Buckeye Surgeon

Blunt

2011-07-22T20:23:00.000-04:00

I took care of a trauma patient a few months ago who was in a motor vehicle crash on her prom night. Initial imaging showed some left sided rib fractures and a broken leg. She was admitted to the regular nursing floor for further observation. When I saw her in the morning (4 hours after arrival) I found that she had one of those classic "seat belt signs". She was also was quite tender on abdominal exam. Her labs revealed an elevated white blood cell count, in itself not necessarily a concerning thing as young trauma patients with broken limbs will often mount a reactive leukocytosis. But her abdominal exam bothered me. I reviewed the CT with the radiologist. She didn't see anything unusual. So I repeated the CT and the blood work 2 hours later. Her WBC count was now over 20. The CT scan, however, was again read as "normal". When I examined her, she had frank peritonitis.

I took her to the OR and found she had perforated her proximal jejunum. Enteric contents were actively leaking into her peritoneal cavity. Everything else looked OK. We lopped out the damaged intestinal segment and put everything back together again. She did very well afterwards.

Blunt injury to the intestinal tract is a terrifying diagnosis in the world of trauma surgery. The CT image you see above is from the young lady's 2nd scan. What you don't see is anything that would ordinarily mandate an operation. There is no free air. No ascites. No obvious evidence of bowel injury. You just have to be patient with these cases. Examine the patients frequently. Don't be comfortable with negative CT scans. It also helps to have a firm grasp on what is meant by the term "peritoneal signs".

These are the cases where you simply have to know what the hell you are doing, individually. Collaborative care won't get you anywhere. You won't receive an award for just removing the patient's foley after 24 hours. Your Accountable Care Organization won't send you an Olive Garden gift certificate for limiting the total inpatient costs. It's all on you, buddy. Prom night 2012 is ten months away.

Sizemore Opts for "Sports Hernia" Surgery

2011-07-22T15:14:00.000-04:00

Washed up Indians center fielder Grady Sizemore was just put on the disabled list following surgery for a "sports hernia". This news came as a bit of a surprise to those of us masochists who follow the Tribe because press releases last week indicated that Sizemore would be out of action for a few days due to a "bruised knee" sustained while running the bases. Apparently, he had also been suffering from groin pain and his doctors felt that, as long as he was going to be out with a knee injury, he might as well undergo the procedure on the groin.

Sizemore hasn't played a full season of baseball since 2009. He had microfracture knee surgery last Spring. He was batting in the .230's and striking out every three trips to the plate this year. The guy is clearly going to pieces. I feel bad for him. But sports hernia? I hope to God Sizemore isn't thinking this is going to help him rediscover the art of actually making contact with the baseball.

The sports hernia craze is nothing short of amazing. It truly amazes me that such a procedure is being done so commonly on world class athletes. I've read the literature. I've done the research. And I still have no clear idea what a "sports hernia" is. I've read that it is everything from a "weakness" or a "bulge" in the inguinal floor, to a torn adductor muscle, to an entrapment of the obdurator nerve. What is it? Is it simply a Syndrome of Pathology? Is it multifactorial?

And what exactly is being done in the operating room? It sounds like most of these repairs involve placing a synthetic polypropylene mesh in the inguinal area, either via an anterior Lichtenstein approach or a laparoscopic, preperitoneally placed mesh in the Space of Retzius. I found one randomized trial on PubMed comparing conservative therapy with laparoscopic surgery. The mystery and lack of uniformity surrounding the technique certainly raises a few questions.

The mesh repair seems a little dubious to me. In true hernia repairs, the mesh acts as scaffolding, to allow natural scar tissue to form and strengthen the fascial defect. The mesh actually bridges the fascial defect. There are no anatomic fascial defects in the sports hernia. It's not clear to me, therefore, why exactly one needs to be implanting mesh in these patients. If you tear a muscle in your calf and I take you to the OR, stitch a piece of mesh over your muscle and tell you not to do anything strenuous for three months, there's a real good chance you'll feel pretty darn good after three months. But if you rest anything for 3-6 months, I suspect most will see significant improvement with or without surgery.

Here's what I propose to those who are advocates of sports hernia surgery:

1) Someone write an expository paper with pictures or intra-operative video footage detailing the exact technique of the repair.

2) I would love to see a randomized controlled trial comparing a sham surgery with real surgery in patients who have experienced 6 months or more of refractory groin pain despite conservative management. If something like this demonstrated statistically significant improved outcomes, I could be persuaded that maybe, just maybe, sports hernia is a real live entity.

Irrational Death

2011-07-17T23:52:00.005-04:00

My mind has been wracked by this story of a man falling out of the stands at a Texas Rangers game while trying to catch a game ball tossed into the crowd by star outfielder Josh Hamilton. He was a 39 year old firefighter and a husband and a father. He had driven his 6 year old son Cooper three hours to the game to watch their beloved Rangers. By all accounts he was a great fireman; fearless and a leader of men. He was a husband and a father. He took his son Cooper everywhere with him, to the fire station, community events, to baseball games at Rangers Ballpark.

He fell on his head reaching for a baseball. In the end, that's what it comes down to. The injury was probably an epidural hematoma that expanded rapidly. By the time he got to the emergency room, he was probably already on the verge of brainstem herniation. He didn't have much of a chance. Again, he died reaching for a goddam baseball. Sports columnists and writers will try to spin this as a "tragedy at the ballpark". They will dress it up in the narrative of fathers and sons and how baseball is a metaphor for life and fatherhood and growing up and all that Field of Dreams nonsense. But it's all bullshit. This wasn't a tragedy, not in the Greek sense of tragedy describing a character's fall from grace due to an unrecognized, fatal moral flaw. He didn't fall as a result of some fatal moral flaw. It was momentary lapse of judgment. A split second of reflex reaction, the excited boy in the heart of a man reaching out for a real live ball at a game. To give to his son. He died stupidly, and I don't mean that as an attack on Shannon Stone. I'm not saying Shannon Stone was a stupid man; just that the circumstances of his death were absurd, in the existential, Albert Camus-sort of way. There are plenty of stupid deaths that happen every day. Rarely does such a death reflect on the intrinsic worth of the individual who succumbs to it.

The difficult part is how this death doesn't easily lend itself to any rational narrative. Humans have a natural inclination to tell stories about the things we don't understand. We tell ourselves stories to make sense of a seemingly random, brutal existence of winners and losers and arbitrary suffering. A death, especially a premature one, has to be explained in a way that makes it meaningful. Otherwise the pain of meaninglessness is intolerable. When the ones we love slip away into the eternal darkness of the great unknown, we grasp feebly for a narrative that can show the natural progression of a Life and how the end came "in good time". We strive to demonstrate that it was "meant to be."

In the ICU I see such narratives play out every day. These little old ladies who fall and strike their heads and spiral into oblivion. The bedside is adorned with pictures of earlier, healthier times. Surrounded by grandchildren and everyone smiling, a cake in the foreground, inter-generational gatherings, the completeness of a life captured on film. Those primitive drawings from children. Get Well, grandma. Everyone can gather and celebrate a life well lived.

My grandfather had one of those textbook "perfect deaths". He was in his mid-eighties and every morning he swam at the YMCA before work. Yes, he still worked with my Dad. The morning he died, he met my Dad for coffee and then went to the Y for his morning exercise. According to Y attendants he was in his usual good spirits, smiling and wishing everyone a great day. He swam his laps and then, in the shower, he suddenly collapsed and died instantly from a massive stroke. He had lived a full life. He had watched his children grown up. He had been in a fifty year marriage. And then he died just after doing something he loved. You couldn't have scripted it any better. There was no bewilderment at his funeral. You didn't look around and see blank, baffled faces mottled with grief and confusion. Death had simply come. No one could quibble about the timing. It was a reasonable death.

There are other good deaths. The Army private who dives on a grenade to save his buddies. The father who dies protecting his family during a robbery. The secret service agent who takes a bullet for the President. I read recently about a Thomas VanderWoude in Virginia who died in 2008. His youngest son, Josie, had fallen through a septic tank cover into a deep pit. Josie had Down's Syndrome and he was an adult and lived with his parents, semi-independently. Mr VanderWoude immediately jumped into the septic pit, immersed himself in eight feet of raw sewage and propped his son's head above the surface until he could be rescued. By the time Josie was safely extricated, Mr. VanderWoude had already died from the asphyxiating fumes. This was his seventh and youngest child, a boy with Down's Syndrome and he didn't hesitate to put his own life at risk. There was no moral calculus in the decision, no weighing of the costs and benefits---just instinct and love. This is what we mean by a heroic death.

But it doesn't always have to be an act of heroism. Sometimes death is reasonable if it just alights upon us gently. Even the cancer death can be a good one. Usually one dies from cancer slowly. Slowly one wastes away, after all the surgery and chemotherapy and experimental treatments. The end presents itself. But at least it's an honest end. There are no surprises. One cannot deny that Death beckons. One look in the mirror will shatter all those illusions--- the sunken cheekbones; the amber-tinted, dulled eyes; the protruding skeleton; the wasting away of vitality and slow erasure of prior Being. One cannot hide. But there is solace in finality. One cannot procrastinate any longer. The end is near, inevitable, but there is still time to make amends, to heal old wounds, to express love, to say things you were saving for an indeterminate denouement, to make peace with God, soul, life. You have time to touch up the narrative of your life. Although the end is premature, you are given the gift of writing the final chapter. You have time to make sense of it all, to reconcile yourself to extinction.

But there is another kind of death that we don't like to discuss. There are deaths that don't announce themselves. Deaths that ambush us suddenly and without warning. The 18 year old valedictorian who dies in a graduation night car accident. Len Bias. The five year old who is abducted and murdered. The 44 year old father of five who dies of a massive MI during his seventh marathon. The 32 year old who is struck by lightning while golfing on his honeymoon in Bermuda. The 13 year old Afghani girl killed by a Predator drone strike. The 18 year old high school senior with a full ride football scholarship who dies on spring break in Panama City after drunkenly falling backwards off a third floor hotel balcony. The four year old who runs out into traffic after a ball and is struck dead right outside his house. I remember this patient from medical school while I was on a trauma rotation. They announced him as a motor vehicle crash (MVC) and when they wheeled him in, he was already intubated. He wasn't moving anything and they hadn't given him any sedation. The story was, he was sitting at a stop sign in a Topaz or whatever, awaiting his turn to go. He was an IT specialist, or something along those lines, for a local industrial behemoth and he was on his way home from the grocery store. He was a bigger man, but he seemed soft and doughy, like a high school math teacher. The worst part was that he was completely conscious when he rolled into the trauma bay. I remember looking into his terrified eyes. I was a green and arrogant student then, completely out of my league. I guess I had never seen true Fear before. This was the real deal. Anyway, he was sitting at that stop sign, just another day in an anonymous life, when a pickup truck, piloted by a drunken repeat offender, plowed into him from behind. The impact whipped his neck forward with a violence that snapped his cervical spine at C2 and C3. The CT scan was obscene. There was nothing to be done. I recall being forced to attend the meeting with the man's wife in the consultation room. This was for our edification, as medical students. His wife was there by herself, surrounded by about 8 people (Trauma surgeon, Neurosurgeon, residents, students, etc). I remember the look on her face as the Neurosurgeon methodically explained that her husband was condemned to a life of quadraplegia, as a best case scenario. She had this look on her face like someone who sneaks into a Harvard mathematics class where the professor is lecturing on how 2+2=5, while everyone nods their head and takes notes. The anger and incredulousness on her face betrayed all decency. They had a three year old girl at home. He died within the week.

Let me now venture into a prohibited zone for just a moment. You know, while we're on the subject of unjust deaths that are redeemed by narrative. The mother of all examples is, of course, the story of Jesus of Nazareth. Let's review: God watched us for two centuries. He tried Law and Covenants and Promises. Over the eons, we continued to disappoint Him and betray Him. God was pained beyond understanding. But His love for us was infinite. So He sends down his Son, Incarnate in Man, as a final offering. This Son is to live and suffer and ultimately die for all mankind's sins. He dies violently on the Cross and rises again on the third day. Man, if he chooses, is redeemed through Grace and Faith.

Now that's a good death, no? To die as the sacrifical lamb for all mankind, the vessel through which all can be saved from eternal damnation. It's a beautiful story. A father sacrificing his only son for a greater cause. A supernatural diety trying to connect with his creation in terms that they can identify with. But then I start wondering. Why did old Jesus have to die such a violent, unjust, horrifying death? The Passion of the Cross is certainly dramatic. There's no doubt about that. Just ask Mel Gibson. But does the mode of His death somehow overshadow the ultimate message? Would it have mattered if old JC had died of typhus or malaria or leukemia in some clay hut in Palestine? If He had succumbed to famine or flood or pestilence? What if He had simply tripped over a rock after 40 days in the desert with Satan and fallen down a cliff? What if He had sustained a massive heart attack ten minutes after delivering the Sermon on the Mount? What if He had drowned while bathing one morning in the river Jordan? Would it have mattered? Would the stupidity of His death detracted from a lifetime of everyday suffering? Did it have to be so dramatic? Would the story have been any less compelling without the Passion? (I know, there's probably something to be said for Original Sin and how Man's Fall from Grace during the Edenic phase mandated that humans were wholely responsible for the Savior's death. But still. It bothers me. Sort of an abrogation of responsibility, in my mind. And I hate the Original Sin argument anyway, especially when it's used to justify the death/suffering of innocent children. Tangent ends.)

We humans need a coherent narrative, not just for those whom we choose to worship, but for the flesh and blood we share our lives with. Death disconnected from narrative is intolerable. It's too much of an obstacle, even for a great Faith.

I don't know the answers to these questions. I'm no theologian. I'm a traveller through the inexplicability of life like anyone else. But I think we should all pray,or something along those lines, for Cooper Stone. He is a child now without a father. But he has a long ways to go (hopefully) before his time on earth expires. He has time. He will grow into a man someday. He will exercise a free will. And he will tell himself stories about a father he barely remembers. He has time to construct a meaningful narrative for a father who missed the bulk of his life. And there is Hope in that. There is Hope in the possibility that somehow, someway, Cooper Stone can eventually explain his great loss to himself through a fictive amalgam of memory and imagination. Perhaps his mind is seared with images of going to the fire station with his daddy, playing catch in the hot Texas afternoon, the way his daddy smelled when he came home from work, the prickliness of his unshaven, up all night face. This is all we have. The dead are lost to us otherwise. They die in a multitude of ways. They are extinguished like flickering candles in a November wind. The way they die is immaterial. It won't always make sense. The story just begins. They leave fragments and remnants and shattered pieces of a life. It's just lying there, fluttering in memory and anecdote, evanescent snippets of reality. And it is up to us, the living, to put those fragments back together again when we finally choose to speak of the dead we have lost and loved. I think this is the essence of a True Faith--- to believe these assuaging stories with all our hearts, in spite of all the evidence to suggest otherwise, in spite of the irrationality....

Sorry for the heaviness.

