incisionless surgery. Hooray. No more unsightly 1 cm scars under your belly button that you can't even see anyway. An endoscope is advanced either through the mouth or vagina and the peritoneal cavity is accessed by creating a transluminal incision in either the stomach or female organs. Instruments are then inserted and the gallbladder or appendix or whatever is dissected and removed via the mouth or vagina. Sounds appealing right? Miniscule scars begone! Replaced by a man made sliceroo in the old stomach (gastrotomy) or, even better, through a woman's vagina. Let me repeat that. A cut is intentionally made in a woman's vagina through which a dirty, inflamed appendix is sucked out.

The technique was pioneered in India. Excitement for anything new in surgery spreads like wildfire, and inevitably it has arrived on our shores. Dr. Lee Swanstrom just removed a woman's gallbladder in Oregon on June 25 of this year. The question: is this cause for celebration or alarm?

An innovation in surgical technique, different from established standards of care has to prove that the benefits of implementation will outweigh the costs of new equipment and the time involved in training surgeons across the nation a brand new procedure. Furthermore, the safety of the new procedure needs to be evaluated and compared with the standard procedure and proven to be at least as safe. And the long term safety of POOV won't be known until a large series of patients has been collected and followed. The first patient who ends up with peritonitis from a leaking gastrotomy closure or the woman who comes in with dyspareunia from vaginal scarring perhaps will bring a quick end to the POOV era.

So what are we comparing here? Incisionless transluminal surgery versus laparoscopy. Laparoscopy provides a minimally invasive, relatively pain free technique to treat some of the most common gastrointestinal surgical diseases on an outpatient basis. That's a pretty tough customer for POOV to have to beat. What is being improved upon? The mere absence of incisions is enough to justify scrapping a perfectly good surgical procedure? I don't get it. And the idea of creating an intentional enterotomy seems to run counter to fundamental surgial principles. Not to mention the fact that the vagina and mouth are crawling with bacteria, inevitably to be dragged into a sterile peritoneal cavity. I think we, as surgeons, sometimes get infected with LookAtMe-itis. Look what i can do! Well, great. Is that doing the patient any favors? Is it doing our already overburdened health care system any favors, financially?

This isn't laparoscopy versus open surgery part II. That's not a fair comparison. The benefits of laparoscopy are tangible and real. Shorter hospital stays, fewer wound complications, less patient discomfort, fewer adhesions and bowel obstructions long term. And on and on. What are we gaining with POOV? A scar on your vagina or stomach versus tiny scars on the abdominal wall? I think you're going to have to do better than that. It's like scanning the 2006 Colts roster and noticing that maybe the left guard was below average and instead of simply replacing him, replacing the whole freaking team. That's what POOV is to me. The surgical equivalent of cutting Peyton Manning.

Anyway, that's enough on that. Doc Schwab had a good post on NOTES back in April.My wife just finished her anesthesia boards. We're going to go out for drinks. She worries about me and this blogging business....

Thursday, July 12, 2007

Pics from spiegel

Figured it out.

midnight ramblings

It's midnight and I just got home from a laparotomy for a bowel obstruction. One band, one snip, ten minute case. I love bowel obstructions. What i don't like is doing them at 11pm. This was a case I actually posted at noon. Not an emergency, necessarily, but I didn't want this lady to wait another night. I'd given 48 hours of nasogastric suction and her films still sucked and she was starting to develop some tenderness. I figured they'd be able to get me on at least by 5. No sir. I ended up being something like the fifth add on and by three o'clock, the OR whittles down to two functional rooms. So I waited. And waited. I went home. Ate a turkey burger, a la Foreman gourmet. Finally I get a call at 10pm. Drive all the way back for a ten minute snip snip jobberoo. Now I'm wide awake. Amstel light in the fridge. You make the call.

Also did a sweet little elective femoral hernia today. I approached it from below the inguinal ligament, reduced the hernia into the femoral space and plugged it with some mesh with prolene sutures securing it to coopers ligament and the inguinal band. Anyone else repair these via a preperitoneal approach? Laparoscopically? Im all ears. Incarcerated femoral hernias, I agree, ought to be approached either anteriorly or preperitoneally, but for these elective jobs, it seems a lot faster and easier to stick a plug in infra-inguinally. Inguinal. Inguinal. Ingwinal.

