Wednesday, September 30, 2009

American Rogue

I just can't wait. The suspense is titillating. Sarah Palin has announced that her memoir will be released on November 17th! According to reports, the book is over 400 pages long (not clear if this includes pictures and pop-ups) and was written in a little over 2 months. Oh, and one other little tidbit. Her ghostwriter is one Lynn Vincent, an avowed creationist, anti-science whack job who has collaborated in print in the past with the unabashed white supremacist Robert Stacy McClain. Should make for a juicy read!

Laryngeal Crush

Stafon Johnson, a running back for the USC Trojans, suffered a severe crush injury to his larynx this week when he dropped a barbell on his throat while bench pressing. Apparently his spotter allowed the bar to slip through his hands at the end of a set of repetitions and the full brunt force of the weight slammed into Johnson's neck. Johnson was rushed to the nearest trauma center where he underwent 7 hours of emergency surgery to stabilize and repair the injuries. It sounds like he had to have a tracheostomy placed and a feeding tube, suggesting severe injuries to his larynx and possibly the esophagus.

Laryngeal trauma is a scary entity. The larynx (voicebox) is a complex musculo-cartilaginous structure located in the upper cervical portion of the trachea. Any direct trauma to the larynx can compromise passage of air and the ability to breath or speak. Because the neck is a closed space, inflammatory swelling and/or hematoma formation secondary to trauma can compress the trachea and cause airway compromise even in the absence of major laryngeal injury.

It sounds like this kid got lucky. He was able to maintain his own airway (with difficulty according to reports) by using the accessory breathing muscles of the neck. This bought him enough time to get to the hospital where I assume they rushed to the OR for an emergency tracheostomy and whatever else.

Besides the tracheal/laryngeal injury you also have to evaluate for any esophageal or vascular injuries. Presumably some sort of angiography was performed to assess the carotid artery and jugular veins. I suspect that once a secure airway was established, the surgeons also directly explored the esophagus and endoscopically inspected the mucosa. Repair of complex laryngeal injuries is beyond my expertise but you can read about it here.

Long term, the kid should be ok. You worry about stricturing of the repair and possible permanent voice changes from a recurrent laryngeal nerve injury but these are things that can be managed. The kid easily could have died. Nice work by the trauma team at California Hospital Medical Center. The next time I find myself bench pressing 300-400 pounds I will certainly make sure I have at least two spotters....

Friday, September 25, 2009

Forgotten Man

I recently finished Amity Shlaes' book on the Great Depression, The Forgotten Man. It's a compelling, swift read; I encourage all to check it out. The term "forgotten man" was originally coined by this guy named William Sumner in the 19th century. His formulation was as follows---- Suppose you have entities A and B who are in positions of economic and political power. Both realize that entity C is unfairly compromised and excluded from sharing in their bounty. A sense of shame and justice and perhaps humanitarianism prompts A and B (the federal government and the capitalistic Masters of the Universe, respectively) to get together to try and find a way to help C (the poor and needy). But instead of directly assisting C, A and B instead identify X--- the forgotten man, the man who grinds through life, earns his own way, pays his taxes, doesn't ask or require anything of the government--- but because X lacks political standing, A and B find it is easy to place the burden of philanthropic redistribution on him. FDR of course had his own formulation of the forgotten man. In FDR's scheme, the forgotten man is just C and it is up to A and B to provide for his welfare.

Anyway you define it, I'm drawn to this concept of forgotten men in American life. As a surgeon, I cross paths with the downtrodden and forgotten rather frequently. We meet in the middle of the night, often, in lonesome, half-lit emergency rooms. Usually I find them sprawled uncomfortably on rickety stretchers, a thin hospital sheet stretched across their torso and limbs, never long enough, yellowed toes, bony pale hairless shins exposed. They never remember me the next day. They lay in the stretcher writhing in pain. They ask for more morphine. They can't remember how they ended up here. It's been going on for days. It hurts. Doc, it hurts and they turn towards the wall, clutching their abdomens. I review the films and the lab work and I try to explain what is happening, the perforated viscus, the appendicitis, whatever the hell it is, but I can tell they don't care. Just make it better they say. But when I turn to look for family, for a loved one, there's no one there. There's no one to call either. They've come into my life seemingly all alone....

