Friday, August 31, 2007

Labor day holiday...

I was starting to get a little burned out last week, so my wife and I took a little vacation. I hadn't been off since February. Life was grinding away rather than gliding smoothly forward . Little things were bothering me more than they should. I had two laparoscopic cases I had to convert because of lack of progression. Trauma call was busy. Lots of phone calls at night. Had to re-admit a wound infection. Just one of those weeks and I guess I was cooked to begin with. So we went away to Niagara Falls. Last time I was there, I may have been two or three. Tell you what, NF is a highly underrated little getaway destination. For one thing, the Falls are beautiful, breathtaking, awe-inspiring. The steady, thrumming roar of the water rushing forward, cascading over the precipice, the mist of the crashing water wafting around you like an ocean fog is something you just have to see. Not many things on this earth you can just stand there and stare at for an hour. It was only a three hour drive and it was just what the doctor ordered. We stayed at the Hilton and did all the touristy things (Maid in the Mist, Cave in the Wind, etc) and just ambled our way through the town and ate well and slept in late. And did I mention there is Casino? Yes, Casino. A little more delicate when you're with your wife, but I put in some profitable time at the tables.....

On Saturday we went to my nephew's pee wee football game at some middle of nowhere middle school field in Springfield. I love watching little kids play sports, especially football, with the awkward, oversized football helmet and pads seemingly ready to capsize the skinny mites who donned them. My nephew played hard. He likes to take off his helmet and stare up at the bleachers at his family, but that's all right. I had to keep yelling at him to pay attention and watch the game. Late in the game, he crashed through the line and caused a fumble and we all stood and screamed and pumped our fists. Later that night was a birthday party for my niece. We all drank too much and got the latest gossip and watched the Indians. It was nice. My uncle gave us a bucket of full sized Koi for our backyard pond. Now I have to figure out why the water keeps turning green. And the Buckeyes won handily. After all, it was only Youngstown St, a division I-AA school. No one loses to I-AA schools, right? Oh, except for that evil school up north. I'm not allowed to gloat (wife a UM alumnus) but how about those appalachian state mountaineers?

Back to work tomorrow. The time of rest is over. Looks like a busy day scheduled. I can't wait.

Monday, August 20, 2007

NY Times From Sunday

This article is mildly disturbing, if you think about it. On the surface, Medicare refusing to pay for "avoidable medical errors" would seem to make sense. But just delve a little deeper and such a policy ought to frighten most physicians. Take for example IV catheter site infections. Certainly if you leave a peripheral line in for 12 days and it causes a thrombophlebitis, one would consider that an avoidable medical error. One that could be avoided by implementation of an institutional policy that requires IV sites to be changed every three days. But what about the patient who comes in with perforated diverticulitis and you put in an emergency central line for resuscitation prior to the OR and, three days later, blood cultures show staph growing from the line. It's technically a line infection. Was it avoidable? Is it an error? Who decides? This opens a huge can of worms. What about any post operative complication: DVT, UTI's, wound infections? Can't you just see some bureaucrat from Medicare deciding that these were "avoidable" and therefore will not be covered under the patient's plan? And if Medicare won't pay, the bill goes to the patient who is going read the phrase "avoidable medical cost/error" and head straight to his/her area tort lawyer.

Sunday, August 19, 2007

Acute abdomen and other thoughts

Strange and unexpected findings in a ER case this week. A 45 year male with a history of mental retardation was transferred into the ER from an institutional facility because of "unusual breathing patterns". Apparently, he had been complaining of stomach pains and nausea for three or four days and then developed cold sweats and rapid breathing. I was called by the on-call hospitalist who sounded worried as hell about the guy. The patient wasn't much of a historian given the underlying mental retardation, but one glance was all it took to realize he was in some sort of trouble. You see enough critically ill people in surgery that one glance is usually all you need to tell if someone is "sick". And when a patient doesn't look good, I usually go into trauma mode. This means starting with the A,B,C's: airway, breathing, circulation. He was able to speak, so airway was patent, but his respirations were over 40/minute (the unusual breathing pattern, I guess) and his oxygen saturations were in the high 80's despite being on an high flow oxygen face mask. So breathing not so good. Circulation evaluation revealed a clammy, cool, pale middle aged male with a BP 80/40. I pushed the saline and did the rest of the exam. His abdomen was rigid and flat and peritoneal signs were evident on palpation. Plain films revealed some stacked loops of small bowel, but no free air. Then his labs started trickling back. WBC 38. Lactate 9.5. Bicarb 12. Hemoglobin 16. The metabolic acidosis and peritonitis had me worried about dead bowel, or some sort of intra-abdominal catastrophe. It was strange though; the guy was only 45 years old and had no history of heart disease, dysrhythmias, or otherwise. Perhaps it was a perforated ulcer and for some reason the free air wasn't showing on the films. Whatever was going on, it was apparent that definitve diagnosis and treatment would require a laparotomy. He stabilized hemodynamically after three quick liters of saline and his saturations improved with the non-rebreather mask.