Ran into one of my old patients today, hospitalized for a severe nose bleed of all things. I took out his spleen emergently last October after he'd sustained a few broken ribs when he fell against his coffee table. He was on coumadin (of course) and he came in white as a sheet, his hemoglobin 3.5. He has this terrific wife and four sons who are all like 6'4" and we became quite close during his recuperation. He was one of those tough guy, no-nonsense sort of dads, you could tell. The nurses all hated him because he was a demanding pain in the ass, but I liked him. He got better. In the office, a few weeks later, he was his usual surly, dryly sarcastic self at first. But towards the end of the visit, he held up his hand. Hold on a second, he said. Its important to me... that you know..... how .... how grateful I am..... his voice breaking down.... I hugged the old son of a bitch, my eyes burning a bit. He's my buddy. That goddam coumadin is still vexing him but he's doing all right.

Tuesday, July 10, 2007

Mercy MRSA

It's officially an epidemic. As the junior surgeon at the hospitals where I staff, I tend to get more than my share of perianal abscesses, "butt pus", and other consults for various subcutaneous abscesses needing incisional debridement. It used to be, you'd drain them in the ED, tell them remove the packing in 24 hours and start three times a day sitz baths subsequent to that. We'd see them in 7 or 10 days and all evidence of sepsis had resolved. Not any more. I had a lady about 6 months ago, a PR vice president, who came to see me about a buttuck abscess. I drained it. The induration and erythema persisted. She got another one on the other butt cheek, and the beginnings of one on her medial thigh. I took her to the OR, opened everything up and placed a penrose drain. Final cultures: Methicillin Resistant Stapholococcus Aureas (MRSA). She ended up going home with six weeks of doxycycline. This was an upper middle class lady who was absolutely traumatized. MRSA used to be the bane of ICU's, the so called nosocomially acquired infections. Now, it's become a widespread community acquired infection. Why is this a problem? It's an aggressive little sucker, for one. You can't eradicate it simply by doing an I&D (incision and drainage). It comes back. Always. And not necessarily in the same place. Antibiotics must complement the I&D. And penicillin derivatives don't work. Or Levofloxacin. Or Clindamycin or anything else except for IV Vancomycin, doxycycline, Linezolid (if you feel like dipping into your IRA), and occasionally Bactrim.

I changed my practice after that lady. I culture all abscesses now. If the preliminary reading from the lab demonstrates gram positive cocci in clusters, I call in a prescription for Doxycycline. Patients that look septic get admitted for IV vanco. Often, I refer them to an Infectious Disease specialist. Sometimes I can even tell if it's going to be MRSA or not clinically. MRSA infections tend not to have the foul smelling, purulent pus that you see with a typical E Coli perianal abscess. There's a lot of induration and erythema, but a strange absence of white pus. It's almost a brownish, necrotic purulence. Those people I start on Doxycycline right away.

The last 15 subcutaneous abscesses I've had to drain, 14 of the cultures came back MRSA. (I've kept track). And all patients were young, relatively healthy people who were admitted from the community. Not one was a chronic ICU lingerer. So the next time you notice a boil or persistently reddened, painful mosquito bite, don't blow it off. Go see your FP.

Monday, July 9, 2007

der spiegel

Cool case. This was a 87 year old lady who came in with an acute onset of abdominal pain, nausea and vomiting. Her history included HTN, remote breast cancer, and the ubiquitous hyperlipidemia. Surgical history included mastectomy, laparoscopic ovarian something or other, and an umbilical hernia repair with mesh. She seemed uncomfortable, had been languishing in the ED for several hours, and there was a kidney basin at bedside full of green bile. Exam demonstrated distention, tympany and a tender mass in the left lower quadrant. CT of the abdomen and pelvis (see above)suggested incarcerated spigelian hernia.

I chose to fix this daddy laparoscopically. Upon insufflating the abdomen and tilting her right side down, the incarcerated segment of small bowel spontaneously reduced. Of course I examined it. Although beefy red and edematous, stigmata of ischemia or perforation were absent. No reason for bowel resection. The defect was 3x3 cm. For hernia repairs with mesh, I always get nervous when incarcerated bowel is involved. Although not technically a "dirty" field, I worry about translocation of bacteria anytime you have engorged, obstructed, potentially ischemic bowel in area where I'm about to place a permanent foreign body. So I fixed the defect with Alloderm (acellular dermal matrix) using four full thickness abdominal wall sutures and reinforced with circumferential ProTacking. Very satisfying.

Spigelian hernias are somewhat unusual, although case reports have started to pour in over the years (almost certainly secondary to the widespread use CT scans). Lateral to the rectus sheath, below the level of the umbilicus is the spigelian fascia. Defects in this layer are known as.......Spigelian hernias! Most of the time, the aponeurosis of the external oblique is intact, thereby often obscuring rapid clinical diagnosis. Laparoscopic repairs have been done, even in acute cases of incarceration. But I believe this is the first reported case of repair with Alloderm. We will now pause for the self congratulatory applause to die down....

