Tuesday, October 30, 2012

The Election

Barack Obama and Mitt Romney have been campaigning for our votes seemingly for the past two years.  I have been getting emails from Juliana Smoot and Jim Messina for well over a year.  A President gets about 2.5 years after being elected to accomplish something before he/she must inevitably start the process all over again of "reaching out to the base" and "appealing to independents" and "articulating a narrative" and all that other pundit-speak that crackles my ears. Democracy in America has become degenerate.  We are run by a plutocracy of wealthy oligarchs who choose behind closed doors the figure heads to personify and articulate the narrow band of policies that they have deemed worthy of national discourse.  The Citizens United decision has entrenched the concept that the "monied interests" are the drivers of the political discourse.  The reality of our two party system is that there are very few differences existing on pertinent issues such as social security and national defense and executive authority between Republicans and Democrats.  We are led to believe that this  choice of President is "historic" and "fundamentally altering".  We are fooled into thinking that each party offers fundamentally different visions for how the nation will deal with future troubles.   The legitimacy of democracy depends on this perception;  for if the general population realized that choice A differed from choice B only in ornamental, unimportant ways then the facade-----"of the people, for the people"---- is shattered.  I say this as a preamble to the Buckeye Surgeon endorsement for President.   Never have I felt so disillusioned with my voting responsibility.

Friday, October 26, 2012

How I Do It: Severe perforated diverticulitis

Diverticulitis has a range of presentations.  Most cases are amenable to outpatient antibiotic therapy.  A small, but not inconsequential, percentage of patients will present with free air and peritonitis.  These patients warrant immediate exploration in OR, generally.  Findings usually include extensive inflammatory changes involving the rectosigmoid colon, along with secondary serositis of loops of small bowel entrapped by the process.  Purulent ascites is the norm and sometimes frank stool will be present.  Classic teaching states that the surgeon should wash out the abdomen, perform rectosigmoid resection, and then temporarily divert the stream of stool with an end colostomy (i.e. the Hartmann's procedure).

Recently, there has been a transition toward trying to re-anastomose the descending colon to the rectum, even in contaminated cases.  The benefit of such an approach is that one avoids a colostomy bag.  Colostomy reversals are notoriously tough cases and statistically only 70% will ever be reversed.  The drawback is that you are connecting bowel in very sub optimal circumstances.  The patient is septic.  The blood pressure may be labile post operatively.  And the tissues during acute peritonitis can be very friable and inconducive to holding staple or suture lines.  No one likes a leak.

Here's my management strategy for different scenarios:

Wednesday, October 24, 2012

Missing the Mark

A recent study from England has demonstrated an unexpectedly high re-operation rate in women who undergo breast conservation treatment (BCT) for breast cancer.  One in five women (out of 55,000) who were treated with lumpectomy required another surgery to ensure clear margins in a retrospective study of the years 2005-2008.  Re-excision rates were noted to be associated with the presence of ductal carcinoma in situ (DCIS) in the specimens, an entity that can often be multifocal on presentation. 


What we watched last night in the foreign policy-themed Presidential debate was a travesty.  On the one hand we have a candidate from the Republican Party who was applauded by partisan supporters for adopting the "strategic" approach (i.e. don't rock the boat, just get a draw or something close) of running and hiding  (i.e. lie and distort) from the bellicosity and war mongering rhetoric he has repeatedly put on the record  over the past 12 months and simply averred that we ought to be doing exactly what Obama is doing, only more "severely". 

On the other hand, we have a President, a supposed lefty, commie, peacenik, Age of Aquarius, progressive liberal bragging about how many Muslims he has killed and how many Iranians he has starved over the past 4 years.  The bravado was nauseating.  The Commandeer in Chief as designated National Hitman.  Someone mentioned this already--- the true winner of last night's debate was George W. Bush.  Shoot first and ask questions later.  America is Good and Noble and the rest of the world can Suck on This.   The President is our fearless, Morally Pure Leader. 

There was one question about drones:  something to the extent of whether Romney would embrace them.  Of course, he says.  Romney at the controls of drones.  Hell yes.  Just give me that chance, his maniacal wide eyed grin seemed to say.

Here are some things that are happening in American foreign policy right now that were indisputably not addressed at the "foreign policy" debate last night.  It is up to all Americans to decide whether or not this even matters.