I had a guy not too long ago who presented with a perforated duodenal ulcer. It was 3AM but I didn't mind driving in, already awake from my baby crying. It's nice sometimes to drive with the windows down on a cool summer night while the rest of the world slumbers. The smell of the dew dampened trees and grass and the sounds of the nighttime insects. The ER was empty. It must have been a Monday or Tuesday night. According to the EMS runsheet, the patient had been found down at the Shell gas station where he worked. He had peritonitis and looked deathly ill. He was 48 years old. His teeth were bad and he had that look of a chronic alcoholic, thin and disheveled and beaten down. We rushed him upstairs to the OR. After washing out a couple of liters of bile and gastric acid from his abdominal cavity, I patched the ulcerated hole in his duodenum with a tongue of well vascularized omentum. It was a quick, efficient case. We got him to the ICU within the hour. The family waiting area afterwards was dark and empty. There were no phone numbers of loved ones on his chart. I showered, lay down for an hour and then started my rounds.

A few days later I was surprised to see an older woman in his room while he slept. She introduced herself as his aunt. He had been living with her for the past several months. She asked about his condition. I informed her he was improving. She rolled her eyes. Probably fell off the wagon again, she said. Actually, no, I said. His blood alcohol level was zero when he arrived. Well, I'm sure this little adventure will give him an excuse to start hitting the bottle again, she said dismissively. I don't know how the hell he's going to make his rent this month. And then she walked off. I never saw her again.

As the days went by, my patient made remarkable progress. He turned out to be a very gentle and genuinely nice man. He seemed ever grateful for the care he'd received. He shook my hand on rounds. He always smiled, even when it was obvious he was hurting. The nurses loved him. He worked hard every day, walked the halls, used his incentive spirometer. I had had him on a prophylactic alcohol withdrawal protocol but that turned out to be unnecessary. He had been dry for 8 months now. He was working 50 hours a week at the gas station, saving his money. By day 6 he was eating and we were able to discharge him home.

Two weeks later, I saw him in the office. I hardly recognized him. He had showered and shaved and was wearing a button down shirt with corduroy pants. You could tell the clothes were brand new, the packaging creases still prominent. His wound had healed beautifully. He was back to work already. His boss had been very kind, granting him some time off. After a quick exam we talked for a bit. He opened up about his life. He was moving out of his aunt's spare bedroom into his own apartment. He didn't like his aunt so much. But she was the only family member who hadn't completely rejected him. Admittedly, he hadn't always lived his life the way he would have liked. He had made mistakes. He had been selfish. There was a lot in his history he wasn't proud of. But things were different now. There was hope etched into the lines of his coarse, aged face. He was hoping to get a night manager's position at the gas station later in the summer. Things were better. He had met a woman. He had a daughter in Phoenix he hadn't seen in years he was hoping to visit in the fall. And he was categorically grateful for the second chance he'd been given to make his life better. I can't express how thankful I am you took care of me, he said. You saved my life. It's hard to know what to say or how to act when someone says stuff like that to you. You were just doing your job. It wasn't personal. I'm just happy you got well again. It doesn't become personal until later, once the patient has conclusively recovered. And then you allow for a bit of unadulterated emotion to seep into the doctor-patient relationship, like two old war buddies talking about old times over a beer years later. Actually, that's not exactly true. As doctors we become attached to many of our patients almost from the beginning. But we hold back, restrain the heartstrings from thrumming for the sake of clinical objectivity and professionalism. There will be time for letting down your guard later, after you've successfully led the patient through the morass of illness. Eventually he had to leave. I haven't seen him since. I hope things are still well. I hope he's still dry and made amends with his estranged daughter. Hopefully he got that night manager's job. As time elapses, it gets harder and harder to remember what he looks like, the haziness of time blurring the edges of his face.

There was another forgotten soul from this summer I've wanted to write about. He was a veteran of the Vietnam War who had been battling alcohol abuse for years. He had been bouncing around Cleveland for the past decade, intermittently homeless, sometimes living with a loyal brother, sometimes crashing with fellow bums in ramshackle abodes. About five years ago he had tried to kill himself. His employment record was spotty. He was basically eking out an existence on the periphery of the American Dream. One night, after a massive binge, he took a pistol, pointed it down at his abdomen, and pulled the trigger. I was on trauma call that night when he rolled into the resuscitation bay. He was this emaciated, broken heap of a man bleeding out from his self inflicted wound. We intubated him, stabilized him as much as possible and rushed him to the OR. The bullet had entered his abdomen just below his ribcage on the right side, tore through the left lobe of his liver, blasted through the tail of his pancreas, exploded the top half of his left kidney, finally coming to a rest in a muscle belly of his back, inches from his spine. I opened his abdomen and encountered 3 or 4 liters of blood. We moved quickly. You pack all four quadrants, maintain your cool, and then systematically explore. The liver injuries were controlled with pressure and some whipstitches. Half of his pancreas was unsalvageable so I had to do a distal pancreatectomy. The kidney looked like a grenade had gone off in it and it was actively spurting blood so I performed a quick total nephrectomy. Foprtunately his bowels had been spared. There was no fecal or enteric contamination. I put some drains in and closed up shop. Initially his course was a little stormy. He went into alcohol withdrawal. He was intubated for over a week. But he slowly got better. He developed a persistent yellowish/brown drainage from one of his Jackson-Pratt drains and the evaluation of the fluid revealed this to be evidence of a pancreatic fistula (a not uncommon complication of pancreatic resections, especially when performed under duress). He went to a rehab facility with his drain and has been seeing me every few weeks in the outpatient clinic. He has VA eligibility but he doesn't want to see anyone else. Every few weeks we review the daily drain output volumes that he has meticulously written down on a wrinkled shard of paper, sometimes even the back of a napkin. The outputs remain too high. The fistula may not close spontaneously. So I've had to make arrangements for him to see a GI specialist in the VA system for an ERCP and to make sure he gets approved for the pancreatic secretion-reducing medication octreotide. It adds a lot of work to my ledger. I guess it would be easier to just dump him onto a surgeon at the VA for management. But I dont. He doesn't want that. See you in a few weeks Dr. Parks, he says.