Pancreatic Pseudocyst

2011-07-11T08:58:00.000-04:00

One of my long time patients came to see me a while back with a complaint of abdominal distention, pain, and early satiety. A few years prior to this visit I had taken care of him during a prolonged bout of severe necrotizing gallstone pancreatitis. The scan above shows a giant pancreatic pseudocyst. A pseudocyst lacks a true epitheliazed wall. After an episode of severe pancreatitis involving parenchymal destruction and damage to branches of the pancreatic duct, pancreatic juices leak out into the surrounding retroperitoneal tissues. Once the flow of pancreatic secretions is tamponaded off (the ultimate size of the cyst is a function of the degree of ductal damage or obstruction) it will organize itself into a discrete cystic collection. Symptoms generally arise due to the mass effect of the cyst. Pseudocysts can also become superinfected leading to sepsis. Pseudocyst rupture is another rare complication.

We usually adopt a stance of watchful waiting with regards to pancreatic pseudocysts. Most will spontaneously regress as the duct/parenchymal injuries heal. Those cysts that persist past 6-12 months are unlikely to ever go away. Furthermore, cyst size is predictive of regression--- those greater than 6cm are less likely spontaneously resolve.

This cyst was over 20 cm. I watched it for a while but it never got smaller and his symptoms persisted. Treatment options include endoscopic vs. percutaneous vs. surgical decompression. Percutaneous drains are generally a poor choice because you simply convert a contained internal pancreatic fistula into an uncontained external fistula with all the attendant fluid/electrolyte sequelae. Endoscopic drainage of pseudocysts into the stomach utilizing endoscopic ultrasonography is an exciting new option but it isn't universally available and long term results are lacking.

The standard treatment has long been surgical decompression of the cyst into either the stomach or small intestine. I performed a cystogastrostomy on this patient. It's a nifty little procedure. By the time you operate the cyst wall has densely adhered to the posterior wall of the stomach. So all you do is open up the stomach anteriorly, palpate the bulging cyst through the posterior wall and excise a wedge of the gastric/pseudocyst confluence. Classic teaching is to send off that specimen to the path lab to rule out a neoplastic process. The image below represents the 3 month follow-up appearance of the upper abdomen.

The Cancer Racket

2011-06-09T09:14:00.000-04:00

News of a new weapon in the "War of Cancer" raged across the internet last week with the publication of a paper in the New England Journal on vemurafenib, an immune system-targeting drug used in cases of advanced melanoma. Heretofore, prognosis of patients with stage IV melanoma has been dismal, at best. Most die within 6-10 months. Various attempts over the past 15 years to improve survival with the likes of chemotherapy or immune-modulating drugs such as interferon have miserably failed to meet expectations. Paul Chapman's group at Sloan Kettering trumpets the fact that, at 6 months, 84% of participants using vemurafenib were alive compared to 64% who took the chemo agent dacarbazine.

This paper was presented at the American Society of Clinical Oncology and the resultant fanfare would have you believe Jonas Salk himself had announced a cure for the common cold. Here's a sampling of headlines from major media outlets covering the presentation:
'Time to Celebrate'; New Metastatic Melanoma Agent Wows ASCO
---Medscape News
Drugs hailed as a 'major breakthrough' in treating deadly skin cancer
---LA Times
The Biggest Skin Cancer Breakthrough In 30 Years
----Business Insider
Skin cancer 'wonder' drugs that could offer years more life in biggest breakthrough for 30 years
---Daily Mail (UK)

Pretty exhilarating, no? But let's take a look at the actual data. At six months, 84% of patients on vemurafenib were alive compared to 64% on the other standard chemo agent, dacarbazine. Based on this modest 6 month improval, the patients in the dacarbazine group were then switched over to vemurafenib for "ethical" reasons. So there is no data on longer term efficacy or median survival. Since the patients were switched, we'll never know if survival at 12 months, 18 months, or even two years is any different between the two drugs. Isn't that something that would be interesting to know? Furthermore, the results show that less than 50% of patients even responded to vemurafenib. And close to 40% of patients experienced toxic side effects incapacitiating enough to mandate dose modification or even outright temporary cessation of the vemurafenib.

The cost of the drug has not been released but a similar medication, Yervoy, retails for close to $120,000 for a one year course of treatment. Presumably, verumafenib will cost somewhere in this neighborhood.

Now I don't want to belittle the scientific achievement that vemurafenib represents. Being able to manipulate the expression of certain viral and neoplastic proteins at the genetic level is an exciting new frontier. But let's not confuse modest, incremental scientific advancement with real life efficacy. The headlines suggest a quantum leap in medical insight and intervention; which is misleading at best and perilously close to fraudulent misrepresentation at worst.

When it comes to late stage cancer, these pharmaceutical firms and the doctors doing the research have a major financial stake in promoting these newer drugs. Billions of dollars are in play. But this misleading propaganda campaign shamefully exploits a very vulnerable, desparate patient population....

So Fast

2011-06-08T19:05:00.000-04:00

It sneaks up on you. One day your little girl clambers up for story time before bed and you realize that she just doesn't quite fit in your lap the way she used to. She sort of overflows the confines of the rocking chair and spills across your torso, legs dangling, everything suddenly awkward and cramped. You have to look around her head to see the words on the page. She has to keep shifting to find a comfortable spot. On the one hand you're happy; your child is healthy and growing, becoming a little person. But it still doesn't change the fact that it sort of stings when it happens.

More Checklist Consequences

2011-06-06T16:13:00.000-04:00

One of the SCIP protocols involves removing foley catheters post op within 48 hours to reduce hospital acquired urinary tract infections. UTI's acquired during a hospitalization, of course, are a "never event" and hospitals are loath to subject themselves to reimbursement penalties therein. One way to control this is to program the Electronic Medical Record (EMR) for Physician Order Entry (POE) such that all foley catheters are automatically removed by post op day #2 no matter if the surgeon wants it or not. By making foley removal the default pathway, you improve foley removal rates and, presumably, lower rates of acquired UTI's. The doctor is removed from the decision-making process altogether.

My partner operated on someone with an incarcerated hernia not too long ago. The patient was an older guy and he had to perform a limited bowel resection. A foley was placed prior to incision. The guy had a history of severe BPH and it was a struggle to get the catheter in. In his post-op orders he checked the standard box on the POE for Foley care (usually a bag to free gravity).

Unbeknownst to him, the "Foley care" order contained a drop-down box (accessible by clicking a separate tab) mandating that the catheter was to be removed on post-op day #2. In the evening of post op day #2, my partner received a phone call from the nurse---your patient hasn't been able to void since the catheter came out.

"Why is it out? I never wrote that. The guy has a prostate the size of a tennis ball."
"I don't know doctor. But he's having a lot of pain. The lasix you wrote for worked though. The bladder scanner says he's retained 700cc of urine."

And of course the house officer couldn't get the Foley in. Urology had to be consulted, urgently. The guy ended up getting another catheter placed, this time without the benefit of deep anesthesia. According to one of the nurses on that night, it took about 30 minutes of penis stabbing to get it in. But at least the hospital's SCIP data will look good.

The Unintended Consequences of Algorithmic, Bureaucratic Medicine

2011-06-03T16:30:00.001-04:00

Whenever someone is scheduled for an operation, the assigned nurse is required to fill out a "pre-op checklist" to ensure that all safety and quality metrics are being adhered to. Before the patient is allowed to be wheeled into the OR we make sure the surgical site is marked, the consents are signed, all necessary equipment is available, etc. One of the most important metrics involves the peri-operative administration of IV antibiotics. SCIP guidelines mandate that the prophylactic antibiotic is given within an hour of incision time to optimize outcomes. This has been drilled into the heads of physicians, health care providers, and ancillary staff to such an extent that it occasionally causes total brain shutdown.

Let me explain. For most elective surgeries (i.e. hernias, lap choles) I give a single dose of antibiotics just before I cut. For elective colon surgery, the antibiotics are continued for 24 hours post-op. This is accepted standard of care. You don't want to give antibiotics inapprpriately or continue them indefinitely.

But what about a patient with gangrenous cholecystitis or acute appendicitis? What if, in my clinical judgment, I want to start the patient on antibiotics right away (i.e. several hours before anticipated incision time) and then continue them for greater than 24 hours post-op, depending on what the clinical status warrants? I should be able to do that right?

Well, you'd be surprised. You see, at two different, unaffiliated hospitals I cover, the surgeons have seen that decision-making capability removed from their power. If a young patient comes in with acute appendicitis and I feel that it would be prudent to continue the Zosyn an extra couple of days, an automatic stop order is triggered in the department of pharmacy and the antibiotic is stopped after 24 hours, no matter what. Unless the surgeon specifically writes "please do not stop this antibiotic after 24 hours; it is being administered for therapeutic purposes, not prophylaxis", the antibiotic will not be sent to the patient's floor for administration. As a result, patients end up being treated sub-optimally, and potentially harmed, due to an over-emphasis on "protocol" and "quality care metrics".

Similarly, the 60 minute timeline for preoperative antibiotic administration can be problematic. I have had patints come into the ER with appendicitis or cholecystitis and, in my pre-op orders, write for Zosyn or whatever, to be started ASAP, no matter what time the operation is scheduled. Not too long ago, I admitted a gallbladder over the phone at 2am. I gave the nurse admitting orders which included one for a broad spectrum antibiotic.

When I saw the patient in the morning, I added her on to the OR schedule. By the time a room opened up, it was about 1030AM. The OR nurse asked me if I wanted to give an antibiotic for the case. I told her that the patient was already on antibiotics as part of her admit orders for treatment. The nurse shook her hand. It had never been given; the floor nurse held it so that it wasn't administered until 60 minutes before the scheduled OR time, just like the algorithm dictates--- despite the fact it had been ordered nearly 8 hours prior to the case, not for peri-op prophylaxis, but for treatment of an established pathology. And there it was, the cefotetan, hanging on her IV stand. Now nothing bad happened but here you have a situation where health care providers are so terrified of violating Quality Assurance Protocol that they end up withholding necessary treatment. It's just astounding.

As surgeons, we have bitched and moaned. You would think that these issues would be quickly rectified. But no. It is the responsibility of the surgeon to write qualifying statements for therapeutic antibiotics because the default mode is to override a licensed physician's clinical judgment. This is what I'm talking about when I say that blind allegiance to a top-down, systems analysis-driven algorithm can turn everyone involved in health care into a bunch of mindless drones.

Errata- In a previous iteration of this post, I mistakenly substituted NSQIP for SCIP. I mix them up all the time. The above version is now correct.

Macho Man!

2011-06-02T10:03:00.000-04:00

The very driven Maggie Mahar has a sweet takedown of little old me over at her Healthbeat blog. Please go check it out pronto. I've read through it a couple times, in addition to the attached comments, and I must say I honestly feel thoroughly Tressel-ized. I learned quite a few interesting facts about myself of which I was heretofore previously unaware. According to Ms Mahar I am pretty much an asshole who manifests a "macho" attitude toward patient care. I exhibit paternalistic and faintly misogynistic chracteristics. I have no compassion, in fact I have "contempt", for the poor and uneducated patients of America. I'm also not very eloquent, an assertion I wouldn't ordinarily object to, but it certainly isn't because I haven't been "a regular contributor to the New Yorker". Adam Gopnik is horrible. And I can't stand Hilton Als and Sasha Frere-Jones. Tom Junod at Esquire writes circles around everyone at the New Yorker. But anyway.

The bottom line is this. I agree with Atul Gawande on some things and disagree (vehemently) on others. We can have a back and forth debate like gentlemen. But that wasn't the point of my previous blogpost. The point was to draw attention to the fact that the commencement address was lame and uninspiring and completely inappropriate, given the context. I mean, this was a medical school graduation speech! The graduating students had just spent the past 12 years grinding through a very rigorous and exhausting phase in their lives. And now they are to embark upon a life of selfless labor, dedicated to the well being of their future patients. To use that moment as an opportunity to give a wonkish health care policy speech is entirely self-serving and, well, boring.

In fact, Dr Gawande was in the area last weekend when my little sister got married. I saved the transciption of his wedding toast:

"Jen and Brandon, congratulations on your recent betrothal. I know it's exciting and all but please beware of indulging your romantic fantasies too much. The truth is, we Americans don't do so well at the institution of marriage. Over half will end in divorce. Domestic violence is on the rise. Children can be emotionally scarred by the fallout from broken homes. I would advise you to throw away your Shelley and Lord Byron, your Shakespearean sonnets, your anachronistic Valentine's Day traditions. Such mindlessness is old school and inappropriate in the modern age of love and marriage. Instead, I would encourage you two to engage one another in more actionable displays of a solid married life. Instead of random weekend getaways, consider a more robust, algorithmic approach to love. Those warm fuzzy feelings you get from time to time are completely unpredictable. Do not trust them. It is a cowboy mentality to lose yourself in a sappy loving brain goo. You have to collaborate in a pro-active, value added fashion. My wedding gift to you is a special Love Checklist that I have released to you, free of charge, prior to its intended publication date in the fall. Please review it and implement its tenets and re-purpose its structure for your own needs. Thank you. Again, my heartfelt congratulations."

/cue electric slide.

The Most Uninspiring Med School Graduation Speech Ever

2011-05-30T14:10:00.000-04:00

Atul Gawande's recent commencement speech to Harvard Medical School is here. Read it if you like. It won't exactly send chills down your spine, to say the least.

His essential message is this: Healthcare is far too complex for any one doctor anymore. So gear up to be an interchangeable part, a faceless drone who performs menial tasks according to checklists and algorithms that Really Smart People will provide for you. Don't be a Cowboy (in the romanticized, individualistic sense of a bygone era) unless you want to be like a real live lower-case "c" cowboy in Wyoming who functions as part of a team and follows protocols (Dr Gawande talked to one himself, it's true!). All that debt you've taken on to be a physician? It's so you can be an anonymous member of an integrated Team. Like a Pit Crew. Who doesn't get jacked up to join a pit crew? I sure do!!!

Is it any wonder that Dr Gawande is the very Messiah of future healthcare delivery to people like Maggie Mahar and Ezra Klein? Not a word about being a better physician, about recapturing the old ethic of patient ownership. Nothing about the challenges individual doctors face to stay on top of new medical developments and how they can be surmounted. Nothing about personal accountability. Nothing about putting your heart and soul into this noble calling.

Weekend Surgery Puzzle

2011-05-20T11:22:00.000-04:00

So a patient comes in with hypotension, tachycardia. His family found him down on the bathroom floor laying in a pool of dark maroon stool. In the ER he is immediately intubated and we resuscitate him with saline and PRBC's. An orogastric tube is placed and massive amounts of blood is evacuated from the stomach. The stomach is then copiously lavaged with saline until clear. An upper endoscopy is subsequently performed that morning which shows 4-5 large duodenal ulcers. But none of them are actively bleeding. No visible vessels are present.

He goes to the ICU on a protonix drip and stabilizes his hemoglobin for 48 hours. Then one Sunday he drops his pressure and starts passing large amounts of blackish-red stool. The GI doc and I are there simultaneously. His blood pressure is tenuous, despite aggressive resuscitation. It seems like he has re-bled from his duodenal ulcers and may need emergency surgery.

But the orogastric tube is putting out bilious contents. The GI guy quickly slips an endoscope into his stomach. And then there's no blood. The ulcers appear stable. Bile washes back from the duodenum.

What is the next step? What operation do you think the dude will need?

Rules for Case Blogging

2011-05-19T11:01:00.000-04:00

Last week Kevin Pho wrote about a physician in Boston, Alexandra Thran, who was disciplined by both her hospital and the state medical board for writing about a trauma patient she had seen. Although Dr. Thran hadn't divulged the patient's name, enough information was conveyed that allowed others in the community to identify the patient in question.