After consent was obtained from a distant sister, we went straight to the OR. Upon entering his peritoneal cavity, I encountered liters of bloody/straw colored acites. Unexpectedly, however, the bowels looked perfectly pink and healthy from ligament of trietz to cecum. The colon seemed normal. There was no fecal or enteric contamination. I examined the stomach and duodenum closely, even doing a kocher maneuver, to identify any possible ulcer perforations. Nothing. The fluid seemed bloodier and darker from around the stomach, so I opened the lesser sac, in order to better evaluate the posterior gastric wall. And then boom, it was clear. Lying in the posterior retroperitoneum was a partially blackened, necrotic appearing pancreas with surrounding peripancreatic inflammation and necrosis: Necrotizing pancreatitis, every surgeon's nightmare. Severe pancreatitis leads to leakage of pancreatic enzymes around the pancreas which auto-digest the surrounding tissues and set off an inflammatory cascade known as S.I.R.S. (severe inflammatory response syndrome) which can manifest as respiratory failure, kidney failure, and cardiac dsyfunction. When the pancreatic inflammatory phlegmon gets infected, the only hope for survival is aggressive surgical debridement and washout. Usually though, surgery is delayed for 1-3 weeks after the onset of necrotizing pancreatits, which allows for better tissue demarcation and safer debridement. This was a very unusual situation I found myself in where I was operating acutely in new-onset pancreatitis. I started to debride some of the friable, blackened gunk (like the black, charred grit left on a grill after an afternoon of cooking) until I got into a little bit of bleeding. And by little bit, I mean half a liter in 30 seconds. There's a rich vascular network around the pancreas and millions of little branches to disturb. Tiger country, we call it. Not someplace you want to often be, even in the best of circumstances. In the setting of acute pancreatitis, with all the attendant inflammation and edema, this was like navigating a tight rope in the dark. A combination of sutures and clips were able to finally stem the ongoing exsanguination, allowing me to take a step back and make sure my boxers were still clean. So I got the hell away from there for a while and did a standard open cholecystectomy. His gallbladder was contracted and inflamed and full of marble sized stones. Severe pancreatitis is either a result of heavy drinking or gallstones passing near the pancreatic duct. So standard procedure is to remove the source of continuing irritation, in this case the gallbladder, presumably. I went back to the pancreas and debrided some more obvious loose necrosis near the body and tail and then washed everything out. Put a couple of sump drains in the lesser sac and closed the gastrocolic ligament. Finished it off with a feeding jejunostomy tube and closed him up. This was three days ago. He's now extubated and doing better. We'll see how it turns out in the end. In hindsight, perhaps I could have waited and obtained a CT scan and treated him conservatively. Or at least waited until clear cut infected pancreatic necrosis set in....

Sunday, August 12, 2007

Sunday evening

Incarcerated umbilical hernia today. I've been using Ventralex mesh for these. It's a cool little product that allows a nice underlay repair without having to undermine and create huge ass subcutaneous flaps. No topic incites more debate amongst surgeons than ventral/incisional hernia repairs. I'm from the school of thought that underlay repairs are technically superior. Think of plugging a hole in a barrel with cork. Is the cork going to stay in longer if you stick it in from the inside or the outside? The answer is "on the inside", if you can't wrap your mind around that analogy. By the way "wrap my mind around" is the next hipster phrase. I had an old college buddy who lives in California drop it on me a few months ago. Since then, I keep hearing it more and more, as it works its way back to unhip, three months behind the times midwestern USA. In about two years it will be the punchline to some lame joke on According to Jim. So get in now while it's hot.

