Friday, April 29, 2011

Large Bowel Obstruction

It cannot be emphasized enough: suspicion of a large bowel obstruction mandates an early surgical evaluation---- even if you think it's just a little old lady with another episode of constipation. LBO represents a potential surgical emergency. These patients ought not to be sitting on regular nursing floors for days and days. Within hours of arrival, a surgeon needs to be on the case. The consequences of delay can be catastrophic. Patients who perforate and dump liters of feces into their own abdominal cavities don't do so well.

Here's what to look for:
1) Colonic dilatation, especially cecal, greater than 6-8 cm.
2) Severe distention with tympany
3) PAIN. This is a sign of impending vascular compromise.
4) Don't be fooled by a report of "patient had some diarrhea". In a high grade colonic obstruction, sometimes passage of liquid fecal matter is the only stuff that gets through. Never assume that this suggests complete resolution of the blockage.

Here's what you do:
1)Consult surgery
2)Bowel rest, possible NG tube
3)Do not give oral motility or bowel cleansing agents

Here's what we will do:
1)Review films and examine patient. Pain on exam sets off our alarm systems.
2) Obtain barium enema study vs flexible sigmoidoscopy (usually in concert with our GI colleagues)
3) Operate

The type of operation can vary from case to case. Left sided obstructions usually result in a colostomy (unless you have endoscopic stenting specialists in your hospital). Right sided blockages can be addressed in a single stage without diverting ostomies. Sometimes all you can do is decompress the patient with a loop colostomy or even a cecostomy. But you can't let these patients with 10 cm cecums linger on the floor. The Law of LaPlace is an immutable physical reality.

Taxanes and Neutropenic Colitis

One of the dreaded complications of taxane-based chemotherapy agents is severe neutropenic colitis. The images above are pretty classic. Mortality rates approach 50%. Surgical treatment is usually an ileocolectomy with an ileostomy. When I saw this particular patient, there wasn't much to be done. He had extensive mottling of his legs and abdominal wall and, hemodynamically, he was already starting to crash. (As an aside, mottling is one of the most ominous random clinical findings you can encounter. The bluish-black stippling of the skin is an imprint of death itself.

Friday, April 22, 2011

Greenfield Doubles Down

In response to stepping down as incoming Preseident of the American College of Surgeons, Lazar Greenfield MD fired off an unrepentant, angry-as-hell email to several national media organizations on Wednesday. Here's the full text (with my comments in italics):

"The reports surrounding my resignation as President-elect of the American College of Surgeons lead readers to conclude that I represent an old-guard generation that represses women in surgery. Since nothing could be further from the truth, I can no longer remain silent in an attempt to protect the organization.

"These are the facts:

"1. The editorial was an opinion-piece written for a monthly throw-away newspaper, not a scientific journal. It reaches supposedly mature readers interested in new discoveries. (All of a sudden Surgery News is just a "throwaway newspaper". I'm pretty sure Doc Greenfield doesn't describe his tenure as editor of Surgery News as "Editor of Throwaway Newspaper" on his CV. And anyway, what difference does it make where it was published? You click "publish" on your laptop, you have to deal with the consequences. Would it matter if he had slipped his Discourse on Semen into the Archives of Surgery? In Mad Magazine?)

"2. The biochemical properties of semen that were reviewed have been documented in peer-reviewed journals and represent the remarkable way that Nature promotes bonding between men and women, not something demeaning.
(The "science" on this is a little suspect, at best, as per Orac. And besides, I thought this was supposed to be a "joke". Is it a joke or was it science? Or humor lightly sauteed in scientific olive oil? I don't know whether to laugh or run a PubMed search.)

"3. My light-hearted comment related to Valentine's Day was intended to amuse readers, but some found it offensive, so I extended sincere apologies and resigned as Editor-in-Chief of the paper. No one questioned my intent, since I have a long record of recruiting and promoting women in surgery. (Ah, the old "well some of my best friends are black people" defense.)

"4. That was not sufficient for some women who convinced the leadership that I was unsuited for the Presidency to which I had been elected. Facing threats of demonstrations by women at any medical meetings I might attend, I resigned.
(Only women found the article stupid and puerile and genuinely unfunny? Sure about that Lazar? I don't have a vagina. And I thought you sounded ridiculous and would have laughed my ass off from the back row every time you got behind a podium to give a speech as President of the ACS).