That story really freaked me out. Because, as you know, I sometimes write about my adventures in general surgery. Am I a dead man? Is the Ohio State Medical Board going to give me the Bradley Manning treatment? Am I destined to working the night shift at a CVS minute clinic in five years?

As with most ethical issues, there is a lot of gray and nuance. But in general, I think you are safe writing about personal cases from your practice if you exercise a certain degree of reasonable restraint. Write about your experiences, not as a form of personal aggrandizement, but as an attempt to share, educate, and converse with laymen and other professionals about disease processes and treatment options in the open forum that is the Internets.

Here of some general rules of thumb:

1) If someone famous comes under your care, just don't write about it. If the patient is famous enough, some aspects of his/her clinical condition will leak out. There may be understandable angst and resentment that Celebrity X's privacy isn't guarded as well as anyone else's. If you write about the celebrity's case, even if you conceal it, there's too great a risk that details will overlap with leaked information from other sources. Then a giant HIPAA target forms on your back. So don't write about how the back up center for the Bulls came into the ER at 3AM with a sex toy stuck in his rectum, thinking that simply using pseudonyms gets you off the hook.

2) Strive to present cases for educational purposes. Ramona Bates is the exemplar for medical blogging when it comes to case presentation (how she has the patience to type out full bibliographies just kills me). I'm not so regimented but I try to at least provide a little pathophysiology and surgical dogma background. Compare a write up of cecal bascule in a peer reviewed journal here with my post on the same topic. My post was certaintly a little less dry and stuffy, perhaps a little too irreverent, but that's why you won't be reading much of my work in renowned journals. Conversely, my cecal bascule post was read by a lot more people that the one in Applied Radiology.

3) When you post images/scans, make sure you have removed all identifying data. Duh.

4) Let the case marinate in your mind a bit. Don't rush immediately from the OR/ER to the laptop. I usually give the cases several weeks/months to mature.

5) Review the literature to make sure your management correlates with standard of care protocols. You don't want to write about that APR you did on an early stage squamous cell anal cancer, and then have someone point out on a public blog that you ought to have sent the patient for an oncology consult to discuss the efficacy of the Nigro protocol (chemo/radiotherapy) as sole treatment.

6) Don't be a jackass. Don't brag or write things like "the patient was in good hands that night.."

7) Make sure your operative consents contain a section about "using images for educational purposes".

8) For cases that involve detailed, individualized descriptions of the operation, post op events, and eventual recovery phase---- discuss your plans to blog about it with the actual patient. Even let them read the post before you publish it.

Andrew Sullivan Continues his Anti-Physician Drumbeat

2011-05-18T13:45:00.001-04:00

The Cause Of Death: Greed?
Earlier this week, Michelle Andrews reported that "hospitals perform autopsies on only about 5 percent of patients who die, down from roughly 50 percent in the 1960s." She also dug up a 1998 report that found "autopsy results showed that clinicians misdiagnosed the cause of death up to 40 percent of the time." Robin Hanson has a theory:

A pretty obvious explanation for fewer autopsies: docs don’t like being proven wrong. Such dislike can lead to lawsuits, and generally make docs look bad. ... Could there be any clearer evidence that docs care more about getting paid than about healing patients, yet the public can’t bring itself to imagine docs are that selfish?

That was from one of his blog-link posts this morning. Let me first deconstruct the incoherence of the assertion of the title---> "The Cause of Death: Greed?" I mean seriously. What is being scrutinized here is the decrease in autopsies that are performed in American hospitals over the past 50 years. What on earth does that issue (worthy of investigation, certainly) have to do with greedy physicians being the cause of those patients' deaths? If the patient is already dead, then what does the relative generosity of a physician have to do with what caused his death, in the context of whether or not an autopsy is done? Let's say an autopsy would reveal that the physician made an error and he wants to conceal that fact by quashing an autopsy, then one could make the assertion that the physician is acting greedily by seeking to reduce autopsies and enhance his reputation amongst peers/patients. But by no means can one use such behavior to infer that the physician also caused the patient's death through avaricious conduct. It's a malicious, misleading headline that attempts to re-assign after the fact vices as the precipitating factor that led to the event in question. In other words, if a kid knocks over his aunt's thousand dollar Chinese vase and attempts to cover it up by lying because he knows she will make him pay for it you could rightly infer that his greed led to his deceitful post-event behavior. But you wouldn't ever state that the kid's greed led to the vase getting knocked over in the first place would you?? It's absurd.

The piece furthermore leads the casual reader to infer that doctors are engaged in a nation-wide conspiracy to cover-up the causes of death in hospitals, like some cheesy Robin Cook novel. Do you think this is true? Are doctors actively trying to talk family members out of autopsies on their dead loved ones? I don't think so. I know for damn sure if I lost a loved one in the hospital and a bedraggled doctor immediately tried to talk me out of getting an autopsy, the first thing I would do would be to demand an autopsy STAT. I think the fact that fewer autopsies are performed has less to do with doctor practices/behaviors than with our preferences as a society. We aren't comfortable with actual death (unless it's the patriotic, hyper-violent, glorified kind you see in video games and American pop culture). It's a sociocultural issue. We can let Malcolm Gladwell figure that one out. The reality is, when someone dies in the hospital, a doctor has to fill out the death certificate. On that certificate, we have to indicate whether or not the incident qualifies as a coroner's case (mandatory autopsy) and whether or not the family decided to pursue an autopsy.

The article Sullivan links to contains this paragraph:

Autopsies play a critical role in helping to advance understanding of the progress of a disease and the effectiveness of various treatments. At the same time, they may identify medical conditions that clinicians and high-tech imaging miss or misdiagnose. For example, Elizabeth Burton, deputy director of the autopsy service at Johns Hopkins Hospital in Baltimore, recalls that when she autopsied a 50-year-old alcoholic patient, what appeared to be cirrhosis of the liver was actually cancer.

You know what a risk factor for liver cancer is in this country? Cirrhosis, either from alcohol or viral hepatitis. So in the above example, the autopsy revealed something that, although undiagnosed at the time of death, didn't necessarily cause the patient's demise (almost certainly the cirrhosis did) and is a clinical finding most clinicians would find unsurprising.

In the 1960's we often had no idea why in the hell people died. We didn't have CT scans or coronary angiography or high tech hemodynamic monitoring devices like we do today. Nowadays we can explain to patients with a reasonable degree of certainty that patient X died "likely due to condition X, Y, and Z." Autopsies in the 60's gave families and doctors closure. A family member just wants to hear something other than "I don't know what happened".

I'm a Sullivan fan, generally (torture, Palin, etc). But he's out of his league on the health care issue.

Health Costs: Blame the Doctors?

2011-05-17T13:19:00.001-04:00

I'd like Andrew Sullivan to square his stance that simply allowing the SGR-determined cuts on Medicare reimbursement to physicians to stand (due to be about 29% in 2012) with the below graphs. He seems to think that all we have to do is chop physician reimbursement and a big chunk of the spiralling health care deficit can be bridged. Well, you can't squeeze a gin martini from a cold stone, buddy. We surgeons get paid 3% less than what we were paid in the mid-nineties for a laparoscopic cholecystectomy. I have a feeling that your local plumbers or lawn mowing companies aren'tcharging 3% less than what they did ten years ago to plug a leak or mulch your lawn.

Laparoscopic Adrenalectomy

2011-05-17T07:38:00.000-04:00

I love these cases. A patient was sent to me with an adrenal mass that had been increasing in size over the past 2 years. You can see it in the above image (hint: look above the right kidney). Adrenal masses over 6 cm (or even 5 cm in women) have a high likelihood of being malignant. But before you get them on the OR table you have to do some boring doctor-work first. Specifically, you have to make sure you aren't dealing with a functional adrenal adenoma. That means sending off a barage of blood/urine tests to rule out aldosteronoma, pheochromocytoma, or a cortisol-producing tumor.

The big one to worry about is a pheochromocytoma. Pheos produce catecholamines (adrenaline) and indentification of one prior to surgery is crucial. At least two weeks of pre-operative alpha blockade (a specific anti-hypertensive agent) is required to protect the patient from the surge of adrenalin release that can occur during the operative manipulation of the tumor, and also the sudden drop in systemic catecholamine levels once the tumor is removed.

This particular tumor ended up being a benign adenoma. The case hinges on identifying and controlling the adrenal vein. The little bastard is about two centimeters long and it enters directly into the cava. If it tears you end up with torrential bleeding. Which sucks. Until you get clips on the vein, snip it, and watch the bulging blue vena cava gently roll away from the gland it's a very high tension environment. I keep the music down and, believe it or not, I can get a little snippy and high maintenance. Sliding my Maryland dissector under the vein, then slowly spreading to break up the adventia, watching it flatten and whiten and elongate, stretching out away from Big Blue, nearing its maximal tensile strength.... shit, I'm getting beads of forehead sweat just thinking about it. But once it's controlled, it's time to blast the Playing in the Band and have a good time. All that's left is to hack the gland out of the retroperitoneal fat with my harmonic scalpel. For Academic Endocrine Surgeons, the hacking out part is probably a bothersome distraction, best left to the fourth year resident who, heretofore, had been assigned to camera-holding duty. But I like it.

Torture as Party Platform

2011-05-17T07:18:00.000-04:00

Outrageously, we are now a country where potential candidates for President of the United States can raise their hands at primary debates and aver their unabashed support for torture without suffering any backlash. Listen to the audience roar their approval to see three of five hands held aloft. Waterboarding has always been considered a form of torture. The definition doesn't change just because America sanctioned it during the Bush regime. Torture is torture. It is illegal, a moral transgression of the highest order, and a permanent stain on the integrity of this country. And apparently it has now become a litmus test for Republican party purity.....Unbelievable.

Large Bowel Obstruction

2011-04-29T13:27:00.000-04:00

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

2011-04-29T11:32:00.001-04:00

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.

Greenfield Doubles Down

2011-04-22T14:30:00.003-04:00

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

2011-04-22T13:48:00.000-04:00

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??

Lazar Greenfield's Cure for Depression

2011-04-15T15:42:00.039-04:00

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?

UPDATE:

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

2011-04-15T09:29:00.000-04:00

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

Weekend Palin/Trig fun!

2011-04-14T11:54:00.000-04:00

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

2011-04-14T09:20:00.002-04:00

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.

Poem of the Week

2011-04-13T15:35:00.001-04:00

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

Portal Venous Gas and Cecal Bascule

2011-04-10T08:58:00.000-04:00

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.

It's Time

2011-04-06T13:16:00.006-04:00

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.

Over Treatment

2011-03-31T19:49:00.006-04:00

With utter dismay I've been following President Obama's unconscionable usurpation of limitless executive power with regards to the War in Libya. And let us clear: The bombing of Libyan ground targets, the arming of rebels, and CIA presence on Libyan soil (in an advisory capacity, so they say) all represent aggressive acts of war. This is a third war we have now embarked upon in a Muslim country. Absurdly, once again, American missiles are being fired at a country that poses absolutely zero threat to our national security. And this time our Commander in Chief has committed us to war by executive fiat. No congressional approval. No meaningful debate. Not even a symbolic vote by the legislature to at least give the pretense of abiding by the dictates of Article I of the US Constitution. Everything this man campaigned on---- hope and change, the dawn of a post-partisan era, the end of the Imperial Presidency-----all a complete fraud.

I'm no foreign policy guru. I'm not there in the Situation Room. I don't presume to think that my feelings wouldn't be different if I had access to all the relevant information that the national security council has. But such a monumental decision cannot be contingent on personal feelings. It's one thing to help avert a potential slaughter, such as at Benghazi (although such rationale appears to be somewhat arbitrary; otherwise why aren't there bombs raining down in the Ivory Coast, Yemen and Bahrain?) It's quite another to unilaterally assert the right to bomb the bejeesus out of a foreign land. We are not a nation of Great Benevolent Men. We are rather a nation of laws. Believe it or not, even the President of the United States must abide.

I see parallels in this current military overreach with what is happening in healthcare. We spend 30% of a person's lifetime Medicare outlays on care provided during the last year of his or her life. We spent $50 billion of Medicare dollars last year on dying patients' last two months of life. Why are we doing this? Why has that 30% number remained unchanged for almost 30 years? Why do I continue to see consults on demented 89 year olds in the ICU who are intubated and unresponsive and suffering from multiple organ failure? And they linger for days and days. And the chart contains consults from numerous highly trained specialists, all dutifully offering the best that American health care can provide.

Is it greed? In our procedure-oriented, profit-driven health care culture, you eat what you kill. Why spend an hour doing a thorough history and physical examination, talking with family members and concluding that no further treatment is warranted when you can send your PA to do a quick consult, sign her note, and schedule the patient for a lucrative procedure the next day. Are we in Libyan merely to protect Italian oil interests? Are we there just to safeguard British Petroleum investments? Or is it truly a "humanitarian" venture?

Do we do it just because we can? Hey, we have a pulmonologist on staff. That 94 year old is dying of congestive heart failure. Send him down to the ICU, consult the pulmonologist who then orders the patient intubated based on an ABG that the nurse gives him over the phone. Then get the interventional cardiologist involved. And did you know, the hospital just recruited a new endocrinologist. The patient has a blood sugar of 356. Consult the new guy so we can tweak his insulin dosage. And on and on. Similarly, here we are sitting on the greatest military arsenal the world has ever seen. American military spending in 2010 was over $650 billion. That's 7 times more than the second highest national military budget (China). All this ordnance and materiel that, which each passing year, becomes more and more obsolete, necessitating even more spending in the future---might as well use it whenever a vaguely justifiable reason develops somewhere in the world, right?

Is it our arrogance? As doctors, do we presume to be the arbiters of life and death? Has our power to save and extend life been corrupted by an overweening sense of infallibility and righteousness? Has the American Hegemon unequivocally declared itself the Exceptional, Indispensable Nation? Do we truly believe we know what is "best" for every other group of human beings scattered across the expanse of the globe? Has the condescension of the White Man's Burden been passed on to 21st century America?

It's probably a combination of all those reasons, to some extent. Fundamentally something is rotten at the core of our nation. We define things in superficial terms. We demonize with catch phrases and sound bytes--- i.e. "death panels" and "they hate us for our freedom". We dare not look under the surface into the complexity and confusion and unpredictability of reality. We close our eyes to the discomfort of uncertainty and nuance. We would rather wear flag pins and dress up like 18th century New Englanders and sing God Bless America and publish papers on the effectiveness of colon surgery on nonagenarians. Death and decline prey upon us all---individual and nation as a whole. Nothing lasts forever. Clinging to a platitudinous nationalism, a jingoistic pride, a sense of professional omnipotence---these are all forms of an incipient dishonesty that threatens our collective soul. Death and decline are not to be feared. We can't save all patients. We can't rule the world forever. There are limits to human achievement. There is nothing shameful about recognizing futility. It's time we summoned the courage to look a little deeper, to find a sliver of humility through self analysis, and to reconcile ourselves to our ineluctable imperfection in this fallen world.

Dentists: Patient Advocates

2011-03-29T15:13:00.009-04:00

From the New Haven Independent 3/24:

State dentists could get a monopoly on the lucrative business of teeth whitening pending action by a commission they control.

The State Dental Commission held a hearing in December to review whether teeth whitening should be classified as "dentistry" - a move that would result in the procedure being done only under a dentist's supervision. The commission is set to vote on the issue at its May 11 meeting. If the panel rules that it is dentistry, others who provide the service in shopping malls, salons and spas could be put out of business.

