Thursday, November 29, 2007

Efficient use of resources

Another classic example of the wasteful nature of the American way of providing medical care. An elderly lady came into the hospital last week with three days of severe RUQ pain. An ultrasound done in the ER suggested a dilated gallbladder with peri-cholecystic fluid and a positive sonographic Murphy's sign, but no gallstones. She was admitted to the medical service. A GI consult was obtained the next day. A CAT scan was ordered. Again, the imaging suggested edema around the gallbladder. She had a WBC count of 15k. Her hemoglobin was 12 (slightly anemic, technically.) So a surgical consult was obtained, right? Hardly. She was bowel prepped and underwent upper and lower endoscopy. Of course, the ubiquitous "antral gastritis" was diagnosed and she was immediately started on IV Protonix. Unfortunately, she continued to have RUQ pain (can you imagine, despite the protonix?). Cardiology was contacted but troponins and ekg's were negative. The next day a HIDA scan was obtained. This demontrated non-filling of the gallbladder up to 6 hours. At 5pm, my office received the consult for this poor lady. It hurts right here doctor, she said, pointing to under her right rib cage. The next morning she underwent a laparoscopic cholecystectomy, with severe inflammation of the gallbladder noted. She was in the hospital three days before a surgeon saw her. Multiple radiographic tests were obtained. Invasive procedures were performed. What is going on here? I'd love to see her hospital bill and tally up all the unnecessary work that was done. Multiply this case by the surprisingly numerous times similar patients are managed you'll find a gigantic sinkhole into which much of our health care dollars are lost.

The County

Sid Schwab's recent post about his time at San Francisco General Hospital got me reminiscing about my experiences at Cook County Hospital in Chicago. The place is closed down now; they built a brand new building just behind it five years ago. But I spent my first two years (the grunt years) as a surgical resident in that old claptrap. Rush has an integrated residency program where residents spend half their time at the Mother Ship (Rush) and half at the County. The disparity in care was striking. At Rush, you could count on air conditioning, clean supplies, efficient phlebotomy teams, rapid OR turnovers, VIP suites, and everything else you expect when you enter a modern American hospital. At the County, you could count on ... well, nothing. You'd see hundreds of employees milling around in the halls and common areas and it wasn't clear exactly what it was any of them did. We drew all our own blood. We wheeled patients down to radiology ourselves. We set up all the necessary discharge arrangements. We called patients at home the night before surgery ourselves to make sure they remembered to come in. You couldn't take anything for granted. Not even vitals. Ninety percent of patients on the wards would coincidentally have the exact same vital signs; 120/80 RR20 HR80, as if some mysterious magnetic force was compelling all the patients to breath and circulate blood simultaneously. You always checked pulses on your own. It was a culture of incompetence and laziness. No one seemed to care. It was the County system. That's the way things were. You could either fight the system and go home every night maximally frustrated or you could say hell with it and just be a bad doctor.