"I had hoped to make my experience one that others could learn from by appearing at meetings of women surgeons to discuss forms of hidden or unconscious discrimination, but that did not fit their agenda. There should have been a way to reach a less destructive outcome. (WTF does this paragraph even mean? Is he admitting that he may have expressed "hidden" or "unconscious" discrimination with his op-ed? Or is he implying that he is the one being discriminated against? And I love the phrase "destructive outcome", turning the tables and presenting poor Doc Greenfield as the victim.)

"So lets reverse the situation, and say that a woman editor wrote something that some men found offensive. After they voiced their history of repression, she decided it would be best for the paper if she resigned as Editor. But that wasn't enough, and other men's organizations demanded that she resign as the incoming elected President. The conclusion is obvious: men are ruthless and vindictive.
(Oh my god. That might have been the most retarded concluding sentence to a written defense that I have ever read. The old role reversal argument! Which makes no sense! And allows him to passively assert that the women who bitched about his semen treatise are RUTHLESS and VINDICTIVE!)

"Lazar J. Greenfield, M.D."

Clearly, that email was just awful. Could he have come off any whinier and self-pitying? He seems convinced that a small cadre of feminazis colluded to deny him his long overdue anointment as the chief representative of American surgeons. The email makes him look even more sexist than how he appeared after the original op-ed. Not a lick of contrition to be found. The clueless lack of self-awareness is just stupefying. The dude honestly feels like he's been egregiously wronged. Anyway, that's about all the Lazar Greenfield I can take for a week. Happy Easter everyone.

VA MRSA reeduction

The New England Journal of Medicine recently published findings from a multi-institutional VA study that demonstrated drastic reductions in hospital-acquired MRSA infections when a "bundled approach" infection reduction was adopted. This MRSA "bundle" included universal screening of new patients for MRSA colonization, strict isolation and contact precautions of infected patients, and a strong emphasis on hand hygiene after patient contact. After three years, ICU-related MRSA infections had dropped by 62%.

Those are good results, of course. MRSA is depressingly common in the hospital, and even outpatient, setting. Simple maneuvers like washing your damn hands after examining a patient in the ICU have to be considered standard of care measures. I'm not convinced that it's cost effective to screen every single patient who walks in through the ER for MRSA (why not just adopt universal precautions?) but the results certainly speak to the beneficial effects of increased attention to hygiene and a checklist-oriented approach to medicine.

But it strikes me as a somewhat hollow victory. So we've learned how to reduce MRSA and other hospital-acquired infections. Terrific. We could also completely eliminate all hospital infections by forcing doctors and nurses to don HazMat suits when entering a patient room and quarantining every patient in sealed iso-chambers like it's some hackneyed, faux-thriller Ebola outbreak movie on Lifetime Channel starring Brian Austin Green and Valerie Bertinelli.

My question is, what are we doing to address the underlying source of rampant antibiotic-resistant bacterial infections? If MRSA and C. Diff are never events, then why isn't indiscriminate use of prescribed antibiotics also being monitored as strictly? Why don't we have databases documenting all the unwarranted orders for oral and Iv antibiotics? When a PCP calls in a script for a Z-pack on a patient who complains of a "head cold'", why isn't that considered a "never event??

Friday, April 15, 2011

Lazar Greenfield's Cure for Depression

Lazar Greenfield is one of the truly pre-eminent, almost legendary figures in modern general surgery. He has mentored countless academic surgeons over the years at the University of Michigan. He is the eponymous originator of the IVC filter used to protect high risk patients from potential pulmonary embolisms. He is the editor in chief of Surgery News, the official newspaper of the American College of Surgeons (ACS). And recently he won election as the new President of ACS. That's a hell of a resume'.

And then old Dr Greenfield had to cap off a sterling career by writing a bizarre op-ed piece in Surgery News this past February wherein he makes the argument that women would be a whole lot happier if they, um, absorbed a little more semen into their bloodstreams. Yeah, unfortunately, I'm dead serious. Semen. As in man sauce. Based on exhaustive research into fruit fly mating habits, apparently. Or something like that.
It’s been known since the 1990s that heterosexual women living together synchronize their menstrual cycles because of pheromones, but when a study of lesbians showed that they do not synchronize, the researchers suspected that semen played a role. In fact, they found ingredients in semen that include mood enhancers like estrone, cortisol, prolactin, oxytocin, and serotonin; a sleep enhancer, melatonin; and of course, sperm, which makes up only 1%-5%. Delivering these compounds into the richly vascularized vagina also turns out to have major salutary effects for the recipient. Female college students having unprotected sex were significantly less depressed than were those whose partners used condoms (Arch. Sex. Behav. 2002;31:289-93). Their better moods were not just a feature of promiscuity, because women using condoms were just as depressed as those practicing total abstinence. The benefits of semen contact also were seen in fewer suicide attempts and better performance on cognition tests.