You think this is unreasonable? You think this is just a craven power play by a State Commission to monopolize a lucrative side business flimsily related to dental health? You see a conflict of interest in that the Dental Commission is comprised almost entirely of...dentists? Are you crazy? Just wait till you see what is coming down the pike in other fields:

The American Hand Surgery Commission is considering a resolution that defines all finger nail clipping as "digital-related surgery". Early drafts of the bill would require Americans to obtain finger nail clipper licenses from a Hand Surgeon-approved weekend instructional class. (To be renewed every three years.)

Rumors have it that the American College of Dermatologists are hoping to define the application of any SPF lotion above 30 as "practical dermatology" thereby mandating a visit with your local dermatologist and a prescription prior to that summer trip to the Outer Banks.

Working its way through subcommittees is a resolution from the State Board of Pediatrics that would try to re-classify classic remedies for your kids' colds as "rudimentary pediatric medicine". So no more over the counter Vicks to your kids' scrawny chests. No more TLC. No more ginger ale without a prescription. And the only chicken soup you can administer your kid is the the leftover slop that your pediatrician fed her family the previous night.

The Bariatric Surgery Commission is close to an agreement that would deem any form of exercise as a "bariatric intervention", to be monitored by highly trained obesity specialists. GPS monitors would be placed on anyone with a BMI of over 30 to ensure that nobody obese is moving faster than a crustacean without first seeking advice from a friendly local bariatric surgeon and informed of the harmless, easily tolerated surgical options in the War on Obesity.

Finally, the American Society of Pulmonologists and Critical Care Intensivists is lobbying to regulate the way Americans breathe. It isn't just a gasp or a sigh or a mere inhale. No sirree. Just because you breathe involuntarily doesn't mean that a highly trained sub specialist shouldn't be lucratively involved in your own personal world of O2/CO2 exchange. A mechanism that complex requires close surveillance. If enough votes are garnered, citizens will be forced to see a pulmonologist every 6 months for a full assessment of his or her "respiratory mechanics".

Chart of the Day

2011-03-29T15:00:00.004-04:00

Hedge Funds for Lawsuits

2011-03-24T16:40:00.000-04:00

This is awesome. As if there aren't enough shady financial instruments out there for nefarious money making purposes. We now enter the era of the hedge fund- financed medical malpractice lawsuit.

I get it. Mounting a malpractice trial is expensive. You have to spend hours upon hours (at $500-800 per) taking depositions. You have to pay off, er, compensate whores, er, I mean, expert witnesses for their time. For a garden variety med mal case, trial attorneys can expect to spend upwards of 100 grand of their own stash. Given that physicians end up winning 70-80% of med mal cases that go to trial, this anticipated outlay of personal funds prior to a verdict can be somewhat discouraging to the less testicularly fortified litigation firms.

And this is part of the reason why malpractice lawsuits have declined over the past ten years. It doesn't have anything to do with the merits of cases; it's just simply too damn expensive to take a complaint to trial. This is the moral hazard that dissuades too many "frivolous" lawsuits. But it also hurts patients. Patients who have been injured through possible negligence may find that there are fewer firms willing to acept the case.

So what to do if you're a med mal lawyer without a fat bankroll? Contact one of these rapacious "lending firms" to front the costs of the litigation. You then pass the burden of the exorbitant interest payments on to your client. Awesome! So if you win the case, the first chunk goes towards your fee (did you think otherwise?). The second chunk pays off the interest on the loan. And whatever is left goes to the patient/client. And you aren't required by law to inform your client that you have leveraged the costs of the litigation. What a country!

Yeats for March Madness: Who Goes With Fergus

2011-03-19T16:48:00.003-04:00

I forgot to post this on St Paddy's Day. Go Bucks. (And yes, Drackman--- Jim Tressel is an embarassing phony).

Who will go drive with Fergus now,
And pierce the deep wood's woven shade,
And dance upon the level shore?
Young man, lift up your russet brow,
And lift your tender eyelids, maid,
And brood on hopes and fear no more.

And no more turn aside and brood
Upon love's bitter mystery;
For Fergus rules the brazen cars,
And rules the shadows of the wood,
And the white breast of the dim sea
And all dishevelled wandering stars.

Mr. Obama, What Are You Doing About the Torture of Bradley Manning?

2011-03-17T11:03:00.008-04:00

Bradley Manning may have broken the law. He allegedly is the source of the "Collateral Murder" videotape wherein an American Apache helicopter was filmed gunning down innocent Iraqi journalists. But he certainly may have violated military codes by leaking classified information. These allegations warrant an investigation. But Bradley Manning has been held in solitary confinement for 23/24 hours a day for ten months. He is now being forced to sleep nude. He is watched by military personnel throughout the night and is awakened roughly if his face is not visible to the surveillance cameras. Most concerningly, he has yet to be convicted of a crime.

Glenn Greenwald has been an invaluable thorn in the side of the US government's apparent mission to bring down Wikileaks and intimidate whistleblowers who dare to question military/executive branch authority.

His article on what exactly Wikileaks revealed to the world in 2010 is here.

Posts on the inhumane treatment suffered by PfC Manning can be found here and here.

Further embarassing are the brig psychiatrists who are signing off on the forms that deem Manning a "suicide risk", thereby providing the US government with the legal cover to continue its torture of a lowly private. Maybe one day the kid will simply break down and implicate Julian Assange and Wikileaks as co-conspirators. Surely, that's not what our noble, godly military/executive leaders had in mind all along is it??

Why did Manning do it? For money? Because he's a traitor to his country? In his own words:

well, it was forwarded to [WikiLeaks] - and god knows what happens now - hopefully worldwide discussion, debates, and reforms - if not, than [sic] we're doomed - as a species - i will officially give up on the society we have if nothing happens - the reaction to the [Baghdad Apache attack] video gave me immense hope; CNN's iReport was overwhelmed; Twitter exploded - people who saw, knew there was something wrong . . . Washington Post sat on the video… David Finkel acquired a copy while embedded out here. . . . - i want people to see the truth . . . regardless of who they are . . . because without information, you cannot make informed decisions as a public.

Hospital Royalty

2011-03-17T09:22:00.003-04:00

This article from the Times did not surprise me in the least. In this era of exponentially increasing health care costs, to an extent that the very solvency of our nation could hang in the balance, we have identified that one sacrosanct budget item that will not go under the knife--- hospital CEO salaries.

At Bronx-Lebanon, a hospital that exists only by the grace and taxed fortunes of the people of New York State, the chief executive was paid $4.8 million in 2007 and $3.6 million in 2008, records show. At NewYork-Presbyterian, a hospital system that receives nearly half a billion dollars annually in public money, the chief executive was paid $9.8 million in 2007 and $2.8 million in 2008.

Is anyone surprised? I know, it's so cliched to begrudge someone what the market will bear to pay them. I'm sure there are manifold reasons for a hospital CEO to pull down 7 figures, even at "non-profit" hospitals. But when you have states chopping Medicaid left and right, when Congress faces an imminent debate on the inevitability of entitlement cuts (i.e. Medicare) in order to achieve some semblance of fiscal sanity, is it altogether justifiable for appointed leaders of non-profits to be so generously compensated?

We live in an age that deifies the famous and powerful. No one blinks an eye when Kendrick Perkins signs a $36 million extension. Tom Cruise's $20 million/per picture demand is met with a collective yawn. Sarah Palin commands 100 grand speaking fees. And now celebrity culture has infected the business world. Wall St. collapses and yet, within a year, all time-high bonuses are handed out to the very same idiots who contributed to the financial catastrophe. We expect our leaders, our winners if you will, to be obscenely compensated. They deserve it. This is the American Dream. This kingly submission to the "winners" in the capitalist game is what ultimately holds the entire house of cards together.

Shifting Appendectomy Consensus

2011-03-17T08:36:00.002-04:00

An interesting article from Archives on the optimal treatment of children who present with perforated appendicitis. Previous dogma dictated an initial non-operative approach---- dick around with IV antibiotics, CT guided drains, etc--- and then bring the child back in 6-8 weeks for an "interval appendectomy". This article demonstrates that getting the kid into the OR ASAP leads to better outcomes and a faster return to normal activities.

I've advocated for this approach before. Explore the kid laparoscopically, evacuate any abscess collections, leave a drain in certain cases, and take the damn appendix out. I would even extrapolate from the pediatric population and apply such management to all patients with complex appendicitis.

The Best

2011-03-05T20:49:00.001-05:00

Now that ESPN has been showing more soccer, don't miss a chance to watch Leo Messi play when Barcelona is on during the final stages of Champions League play. He's the best I've ever seen.

Stomach Partitioning

2011-03-05T19:28:00.007-05:00

There are two articles in the latest Archives of Surgery that compare different techniques of bariatric surgery in terms of long term efficacy. (If you're interested, the more complex gastric bypass seems to lead to better diabetes control and quality of life compared to other techniques.) One paper was from Taiwan, the other from Wisconsin. I didn't realize Taiwan had such a problem with Chalupas. But it's true, apparently Taiwan has seen an increasing rise in obesity over the past two decades (that's what you get for aligning with America over the Chinese mainland!). Wisconsin, well, that's where all the Cheeseheads are.

But it's amazing to me the number of bariatric papers that get churned out every year by major surgical journals. It's really difficult to read Archives or Annals or JACS on a month to month basis without seeing at least one paper devoted to bariatrics.

Is this a good thing? Is this science on the march? Are we monthly witnesses to the ineluctable forward thrust of the scientific method in human endeavor?

The bariatric lobby has won the war I suppose. You no longer read dissents that question the philosophical nature of the "disease" of obesity and the appropriate steps a society ought to take to remedy it. The more papers they can manufacture touting the efficacy of chopping your stomach up into various new shapes and forms, the more they can avoid the fundamental question of means and skip ahead to ends. Obesity surgery works. But we've stopped asking why obesity exists to such a grave extent. The ontological nature of obesity has been buried under an avalanche of teleology.

Are we so resigned to the epidemic of morbid obesity that we no longer hope to change human behavior or the way we provide food on a massive scale? Have we become passive reactants to a national health scourge, offering only the option of anatomic rearrangement?

I've always felt that bariatric surgery ought to be an esoteric, poorly understood specialty, where patients were only rarely referred due to underlying metabolic or genetic abnormalities. I never thought it would flourish, sustainably, like the way it has. Surgery departments at major tertiary centers all have their own bariatric programs. The casual prevalence of such a development ought to astound us all.

Serena Williams and Anticoagulation Complications

2011-03-04T17:56:00.000-05:00

Serena Williams was in the news recently. Apparently she was diagnosed with a pulmonary embolism last week. These typically arise from blood clots in the leg or pelvic veins that break off and propagate into the pulmonary arteries. Patients present with shortness of breath, chest pain, blah blah blah. You can also die from them. I'm not going to spend all morning writing about why you get them; the thought of doing that is excrutiating to me. Google it if you like.

I bring the story up because it sounds like Ms Williams had to undergo an emergency operation this week, several days after the original diagnosis of PE. All the news organizations are writing headlines like "Serena has emergency operation for Pulmonary Embolism". That strikes me as odd. Treatment of PE is typically not a surgical problem. Treatment involves placing one on the blood thinner coumadin for 6-12 months. Because coumadin takes several days to "kick in", a lot of docs will bridge the anti-coagulation therapy with either a heparin drip (inpatient) or subcutaneous high dose Lovenox (can be administered as an outpatient). In rare cases, such as when the patient presents in extremis, an emergency embolectomy is performed via a sternotomy while the patient is on cardiopulmonary bypass. Catheter directed fibrinolysis has also been described as an option for these very sick patients.

So in general, surgical intervention for a PE is a sign of impending doom--- it's unlikely Serena Williams had her chest cracked open. More plausibly, she required invasive intervention for a complication of the anti-coagulation therapy that all patients with PE's are administered. Spontaneous bleeding from the retroperitoneum spaces is a known, not uncommon, complication of lovenox or heparin induced anti-coagulation.

The pictures above demonstrate the extensive retroperitoneal hematoma of a lady I took care of several months ago who had been started on high dose lovenox and coumadin for a heart arrythmia. Initially you try to correct their coagulopathy and transfuse packed red cells because most of these spontaneous bleeds will eventually tamponade. This lady kept bleeding. I think she received something like 12 units of packed red cells, 10 units of plasma, and several transfusions of platelets and cryoprecipitate. Furthermore, the massive hematoma was starting to compress the right kidney, leading the renal consultant to believe that its very viability was compromised.

Reluctantly I took her for surgery. These aren't fun surgeries. Outcomes are generally pretty poor. Often, you never pinpoint the source of bleeding. You just scoops giant handfuls of gelatinous purplish-black clot into shiny metal bowels, coat the raw surfaces with thrombin/topical clotting agent and hope things don't get out of control. For some reason, just evacuating the hematoma can help halt the death spiral of sustained fibrinolysis that evolves in the setting of large in-situ clots. Anyway, she did allright and went to a nursing home.

The "Tyranny" of the Open Breast Biopsy

2011-03-03T12:32:00.005-05:00

I found this article via the NY Times. A Florida study assessed the rate of needle versus surgical breast biopsies over a period of five years. What we're talking about here are non-palpable abnormalities that are identified on screening mammography. A mammogram report will come back that assesses the relative risk of an abnormal collection of calcifications harboring an invasive or pre-invasive cancer (staged on a scale from I-V). With such data, one is obligated, as the patient's advocate, to prove whether or not the mammogram represents true or false positive findings. This means doing a biopsy.

Two ways to go about clarifying the cancer/no cancer conundrum: A needle biopsy is scheduled in the department of radiology. The interventional radiologist uses the stereotactic images to advance a specialized needle into the midst of the concerning area and subsequently vacuum aspirate several "cores" of tissue. The technique is not without complications, but is generally very well tolerated without the complications seen from surgical biopsies (bleeding, infection, unsightly scars, etc). The sensitivity approaches 97-99%. A negative needle biopsy, although reassuring, still demands that close follow up is necessary, i.e. re-imaging of the breast within 3-6 months.

The open biopsy is a surgical procedure. And it involves two phases. One, a woman has to go to the radiology suite for directed placement of a wire such that the tip resides in the hot zone of concern. She then is wheeled to the surgical area where she is sedated and anesthetized. The surgeon then makes a 2-5 cm incision in the skin and excises a lump of breast tissue containing the area of concern, using the pre-placed wire as a guide. She goes home the same day. Bleeding and infection complicate 1-3% of these procedures. Sensitivity is 100% and, if a cancer is confirmed, phase one of treatment has already been accomplished (excision of tumor).

This is the conversation, along with the options presented, that surgeons across the country have with patients who are referred to us with an abnormal mammogram. According to the paper cited above, 70% of women opt for the needle biopsy approach, while 30% are undergoing open surgical excision. My personal feeling is that it's always better to start small/less invasive and expand the armamentarium as needed. Acording to the authors of the paper, and other leading light Breast Surgeons, the idea that 30% of breast biopsies in this country are being done via the open approach is a miscarriage of justice akin to the 30 year torture/dictatorial regime of Mubarak in Egypt. (Seriously, some eminent scholar of supreme reknown named Melvin Silverstein, breast surgeon extraordinaire in California, actually compared lowering the 30% open biopsy rate to the recent uprising in Egypt to overthrow Mubarak. I'm not kidding.)