My first month as a surgical resident was at the County. It was July in Chicago and the temperatures were running in the high nineties. I remember the moment I first set foot inside the side entrance. A wave of heavy, stifling, steamy air swamped me and almost took my breath away. It was sweltering hot. My button down was saturated by the time I had walked twenty paces. It was if I had been magically transported to some jungle hospital in the middle of Cambodia. My instructions were to meet on the sixth floor at Ward 60. There were two options to get there. You could go up six flights of stairs. Mind you, these were real flights; 15 steps each direction back and forth. You'd pass overweight/out of shape residents paused on a flight, half way up, sucking air. It seemed there was always a code blue in the ICU (7th floor) when I was downstairs in radiology or somewhere and I'd have to race all the way back upstairs, jump on the bed and start pumping some lifeless body with chest compressions. Half the time you needed to be hooked up to the EKG monitor as well. The other option was to stand in the lobby with about 35 other people and wait for one of the two functional elevators to arrive. The wait could stretch as long as 30 minutes. The elevator would arrive and another few minutes would elapse as 15 or twenty people filed out. Then you had to get past the elevator operator. Yes, that's right, an elevator operator. These folks would make an East German border guard proud with the way they scrutinized ID's on people trying to get on board. No ID, no entry. It didn't matter who you were or what you looked like. A white lab coat, stethoscope hanging out your pocket, gauze and scissors and patient lists and xrays, nothing mattered except your picture on a laminated piece of plastic. The chairman of the department of surgery was once denied entry because he had left his ID in his office. He ended up taking the stairs. The elevator operators basically rode up and down all day in this tiny, suffocatingly hot little cubicle. Such a mode of employment attracted some interesting characters. There was the Jesus lady, who dressed like a nun, but wasn't one, who would sing everything to you rather than talk, like you were trapped in some horrid musical. May jesus bless you, she'd sing as you squeezed your way off at your floor. She actually had a nice voice. There was Carl, the black power advocate who was always reading some tome by Malcolm X or one of the Black Panthers. All the African-American men and women were addressed as Brother So-and-so or Sister so-and-so. Have a great day My Black Sister, he would say as they exited. Short white doctors like me weren't really acknowledged, maybe a grunt if you were lucky. There was a younger guy who frightened us all because he never spoke, just rhythmically banged his forehead into the metal wall and muttered unintelligible things as we rose through the shaft. Most of them brought chairs or fans or something to read. I can't imagine doing what they did all day long.

Once on the Ward, organized chaos ensued. The other intern, who had been there for a week already, tried to orient me, but there was too much keep straight. Rounds were a blur of gauze and tape flying back and forth and rapid talking and orders barked out by the chief resident and furiously trying to scribble down notes on what was expected, what needed to be done on each patient. Then the seniors went off to the OR and the interns were left alone to do all the work. One of the biggest jobs was making sure everyone had their blood drawn for labs. The phlebotomy service was arguably the most worthless department in the hospital, although strong cases could be made for radiology and nursing. Unless the patient was a 20 year old male with ropes for veins there was basically no chance in hell that your patient was getting his/her CBC drawn. So I became a pretty darn good phlebotomist. The first day, though, it took me four hours to get everything drawn on the 15-20 patients on our service. The worst part was nighttime. The lab where the blood samples were processed was actually across the street in a separate building. After hours, there wasn't a transporter to take the vials there. You had to deliver them yourself, if you wanted results that night. Let's just say the area around Cook County isn't exactly a place you'd want your wife wandering around at dark. The other option was to use the underground tunnels that connected the buildings (the Catacombs) but no one ever did that because there was some rumor that "people" lived down there and would rape and kill you if they stumbled across you. The main entrance to the lab building was locked at night so you had to use the service entrance around back. This deposited you in the basement where the morgue was. Nothing like standing in the basement of some creepy old building waiting for the elevator to arrive surrounded by a bunch of corpses. The worst sign out was when vascular wanted you to check PTT values on patients getting a heparin drip. Sometimes you'd make three trips during the shift as you tried to titrate the the drip to therapeutic range.