We never formally talked about why he ended up like this. We never directly addressed his suicide attempt. He saw a psychiatrist and all that and he denies any persistent suicidal ideations currently but I still worry about him. He hasn't had a drink since the accident and he seems to be somewhat hopeful about the future. But he also knows the score. He's 58 years old. He hasn't done a whole lot with his life. Other than his brother, he doesn't have much of a social support structure. He never married. He has no children. He's been in and out of trouble with the law in multiple states. Since the accident, though, he's lived a very simple life. He doesn't drink or brawl or stumble around in chaos anymore. He wakes, eats a little, empties his drain and records how much comes out. He walks the streets where his brother lives. He used to bowl but he doesn't do that anymore. Before bed he empties the drain again and writes down what comes out. I half hope that damn fistula never closes.

I don't care what formula you want to use for who the forgotten man is. A, B, C, or X. In real life, there are no equations or secret formulations for the downtrodden and forgotten. They're all around us. We get so caught up in our silly, post modernist American lives we don't notice them, or we choose not to notice. Lonesomeness is pervasive. Those forlorn blank faces that pass you on the street, sitting silently across from you on the bus, the gaunt and weary who disappear into the background tapestry of life. We don't see them. We choose not to. We fear the light they shine into our own souls, the precariousness and utter abandonment of it all. We turn our heads, afraid to see our own reflection mirrored in the forgotten shadows of their lives....

Weekend Cool Tune: Bell XI and the Great Defector

Thursday, September 24, 2009

Waste or Economic Engine

Newt Gingrich (not usually my favorite guy) had a piece in the WSJ last week that caught my attention. I like outside the box thinking, arguments that challenge pre-conceived notions of reality and Gingrich raises a good point--- namely, why do we automatically assume that spending 17% of our GDP is too much? The standard interpretation is that this repesents an ungodly waste of resources and money. No other country spends so much on health care. What can we do to reduce such exorbitance, the thinking goes.

But there's another way to look at it. Maybe in America, we don't have so much a health care system as a health care industry. And this industry is an economic lifeforce for many Midwestern cities in this post-industrial, post-manufacturing era of American hegemony. In Cleveland, Ohio, if it weren't for the Cleveland Clinic and University Hospitals, unemployment would be over 20% easily. Blue collar America doesn't have the steel mills and the automotive factories to send its men and women off to every morning. Those jobs are gone, never to return. And the healthcare industry has stepped in to bridge the gap. Whether this is a sustainable long term economic model is difficult to say. But for now, all those expensive pharmaceutical drugs and outpatient radiology centers and the titanium hip components and fancy new hospital atrium construction also provide jobs and a means of existence for Joe the ex-plumber.

We need to ask ourselves whether this is all a mirage. Is it reasonable to assume that the jobs created and capital raised from the health care/innovation sector can replace the factory-based way of life that has been the foundation of blue collar America for half a century? And if it isn't, then what the hell is the alternative? People need to work. Green jobs? High tech digital? Biomed? Transitioning from an industrial economy to whatever else is next is America's next great challenge. But before we demonize the healthcare sector as just an expensive, bloated monstrosity, perhaps we ought to make sure there's a safety net to catch those end up losing jobs when we start shutting down surgicenters and outpatient radiology clinics and making it more difficult for the pharm industry to get new drugs approved....

Cal Coolidge once said, "the business of America is business". But what happens when that business is also burdened with heavy moral baggage (fair and equitable distribution of health care to all) which can compromise the pure profit driven motives of most industries?