The study found that the open biopsy rate of Academic Breast Surgeons was about 10%. Private practice general surgeons conversely performed open biopsies 37% of the time. The discrepancy was attributed to several factors--- lack of knowledge by podunk non-academic surgeons, and pure greed being the main ones. Because, you know, if a surgeon refers a woman to a radiologist for biopsy of a suspicious lesion, then s/he loses the cost opportunity for an open excision. Only the holy white tower of academia prepares one for a surgical career free from financial incentive, didn't you know?

I love this passage from the NY Times article, again from the esteemed Dr Silverstein:

One way for hospitals to stop excess open biopsies is to ban them, Dr. Silverstein said, unless they are truly necessary, as in uncommon cases in which a needle cannot reach the spot.

“We made a rule,” he said. “If it can be done with a needle, it has to be. We embarrass you if you do an open biopsy. We bring you before a tumor board to explain.”

What a tool. Hey Dr Silverstein guess what? Not every freaking surgeon who takes care of patients with abnormal mammograms lives within two seconds of a giant tertiary care center with experienced, reliable interventional radiologists and pathologists available at all times. We don't all spend our Tues and Thurs morning sipping coffee for three hours in multidisciplinarian breast oncology conferences. Some Americans actually live in the rural midwest and sparsely populated western plains. Furthermore, surgeons who do fewer breast biopsies per year than a dedicated breast oncologist will have inflated stats if a few patients opt for the open approach. Also, some women actually prefer the option of surgical removal. Even if the needle biopsy is negative, the lesion may still show up on a subsequent follow-up mammogram. The report may call it "suspicious" or maybe it will be down- graded to "close follow up recommended". Either way, she must continue to live with it, knowing she harbors something "not quite right", albeit almost assuredly benign, in one of her breasts. Some women, believe it or not, just don't like to have to carry around that secret knowledge. Some women stop you short when you get to discussing the minimally invasive options: "just take it out", they say.

Again, I am a strong proponent of stereotactic needle biopsies for the initial assessment of a concerning mammographic lesion. But this pompous posturing by some in the field of academic breast surgery is simply intolerable. Non fellowship trained surgeons who perform lumpectomies and mastectomies are fully capable of staying up on the medical literature. We are adept at following best treatment guidelines. You don't need a special little framed fellowship certificate on your wall to have an informed, back and forth conversation with with a patient in a very vulnerable position.

Time to Leave

2011-03-02T17:49:00.002-05:00

Enough is enough? Remember, this adventure in Afghanistan has gone on longer than the Vietnam War.

Colon Cancer Presenting as Intussusception

2011-02-14T15:12:00.003-05:00

This patient presented with several weeks of crampy abdominal pain and blood-tinged stools. The images above show intussusception of terminal ileum into the cecum. Intussusception (perennial spelling bee candidate, incidentally) occurs when the proximal bowel telescopes into the lumen of the more distal bowel, causing bowel congestion, obstruction, even ischemia. In adults, it's a red flag for cancer. In this case, it was a giant fungating goomba at the ileocecal valve acting as the lead point. Laparoscopic right colectomy = cure (stage II disease).

T-cell Small Bowel Lymphoma

2011-01-25T16:19:00.003-05:00

Interesting case of a small bowel obstruction due to a T-cell lymphoma. T-cell lymphomas arise in the setting of underlying celiac sprue. The prognosis is generally poor, even after definitive surgical resection and adjuvant chemotherapy. One and five year survival rates are 38% and 19%, respectively, according to this paper.

American Exceptionalism Needs a New Heart

2011-01-23T14:15:00.003-05:00

Former Vice President (and still war criminal) Dick Cheney may soon place himself on the list for a heart transplant, according to this WSJ article. Usually heart transplants are restricted to those patients younger than 70 (Cheney turns 70 next week). I say, let the old bastard get on the list, on the condition that he submits to being waterboarded as a live, pay per view event on HBO. He doesn't have to get the full KSM treatment (i.e. 187 waterboardings). Just once is good enough for me.

Lethal Shortages

2011-01-22T13:27:00.003-05:00

It seems there is a critical shortage of sodium thiopental in this country. Sodium thiopental, you may be curious to learn, is one of the main drugs used in lethal injection cocktails administered by state governments to condemned convicts. So unfortunate. Now we won't be able to continue with the barbaric task of state-sponsored executions in this country. Well, at least in some states. I'm sure Texas and Nevada are dusting off their hangman's scaffolds and electric chairs as we speak.

And why is there such a shortage of sodium thiopental, you ask? Because the American company that produces it actually makes it at a plant in Italy and the Italian government prohibits export of the drug if its intended purpose is for capital punishment. What, are you surprised by this? You thought the rest of the world also strapped their murder convicts to gurneys and pumped life sucking chemicals into their systems? Actually, no; most of western civilization has banned it. It's just the United States and other paragons of liberal democracy such as China, Cuba, Egypt, Iran, Iraq, Jordan, North Korea, Libya, Malaysia, Pakistan, Rwanda, Saudi Arabia, Singapore, Sudan, Syria, Thailand, and Uganda.

Besides, trial by jury is a 100% infallible method of determining guilt, right?

Gawande and O-Mama-Care

2011-01-22T12:54:00.007-05:00

Atul Gawande's latest piece in the New Yorker is out this week and I suspect the raves will be soon to follow. President Obama is assuredly frantically scrambling to slide a reference to it in his upcoming State of the Union Address.

The article deals with a possible solution to the conundrum of "high utilizers" in the health care system. By "high utilizers" (HU's) we mean those 1% of patients who, due to a combination of generalized sickness/ non-compliance/poor physician management, account for gargantuan shares of systemic health care costs (sometimes up to a third of all hospital expenses). Gawande investigates why this is the case and hangs out with a couple of idealistic physicians who may have stumbled upon a potential fix.

Unsurprisingly, HU's tend to come from lower socioeconomic classes. The diabetic who doesn't have health insurance and only rarely seeks medical attention for severe complications of his diabetes in an ER is obviously going to accumulate more societal costs for his disease over the course of a lifetime compared with the compliant diabetic with decent health coverage who sees a doctor every six months for preventative therapy. So Gawande discovered a couple of altruistic visionaries who decided to create entire medical practices devoted to the care and management of these HU's. Sounds pretty cool so far, right? Focus on the non-compliant patients without insurance who plow through health resources like my buddy Starhay does sliced cheddar at a fantasy football draft and you may be able to lower overall expenditures.

But here's where Gawande's paragons of medical philanthropy start to lose me. The practices he follows around (one in Camden, NJ and the other in Atlantic City) aren't just garden variety charity clinics for unhealthy, uninsured patients. These practices are High-Intensity, Life-Management Centers for the downtrodden and woebegone. Multidisciplinarian teams of doctors, nurses and social workers attack these HU's like it's the first day of July two a days for a team coming off an 0-10 football season. Patients are assigned "health coaches" who schedule appointments, make sure patient X has a ride to office, double check that patient X has filled prescriptions, double checks that pills are actually being taken on a daily basis, arrange exercise time, suggest dietary changes, encourage religious worship (?!?!), make follow up house calls, fill out paperwork for disability/public aid, provide psychologists for mental health issues, enroll in Yoga classes, improve housing conditions, and provide hour long full body massages once a week. (OK, I made the last one up). There's even a passage detailing how one health coach was able to reduce 911 calls and ER visits. Initially, the patients were told to simply program the clinic number into their cell phone speed dials. But too many didn't know how to do this. So the coaches did it for them. Voila. Reduced 911 calls.

I mean seriously? Aren't we talking about grown adults here? Apparently there are professionals who think that taking someone's cell phone and programming a number into his speed dial because he can't figure out how to do it himself, or even just write the damn clinic number down on a piece of paper taped to his refrigerator is some sort of triumph in social re-engineering? This isn't a solution to the health care crisis. It a thinly veiled play for bureaucratized, state-sponsored citizen dependency.

I mean, I'm all for social safety nets and making sure a bare minimum of health care is universally available to all. But this is crazy. Whatever happened to personal responsibility? Why is it "inhumane" to expect an adult human being to take care of himself? People talk about the encroachment of the "nanny state" with health care reform--- but this is a Mommy State plan. Besides, how many people are going to want government-subsidized social workers and psychologists crawling up their ass every minute of every day, asking if they ate their vegetables for dinner.

To be clear, I am impressed by the results achieved by the doctors cited in the article. Their selfless toil and humanistic approach to health care is admirable. But we have to expect a little more from our citizenry. There are many ways we can be better. Foremost involves acting like a freaking responsible adult.

Slaughterhouse-9

2011-01-19T13:17:00.007-05:00

Before a Dept of Surgery meeting the other day, a rep from some company called Proxy Biomedical gave a presentation on a newer anti-adhesion barrier called Human Peritoneal Membrane (HPM). HPM is similar to the more well known Seprafilm--- marketed as a product that can theoretically reduce adhesions that form between the bowel and mesh/abdominal wall after open surgery. Fewer adhesions can potentially mean fewer subsequent bowel obstructions and certainly will make any re-operative surgery much less difficult.

The rep was very smooth and tall and quite possibly has a minor recurring role in Mad Men. The crux of his argument rested on an article that had been published in some on-line outfit called the Journal of Surgical Research last year. The "study" had been entirely funded and conducted by researchers affiliated with Proxy Medical---i.e. propaganda under the guise of scientific inquiry. Usually I just use these faux-science articles as a placemat for my morning bagel. But I read this particular one because one of the "authors" was Michael Rosen MD, an eminent local surgeon here in Cleveland, well known for his work on abdominal wall hernias. Plus, the rep's gleaming white cinder block teeth were too much for me to look at any longer.

The study was conducted as follows. Nine pigs were anesthetized and then had an anti-adhesion barrier sewn into its abdominal wall after laparotomy. Laparoscopies were then conducted at day 30 and day 90, noting the degree of relative tenacity of visceral adhesions. Then the pigs were killed and the extent of tissue inflammatory response was determined microscopically.

Now I'm certainly no fan of PETA. I actually have a pronounced distaste for most animals. Cats suck. I don't believe dogs should live under the same roof as a human. I hate movies where the animals talk and perform human-esque feats. I'm especially averse toward the porcine species. If I had to choose a favorite Winnie the Pooh character, it's certainly not the lugubrious, wimpy Piglet (Tigger is the pick here). No moral compunction prevents me from enjoying one or three hot dogs layered in brown mustard at the ballpark. Every time I read The Three Little Pigs to my little girl I make sure to change the plot such that the wolf actually gets to eat the cheap assed pigs who built their houses out of sticks and straw. I don't allow any books about Porky the Pig in my house.

So I'm not some bleeding heart porkophile. Nevertheless I found myself feeling strangely disturbed by the article. Nine pigs were basically sliced and diced and then euthanized in order to determine that.... some new-fangled anti-adhesion barrier (which costs 800 bucks per 10 cm square, incidentally) may lead to a decrease in intra-abdominal adhesion formation? Really? That's it? What's next on Proxy Medical's to-do list of Mengelian science experiments? Chop off 58 monkey hands in order to determine which brand of gauze is more highly absorbent of blood (squaring off against competitors from Johnson & Johnson and Brawny)? Forcibly break the front legs of 17 cougars to assess the relative comfort of their new knee immobilizer (based on decibel levels of cougar screams)?

I dunno. It all seems like a hell of a macabre business to me.

Ortho Corruption

2010-09-17T08:45:00.007-04:00

This story about orthpedic surgeons not disclosing financial ties to the medical device manufacturers in their scientific papers is nothing new. Lack of transparency plagues the medical literature, especially in lucrative, product-driven fields like ortho and cardiology. What struck me were two points.

One, over half of orthopods who accepted over a million dollars from device companies in 2007 did not disclose this information in articles they published in the subsequent year. That's astounding. And illegal according to anti-kickback laws.

The medical device industry's practices were so flagrant that they prompted an investigation by the Justice Department. Indeed, the payments reported in the new study appear in Internet listings set up by five big orthopedic device makers — Zimmer, DePuy Orthopaedics, Biomet, Stryker and Smith & Nephew — as part of a September 2007 settlement that capped a federal inquiry of company kickbacks to doctors. Zimmer, DePuy Orthopaedics, Biomet and Smith & Nephew also paid the government $311 million in penalties.

Secondly, the amount of money is just staggering. The study from Archives of Internal Medicine indicates that 41 orthopods were paid a total of $114 million, with pay outs varying between $1-$8 million to each surgeon. My God, I chose the wrong specialty.

The good news is that there is some law that will go into effect in 2013 whereby a government database will keep track of doctor gifts/payments of more than $10 bucks. So we have that going for us. Which is nice.

Get Rid of the 4th Year of Med School

2010-09-16T09:49:00.004-04:00

A poorly kept secret amongst recent med school grads is the fact that the last year of medical school is a complete joke and waste of time. Most 4th years will do rotations in July and August in the specialty they hope to match in, for the purpose of cozying up to attendings for recommendation letters. But after that, it's a 6 month vacation until match day. I did a surgical ICU rotation in July and then followed that up with a stint on cardiothoracic surgery. I spent the rest of the year half assing my way through rotations like radiology, anesthesiology, and pathology case studies. Most days I got to the gym around noon for a 4 hour session of pick up hoops. And oh yeah, I borrowed about $35,000 to finance that lifestyle.

There are two main reasons to reorganize medical school education along the lines of a three year program. One, it's a waste of loan money and squanders a year of earning potential. Two, it just may be a contributing factor in driving more students out of internal medicine, primary care, and general surgery.

Let me explain. If you eliminated the fourth year, students wouldn't have the oportunity to rotate through subspecialties like dermatology and radiology and cardiology and orthopedics. Hence, less chance to be brainwashed into thinking that general medicine and surgery were beneath them. The third year curriculum would expand the exposure to internal medicine and general surgery and family practice. Someone who really really wanted to do a cardiology rotation could do so, but would have to eliminate either OB/gyn or psychiatry. As it is now, the entire fourth year is built around the idea of winning praise from subspecialist academic physicians. Is it any wonder that medical students look down upon the "mere generalist" professions?

NSQIP Appendicitis Data

2010-09-15T12:43:00.003-04:00

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database has yielded some great ammunition to my preferred side in the ongoing open/laparoscopic appendectomy (OA/LA) debate. In this paper, over 17,000 cases of appendicitis were reviewed from 2008. Interestingly, over 14,000 of the appendectomies were performed laparoscopically, indicating a sea change in OR strategy on a wide scale. Pertinent findings:
*Shorter OR time for LA
*Lower incidence of superficial and deep surgical site infections with LA
*Shorter hospital stay for LA
*Significantly lower mortality in the LA group

Finally, the surgical literature is catching up with the facts on the ground. For the life of me, I just don't understand why any surgeon would want to make a McBurney incision anymore.

Surgical Buy In

2010-09-14T17:30:00.000-04:00

Pauline Chen had a post in the Times last week about surgical informed consent. Informed consent is an important part of the surgeon/patient communication transaction. Surgeon reviews the proposed operation, the rationale behind it, and the possible complications. For example--- a patient comes in with biliary colic. We describe the anatomy and pathology. We aver that surgical resection will lead to cure. The operation (laparoscopic cholecystectomy) is described in detail. Potential complications are addressed (bile leak, CBD injury, bleeding, infections, cardiopulmonary morbidity, etc.) Patient is informed that although complication rates are low, there is still a statistical probability that her procedure will encounter such problems. Given all this information, patient then decides what she ultimately wants to do. Informed consent.