Speaking of vascular, that was easily the worst rotation. For some reason they never put more than one intern on the service even though it was by far the busiest service in the hospital. Vascular patients are a different breed. The atherosclerosis that affects their femoral arteries also inevitably affects their coronaries and carotids. They're the highest risk patients in terms of cardiovascular morbidity. If you want to do elective surgery (fem-pop bypass) a huge cardiac clearance evaluation is essential. This means everyone gets a stress test and a carotid doppler ultrasound and medical and cardiology consults. Generally, in a real hospital, this can be done on an outpatient setting. Not for County patients. There's no system in place for that. Your only option was to bring everyone into the hospital and do the workup as inpatients. The patient list would be three or four pages long. You had post ops, pre ops, patients in the midst of a workup, and emergencies/traumas. The intern had to keep track of it all. Four people would need stress tests, three would have to go for ultrasound, another six were awaiting final clearance from the cardiology service and on and on. Of course it was my job to make sure the patients actually got to their specific testing areas. Transportation only happened if an intern found a gurney, wiped it off, put new sheets on, and loaded the patient onto said gurney himself. The you had to push patient/gurney complex and any IV poles solo down the hall, into the elevator, through various corridors until you got to the stress test area. It was exhausting. Then you'd race back upstairs, load the next patient, draw more blood, change a dressing, fill out Byzantine discharge forms (called CAPS), pre-op the next day's surgery patients, write orders, follow up on tests already done. By evening rounds (Flip, we called it), everything was expected to be done. Another garagantuan list of chores would be piled on by the chief resident at Flip, and you'd spend another two or three hours taking care of business. Then you either went home (usually after 8pm) or starting taking call (and cross covering multiple other services). I lived in a tiny studio in Lincoln Park that first year without air conditoning. The only window opened up on a brick wall. I'd get home and collapse in a heap on the couch, eventually pass out with a half eaten pan of mac and cheese on the floor beside me. The alarm would go off at 4am and I'd start the whole thing over again. There were no days off. No one complimented you or held your hand. The expectation was that you'd be a professional and perform. The senior residents depended on you, but more importantly, the patients depended on your efforts. You learned how to be a doctor on that service. You took care of pneumonias and diabetes. You managed acute MI's. A sense of ownership developed; these were my patients. I was responsible for them. The recent changes in residency programs involving work hour reform makes it hard to inculcate such an ethic. Interns now go home at 7am post call no matter what. There's a disconnect between the theoretical benefits of reducing a resident's sleep deprivation and building the sort of doctor that society deserves. The lessons I learned at the County are with me even now. I practice medicine the way I learned it then. Anyway, this post is starting to get too long. Future posts on this subject almost certainly will be forthcoming.....

Wednesday, November 28, 2007

NFL tragedy

Sean Taylor died from a gunshot wound to the groin yesterday. It sounds like he sustained a significant injury to his femoral artery and lost massive amounts of blood. When EMS arrived he was barely conscious and vitals signs were negligible. Untimately he underwent 7 hours of surgery to fix the artery (and fasciotomies I presume) but he expired the next day. It's unusual to die from a gunshot wound to a peripheral vessel in civilian penetrating trauma. The femoral artery is ensheathed in layers of fascia and muscle such that, even in transecting injuries, the pressure of the surrounding hematoma will tamponade the pulsatile flow. I've seen plenty of major femoral and popliteal gunshot injuries from my time at Cook County where the patient presented relatively stable because the proximal injury had simply thrombosed. I suspect that perhaps Mr Taylor was shot by a high velocity firearm that caused significant soft tissue destruction around the vessel, thereby exposing the artery and allowing it to simply bleed out. The fact they were able to get him to surgery indicates that they were able to resuscitate him to some extent with blood products and saline. Why he died 24 hours after the attack is probably due to secondary events such as anoxic brain injury, ARDS, and SIRS caused by the initial insult of such massive blood loss. Just a nightmarish occurrence.