Tuesday, September 22, 2009

Breast Cancer and the Elderly

With our aging population, we are starting to see more and more elderly women in our clinics with early stage breast cancers. If you live long enough, these things are inevitable. Generally, for early stage breast CA, we offer breast conservation therapy--- lumpectomy + sentinel lymph node sampling/axillary dissection + whole breast radiation +/- adjuvant chemotherapy/hormonal therapy--- as an alternative to modified radical mastectomy. But what about when your patient is 81 years old? Do they really need whole breast radiation? Do the elderly in general need to be treated exactly the same way as a 55 year old with breast cancer?

This paper from Italy (Martelli et al) tries to answer that question. The authors followed over 350 patients over the age of 70 who were treated solely by wide excision and post operative hormonal therapy. Lymph node sampling/dissection and whole breast irradiation were omitted. Recurrence and survival outcomes were followed over a median of 15 years and results were noted to be nearly equivalent to published data on patients treated with the standard BCT. The key is to get a wide excision with clean margins and to make sure that all patients are treated with hormonal therapy.

This is one of those underrated, yet reassuring, papers that community surgeons like myself can use to support individualized therapy for their elderly patients. Whole breast irradiation can be a pain in the ass. You basically have to drive into the hospital every weekday for 6 weeks for treatment sessions. If you're 83 years old and maybe you don't drive so well or your grown children work during the day and can't chauffeur you around, this can be a major problem. Furthermore, axillary dissection amps up the complication rates of breast surgery. A paper like this allows a surgeon to reasonably offer simple wide excision and adjuvant hormonal therapy (assuming the tumor is ER/PR positive), knowing that he hasn't compromised the patient's potential outcome by failing to meet the "standard of care". More importantly, knowing that one may avoid an extended course of radiation therapy may make elderly patients more apt to seek treatment of small mammographically detected abnormalities. So...good job Italy!

Monday, September 21, 2009

War on Obesity

Cleveland Clinic CEO Toby Cosgrove MD has been the target of a media firestorm lately over recent remarks he made to the NY Times about morbid obesity in this country. He averred that, given legal protection, he would seek to limit the hiring of the morbidly obese at his hospital.
Which is why it is so striking to talk to Delos M. Cosgrove, the heart surgeon who is the clinic’s chief executive, about the initiative. Cosgrove says that if it were up to him, if there weren’t legal issues, he would not only stop hiring smokers. He would also stop hiring obese people. When he mentioned this to me during a recent phone conversation, I told him that I thought many people might consider it unfair. He was unapologetic.

“Why is it unfair?” he asked. “Has anyone ever shown the law of conservation of matter doesn’t apply?” People’s weight is a reflection of how much they eat and how active they are. The country has grown fat because it’s consuming more calories and burning fewer. Our national weight problem brings huge costs, both medical and economic. Yet our anti-obesity efforts have none of the urgency of our antismoking efforts. “We should declare obesity a disease and say we’re going to help you get over it,” Cosgrove said.
This elicited quite the backlash from the local and national community and Dr Cosgrove eventually apologized for any implied hurtful intent. But yesterday in the Plain Dealer he wrote an op-ed further clarifying his stance. I give the guy credit; he's taken on a topic that makes a majority of Americans uneasy. Over 60% of Americans are either overweight or obese. This isn't some negligible, dark corner, universally comndemned social issue like crack cocaine or drunk driving. It's unfortunately all too pervasive. I like how he drives home the point that personal accountability has to be a major component of any meaningful health care reform. Just as campaigns to reduce smoking and drunk driving were effective using both information/instructional techniques along with more sensationalistic ads meant to ostracize and demonize undesired behaviors, Dr Cosgrove is calling for the same societal commitment to the fight against obesity. I don't see anything controversial about that. I'm just worried that how well this message is received will be contingent on what number you see when you look down at the scale in your bathroom...

Friday, September 18, 2009

Calling Audibles

Peyton Manning's modus operandi is to approach the line, stand there behind his center gazing over the defensive alignment, and then to start barking out commands in cryptic NFL-code. It seems to go on forever. Just run the play, you think. It's annoying as hell. Sometimes it seems as if he's just doing it for show, to draw attention to himself. What he's doing is he's changing the play at the line, he's calling an audible based on the defense's personnel and formation. A lot of times the Colts don't even huddle. Manning just lines the squad up and he calls a play based on what he sees.

In general surgery, we usually just "run the play". Patient has an inguinal hernia, we book the case, and go through the rote maneuvers, almost mindlessly, to repair it. Repetition is good. Muscle memory becomes ingrained. Laparoscopic cholecystectomy becomes an orchestral procession of unspoken movements and techniques. But the wonderful thing about general surgery is that every once in a while you have to improvise; you have to veer off the reservation a bit and change the play at the line of scrimmage.