Dr. Chen talks about this concept called "surgical buy-in" where the patient is prepared for worst case scenarios prior to the operation. When a case goes bad, we surgeons have a tendency to implement the full court press, whereby we try anything and everything to get our patients back on course, even when the situation begins to look futile. It's our ingrained sense of responsibility and duty to try to reverse the deterioration. But sometimes these last gasp maneuvers are not what the patient would have wanted.

There's an article in Critical Care Medicine from March that talks about this buy in. For complex elective operations (Whipples, liver resections, transplants, rectal surgery) surgeons would negotiate with patients prior to the surgery the extent to which both the surgeon and the patient were willing to labor if things took a turn for the worse. In other words, the surgeon would say something along the lines of: "If you leak from your pancreaticojejunostomy and get septic would you be willing to be reintubated? Taken back for revision? If you were unable to be weaned, would you consider a tracheostomy? What about CPR? Is there a time limit you would restrict aggressive intervention to, i.e. if you weren't improving by 6-8 weeks of intensive therapy, then palliative measures would be undertaken?"

It's a great idea. As long as we restrict the protocol to those complex operations. I'd hate to put my patients through such a terrifying question and answer session prior to a lipoma excision or a breast biopsy.

Obstetric Trauma on Healthbeat

2010-09-13T09:59:00.009-04:00

An interesting thread developed last week at Maggie Mahar's Healthbeat blog regarding a guest post by one Jordan Grumet, an internist in Chicago, writing about an experience he had while a medical student rotating through OB/gyn.

He writes about a patient in the third trimester of pregnancy who arrived in the trauma bay bleeding profusely from a stab wound to the neck. As the trauma team fought to control the bleeding, Grumet's chief resident donned a gown and grabbed a scalpel. The woman's blood pressure dropped. The fetal monitor showed deccelarations in the baby's heart. I'll let Dr. Grumet describe the rest.

My chief cleared her throat: "Okay, guys, we're gonna lose the baby if we don't do something fast!"

Without taking his eyes from the patient, the trauma surgeon said authoritatively, "We can't. If you cut her, she'll die. Give us a minute."

"It will take a minute-and-a-half to have this baby out," said my chief. She got no answer.

She stood poised over the patient's abdomen, arm raised, scalpel in hand and ready to pounce.

The patient's blood pressure dropped even faster, and the baby's heart rate plummeted.

"It's now or never," said my chief. Then the cardiac monitor began beeping.

"Ventricular fibrillation!" The ER physician grabbed the cardiac paddles and shouted, "Clear!"

With a sweep of his arm, the trauma surgeon moved everyone away from the table, then stepped back--and crashed into my chief. She fell to the floor, extending her arm to avoid slashing anyone with the scalpel.

Dramatic, no? I especially like the image of the resident bravely controlling the scalpel so as not to "slash" anyone as she toppled to the ground. The writers on ER couldn't have scripted a better scene.

My initial comment on the post was this:

I work as a trauma attending. In obstetric trauma, the mother always takes precedence----the single biggest determinant of fetal survival is mother survival. This is Trauma Surgery 101. Once the mother progresses to unsalvageability, there is some evidence to suggest that post mortem delivery of the baby can lead to meaningful survival, albeit at meager rates of success.

Maggie Mahar responded by averring that such guidelines "must be a mistake". I then posted a second comment, politely reminding her that simply disagreeing with the evidence based, algorithmic approach to major trauma purely on emotional grounds is not a credible argument. I even posted a power point presentation I give for CME at one of my hospitals on obstetrical trauma. Pay particular attention to slide #15.

Maggie then posted a final comment where she basically just reiterated her contempt for established trauma practice. She gave no indication that she reviewed any relevant literature or even the power point link that I provided.

If the mother is hypotensive, the baby also is not getting enough blood flow. Hence oxygen exchange is compromised at the placental level. In layman's terms, if the mother is unstable, the baby is in just as much trouble. The fastest way to improve a baby's condition is to make the mother better. Maggie is seemingly unaware of the fact that a c-section requires an actual incision in a mother's belly. Furthermore, anticipated bleeding from a c-section, even in ideal circumstances, is generally expected to be around a liter. So not only would trying to perform a c-section in a hemodynamically unstable, actively bleeding pregnant woman be negligently unwise, it would arguably venture perilously close to the realm of criminal assault.

Maggie Mahar does great work analyzing the intricacies of health care policy and reform but in this particular post she has written irresponsibly. If you're going to use a wide platform like Healthbeat to write about actual medical practice, then you have a journalistic obligation to do so in a much less capricious fashion.

Sunday Quote

2010-09-12T14:57:00.004-04:00

Every summer vacation I re-read the Meditations of Marcus Aurelius. It always reinvigorates my heart and prepares my mind for the inexorable vicissitudes of life. A few choice selections:

"Adapt yourself to the things among which your lot has been cast and love sincerely the fellow creatures with whom destiny has ordained that you shall live."

"Loss is nothing else but change, and change is Nature's delight."

"What more do you want, man, from a kind act? Is it not enough that you have done something consonant with your own nature- do you now put a price on it?"

"When you arise in the morning, think of what a precious privilege it is to be alive--to breathe, to think, to enjoy, to love."

"Remember that man’s life lies all within this present, as it were but a hair’s-breadth of time; as for the rest, the past is gone, the future yet unseen. Short, therefore, is man’s life, and narrow is the corner of the earth wherein he dwells."

"Each of us lives only the present moment, and the present moment is all we lose."

"The soul is dyed by our thoughts."

"Perfection of character is this: to live each day as if it were your last, without frenzy, without apathy, without pretence."

Bucks Roll

2010-09-12T11:11:00.001-04:00

Just for Drackman.

Quote of the Day

2010-09-10T17:45:00.002-04:00

"A democracy cannot exist as a permanent form of government. It can only exist until the voters discover that they can vote themselves largesse from the public treasury. From that moment on, the majority always votes for the candidates promising the most benefits from the public treasury with the result that a democracy always collapses over loose fiscal policy, always followed by a dictatorship. The average age of the world's greatest civilizations has been about 200 years. These nations have progressed through this sequence: From bondage to spiritual faith; From spiritual faith to great courage; From liberty to abundance; From abundance to selfishness; From selfishness to apathy; From apathy to dependence; From dependence back into bondage." - Alexander Fraser Tytler.

(h/t Daily Dish).

Update: Joe Sucher has informed me that the provenance of the above quote is in dispute. See the wikipedia article on the author for the details. Anyway, I thought it was a good quote.

Anachronistic Specialties?

2010-09-07T11:52:00.002-04:00

The NY Times has jumped all over a couple of recent scientific articles asserting that certified registered nurse anesthetists (CRNA's) provide equivalent care as MD anesthesiologists. Already, it is legal in 15 states for CRNA's to dispense anesthesia without the overarching supervision of a physician. Furthermore, a study from the Lewin Group in California has demonstrated that CRNA-only models of anesthesia provision are far more cost effective that our current dual profession paradigm.

In the long run, there also could be savings to the health care system if nurses delivered more of the care. It costs more than six times as much to train an anesthesiologist as a nurse anesthetist, and anesthesiologists earn twice as much a year, on average, as the nurses do ($150,000 for nurse anesthetists and $337,000 for anesthesiologists, according to a Rand Corporation analysis). Those costs are absorbed by various institutions and public programs within the health care system.

This is a fascinating debate. And I expect MD anesthesiologists to fight for their interests tooth and nail.

To some extent, MD anesthesiologists have become a victim of their own excellence. Deaths during the administration of anesthesia occur at a paltry rate of 1/250,00 cases nowadays. This remarkable improvement can be attributed solely to technical improvements in the monitoring of patients during a procedure. Things like continuous pulse oximetry, end tidal CO2 monitoring, and fiberoptic-based intubation equipment have almost completely eliminated major morbidity from the profession. This is a good thing. But maybe not so good for anesthesiologists. They practice in a very algorithmic, checklist-based manner. Thus, it was relatively easy to teach their methods to CRNA's during a period when the exponential rise in operative case loads made it necessary to incorporate "anesthesiology assistants" into a practice, thereby allowing one attending physician to cover multiple rooms. That recent studies have confirmed what everyone else in the OR already knew---that it didn't really matter who was behind the drape while a cholecystectomy was ongoing---- is hardly a surprise. The less variability in clinical excellence one sees from certain specialists, there seems to be a commensurate decrease in perceived prestige. In other words, one's individual reputation as a doctor can be paradoxically harmed when the overall complication rate of your chosen specialty is so low. You are seen as a mere "cog in the machine", a cog that could easily be interchangeable with another doctor or, in this case, a CRNA.

Anesthesiology represents the easiest target. But don't think that the other specialties are exempt from possible onslaught. The more specialized we become as doctors, and the less we emphasize and reward doctors who focus on a holistic approach to medicine (primary care, internists, general surgeons) the easier it becomes for the federal government to replace those pricey specialists with back door, non-MD options who happen to be much less expensive. Imagine an "certified orthopedist" training program that one could enroll in directly out of college with a bachelors of science. You then spent the next three years doing nothing but learning musculoskeletal anatomy/pathology and practicing the basic orthopod operations in virtual reality and on actual patients. Perhaps actual orthopedic surgeons could be enticed to head up such a training program so that these ortho technician graduates learned their techniques from the best. Further imagine that research papers would be published demonstrating equivalent outcomes no matter who performed your knee replacement, MD or ortho technician.

It isn't difficult to see where all this is heading. The cost of healthcare must be controlled to prevent bankrupting our country. Medical school graduates overwhelmingly opt out of primary care and internal medicine. If you can't force or entice our brightest students to stop applying for derm and ortho and radiology residency slots, then maybe you can at least give them a little competition for that business from non-MD sources....

No Surprises

2010-09-06T11:19:00.004-04:00

In the most unsurprising development of health care reform----the Obama iteration that awkwardly tries to fuse private and public coverage plans, thereby preserving the billion dollar health care "insurance" industry---- it has become apparent that the increased costs employers expect to pay for health care have simply been passed on to its employees.

Since 2005, while wages have increased just 18 percent, workers’ contributions to premiums have jumped 47 percent, almost twice as fast as the rise in the policy’s overall cost.

Workers also increasingly face higher deductibles, forcing them to pay a larger share of their overall medical bills. “The long-term trend is pretty clear,” said Drew E. Altman, the chief executive of the Kaiser foundation, which conducted the survey this year with the Health Research and Educational Trust, a research organization affiliated with the American Hospital Association. “Insurance is getting stingier and less comprehensive.”......companies expect that their costs will only go up more under the new health care law because it requires them to provide more benefits, like coverage for preventive care.

Unbelievable isn't it? Who would have thought that for profit entities would do everything in their power to stay in the black. Given the choice to pay the higher health care costs out of a healthy profit margin versus freezing employee wages and earnings, it's hardly surprising that the private sector opts for the latter.

Simply mandating that companies pay for health care without articulating a method of subsidizing it or controlling the escalating cost of health care provision (beyond vague, unspecific programs like the Independent Payment Advisory Board) is not a viable long term solution to the crisis. That is the failure of Obamacare.

Cool Labor Day Tune

2010-09-03T18:36:00.003-04:00

Have a great weekend...... LCD Soundsystem.

Making it Easier to Sue!

2010-09-03T09:52:00.005-04:00

Rumors abound of a plan to revise the federal tax code in such a way that will benefit those poor, struggling plaintiff's attorneys. A bill introduced by Arlen Specter, currently being bandied about Congress, would allow personal injury lawyers to deduct costs accrued during the pre-trial and trial phases of a claim.

Previously, in contingency cases, attorneys would have to front the costs of a major case themselves, and then hope to recoup that investment with a jackpot jury award. This risk assumed by the personal injury lawyer acted to curb the number of frivolous lawsuits submitted. Allowing the lawyers to deduct these costs shifts the financial burden onto the federal government to some extent. Moral hazard is enjoined.

From the Washington Legal Foundation's Walter Schwartz:

If Senator Specter’s proposed modification of the Internal Revenue Code succeeds, the federal government will, for all intents and purposes, share in the cost and risk of bringing the initial litigation. Under current and certainly potential future tax laws, this could be as much as 40% of the cost of bringing litigation.

That's just fantastic.

Prostate Snatchers?

2010-08-31T13:43:00.004-04:00

Interesting article in NY Times today from Dana Jennings reviewing a book called "Invasion of the Prostate Snatchers". (Yeah, that's really the title---I suspect publishers nowadays are contractually obligated to come up with the most outrageously sensationalistic titles possible prior to shipping them off to Borders.) Jennings is a prostate cancer survivor who underwent a radical prostatectomy. His particular tumor was a highly aggressive variant. Surgery probably added years to his life. But according to a recent NEJM study, only 1 out of 48 patients with early prostate cancer who undergo a prostatectomy realize any survival benefit compared to non-operative treatment.

Here's a line that jumped off the page at me:

“Out of 50,000 radical prostatectomies performed every year in the United States alone,” Dr. Scholz writes, “more than 40,000 are unnecessary. In other words, the vast majority of men with prostate cancer would have lived just as long without any operation at all. Most did not need to have their sexuality cut out.”

That quite an astounding proclamation. 80% of the prostatectomies done in this country are arguably unnecessary? Whatever are we going to do with the million dollar DaVinci robotic machines that every private hospital is clamoring to buy and market?

Admittedly, I'm a no expert in prostate cancer. I'd love to hear a rebuttal from any urologists and medical oncologists out there.

Update:
Here's a nice review on early stage prostate cancer from the NCI. It seems that men with prostate cancer younger than 65 years old probably benefit from a more aggressive surgical approach. The older patients don't see a statistically significant benefit from radical prostatectomy.

It's never easy....

2010-08-31T12:38:00.007-04:00

The life of a general surgeon is one fraught with contingency, soul-crushing doubt, unexpected disaster, and overwhelming stress. I wouldn't wish it upon my worst enemy. Fortunately, I was brainwashed to a sufficient degree during residency such that I actually don't mind my job.

One of the reasons general surgery is so tough is that it is nearly impossible to map out your week according to a strict schedule. Maybe at some point in a career, when you're the established, Big Kahuna of the group, you can load up your work week with elective breast biopsies, hernia repairs and lap choles and leave the middle of the night disasters for your more junior partners. In general, however, most surgeons never reach this stage of "easy livin'". It's a lifetime of inconvenience and last minute alterations and ulcer inducing pressure. If you're worth anything as a surgeon, you figure out a way to make things work.

Beyond the scheduling squeeze, the actual business of doing surgery can get to be pretty nerve wracking, no matter how routine the procedure. Anatomic variants, sick patients, hostile abdomens, and the inexorably crushing statistical likelihood of complications (no matter how careful you are) all contribute to the inordinately tight sphincters of surgeons even during the seemingly routine elective gallbladder or breast biopsy.

A few weeks ago I had one of those cases that take a few years off your life. An older thin lady visiting from New Mexico presented to the ER with a partial large bowel obstruction. Her ileocecal valve was incompetent so we were able to decompress her with an NG and prep for colonoscopy. The scope showed a partially obstructing lesion in the hepatic flexure of the colon. She had had a Whipple procedure back in the 80's for benign disease so I planned to do a standard open right hemicolectomy.