Tuesday, November 27, 2007

Bad News

I saw a 28 year old guy about a week and a half ago who presented septic with three to four weeks of crampy abdominal pain and malaise. Initial CT scan in the ER suggested an inflammatory phlegmon in the RLQ consistent with perforated appendicitis. I admitted him, started Zosyn and had interventional radiology place a pigtail catheter in the fluid collection. He quickly got better; pain resolved, WBC normalized, hemodynamic paramters back to baseline. The working diagnosis was appendicitis. The plan was to potentially bring him back for an elective interval appendectomy in 6-8 weeks. Well, he returned to the ER 3 days after his discharge with tachycardia, worsening pain and a leukocytosis. CT scan this time showed a peristent fluid collection in the RLQ and a distal small bowel obstruction. It was obvious he had failed conservative management and I prepared him for the OR. I anticipated finding a bunch of muck in the ileocecal area; ileocecectomy was the likely procedure. Upon entering the peritoneal cavity, everything was stuck in the RLQ. I gently teased the omentum and small bowel away, and immediately broke into a large cavity of pure stool. Further mobilization of the right colon revealed that the posterior (retroperitoneal) wall of the cecum was completely blown out. I'd never seen anything like it. I ended up doing a formal right hemicolectomy just to ensure that healthy bowel would be involved in the anastomosis. He did reasonably well post-operatively. After all, he is only 28 years old. Young healthy males can withstand just about anything. But then I received a phone call from the pathologist on Friday (day after Thanksgiving).
-Your patient appears to have a mucinous adenocarcinoma arising out of a villous adenoma. Eleven of twenty five lymph nodes are involved with the cancer.
-Excuse me? I asked. Are we talking about the right patient? You better double check that specimen. My guy is only 28 years old.
- Sorry... This is the real deal. Any family history?
-No. None...........

I told him the next day. His voice wavered as he struggled to ask questions, to process what he was hearing. Cancer. Chemotherapy. Prognosis. Words he was too young to have to comprehend. Hell, he didn't know what to ask. Why would he? No one prepares you for a moment like that. He has a fiancee'. He works in the health care business. He has a loving, dedicated immediate family. He woke that morning thinking about life as an open field extending as far as the eye could see, into the horizon, limitless. And now there are limits. Boundaries have been drawn. What do you say to him? What is there to say? What comfort can be elicited?

Wednesday, November 21, 2007


Physicians have a different conception of what the word "sick" means. It's different than the meaning an eight year old boy gives it when he tells his mommy he feels "sick". Different than what a college kid means when he relates how "sick" he got after shot-gunning six beers. For a physician, deeming someone "sick" is a declaration of war, of sorts. It means the patient isn't doing well. It means death lurks around the corner. Usually the patient is in an ICU, hooked up to a ventilator, on multiple antibiotics, vasopressors, swollen and distorted, fluids seeping out the vascular system. I was closing the fascia on a guy yesterday who had perforated his cecum. This guy's going to be sick, I kept thinking. Sick patients keep you on edge. There's no relaxing. You can't miss anything. The degree of vigilance has to be ramped up ten fold. They give me an ulcer sometimes. So how do you know if someone's really "sick"? What are the best indicators? How can you predict the ones who are likely to struggle? Here's a top five list of clinical indicators that a lot of docs use:

5. White blood cell count: I'm not a fan of this one. Sure, leukocytosis is usually associated with severe infection/inflammation but I've seen planty of patients on death's door with normal WBC counts.
4. Lactate levels: When tissues aren't being perfused, the cells undergo anaerobic metabolism. Thus, lactate will be elevated. I don't use this one very often. It always takes the lab too long to run it and lactatemia doesn't usually manifest until the patient is already starting to decompensate. So it just confirms what you already know.
3. Heartrate: An old school surgeon from my Chicago residency used to call us in the middle of the night for updates on his post op whipples. I'd ramble off streams of data; urine output, CVP, blood pressure, etc. Stop, he'd say. What's the pulse? That's all he wanted to know. Tachycardia is the first response mechanism to stress. All tachycardia ought to be investigated. Post op tachycardia should make you very very nervous. Find out why it's so fast.
2. Bandemia: I like this one. Bands are immature WBC. In the face of severe infection/iinflammation, the bone marrow will mount a massive leukocytosis. Initially, this won't show up on the CBC. Always look at the differential. Bandemia and left shifts are early indicators of something drasticly wrong.
1. Base Deficit: This is my favorite. Cells that aren't getting enough oxygen will undergo anaerobic metabolism. Lactic acid then builds up in the blood stream, lowering the pH. The body has an amazing buffering capacity, but when it gets overloaded, the pH will drop anyway. Base defict is a way of measuring one's relative buffering capacity. A high base deficit is suggestive of a body being overrun by a catastrophic event.
1a. Gestalt: How does the patient look? If they look like shit, trust your hunch. It's like that Malcolm Gladwell book Blink; sometimes your intial, subconscious perception is right on. Be very afraid of patients with a sense of impending doom, telling you they feel like they're about to die. They probably are.