I had a lady recently who presented with what seemed to be a classic case of gallstone disease. She had developed acute RUQ abdominal pain several hours after eating some chicken wings. The pain radiated to her back and was accompanied by nausea and copius emesis. Her physical exam also supported cholecystitis as the etiology---localized RUQ tenderness, positive Murphy's sign. An ultrasound done in the ER showed multiple stones in the gallbladder, but no typical finding of acute inflammation (wall thickening, pericholecystic fluid). Her blood work showed normal liver function tests and an elevated WBC to 15k. Because she had an acute abdomen, I booked her for a laparoscopic exploration, with intention of doing a lap chole.

We placed our ports, insufflated the abdomen, and started to look around. Her gallbladder was quickly visualized. It had that pearly white appearance that we often see with chronic cholecystitis, but it certainly didn't look acutely inflamed. That bothered me. She was exquisitely tender and had that leukocytosis. Things weren't adding up. So I hesitated. I took a look around. That's the beauty of laparoscopy; the whole peritoneal cavity is your oyster.

Sure enough, I noticed some edema and distortion of the hepatic flexure area of the right colon. The inflammation seemed to extend inferiorly toward the cecum. So I reconnoitered, put in a different port and started to examine the ileal-cecal region a little more closely. I ended up mobilizing much of the right colon from its lateral peritoneal attachments, rolling it over to expose the retroperitoneum. And there was the pathology--- a perforated, retrocecal, gangrenous appendix. The tip of this thing had extended up toward the inferior edge of the right liver. Hence the unusual presentation. But I found the sucker. And the gallbladder lived another day.

I suppose everything would have been easier if the ER had just done the usual, automatic thing and ordered a CT scan on the patient. But then it wouldn't have been nearly as fun. We surgeons like to call our own intra-operative audibles every once in a while too.....

Wednesday, September 16, 2009

For Ezra Klein

But I'd also recommend people read "The Malpractice Myth" by Tom Baker. Or this article I wrote on the topic. The great lie of the medical malpractice debate is that the crisis is in our courtrooms. It isn't. It's on our operating tables. Interestingly, Obama and Clinton once coauthored a pretty good article on this stuff. I summarize it in the piece.
-Ezra Klein in his WaPO column 9/10/2009

The bold face was mine. You see, Ezra Klein feels strongly that we live in the dark ages of medicine and surgery. Especially in the United States. The crisis is on our operating tables, he says. If anything, goes the implication, we ought to be having more lawsuits, more litigation in this dangerous country which is apparently densely populated with incompetent, uncaring, hackjob surgeons and physicians.

I feel obligated to remind Mr. Klein of the following:

-95% of heart bypass surgery patients now walk out of the hospital alive and well.
-86% of liver transplant patients are alive 1 year after surgery
-Since 1980 the average American life expectancy has gone from 73 to 78
-With the development of HAART therapy, patients newly diagnosed as HIV positive patients can expect to live a normal lifespan
-Since the 1970's, the 30 day mortality rate associated with the Whipple procedure for pancreatic cancer has gone from 25% to less than 3%
-The five year survival of women diagnosed with breast cancer (including all stages) is about 76%
-Most surgeries for routine problems like cholecystitis and hernias and ovarian issues are treated with minimally invasive techniques on an outpatient basis
-Type I diabetics can now wear insulin pumps that provide a constant infusion of insulin, thereby reducing the number of shots and improving overall glucose control
-Anal cancer is now treated successfully by chemotherapy/radiation protocols, obviating the need for permanent colostomies
-Implantable electrodes in the brain allow patients stricken with Parkinson's to experience a much higher quality of life than that afforded by medications
-Critical care advances allow patients to walk out of hospitals, nearly fully recovered from pathologic insults that universally killed people a mere 30 years ago (perforated colon, bleeding ulcers, ARDS, acute renal failure, etc.)
-Trauma centers across the country routinely save victims of violence/accidents on a nightly basis
-When grandma gets pneumonia, it isn't a death sentence anymore
-Neonatal intensive care units are saving premature babies who weigh less than 1000 grams regularly and even babies less than 500 grams to a moderate degree

Yes, Ezra, it is a dangerous world we live in. Sequester yourself in that insulated little WaPo bubble as much as humanly possible, and stay far far away from doctors and hospitals---they want your lifesource!

Access Problems

From the Plain Dealer:

Ohio Governor Ted Strickland granted a temporary reprieve yesterday to convicted killer Romell Broom because the death squad team, I mean lethal injection crew, were unable to find suitable venous access for the infusion of the lethal cocktail. According to reports, the team spent two hours jabbing and sticking him to no avail. They even tried the doomed to failure approach of "let's try to get one of those scraggly veins in his foot".