So there’s a deeper bond between men and women than St. Valentine would have suspected, and now we know there’s a better gift for that day than chocolates.

I can only hope that Dr Greenfield just has an awful sense of humor and that he truly thought he was writing a witty, seasonally-appropriate op ed for the Valentine's Day holiday. It isn't far fetched--- academic surgeons aren't exactly known for being Louis CK clones in the doctor's lounge. (Although, precisely because they are academic hot shots, they invariably are feted with guaranteed, disingenuous forced laughter after every awful joke they make by obsequious residents and med students who seek glowing personalized recommendations from them when the rotation is over, and so they never pick up on the fact they what they are saying truly isn't funny, in the standard meaning of the term.)

Anyway, he stepped down as editor of the paper and his status as incoming President of ACS is still TBD. He's sort of a creepy looking chap in that picture isn't he?


Dr Greenfield has officially resigned as incoming President of the American College of Surgeons. There will be plenty of people who denounce this controversy as an "overreaction". Certainly we all have the right to say whatever the hell we want. But the 1st Amendment doesn't protect any of us from the societal consequences of our speech. Dr Greenfield isn't going to jail here. He simply lost his elected position as the primary representative of American surgeons. That doesn't seem unreasonable to me. His op-ed could have focused on something benign and non-controversial, along the lines of "sex makes for happier surgeons". But no, he had to concentrate on semen. And how women need to augment their intake of the creamy white paste. I mean, this wasn't some off hand comment made at a Michigan Surgical Society banquet, after one too many martinis. This was an op ed in a monthly newspaper for God's sakes, which lends an air of premeditation to everything. One mistake doesn't negate an entire career, however. Dr Greenfield ought not to be judged solely on the basis of an asinine editorial but unfortunately, in the modern internet era, you can't hide from a single indiscretion. The internet will find you.

Bin Laden is Laughing at Us

This is the Police State that has wrapped its tentacles around us, so subtly, without a whimper of protest....

Thursday, April 14, 2011

Weekend Palin/Trig fun!

Here's an entertaining read by some history professor in Kentucky who went through the evidence and concludes that Trig is not Sarah P's son. Just remember---before all you Palinites start brandishing your pitchforks---- all Palin ever had to do was produce Trig's birth certificate and the relevant hospital records and this all goes away.....

More Bariatric Follies

There's a paper out in Archives from March that pretty much slams the door on the idea of laparoscopic adjustable gastric banding (LAGB) becoming a universally accepted treatment option for morbid obesity. 151 patients were contacted over ten years after having had LAGB for follow up. Only 60% were overall satisfied with the long term results. Alarmingly, nearly 50% required surgical removal of the bands due to erosion. Long term reoperation rates were over 60%. That's bad medicine, baby.

And then I read an article like this one in the Journal of Pediatric Surgery, that tries to defend/justify the practice of slapping a choker on a teenager's stomach. Here's from the abstract:
One hundred patients aged 14 to 19 years underwent LAGB. Preoperative average weight was 136.7 kg, and median body mass index was 48.7. Comorbid medical conditions were common. Five reoperations were performed for port site bleeding, hiatal hernia repair, possible intestinal obstruction, and port slippage. Eighty-seven patients were followed for a minimum of 6 months. Average weight loss at 6 months was 12.4 (range, 33.2 to 16.2) kg, and average change in body mass index was 4.4 (range, 11.8 to −5.6).
Beyond the fact that their results are mediocre (12 kg weight loss over 6 months), I'm more concerned about the moral implications of the report---that somewhere in this country there are pediatric surgeons at major academic centers sitting down with parents and their 14 year old child, trying to convince them that they ought to consent to implanting a device that has known poor results. I mean, 14 years old. It's ghastly, really.

Wednesday, April 13, 2011

Poem of the Week

The Best of It

However carved up
or pared down we get,
we keep on making
the best of it as though
it doesn't matter that
our acre's down to
a square foot. As
though our garden
could be one bean
and we'd rejoice if
it flourishes, as
though one bean
could nourish us.

-Kay Ryan

Sunday, April 10, 2011

Portal Venous Gas and Cecal Bascule

Most cases of cecal volvulus involve the twisting of a redundant, poorly fixated cecum around its ileocolic pedicle. Cecal bascule is a weird variant of cecal volvulus wherein its anterior wall folds over on itself oddly. I can't describe it in words very well. The first picture above may or may not be helpful.