On a brighter note, Happy Thanksgiving.

Monday, November 19, 2007

Chemotherapy = Poison

Unfortunate case yesterday. I was called emergently to see 50 year old lady in the ER who presented with 24 hours of severe unrelenting abdominal pain. When I arrived she was intubated and hypotensive. They had her in some crazy trendelenburg position (why do people still do this? arterial flow isn't facilitated by gravity. You just impede venous return to the heart.) Most of the history was obtained from terrified family members. My partner had operated on her a month ago for breast cancer. He'd done a lumpectomy and axillary dissection for a T2N0 poorly differentiated, Her2Neu positive, ER/PR positive ductal carcinoma. Nine days prior, she had received her first cycle of Taxane/Carboplatin based adjuvant chemotherapy. Over the past four days she'd suffered from horrible diarrhea, with abdominal pain coming on suddenly over the past 12 hours. Her skin was mottled and dusky and her heart rate was 140. Blood pressure was barely registering. Resuscitation with IV fluids was ongoing and the ER attending had already started multiple pressors. Her exam was unrewarding, as she was still completely zonked from the intubation meds. CT scan had been done prior to her crashing. (By the way, she'd been in the ER 8 hours prior to her decompensation.) The pictures were suggestive of diffuse enterocolitis. I was especially concerned about the cecum, which looked abnormally thickened with questionable pneumatosis. Her WBC count came back <1,000. Basically, I told the family that severe neutropenic enterocolitis carries a grim prognosis. Surgical intervention might potentially be life saving, but it could just as well hasten her demise. Without surgery she most certainly wasn't going to survive the night. She had three daughters, all in their twenties, and they wanted everything done. So I explored her; the cecum and part of the ascending colon were frankly gangrenous but the rest of the bowel looked pink and viable (although thickened and beefy red in some places.) So I did a right hemicolectomy, end ileostomy and transverse colon mucous fistula. She's still critically ill, as one would imagine. I'd give her about a 10-20% chance of meaningful recovery. Without white cells, the body just doesn't do well.

Sunday, November 18, 2007


Go Bucks! Looks like the Rose Bowl awaits. Need West Virginia to lose to have a shot at the title game. God I hope Lloyd Carr doesn't retire. The legend of the red sweater vest continues.........

Thursday, November 15, 2007

Too many doctors?

I read an interesting piece in the Atlantic Monthly last week questioning the almost dogmatic assumption that the United States is facing a physician shortage is the coming years. The link only gives you the first couple of paragraphs unless you're a subscriber, so either subscribe or buy the hard copy off the rack. We're always reading that we need to train more doctors, that with the aging population there won't be enough physicians to satisfy demand. But then I was waiting for the elevator the other day, reading the names of all the doctors on the peg board who practice at one of my hospitals. The board is 4x4 feet and just crammed with names, names, names. It's unbelievable how many doctors there are. There's two large GI groups. There's three general surgery groups. There's three separate pulmonary groups. The ID group has 7 doctors. (Don't get me started on ID again). And on and on. What we have isn't a physician shortage, but rather a physician overabundance. And I don't think it's too different at most suburban hospitals across the country. The scenario isn't one of overworked doctors struggling to keep up with the demands of patients waiting in line for care. Rather, it's a hyper-competitive world of doctors in the same specialty fighting over a limited supply of patients. Hence, all the ass-kissing and overwrought phony letters specialists have to send to primary care docs for "the privilege of assisting in the care of this highly interesting and fascinating patient." If I were to suddenly disappear from the face pf the earth like that Chris McCandless dude in "Into the Wild", the other surgeons here would be more than willing to swoop in and score my referral base. Patients would not be affected (other than in quality, of course). I mean, maybe if you live somewhere in the middle of nowhere in Nebraska or Wyoming, you worry about physician availability, but not in major metropolitan areas at private hospitals if you have insurance.