The surgery went beautifully. She was one of those thin old ladies with very little intra-abdominal fat. Even her mesentery was an ochre yellow sheet of semi-translucent tissue, like a smudged window in the attic. You could see everything. The case took 45 minutes. The ileocolic anastomosis looked perfect. She then did well for the first three days. On the fourth morning, she looked like hell. She was diffusely tender and had developed an elevated white blood cell count. I'm thinking worst case scenarios----anastomotic leak, inadvertent bowel injury, ureteral transection, etc. So I take her back to the OR and encounter something entirely unexpected: 25 inches of dead distal small bowel. I resect frankly gangrenous bowel and start to investigate. First thing I notice is a lack of pulsatile flow in the area where one would normally be able to palpate the superior mesenteric artery (SMA). Then, as I start to mobilize the left colon for either a new anastomosis or a stoma, I discover a rope-like, pounding arterial branch in the sigmoid mesentery, arising from the IMA. I follow it to the transverse colonic mesentery. I think I know what's going on, but I scrub out at this point and open up the CAT scan on the OR computer and get on the phone with the radiologist. I always get a pre-op CT scan of the abdomen on patients with colon cancer. I ask the radiologist to reconstruct the images in a coronal fashion. He calls back in five minutes and confirms my worst fears.

The lady suffered from severe mesenteric arteriosclerosis. We depend on three main arteries to feed the bowels; the celiac, SMA, and IMA. Her celiac artery and SMA were both occluded by thrombus. Her IMA was open and there was a giant meandering mesenteric artery that had developed over the years to compensate for her lack of flow through the other main trunks. So when I performed an oncologic resection of her right colon cancer, I basically transected that lifeline of blood coming over from her IMA to feed her small bowel. When I scrubbed back in, her remaining intestine was starting to look worse. She didn't have a lot of time. She was about to infarct her entire intestinal tract.

While I waited for the vascular surgeon to arrive, I dissected out the SMA origin and harvested some saphenous vein. Then we revascularized the SMA via a saphenous graft coming off the IMA. The next day, her stoma looked awful and I took her back for a second look. I resected another 6 feet of small bowel. The graft had clotted on the SMA side so I did a quick throbectomy to re-establish flow. I heparinized her and said a little prayer. The graft stayed open. She ended up leaving the hospital. Her life will never be normal again. She will suffer from short bowel syndrome and severe fluid/electrolyte disturbances from the high output stoma. The graft could shut down again anytime. But she made it through this battle. I'll take it.

We wade into shark infested waters every time we press scalpel into flesh. Your eyes better be wide open and your head on a swivel. There's no such thing as routine in general surgery. If you have masochistic tendencies, then by all means come join our club. Otherwise you might be better off in dermatology.

First, Do Nothing

2010-08-18T19:43:00.004-04:00

(From the New York Times)

The New England Journal Of Medicine has published an astounding randomized controlled trial this month. 151 patients with metastatic, terminal non-small cell lung cancer were randomized to either receiving experimental chemotherapy alone versus chemotherapy plus palliative care. The group introduced to a palliative care specialist early in the diagnosis experienced a higher overall quality of life as the clock ran down. This part of the study shouldn't be surprising. The benefits of early involvement of an end of life specialist have been known for a while. Patients get better pain control, feel more in control of their lives as the disease unfolds, and are able to address end of life issues more honestly and openly with a professional. The psychological and emotional benefits are simply incalcuable.

The surprising part of the study was that the patients in the chemo/palliative care group lived an average of3 months longer than the chemo alone group. This, despite the fact that the patients in the palliative care group often decided to forgo additional aggressive treaments as they deteriorated.

What does this mean? Can we attribute the small, but significant, benefit simply to the effectiveness of palliative care? Or can we extrapolate further? What if patients who deferred chemotherapy altogether or only underwent an abbreviated course of treament had a survival advantage? Wouldn't it be reasonable to conclude that the chemotherapy itself was the determining variable?

Let's be honest. The literature on salvage chemotherapy in stage IV cancers is pretty weak. Survival "benefits" are quoted in terms of weeks or months. This stuff is basically poison blasted into your veins, in the hope that maybe, possibly, hopefully you will live a couple months longer than the guy who buys a ticket to Costa Rica and sits on a beach drinking Pina Coladas until he dies.

I've always been uncomfortable with the entire rationale behind "medical oncology" in stage IV, terminal disease. Many of these guys are peddling pipedreams and exploiting a very vulnerable patient population for financial and academic gain. It's good to see an RCT paper like this one to help tilt the perception back toward a "less is more" mentality.

My Continued Anti-Percutaneous Drain Crusade in Appendicitis

2010-08-17T09:30:00.003-04:00

A young kid comes into the ER with 36 hours of RLQ abdominal pain. The ER scans him. The scan shows an obvious 4cm abscess next to the appendix. What do you do?

RESIST THE URGE TO ORDER "CT GUIDED PERCUTANEOUS DRAINAGE".

Please. Just take the kid to the OR. Use your laparoscopic suction/irrigator to wash out the abscess. Remove the appendix. Leave a JP drain if you must. The kid goes home in 1-3 days. No more sitting in the hospital for a week with a foul smelling rubber tube hanging out his side. No more prolonged courses of expensive IV antibiotics. No more interval appendectomies. These patients don't need multi-staged management strategies with multiple invasive procedures. Just operate and be done with it.

Between Cases

2010-08-14T20:05:00.003-04:00

Nothing more awesome than spending a Saturday night waiting in the office for the OR room to turnover so you can start the second of three cases. It's hard to do anything real productive (like dictate charts or write a serious blog post) so I tend to screw around on YouTube. Here's Chet Baker tearing things up.

Horseshoe Abscess

2010-08-12T16:18:00.003-04:00

These cases are sometimes a little tricky. The patient had been suffering from severe butt pain for over a week. He couldn't even sit upright in a chair. He was feverish and had an elevated WBC count upon arrival in the ER. But on exam, you couldn't actually see any of the typical findings of perianal sepsis---no erythema, induration, or fluctuance. But it hurt him like hell when you tried to do a rectal exam. So we got the pelvic scan as seen above to help clarify the diagnosis.

What you see is a circumferential abscess/phlegmon, ringing the low rectum. You can't just lance these things at bedside like you can most abscesses. So I took him to the OR and made a couple of counter incisions to help effectuate complete drainage of the deeper pelvic sepsis. Then I like to leave a Penrose drain in situ, connecting the two incisions. It comes out in the office usually in a week.

Surgical Warranties

2010-08-12T10:07:00.006-04:00

The mathematics and specific details of this article from Archives elude me to a certain (substantial) extent, but the main gist of it is this:

Complications and costs of care can be indexed to quality performing hospitals. Warranties for surgical care can reward effective and efficient care and preclude the need for additional payments for complications.

What that means, I think, is that those providers and hospitals that perform colon surgery with a lower overall incidence of complications set the bar in terms of bundled payment reimbursements. Those hospitals with higher complication rates, and therefore accrue higher costs, will find that much of the cost of this additional care and treatment will go un-reimbursed; thereby financially incentivizing them to either do a better job taking out colons or to get out of the colectomy business altogether.

I don't have much of a problem with this, to the exent that it is implemented fairly. A small hospital that recruits a colorectal surgeon isn't going to have the numbers to compete with the big tertiary care centers. As a result, complications that occur in the initial couple of years are going to statistically stand out as blaring clarion calls to cut reimbursements to that small hospital.

And the giant referral centers, teeming with surgical subspecialists clamoring for every square inch of operable human flesh will like that just fine.

Who Are the Torture Doctors?

2010-08-11T15:46:00.011-04:00

JAMA this month has commentary piece on the ethical failure of physicians in the CIA Office of Medical Services (OMS) who helped organize, calibrate, and supervise the torture of unarmed, often innocent prisoners at Guantanamo. The principle of "do no harm" was abrogated by these lackey yahoos as they provided a professional cover to acts universally condemned throughout modern history as torture by all civilized nations.

My question is: Who are these doctors? What are their names? Are any of them practicing medicine in our country? When is anyone going to be held accountable for the despicable, embarassing, morally devastating era of American torture?

The American Psychological Association has already mounted an attempt to strip the license of a Texas pyschologist who participated in the "enhanced interrogation" of Abu Zubaydah:

If any psychologist who was a member of the APA were found to have committed the acts alleged against Mitchell, "he or she would be expelled from the APA membership," according to the letter, a copy of which was obtained by The Associated Press. APA spokeswoman Rhea Farberman confirmed its contents.

We know that Captain John Edmondson, the former Commander of the Gitmo Naval Hospital, is on record as admitting that he countenanced the forced feeding of inmates on hunger strike (an ethical lapse condemned by 262 signatories to a letter to the editor in Lancet).

What else can Captain Edmondson admit to? Is he practicing emergency medicine now as a civilian? How many of the other doctors at Gitmo are now enjoying lucrative private practice careers? Have they all done as well as former Navy Surgeon General Donald Arthur (who now commands a salary north of $400,000 working as the chief medical officer for MainLine health)?

Doctors or Technicians?

2010-08-11T14:10:00.009-04:00

Interesting article recently from Health Affairs (via WSJ blog) about the clinical equivalence between the care provided by anesthesiologists and CRNAs. The article concludes by advocating that CRNAs be given permission to practice anethesiology without physician supervision. It's more cost effective. And there is no compromise to the quality of care delivered to patients.

We recommend CMS return to its original intention of allowing nurse anesthetists to work independently of surgeon or anesthesiologist supervision without requiring state governments to formally petition for an exemption,” they conclude. “This would free surgeons from the legal responsibilities for anesthesia services provided by other professionals. It would also lead to more cost-effective care as the solo practice of certified registered nurse anesthetists increases.” The study was funded by the American Association of Nurse Anesthetists.

A couple of caveats. One, the study was conducted by the American Association for Nurse Anesthetists (sort of like a study claiming that Jeff Parks is the smartest man on earth being conducted by "friends and family and hired sycophants of Dr. Parks"). Also, the study admits that CRNA's tend to work on less complex cases than MD anesthesiologists.

The main thrust of papers like this is to delve into the essence of what it means to be a "doctor". Are all doctors alike? Is the orthopod who replaces 350 knees a year the same as the internist cranking through 30 patients a day with complex medical problems? Is it fair or unfair to further categorize the various specialities according to some sort of intellectual hierarchy? Do some specialties verge perilously close to being mere technicians, thereby inviting the sort of turf war salvo sounded by the above referenced paper?

In reality, I think it goes beyond anesthesiology (although anesthesiologists are an arguably easier target). Most of the work done by a family practitioner can probably be adequately performed by a NP or PA without adverse effects. If you trained a physically gifted person to take out gallbladders and that's all he did, day after day, I bet you would be able to find a paper demonstrating that the non-MD surgeon has a similar complication rate as a formally trained general surgeon. But then what is that automaton going to do when he encounters a cholecysto-colonic fistula or when the cholangiogram shows he has cut the common bile duct? What is the NP going to do when she has to manage a patient with diabetes, heart disease, peripheral vascular disease, and obesity who comes into the office with abdominal pain? Would any CRNA accept the responsibility and stress of running a CABG solo?

The bottom line is, most of the time you don't need a doctor until you really need one. But you never know when that day is going to be. You never know when that seemingly normal patient who walks into the ER ends up turning into a complete disaster. My advice to these non-doctors seeking legitimacy and complete autonomy: be careful of what you wish for.

The Increasingly Unacceptable Negative Appendectomy

2010-08-11T05:38:00.006-04:00

When I was a medical student (really, not that long ago), we were taught on our surgical rotations that one can expect to take out a significant number of normal appendixes during a career. Specifically, a 15-20% negative appendectomy rate was considered appropriate, if not the standard of care. The rationale went like this: you don't want to miss appendicitis, delayed diagnosis leads to complicated outcomes, therefore, it's worth the morbidity of an operation to remove a few normal worms along the way.

This dogma dominated surgical thought right up until the Era of the Ubiquitous CT Scan came into being. Today's scanners are quick and highly sensitive for intra-abdominal pathology. An inflamed appendix rarely eludes its watchful eye. As a result, given the highly litigious environment of 21st century medicine, it's rare for a patient presenting to an ER with belly pain to go home without a scan. Personally, I like the CT scan, even in the so-called no-brainer cases (20 year old male with focal RLQ abdominal pain). For one thing, it helps me plan the surgery better--- is there an abscess in the pelvis needing drained, is it retrocecal, should I place my ports in a certain configuration, etc. For another, I'm a self-described ace when it comes to reading a scan for appendicitis. If I don't see the hallmarks of appendicitis while scrolling through the images, then I'm pretty hesitant to rush the patient to the OR. Finally, I just hate the concept of doing a surgery for no reason. Taking out a normal appendix is a highly unsatisfying endeavor. The only two truly negative appendectomies I've done in my career so far were on pregnant patients who chose not to undergo pre-operative CT scanning but had suggestive clinical histories.

It's funny, in the recent past, a surgeon with such a low negative appendectomy rate would raise suspicions from his local QA committee. It suggested that he/she was "not being aggressive enough" in treating ER patients in abdominal pain. The tide has turned however. A recent article from Radiology demonstrates a decrease in negative appies from 23% to 1.7% over the past 18 years, again directly attributable to the old CT scan. Also, from Surgery, a group at a New York hospital describes a decrease in negative appendectomy rates to around 5%. And that sounds about right to me.

Nowadays, a surgeon who regularly takes out normal appendices is going to come under fire. On one of my QA committees, we "keep an eye on" surgeons who have negative appy rates over 15%. With modern CT scanners, it's hard to justify the old dogma. Of course, someone will probably write up some groundbreaking finding about how all these CT scans lead irrevocably to a higher incidence of cancer---- which will reverse the tide again and we'll be once more teaching residents the value of "laying on of hands" and clinical judgement.

Letting Go

2010-07-30T11:57:00.003-04:00

Atul Gawande has a great piece in the New Yorker this week about the difficult and complex management of end stage disease in terminal patients. (See, I don't always criticize the guy. He writes good stuff.) What happens when we reach the point where further treatment is futile, when death gathers momentum, threatens to overwhelm at any moment? What do we do with these brittle, emaciated, broken human beings, bodies riddled with cancer, when all the latest toxic chemotherapy options have been exhausted and there's no more surgery to offer? What do we do when these patients don't want to hear about "palliative care" and "hospice", when they get angry or accuse you of abandonment when you tell the truth about their prognoses? There has to be something else, they plead, some new trial, some miracle cure. That faint sliver of light is what they grasp for when the darkness begins overtake them. Gawande:

There is almost always a long tail of possibility, however thin. What’s wrong with looking for it? Nothing, it seems to me, unless it means we have failed to prepare for the outcome that’s vastly more probable. The trouble is that we’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets—and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win. Hope is not a plan, but hope is our plan.

It's a great weekend read.

She Chose (b)

2010-07-29T14:16:00.003-04:00

Awesome summary from Deborah Tornello.

2. If, while attending this conference, you experienced leaking amniotic fluid and felt early contractions on the morning before you were scheduled to speak, would you (a) hand the speech to someone else, ask him or her to give it on your behalf, and go straight to the nearest hospital--one that was equipped for handling high-risk mothers, premature births, and special-needs infants--and get yourself checked out by a doctor or (b) continue with your day and give the speech anyway?

Sarah Palin chose (b).