Anyway, I operated on this lady recently who presented with portal venous gas and had peritoneal signs on exam. A deep fold in the anterior wall of the cecum delineated the extent of the gangrene present, isolated to the anterolateral aspect of the cecum. We did an ileocolectomy and she ended up doing well. Then I went home and looked up the word "bascule", because it sounded so stupid. Sure enough, I found it is a French word meaning "seesaw" or "balance". Drawbridges operate on a similar principle. My daughter loves seesaws. There's a park around the corner from where we live that has one. She makes me ride it with her for longer than I would normally enjoy.

Wednesday, April 6, 2011

It's Time

I was asked to see a 95 year old lady with severe abdominal pain a few weeks ago. She had been admitted to the hospital with complaints of fatigue and chest palpitations. Suddenly one morning she developed severe, sharp abdominal pain. Her heart was racing in the 130's. The Xray technicians were just leaving her room when I arrived. Now I know what you're thinking: 95 years old, what the hell is a surgeon doing on the case? But this was a sharp old broad, entirely in control of faculties. She grabbed my ID to make sure she heard my name correctly. "I'm in a hell of a lot of pain doctor", she said.

Her code status was DNR-CCA, meaning that, in the event of cardiac or pulmonary arrest no invasive life saving maneuvers were to be done. When I pushed on her belly the diagnosis was clear enough. She had peritonitis, likely from a perforated ulcer or perhaps diverticulitis. The x-ray eventually confirmed free air. I quietly informed the lady of her predicament. She told me to hold my horses, as her daughter (POA) was on her way in.

I spoke with the daughter on the phone to prepare her. I told her that her mother had sustained a catastrophic intra-abdominal event. I further told her that time was of the utmost importance; we had to determine how aggressive we were going to be, ASAP.

We met at the bedside. The daughter looked understandably strung out and stressed. Her eyes were raw red open wounds. She had seized her mother's pale hand with two of her own, as if she was fervently praying. "I think she wants you to do the operation", was the first thing the daughter said to me. Her voice trembled. She wouldn't let go of her mother's hand. She looked like she had run up the four flights of stairs to get here.

This is where the art of medicine comes into play. I have made the mistake of operating in this situation before, when I was a less experienced surgeon. I used to think it was enough to objectively present patients/families with the options, like a mechanic at a oil change shop. Option A, operate with certain complication rates, including the possibility of death. Option B, palliative care with death to ensue sometime soon. It's your decision. I will support whatever it is you decide. And then to step back, put the onus of responsibility on their shoulders. Sometimes the choice is too overwhelming. The patient is suffering. Please just do whatever will make the pain stop, she pleads to her daughter. What if the pain medications dont work they wonder. Maybe she will be one of those rare patients who survive the surgery and get better. After all, Mom just had lunch with me yesterday at Olive Garden. And so doubt begins to creep in. Doubt about advanced directives and code status orders. It's one thing to fill out end of life documents in an abstract, detached manner years beforehand. It's quite another when actual life rears its unyielding head and strikes at you with its ferocious inexorability. And so adult children of these dying elderly patients will ask----can you save my mom?

I have saved a few. I remember one 89 year old guy I operated on for toxic megacolon. He miraculously survived the subtotal colectomy and was sent to a nursing home. I remembered him as a personal triumph, a transient victory over the brute relentlessness of death. I may have even blogged about it, I can't remember. The story didn't have a happy ending though. I got consulted to see him 8 months after that miracle surgery. He was in the ICU with sepsis from a decubitus ulcer. His granddaughter told me he never really regained his mental or full physical faculties after the surgery, despite the intense rehab. The ileostomy was a constant source of stress and irritation. He had slowly withdrawn into himself and rarely left his bed. He had become a living ghost of the man she had grown up with. He died shortly thereafter.

Sometimes you have an obligation to present a patient's options in such a way that sort of pushes them in one direction over the other. Call it paternalistic if you will. I call it humane.

I told her that an operation would be very difficult (she had had numerous previous surgeries over the years and had an obvious large ventral hernia). I told her that it's certain she would leave the operating room intubated and highly likely that she might never get off the ventilator safely. I told her that many of her organ systems were already starting to fail and that often that process was irreversible, especially in someone her age. I told her that aggressive pain control was an intervention in itself, that she ought not to consider simple pain alleviation as "doing nothing". I told her I would support their ultimate decision....but a surgery would be very tough for her to tolerate.

Well, I've never been one to drag things out, she said. Get me some pain medicine. I don't want any surgery. What are you crying for, she said softly to her daughter. When it's time, it's time.

I sometimes forget how courageous human beings can be if you give them the chance.