But about hernias. It's amazing how many gen surgeons simply close the fascia primarily and suture Marlex as an on-lay reinforcement. There's no doubt recurrences are higher. But the fear of having to go back into an abdomen with intraperitoneal mesh overrides those concerns. Anytime there's such a difference of opinion in surgery, it just means there's no good answer. I think, in the future, optimal repair is going to involve laparoscopic placement of some sort of biologic replacement tissue (like alloderm version-2020).....

Bourne Ultimatum- Go see this flick. Best action movie in years.

I have a guy lives not too far from me with a front lawn that literally looks like the 12th green at Augusta National. I find this highly troubling. Is there any reason for one to install bent grass into a private front lawn? To spend thousands of dollars a year on chemicals and watering regimens and professional upkeep? I mean it would be one thing if he was Jesper Parnevik out there chipping and putting before bed. But it's not. The guy is like 85 years old. If anything, maybe he naps on his luscious green soft grass after his morning enema. I'm tempted to sneak over there one night with my wedge and whack out a few divots....

Great article in the most recent New Yorker (not available on the website unfortunately) about Lesch-Nyhan disease. I'd forgotten what the hell it was. It involves some sort of mutation in the gene coding for purine metabolism and uric acid builds up in the blood. Afflicted individuals exhibit self mutilation, especially of the hands and face. If they live to adulthood, a lot of them have chewed off their lips and fingertips. One patient had removed his right eyeball. Another had gouged off his nose with a dinner fork. They live in a state of terror, from their own actions. And all from one protein being awry.

Friday, August 10, 2007

Lovely transfer

This little, old lady arrived in our ER febrile, malnourished and anemic. Her history was sort of interesting. Two weeks ago she had an open left colectomy performed at another hospital for what sounded like chronic diverticulitis. A primary anastomosis was done and she sort of lingered for a while in a nursing home afterwards. Her family resides near my part of the world and so, as she continued to not thrive, they transferred her to my hospital. She had had multiple cardiac catheterizations and was on plavix and aspirin. Her presenting hemoglobin was 7.6. WBC 9K but with significant left shift. Exam revealed right sided abdominal tenderness with some guarding. Rectal revealed frank melena. We obtained a CT scan and here's some images:

Antibiotics were started, IV resuscitation including 2 units of PRBC. She was hemodynamically stable, but just didn't "look right". I had GI do a EGD that night to rule out proximal source of blood loss. An eschar was seen over a deep duodenal ulcer in the bulb. Fortunately, it wasn't bleeding and no intervention was done other than IV Protonix. Now about those CT images. Any ideas about what's going on? What to do next?

Wednesday, August 1, 2007

Breast Cancer Handout

This is a reproduction of a handout I use when discussing breast cancer with patients. Trying to process the sheer volume of information involved in breast cancer while you're still reeling from the news that you've been diagnosed can be overwhelming so I've found it helpful to give handouts as we talk our way through the maze of diagnostic and treatment options. (Sorry for formatting errors; hard to transfer from Word to blogger form)

Breast Cancer


1. Ductal Hyperplasia
- Abnormal growth of normal ductal cells
- Slight increased risk of developing future cancer

2. Ductal Carcinoma in Situ (DCIS)
- Neoplastic, preinvasive cancerous cells
- Has not yet invaded normal tissue barriers
- Natural history is to progress to frankly invasive cancer
- Surgical intervention indicated

3. Lobular Carcinoma in Situ (LCIS)
- Preinvasive cancerous cells involving breast lobules
- Suggests markedly increased risk of cancer in either breast
- Close surveillance indicated

4. Invasive Ductal Carcinoma
- Invasive cancer of ductal cells

5. Invasive Lobular Carcinoma
- Invasive cancer of lobular cells

6. ER/PR Receptors
- Estrogen and progesterone receptors
-If positive, portends a better prognosis

Diagnostic Modalities

1. Physical exam
- Palpable lumps
- Monthly self exams!
2. Ultrasound
- Determines whether lesions are “cystic” or “solid”
- Complementary to mammograms
3. Mammography
- Identifies early, non-palpable lesions
- Suspicious calcifications should be investigated