So here's a moral dilemma. As a physician in training, what obligations do you have to society in undertaking a career than is essentially one of service? Everyone wants to be a specialist. It pays more. It's more interesting. You get to do procedures. Maybe the lifestyle is better. These are important issues. You're just a human being with selfish desires like everyone else. Why should you go into primary care and work long hours at low pay, based in some practice in Coscocton, Ohio because there's a demographic need? Increasing medical school enrollments isn't going to solve the problem. You'll just end up with proportionally more cardiologists, more gastroenterologists, more cardiac surgeons to flood an already supesaturated metropolitan market. Until we compensate primary care/family practice in such a way wo make it financially appealing to medical students, there's still going to be physician shortages in South Dakota and Southern Ohio and Rural Kansas.

At Cook County hospital in Chicago where I trained, people wait 6-8 months to get their hernias repaired or gallbladders removed. Old guys show up lugging around these fifty pound scrotal hernias. At Northwestern or Rush, you wait a few days or weeks. If you're a VIP, you wait a few hours. Now, I'm not naive enough to be morally offended by this. That's the way the world works. Money talks. Nothing different than the way things have been for a thousand years of human interaction. But there are physician shortages. Right here in front of us. Right in the middle of cosmopolitan, wealthy, sophisticated Chicago. People go without access to health care. What is a physician's responsibility to help remedy this? We all go into six figures of debt to pay for med school. We defer gratification for material things until well into our thirties. And now we have to accept low paying jobs taking care of ungrateful patients in lousy isolated rural towns or inner city free clinics? I don't know. Maybe we should. It's something all docs need to explore, I think. I know I've been thinking about it. Doctors without borders, and other volunteer opportunites are an option. Maybe I'll have to show up one day in South Africa and see what I can do to help old Bongi.

Monday, November 12, 2007

Not just appendicitis

A 36 year old construction worker showed up one night in the ER with excrutiating right sided abdominal pain for three days. Of course, he'd been toughing it out, going to work anyway. But then he started to develop fevers and chills and rigors and finally his wife talked him into coming into the hospital. His temperature was 102.5F when I saw him and he certainly had tenderness and fullness on the right abdomen. The ER had already obtained the CT scan. The pertinent cuts are included above.
It looked like a perforated appendicitis with periappendiceal abscess. Generally, it's advisable to simply drain this abscesses percutaneously to clear the sepsis and consider bringing the patient back in 2 months or so for an interval appendectomy (although this strategy is debatable). The problem was that it was Friday night and getting radiology to come in for weekend procedures is like asking my wife to wear Ohio State Buckeye gear. I've handled this situation before simply by going to the OR and evacuating the abscess laparoscopically. He was young and anxious to have something done quickly so he could get back to work ASAP. So I took him that night and, interestingly, there was no pus. Nor did I ever identify an appendix. The cecum, however, was rock hard and indurated. So I did a laparoscopic ileocecectomy. The path is still pending; grossly it didn't seem like a cancer. In the one cut, you can see a suggestion of an appendicolith, so maybe this was complicated appendicitis with an intramural perforation. Weird.

Friday, November 9, 2007


Consult on a lady with "porcelain gallbladder" today. Traditional surgical dogma was that one should never attempt laparoscopic cholecystectomy in the presence of known porcelain gallbladder because of the high incidence of malignancy. (Concern about port site implants and adequacy of resection.) Recent literature however suggests that one oughn't to rush into open cholecystectomy. The incidence of invasive cancer in the setting of calcified gallbladder is actually much lower than originally thought. Therefore the morbidity of the open approach cannot be routinely justified. Everyone else practice similarly?