Now I don't mean to turn this into a defense or repudiation of the death penalty. (I happen to be opposed to it, FWIW). But it is legal in Ohio. I can't do anything about that fact. If it has to be done according to the dictates of the law, then is it asking too much for the state to be prepared for any and all contingencies? You mean, no one from the crew noticed weeks in advance that the guy had no veins? Were they all seeing him for the first time that day?

General surgeons are often asked to assist in difficult venous access cases. We hate it, though. Don't let anyone tell you anything different. Putting in a temporary central line is one of those annoying, poorly remunerated, time wasting duties that occasionally falls upon us. Thank God for PICC lines.

My question for the state of Ohio is: Why weren't we prepared for the possibility that Broom might have unsuitable peripheral veins? Why was no one available to place a femoral or subclavian central line? What's the plan now? To refer him to some unsuspecting general surgeon for placement of a Mediport or a Hickman catheter? Or maybe just bust out the rusty electric chair, replete with leather cap and straps, sponge stick bite blocks etc.....

Friday, September 11, 2009

Proceed with Caution

This patient presented with severe right upper quadrant pain and the ultrasound confirmed an inflamed, stone-filled gallbladder. But it gets more complicated. I noticed her Liver Function Tests were abnormal. This can often be seen just in simple acute cholecystitis but it also ought to alert one to the possibility that the patient has passed stones into the common bile duct in which case it is prudent to clear the duct prior to surgery with an ERCP (endoscopic retrograde cholangipancreatography). This woman's bile duct was only 3mm on the ultrasound, well within the range of normal, so I sent her for an MRCP (yes, I use expensive imaging tests occasionally) in order to further elucidate this apparent discrepancy of abnormal liver tests in the setting of a normal sized duct.

The MRCP demonstrated no filling defects. But it did show some unusual anatomy. If you look closely at the images above, you can appreciate that the common hepatic duct branches into right and left ducts much lower than normal. The cystic duct off the gallbladder inserts very close to this bifurcation. This sort of anatomy makes surgeons nervous. We like long thin cystic ducts located far from the main bifurcation.

So I brought the patient to the OR knowing this tidbit of information. And I proceeded very slowly. For one thing, the gallbladder was a friable, edematous piece of wet cardboard. Adhesions from the infundibulum to the porta hepatis region were more intense than I like to see. I peeled connective tissue away strand by strand, gently dissecting with the laparoscopic forceps. Ultimately I was able to heft the bulbous infundibulum up and out of the porta hepatis. Voila----cystic duct, on some tension, the only thing left connecting the gallbladder. The cholangiogram I shot is included in the images above. What you see is some narrowing of the distal right duct, presumably secondarily from the inflammation of the adjacent gallbladder. But I definitely had the cystic duct dissected out and isolated. It was safe to clip and cut.

These sorts of gallbladders can be hair raising. But the more prepared you are for a case, the more information you have, the better you're going to be able to handle it. An MRI is expensive but being able to correlate my intraop cholangiogram with the pre-op MRCP pictures was invaluable.

A fresh pair of socks

Did everyone see that the American Trial Lawyers Association recently changed its name? It's now known as the American Association for Justice. Nice upgrade, agreed? I mean, who in this country is opposed to "justice"? Anyone? It's a no brainer. The word "trial lawyer" doesn't seem to evoke the same warm, fuzzy feelings does it? I wonder why? The lawyers I know are such endearing, charming individuals.

It got me thinking. Given the demonization of physicians and the medical profession we've seen in the media over the past 6 months (read Ezra Klein and all the other wonks--- we're greedy and incompetent), perhaps we ought to consider changing the names of our representative organizations. Take the American Medical Association. Do we really need the word "medical" in there? I mean that just conjures up images of unnecessary tonsillectomies and $40,000 amputations and missed diagnoses and the like. How about if we rename it something like the Society of Professionals for American Wellness and Immortality (SPAWI). People love that word "wellness". Even Oprah would want to book the president of SPAWI as a guest. And immortality. Doesn't mean we guarantee eternal life. It just conveys the notion that we sort of vaguely support the concept.

Other possibilities:
American College of Surgeons---- American Collection of Mostly Male Unscary Mask Wearers (ACMMUMW)
American College of Emergency Physicians---- Federal Institute of Individuals Who Will See You at 4am on a Wednesday (FIWWSY@4W)
American College of Cardiology------- Healers for Hearts (H4H), of course

It gets a little tougher for a specialty like dermatology (exorbitant incomes, skin cancer, et al) so just to be safe, they might be better served by going with something like the American Society of Epidermal Patriots (ASEP).

Wednesday, September 9, 2009

Instant Thoughts on the President's Healthcare Reform Speech

An absolute home run. He even slipped in an acknowledgement of the necessity for tort reform. The moral argument underlying the need for fundamental reform and a broadening of the safety net and our duty to do more for the poor, the unlucky, the vulnerable was quite powerful, I must say.