Saturday, October 20, 2012

Of Human Bondage

My step-daughter is starting the process of searching for a college to attend next year.  More importantly, she has begun to look into her financial aid options.  The average cost of a four year undergraduate degree has gone up over 1000%  since 1978 .  Think about that.  Everyone is aware of skyrocketing health care costs and the difficulty of controlling their inexorable rise.  But the college and graduate school tuition explosion is far worse.  The average cost to attend a four year public university runs around $20 grand.  For a private school, the costs average close to $40 grand.  Certainly, these totals are attenuated somewhat by grant/scholarship outlays but, in general, the bulk of the costs are covered by obtaining federal subsidized and unsubsidized loans.  So even with a $5,500 grant/scholarship (the max allowable by current Pell grant rules), one is looking at graduating from say Ohio State or Kent St with a balance of somewhere between 50-75 grand.  Of course, one could always be born to rich parents and simply, as per Mittens, "borrow some money from them".  As for my step daughter, she unfortunately won't even qualify for a Pell grant because her mom married a physician and step parent income is inexplicably included in the application process.     

Further, imagine one decides to pursue a post grad degree in like law or medicine.  Tuition to medical/law schools runs from $25-45 grand.  Moreover, many if not all professional school students have to borrow additional unsubsidized or private loans in order to cover living expenses.  Many medical students are married, have young kids.  How does one pay the rent and put food on the table when one has no income.  Medical school is a fulltime job.  One can't  work part time at Wallmart three nights week while spending nights in the gross anatomy lab.

We are gutting our younger generations with onerous education debt loads.  If you don't get the degree, you're cooked.  If you graduate, then statistically you'll be better off but you'll spend the next 15-20 years forking over substantial chunks of take home pay to loan servicers.  And there is no recourse for those who find they cannot meet payments.  Revision of bankruptcy laws has made it nearly impossible to  evade responsibilities.  Enormous powers have been vested in the federal government to collect outstanding balances over the course of your life.   

Saturday, October 6, 2012

Scenes from Hospitals

The Surgeon strides down the hall to his office, passing a series of patient rooms.  The last one on the right has the door wide open.   
-Mom, can you hear me?  It's me, Franky.  Mom?   I'm here.  Do you recognize me? ............. Ma?

The Surgeon pauses in the hall just outside the door.  He knows the woman in the room.  She had fallen the prior week and sustained a severe, inoperable cerebral hemorrhage.  She can only vacantly stare off into space.  The Surgeon had signed off the case after a few days.  He stands in the hallway and listens.  Nothing more is said.  He moves on.  There are patients waiting in the office.

Later that day he passes the room again.  The middle aged, balding man is still sitting in a chair bedside.  He's looking at his mother, a baseball cap balled up in his hands.  The TV is off and no one tries to speak anymore.  Silence.     

Friday, October 5, 2012

When all the world is shining

The Surgeon has experienced three legitimate "religious experiences" in his life.  The first was one day in the summer in the mid nineties while living at his aunt and uncle's house in Akron.   He was studying half heartedly for the MCAT while working as a backroom kitchen grunt at a local restaurant/cabaret joint.  He didn't have a girlfriend.  His friends were all down in Columbus having an amazing time, apparently, and he spent his days nannying for his two younger cousins.  He was uncertain of the path his life should take.  He felt time was crunched, that he was running out of time to make a decision.  He had been reading too much Hemingway and Fitzgerald and not enough Biochemisty, not enough Biology.  He felt lost.  He wished he were marooned in some Left Bank flophouse from the 20's.  One day he broke down and prayed fervently, unlike anyway he had ever prayed before.  He asked for guidance and forgiveness.  He specifically invoked Jesus and God and asked for supplication.  What followed was a short period of warmth and clarity.  An indescribable joy bloomed within his breast and the future seemed limitless and wide open, and at the same time, irrelevant.  Whatever was to come, was irrelevant.  There was a deeper optimism that suffused his heart that day independent of medical school or musings on Lost Generation literature.  He had never before felt this premonition of impending joy.  Unfortunately, the episode and the feelings it had engendered faded with the end of summer and a return to college.  He went to services at a local campus Presbyterean church once or twice but he lost connection with any feelings of an enduring spirituality.  In retrospect, he feels that perhaps he was not ready to "settle" into a life of dogmatic religion.  He was repelled by the idea of choking off his intellectual curiosity at such an early stage of life and referring all probing questions about the nature of Man and ultimate ends to some 2000 year old book written by men just as confused and misinformed as the ones stomping the globe currently.