This is utterly astounding to me. $4.85 billion dollars? Amazing that the settlement can be considered a triumph for Merck. What does that say about their bottom line? Apparently, each individual will get a little less than $100,000 as a payout (BEFORE the lawyers get their cut.) Once again, the real winners seem to be the attorneys.

Thursday, November 8, 2007


I can't believe I wrote an entire post on Plavix. I must have been bored as hell in clinic yesterday. Quite possibly one of the more tedious posts of all-time. Poor plavix. It was a venomous attack.

The issue today is gifts/favors from patients. I have a cool little Italian lady who is one year out from a mastectomy for multifocal/multicentric DCIS. Just a classy, composed lady throughout the whole ordeal. She returned the other day for a routine follow up. Surveillance mammogram was clean. She was on Arimidex. Basically, it was a social visit. I was asking what she thought the best Italian restaurants were in Cleveland and she named a few, with the caveat that none of them could make sauce the way she could. Then she asked if my wife and I wanted to come over for dinner some time. I took her number and said "we'll see". Is this illegal? Will the HIPAA police come after me? Is it inappropriate to eat delicious lasagna with a patient whom I operated on last year? I'm still hedging.

And then there's the demented old guy I operated on a few weeks ago for severe C diff colitis. Yesterday an aide from the nursing home wheeled him in with a bouquet of flowers on his lap. The card read something along the lines of, thank you so much for helping my husband and god bless. Nice gesture, I thought. And then when I tried to move the flowers to examine him, he shouted "don't you effing touch me!" I had no problem accepting his wife's gift.

Wednesday, November 7, 2007


I felt like writing about my least favorite medicine today. It's called Plavix and it is probably the most dangerous med to have on board when dealing with surgical patients. Plavix (clopidogrel bisulfate) is an anti-platelet drug (like aspirin) that inhibits the binding of ADP to its platelet receptor, thus shutting down platelet aggegation. It's used a lot in patients who have had strokes or myocardial infarctions. After coronary angioplasty and stenting, plavix is used to prevent restenosis. Platelet aggregation leads to thrombosis; shut down platelet aggregation and, theoretically, long term patient outcomes will be better. Now the data to support Plavix, in my humble opinion, is a little suspect. The CAPRIE and CURE trials have established a "statistically significant" but atoundingly modest benefit of Plavix over aspirin. Combined Plavix/aspirin therapy seems to have a more substantial benefit. I'll leave the specifics to the professionals. All I know is that whenever someone shows up in the office for hernia/gallbladder/etc., one the first things I look for is whether the box for "Plavix use" is checked yes or no. I hate the stuff. Platelets are a surgeon's friend. During an operation, it doesn't take long to see the effects of Plavix use; skin edges that won't stop bleeding, the raw liver of the gallbladder fossa that persistently oozes like a skinned knee, taple lines that have to be oversewn. It's a royal pain in the ass. But it doesn't end there. The worst part is the long term effects. Platelets aren't just for clotting. They're actually the intial mediators of the entire inflammatory cascade. Dysfunctional platelets can impair wound healing and infection-fighting capabilities. I've had two seromas for inguinal hernias over the past 6 months. Both were in patients on Plavix. Now, I usually stop it 7 days in advance of an operation, but maybe that's not long enough; lately I keep them off it for 10 days. The other problem is when patients come in with acute surgical illnesses and are on Plavix. You can give platelet transfusions or just bite the bullet. Either way, your stress quotient gets amped up significantly. And non-surgeons won't touch these patients for any interventions. I have a lady in the hospital now with choledocholithiasis who needs an ERCP prior to her lap chole, but the GI guy wants to wait a week before doing a sphincterotomy (reasonable, as she isn't toxic). So I hope this magic pill is preventing thousands of strokes and heart attacks every year because it doesn't do me any favors.