The Specialist Strikes Back!

This academic nephrologist from Penn named Stanley Goldfarb MD has an interesting piece in the Weekly Standard this week. He's apparently outraged that healthcare reform proposals circulating on Capitol Hill include numerous provisions that would emphasize the importance of primary care providers. He's apoplectic about this. His gist is that mere primary care providers are in over their collective heads when it comes to managing most common medical problems. He cites some obscure studies that seem to support this thesis and then drops this paragraph (and please don't let Kevin Pho read it):
Many individual primary care physicians are highly capable and knowledgeable and can provide high quality preventive care. As a group, however, they apparently do not achieve those goals. In truth, they really cannot be expected to given the growth in new information in each field of medicine. They must rely on specialists to support them and to achieve the highest quality care. To rely on guideline-driven, primary care to solve the problems of the high cost of medical care is an example of the triumph of hope over reality.

So....we need MORE SPECIALISTS! Even 2% of medical students going into primary care is too much! It's all a great conspiracy!

It's really a silly opinion piece. For some reason Dr Goldfarb thinks the logical solution to improving patient outcomes is to just refer everyone to nine different specialists rather than to implement strategies that would make internists/primary care providers more accountable for their patients and would encourage practice patterns more in tune with the "standards of care". But this is the Weekly Standard, after all, the head cheerleaders of the Cheney torture program. Why would you expect anything nuanced and well-reasoned from them?

Sunday, September 6, 2009

Ali Soufan Slams the Cheney Torture Program

Great op ed from the former FBI agent Ali Soufan today in the NY Times. I don't expect this, a precis from someone who was on the frontline of the War on Terror, to completely eliminate all our residual torture apologists, but it's a good start.
Some of the information that is cited in the memos — the revelation that Mr. Mohammed had been the mastermind of 9/11, for example, and the uncovering of Jose Padilla, the so-called dirty bomber — was gained from another terrorism suspect, Abu Zubaydah, by “informed interrogation,” conducted by an F.B.I. colleague and me. The arrest of Walid bin Attash, one of Osama bin Laden’s most trusted messengers, which was also cited in the 2005 C.I.A. memo, was thanks to a quick-witted foreign law enforcement officer, and had nothing to do with harsh interrogation of anyone. The examples go on and on.

A third top suspected terrorist who was subjected to enhanced interrogation, in 2002, was Abd al-Rahim al-Nashiri, the man charged with plotting the 2000 bombing of the Navy destroyer Cole. I was the lead agent on a team that worked with the Yemenis to thwart a series of plots by Mr. Nashiri’s operatives in the Arabian Peninsula — including planned attacks on Western embassies. In 2004, we helped prosecute 15 of these operatives in a Yemeni court. Not a single piece of evidence that helped us apprehend or convict them came from Mr. Nashiri.

It is surprising, as the eighth anniversary of 9/11 approaches, that none of Al Qaeda’s top leadership is in our custody. One damaging consequence of the harsh interrogation program was that the expert interrogators whose skills were deemed unnecessary to the new methods were forced out.

Wednesday, September 2, 2009

Chemotherapy Efficacy?

A great NY times piece from yesterday on the movement of the pharmaceutical industry into novel cancer therapies. With patents due to expire on big moneymakers like Lipitor and Norvasc, the industry has refocused its emphasis on new oncologic drugs (860 drugs now being tested in clinical trials). The reason is all too predictable--- you can make a lot of money selling cancer drugs. Since 2006, cancer-related drugs have been the biggest selling category in the industry. Tarceva (a pancreatic cancer drug) and Erbitux (for metastatic colorectal cancer) both cost thousands of dollars per month, sometimes over $50,000 for a treatment cycle. Drugs coming down from the pipeline are sure to be just as pricey. Assuredly these pharm companies have invested millions of dollars in the research and development of the new therapies. From a strict dollars and cents perspective, I'm going to give them the benefit of the doubt to the extent that the exorbitant costs of these new drugs is at least partially justified.

The controversy arises when we start to examine the effectiveness of these newer medicines. For example, the metastatic colorectal cancer drug Erbitux certainly represents an innovative breakthrough in the war on cancer--- use of a monoclonal antibody that specifically targets the Epidermal Growth Factor Receptor, thereby slowing the progression of the disease--- but unfortunately it only adds about about 6 weeks to a patient's life when compared to placebo. Tarceva, the pancreatic cancer drug which targets a specific enzyme on the EGFR protein, improves survival by a mere 12 days compared to those who do nothing at all. At a cost of $3500/month.