The lady went home in two days. I'll try to get the intra-op photos published as soon as I figure out how the hell to do it.

Sunday, July 8, 2007

what im reading..........and why and how (in bed, underlining choice phrases etc.)

I have certain books I've decided Im going to read over and over again until I die. Not consecutively of course. That would be the act of a lunatic. All work and no play makes jack a dull boy. Some books you just know you have to read again. It's a realization as you read that you're not really ready for some aspects of what the author is trying to impart, either mentally, experientially, or, I guess, physically. Well not physically. But you know you'll have to come back again. The Brothers Karamazov was the first one for me. I read it initially when I was 18 years old. It was summertime and I was working as a grunt on a construction crew. I was in a "fertile mind" stage of life. My god I was a cheeseball. I wrote poems and fell in love with every girl who smiled at me. I listened to jim morrison with the intensity of a religious convert. I spent nights sneaking out of my bedroom window, laying (lying, have lain?) on the roof staring at stars, filling up with enormous thoughts and infinite optimism. Sickening, obviously. There's probably a disease or a DSM IV diagnosis for it. Anyway, I read TBK during this phase. I read it in about 4 weeks. I hesitate to write this, because it seems so outlandish and phony, but it brought me to tears at times. How many books do that? Those coupled chapters "Rebellion" and "The Grand Inquisitor" were unlike anything I'd ever read before. You needn't be afraid of life, children, Alyosha saying to the kids at the end... what a perfect way to end it. The book felt holy to me at the time. I carried it carefully, respectfully, almost like a bible. It was the Brothers Karamazov. It was speaking to me. I ended up taking Russian during college because I wanted to read it in its authentic text. Which unfortunately required becoming extremely fluent in Russian. So no dice. I read it again during medical school, third year. I used the same copy I read the first time. (Garnett translation I believe). It had all this pink and yellow highlighter ink in it. Which can be amusing. Why the hell did I highlight THAT, when coming across some especially banal and obvious passage. By the way, Dostoyevsky will never win any awards for style or "detached cool irony." Which is a good thing. We must be able to venerate at least one artist who lacks any semblance of irony, or else we've lost ourselves as a culture. Right? So I read it mostly at night before going to sleep. It took a lot longer, 2 or 3 months I guess. I remember being troubled by the prose. Thinking it spasmodic and wordy and overly emotional. I remember wondering why I was so impressed with it the first time. But I was a know-it-all medical student. I read it the way I read note services while studying for gross anatomy tests. I picked apart every word. Broke down everything. I call it soulless, mechanical reading. Maybe the timing was all off. So now I'm reading it again. My wife bought me the new translation. It's a fresh copy, no highlighter. And truthfully, it feels different somehow. The other one kept trailing off sentences with periods of ellipsis....... as if it couldn't find a close enough equivalent for whatever idiomatic turn of phrase Dostoyevsky used. The new one doesn't make me gag half as much as the other, for whatever it's worth. I'm no linguist.

Thoughts on BK Read #3 at the half way mark:
- I really enjoyed the scenes with old man Fyodor. His insolence and feigned ignorance is hilarious when around the men of the cloth.
- I could see someone like Rachel Wiesz playing Katerina (hot and sassy) in the movie BK.
- Ivan might be my favorite brother. His probing skepticism is all too modern.
- The chapter "Cana of Galilee" is extraordinarily Joycean, with the seamless merging of first person stream of consciousness with third person narrative.
- Reading for the third time, I've noticed how tightly controlled the plot and narrative structure is. He didn't just sit down a la Kerouc and start pounding out pages; a lot of thought and contemplation and planning went into this work.
- The motif of 3. Three brothers, three women, three thousand dollars, three meetings with Smerdyakov, three knocks on the door. And I guess the Trinity factors in somehow.
- Dostoeyevsky's Christianity is one of joyful exuberance. Even in suffering. The miserable ascetic monk, Father Ferapont, is derided as a raving lunatic. Deprivation is a fact of human existence; self addled despondency only clouds the beauty and joy that are potentially all around us. It's a state of mind, more than merely "Christian". Really, it transcends Christianity.
- The sentimental prose and emotional exuberance of BK would be a little hard to take in this age of irony if one wasn't aware of Dostoyevsky's life experience. A man who faced a firing squad, spent years in exile, was constantly broke, fought depression, and then, on the brink of death, in old age, mustered the heroic energy to fire one last salvo, the work of a lifetime, a soul spilling onto pages; this man ought not to be mocked. It would be like snickering at a father who weeps as his only daughter exchanges vows at the altar. Some things are real. BK may not be a great work of "literature" according to modern precepts, but, my god, it is Art. It is for the ages. And as long as I walk the earth, i'll aways have it.