Biopsy Techniques

1. Fine Needle Aspiration (FNA)
- Useful for palpable lesions
- Your surgeon often can perform this biopsy at initial office visit
- Cannot tell the difference between invasive and pre-invasive cancer

2. Core Needle Biopsy
- Usually done with some sort of radiographic guidance (ultrasound or stereotactic)
- Multiple “cores” of tissue are extracted
- Can determine invasive from pre-invasive cancers
- Usually performed by either radiologist or surgeon

3. Open Excisional Biopsy
- Also known as “lumpectomy’
- Done in the operating room by your surgeon
- Completely removes the area of concern

Stereotactic Core Biopsy
Pros: -Minimally invasive
- Allows for complete pathologic dx prior to definitive surgery
Cons:- Small risk of false negative result
- Does not completely remove area of concern, lifelong surveillance!

Open Excisional Biopsy
Pros: - Allows for complete pathologic diagnosis.
- Completely removes the area of concern
- Often is diagnostic and therapeutic
Cons: - More invasive, increased pain
- Complications of surgery such as bleeding, infection, seroma
- Cosmesis

DCIS Treatment

1. Lumpectomy + Radiation
- Clean margins are essential
- Post operative radiation reduces recurrence rate
- Leaves a scar of about two inches
- Role of Tamoxifen/Arimedex (anti-estrogen drugs) depends on final pathology report.

2. Simple Mastectomy +/- Immediate Reconstruction
- Removes 97% of breast tissue on affected side
- No indication for axillary lymph node dissection (except in select circumstances)
- Absolute indications:
* High grade, multifocal DCIS
* Larger tumors relative to breast size
* Patient inability to receive radiation
* Patient choice

LCIS Treatment

-LCIS increases your risk of invasive cancer equally in both breasts.
-Lumpectomy is not indicated.
-Close Surveillance
-Consideration of phophylactic bilateral simple mastectomy in select scenarios

Invasive Ductal Carcinoma Treatment Options

1. Lumpectomy + Axillary lymph node dissection + Radiation +/- chemotherapy and/or hormonal treatment.
- Also known as Breast Conservation Surgery
- Ask your surgeon about sentinel node biopsy
- Equivalent long term survival compared with mastectomy
- Slightly higher rate of cancer recurrence
- Lower incidence of arm swelling and nerve injuries

2. Modified Radical Mastectomy (MRM) +/- Reconstruction +/- chemotherapy and/or hormonal treatment
- Removes 97% of breast tissue
- Complete level I and II axillary lymph node dissection
- Higher rate of complications

random wednesday...

The most read article in the Akron Beacon Journal yesterday was this one which detailed a condo association's crusade to keep a 1 year old tenant out of the swimming pool and a mother's quest to preserve her toddler's "civil rights". Apparently there's a concern about "floating Baby Ruth syndrome". I'm not sure if Carl Spackler was called or not. The shocking thing to me isn't the article (all local papers are guilty of publishing ridiculous fluff pieces like this one), but rather the response from on-line readers. At last check, over 200 people had submitted comments, some of them quite angry and vehement. Ah Middle-Brow America, if only we could muster the energy to get as fired up about things like health care and the War in Iraq and homelessness and poverty as we seem to do for baby pee in a public pool.

The Garnett trade is a bold move by the Celtics. Suddenly that roster looks pretty intimidating with Ray Allen, Paul Pierce and Garnett. Of course the Cavs have been on the sideline all off-season because GM Danny Ferry crippled the salary cap by wasting gazillions of dollars on stiffs like Donyell Marshall and Larry Hughes and Damon Jones. Hopefully Lebron picked up a jump shot over the summer.

Finished reading "Natural Selection" by Frederick Barthelme. It's a witty, funny, sophisticated read. But it's almost too witty. The characters spend the whole novel having these absurdly hyperliterate, intellectual conversations that are just seeping with irony. It's entertaining, but I don't know anyone who talks like that. It almost seems scripted. It's like all the things I would have liked to say to people but don't because I'm not that quick witted. Which can be annoying, to read some guy spouting off perfect lines page after page. Someone needs to write a book where the conversations are all perfectly stupid and banal, just like real life.