Now that's just astounding. And I find it a little unsettling as well. The insidious inference is that these drugs are being offered to people who are vulnerable and bereft of hope. The oncologist tells them they have an incurable disease but this carrot is dangled before them. Try this fancy new drug. We can't guarantee it will prolong your survival or make your life better. But it may. And the flicker of light that such a conversation can elicit gives birth to a billion dollar industry. This exploitation of the dying is reason enough to look harder into the motivations and efforts that go into the creation of these new therapies.

The other reason is that it brings us full circle back to this concept of "Comparative Effectiveness". What the hell does this actually mean? How are we going to define it? Effectiveness has to mean much more than "treatment A leads to better outcomes than treatment B" irrespective of costs, side effects, and the degree to which it is more effective. From the Times article:
“As long as the marketplace does not distinguish between modestly effective drugs and dramatically effective drugs, there won’t be an incentive to shift resources to a greater emphasis on a larger benefit,” said Dr. Neal J. Meropol, an oncologist at the Fox Chase Cancer Center in Philadelphia who has been studying drug prices.

Ezra Klein has a surprisingly weak take on this issue in the WaPo. His stance is that the federal government should just use its muscle to bargain down the prices of these newer therapies, being careful not to compromise the innovation benefits that patients receive from them. Which of course is a convoluted, incoherent argument. Moreover it simply avoids the entire point of asking whether or not it is worthwhile for the pharm industry to invest so much time and money into the development of marginally effective cancer treatments.

Moosehead on the Wall

Via Mindhacks, a recent study from neurosurgeons at the St. George's University in London, UK demonstrates that patients who are able to see the actual fragments (bits of intervertebral disc tissue) from their microdiscectomy procedure have superior long term outcomes in terms of pain and neurologic sequelae compared to those patients who did not get to see the vittles. The study seems to suggest that one's perception of pain/persistent neuralgia is affected to an appreciable extent by the mere visualization, after the fact, of the offending etiology.

No surprises here in terms of the human psychology involved. Any trauma surgeon will tell you that the first thing a gunshot victim will ask after successful, lifesaving surgery is....."did you get the bullet out?" And I suppose if you find yourself mano a mano with a grizzly bear in the woods, recuperation from any injuries incurred in battle will be a lot quicker and easier knowing that your local taxidermist is preparing the grizzly's hide and head as a rug for your mancave at home. Trinkets and hunks of flesh always cement an triumphant experience in one's mind more than the vagaries of mere memory, right?

In my practice, I will occasionally take a picture of a gallbladder splayed on the back table or an appendix intra-abdominally, just before I stick it in the EndoBag. Patients seem to get a kick out of it. I jokingly tell them to frame it and put it in the family archives. But after reading this article, maybe I ought to do more. Perhaps I ought to cut a deal with the pathology department; make sure they save all specimens for me after my operations. Then I could present patients with several options, an a la carte menu so to speak. Appendix in a jar, floating harmlessly in the formaldehyde. Gallbladder anchored on a lacquered oak wall frame, the stones aesthetically spilling out the neck like a Thanksgiving cornucopia. Colon segment, partially opened, displaying angry-red fungating carcinoma, spiralling its way down from a ceiling mount. Breast lumpectomy specimen arranged tastefully in a snow globe paper weight. The possibilities are limitless. Right next to your rack of antlers. And home from the hospital percentage points quicker than the guy who still has only an abstract relationship with his now defunct gallbladder.

Tuesday, September 1, 2009

Pharm Corruption

The NY Times today uncovers further nefariousness from the psychiatric drug industry and the physicians who profit from their aims. A document from Forest Laboratories (FL) in 2004 was recently made public by a Senate subcommittee which details the gameplan FL executives had to make the anti-depressant Lexapro financially successful. Lexapro is biochemically almost indistinct from Celexa, a drug with a relatively short patent life. Lexapro costs about 90 bucks a month vs. $15/month for generic Celexa.

FL is already under investigation by federal prosecutors in Boston surrounding allegations of kickbacks given to physicians who prescribed Lexapro and Celexa to children. In this document, we find out that the corruption runs deeper. The company had budgeted nearly $35 million in 2004 to pay thousands of psychiatrists and family practice docs to give "marketing lectures" (parlance for CME conferences in Big Pharma vernacular).

Now I don't really blame Forest Laboratories. They're just another soulless giant conglomerate that exists in order to maximize the profits of its shareholders. But what about those doctors? Our profession is fighting tooth and nail to ward off unfounded accusations that we are the source of the healthcare failures in this country (see: ridiculous McAllen extrapolations, blue pills vs. red pills, ENT docs whacking out kids' tonsils rather than just giving them some allergy medicine, vascular surgeons getting five figure paychecks for chopping off diabetics' legs, etc etc). The last thing we need is the accredited bad press of physicians succumbing to financial incentives and betraying their ethical obligations....