Laparoscopic CBD Stone Extraction

2010-07-27T09:54:00.005-04:00

This case was sort of fun. The patient presented with abdominal pain, localized in the epigastrium and RUQ. The US demonstrated gallstones and a thickened gallbladder wall. His amylase and lipase values were extraordinarily elevated, suggesting an element of gallstone pancreatitis. Furthermore, his bilirubin and transaminases were abnormal, raising the possibility of a common duct stone. So I sent him for an MRCP which was rather unremarkable, other than showing some edema around the pancreas.

My policy on gallstone pancreatitis is to remove the gallbladder once the pancreatitis abates---on that same admission. That way there, you don't have to worry about relapse if they pass another stone while waiting to get their outpatient surgery done. So I took this guy to the OR and his gallbladder was predictably inflamed. My initial intra-operative cholangiogram (see top pic) demonstrated a meniscus sign in the distal duct and non-filling of the duodenum.

Usually this warrants a post-op ERCP to fish out the stone. But in this case, the patient's cystic duct was quite dilated (even the large clips wouldn't extend across the lumen; I had to secure it with an endoloop). So I decided to make a run at it myself. I slid a fogarty catheter through the stump and into the common duct, all the way into the duodenum. Then you inflate the ballooon and slowly bring the tip back, adjusting for tension as you go. So I did that and boomski, out popped a little yellow stone. The second pic shows a pristine biliary tree with the folds of the duodenum filling in like a coral imprint.

Gut Check

2010-07-26T21:00:00.004-04:00

So it's a Saturday morning and you're making leisurely rounds when a consult comes in for an ICU patient. You show up at the same time as the GI guy who was also consulted. The patient is at the extreme terminus of age. You and the GI consultant review the data together. He had come in through the ER from a nursing home with mental status changes and fevers. His WBC was elevated. A CT scan done the night before showed thickening of the colon from the splenic flexure all the way down to the distal rectum. You walk in and the guy is about to be intubated. He's on three pressors, all maxed out. His belly is soft but you can't really trust your exam. The nurse states that he "just had a seizure".

-Looks pretty bad, you say.
-Yeah. I think I ought to do a quick flex sig to see if he has any pseudomembranes (a sign of c. difficile colitis)
-Ummm...doesn't really matter either way, you offer.
-Yeah, but it would be nice to know. Then we can at least start vancomycin enemas. And with you on board, depending on what the family wants...
-This guy won't be undergoing any surgery, you say. You give him one of those looks, a look that is supposed to transmit a deeper, unspoken meaning---a look that always seems to work in the movies or in bad crime novels, but never in real life. He is already paging his endoscopy team to come in with the equipment.

You move on to the next patient on your list. A little while later a code blue is announced over the intercom as you pass the endoscopy nurse wheeling the unwieldy endo cart toward the ICU.

-You might as well put that thing away, you say.

Work Hour Reform Ctd.

2010-07-26T05:47:00.006-04:00

More from the work hour reform beat (via Health Science Blog):

The researchers reviewed 2,908 laparoscopic cholecystectomies, in which the gall bladder is surgically removed through a small incision in the abdomen, and 1,726 appendectomies to remove patients’ appendixes that were performed at Harbor-UCLA Medical Center from July 2003 to March 2009. These are the two most common operations performed by residents, and the two surgical procedures are often performed at night when residents are more likely to have worked a long shift.

The researchers compared outcomes in these two operations when they were performed during the day by surgical residents who had worked less than 16 hours and at night by surgical residents who had worked 16 or more hours. The researchers concluded that “appendectomy and cholecystectomy operations performed at night by less rested and possibly sleep-deprived residents have similar good outcomes compared with those performed during the regular work day.”

So are you telling me that surgeons do not, in fact, require nappy time if they have been awake for 16 hours prior to performing a cholecystectomy? Really? Who knew? I can't believe it. What about the cookies and milk? Has anyone done a RCT studying the effects of a bellyful of cookies and ice cold milk on a surgeon's competence? Why hasn't the Institute of Medicine investigated this? And don't be trying to pass off a Nilla Wafer as a cookie.

Gastric Volvulus

2010-07-15T10:52:00.003-04:00

This elderly guy presented with acute renal failure due to vomiting everything he tried to eat or drink for a week. He was rehydrated and decompressed. The images above demonstrate a complete foregut obstruction secondary to herniation and volvulus of the stomach through a large hiatal hernia. On the coronal view, you can actually see the pylorus and dilated 1st part of duodenum in the thorax.

I reduced his elephantine stomach and repaired the crural defect. I also did a pyloroplasty and affixed his fundus to the abdominal wall with a gastropexy. He was eating lukewarm hospital chicken casserole by day three. Fun case.

Compromise

2010-07-13T09:37:00.000-04:00

Glenn Greenwald has done a bang up job of exposing the cozy, compromising relationships that the elite press corps has developed with the very Washington DC politicians and insiders they are ostensibly supposed to be covering. In this era of blogging and open source media, the public doesn't necessarily have to seek political news and opinions from the old guard of mainstream media. The elites no longer have a monopoly on defining what is news and how the news ought to be interpreted. So they cling to the one thing that the bloggers will never be able to touch---their sources, connections, and inside contacts.

As a result we get travesties like the Joe Biden party where reporters engage in squirt gun fights with the Vice President and other White House staffers. You get Chris Wallace "interviewing" Dick Cheney without asking a single uncomfortable question about torture and waterboarding. You get Sarah Palin running for Vice President without having to endure a single unscripted press conference. The presentation of "news" becomes merely a propaganda show where journalists and reporters subserviently regurgitate what the politician wants them to say, unchallenged. Because if they don't, guess what? No more access! No more "private sit down" sessions with Mr. VIP! And so the journalist/reporter simply stops doing the job he/she was hired for, i.e. holding governmental persons in postions of power accountable. Getting at the truth isn't so important as maintaining an open relationship.

Similarly, in medicine we often compromise ourselves for nefarious purposes, especially financial. We bitch and moan about tort reform and the insidious malpractice situation but we refuse to hold one another accountable. When another doctor makes an error, no one says anything. It's "too awkward" to say anything or "it creates an antagonistic environment" will be the explanations you hear. And of course this is true to some extent. But a larger reason has to do with the way private practice is constructed. Referral patterns are based on relationships and habit. You refer to a certain surgeon because he seems nice and the patients like him. You refer to a certain endocrinologist because she went to your medical school. Rare does it have anything to do with the quality of care delivered. And as these referral patterns and relationships ossify, it becomes harder and harder to change them. One thing that will change a referral pattern mighty quick would be "tattling" on a referring doctor for providing substandard care. Or receiving a notice in the mail from your QA committee that another physician has submitted several examples of cases where you delayed an intervention.

We specialists don't want to disrupt our profitable and essential referral patterns. So we don't say anything when an internist puts a patient on full strength lovenox 24 hours after a colon surgery. At most we perhaps off-handedly mention to the physician that maybe it would be a better idea to allow the surgeon to decide when to re start anticoagulation. The GI doc doesn't report the surgeon who always calls him for his all too frequent post-lap chole bile leaks. We don't report the internist to QA who prescribes massive doses of IV steroids to a patient with a rash (probably from morphine reaction) who was admitted with diverticulitis, who then decompensates and becomes septic with peritonitis. We just kinda, sorta mention that altering the patient's immunity with corticosteroids maybe wasn't such a great idea. Or maybe we don't say anything at all. Because it would just create an awkward situation.

Decision

2010-07-08T21:14:00.007-04:00

"Thank you all for coming tonight. Special thanks to my sponsors, Rubbadub Latex Gloves Inc. and ShankRite Scalpel Ltd.

After considering all my options I have decided to remain here in Cleveland, Ohio for the prime years of my surgical career. Numerous suitors have approached me over the past 6 months and, frankly, my soul has been wracked by guilt and self-doubt. It's been incredibly humbling. There was the practice in South Beach which offered to provide authentic Shojo Zen back massages during all my laparoscopic cases, while maintaining a steady stream of polysymphonic chill music in the background. There was the group outside Georgia that promised I could operate barefoot (or flip flops at the most) and would never have to wear a tie while in the hospital. And then of course the practice in Omaha that told me they would install a miniature indoor soccer field in my office. And how could I forget the hospital group in Poughkeepsie that told me I would be allotted ten minutes to rifle through all the anesthesiologist's wallets in the locker room between my own cases without reprisal (security cameras turned off, my call) and wad whatever I could gather into my scrub pockets. Again, I was profoundly moved by what others would willing to do to acquire my services. The temptation to leave snowy, decayed, broken-down, riddled with crime and unemployment Cleveland was high.

But I've always been about winning. Perks have no effect on me. I am a winner. I don't take out gallbladders for the reimbursement. I don't come in at three in the morning for an incarcerated hernia just to fill out sixteen duplicate copies of Medicare forms. No. It's about winning, baby. Conquering that diverticular stricture. Whacking out that burst appendix in record time. Victory. Glory. It all awaits me here on the shores of Lake Erie. I can smell it."

/taped delayed interview of above transcript available on local cable access channel 324 on August 23rd.

/screw you Lebron

Complex Diverticulitis

2010-07-08T09:18:00.003-04:00

This is about as bad as it gets. I saw an elderly lady with a chief complaint of frequent urinary infections and passage of stool per her vagina. The images above demonstrate obvious colovesical and colouterine fistulae. The CT also demonstrated significant left ureteral obstruction at the level of the pelvic inlet. What ensued was a complex multi-specialist procedure involving a sigmoid resection, hysterectomy/oophorectomy, and ureteral stenting. Good stuff.

Happy Fourth of July!

2010-07-04T10:21:00.004-04:00

Despite the unemployment, the corruption, the imperialistic foreign wars, the social inequality, the increasing fundamentalism and anti-intellectualism of my conservative party, and the overall uncertainty of what the future holds --- despite it all, there's no better place to live and work and raise a kid than the old US of A. Fire up the grill. Down a few pints. Have a great weekend.

(What song did you think I would use??)

EMT Loses Lawsuit for $10 Million

2010-07-04T10:01:00.005-04:00

(via White Coat and Kevin MD)

I was incredulous to read about the case of the EMT service sued for negligence for transporting a pregnant woman to a tertiary care center in Florida. The woman went into labor in the ambulance and the heroic paramedics had to deliver a breeched 25 week-old baby and then resuscitate him en route to the hospital. The boy lived but ended up with cerebral palsy secondary to prolonged hypoxia during the delivery. The doctors and hospitals had both settled the case for $1.4 million. The EMT company didn't feel it needed to settle, thinking there was no way they could lose at trial. They lost. And the verdict was for 10 million buckaroos.

Apparently, the plaintiffs attorney was able to successfully argue that the paramedics ought to have performed a thorough, independent evaluation of the pregnant mother prior to departure and then refused to transport her; in essence, they should have overruled the judgment of the physicians involved in the case. And they also ought to have resuscitated the child as well as any tertiary care NICU. Even though they weren't physicians. While in a speeding ambulance.

But we don't need tort reform, right?

The Palin Pregnancy

2010-06-30T09:42:00.013-04:00

I'm sorry, but I just cannot resist any longer. The fantastical, magical realism surrounding the events of the birth of Sarah Palin's 5th child Trig just have to be reviewed. (Come on, there's a medical slant to the topic, right???)

Please take a moment to listen to or read the transcript of an interview ex-Governor palin gave to a reporter in 2008. To recap:

In April 2008, Sarah Palin was 43 years old and 8 months pregnant with a known Down's Syndrome child. She had had two previous miscarriages. For some reason she flew to Dallas, Texas to give a speech at a national governor's conference. Early in the morning on the day of the speech, Mrs. Palin states that she started to feel some cramps and noticed leakage of some fluid. So she called her OB in Alaska who apparently reassured her that everything was cool (and who now refuses to speak to anyone from the media about the incident). Again, she describes fluid leaking from between her legs, suggesting a possible premature rupture of membranes (i.e her water broke). While 8 months pregnant with a special needs child. At age 43.

Well that was again if, if I must get personal, technical about this at the same time, um, it was one, it was a sign that I knew, um, could lead to uh, labor being uh kind of kicked in there was any kind of, um, amniotic leaking, amniotic fluid leaking, so when, when that happened we decided OK let’s call her.

So Palin delivered her speech. She then elected to skip the post-speech reception (sort of awkward mingling at a cocktail party with amniotic fluid running down your leg, you know), got on a plane and flew to Seattle, Washington. She then took another plane to Anchorage, Alaska. Finally, she drove the 50 or so miles from Anchorage to Wasilla so that her fifth child could be born in his hometown. (Can't have no fishpickers born down there in the Texas!)

Digest that for just a second. A 43 year old woman carrying a child with known Down's Syndrome in her 8th month of pregnancy voluntarily embarked upon a transcontinental adventure to give some dumb speech. Then, after noticing some cramps and the passage of amniotic fluid, she went ahead with her speech and, instead of proceeding directly to the nearest Dallas high risk pregnancy center, boarded a four hour flight to Seattle. Then she hung out in the Seattle airport lounge for a while and took a connecting flight to Alaska. Then she drives to Wasilla. Finally, she decides to seek medical attention at local Wasilla hospital, a facility lacking a NICU and other high risk specialists. That's her story. In her own words.

There are only three explanations for this extraordinary compendium of events:

1) The Andrew Sullivan Answer: In this theory, Palin was never pregnant and Trig is not her child. To me, this is the least valid of all the theories. The odds of a woman giving birth to a child with Down's Syndrome increase with increasing maternal age. Again, she was 43 years old. I just don't buy it. (But a simple confirmatory birth certificate would be nice!)

2) The Mommie Dearest Answer: In this theory, everything that Palin says is true. In other words, Palin willfully and wantonly placed herself and her unborn child in tremendous danger by flying cross country with amniotic fluid running down her legs. This to me is the scariest possibility because by willingly telling the story, she seems to be under the impression that people would be impressed by her "hardiness" and "toughness". (That's the way we do things up here in the Alaska!) And she is completely oblivious of the fact that this story makes her look reckless and selfish and completely insane. What kind of mother would take a risk like that with her child, let alone a high risk, premature one?

3) The Bridge to Nowhere Answer: The other possibility is that she simply lied. She made it all up. She thought it would make her look tough. So her water never broke. She never felt cramps. None of these things actually happened until she was in Alaska. I suppose this one, banal as it is, represents the most likely answer.

Again, this woman is a major political player in the GOP. She could easily win Iowa and New Hampshire in 2012. She's frightening....

Work Hours Ctd.

2010-06-28T19:41:00.000-04:00

Th ACGME has come out with new and improved recommendations for resident work hour restrictions. Some highlights:

*Interns have to inform patients of their role in patient care (i.e... Although I'm wearing a white coat and a stethoscope around my neck, I'm a pretty green neophyte at this whole doctoring business. Just thought you'd like to know. Enjoy your chicken broth and cold coffee.)

*Interns cannot work more than 16 consecutive hours. Fortunately, the ACGME chose not to co-opt the Institute of Medicine's (IOM) recommendation that residents are allotted time for a five hour nap period after 16 hours or work. Because that's just, you know, sort of embarassing. Because then you have to assign blankies and pillows to all the fresh faced interns and make sure snackies are available in the call rooms and it just becomes a logistical nightmare for residency program directors.

*According to the wording of the ACGME report, it appears that interns are not allowed to do anything involving patient care without "level 1 or 2a supervision". That means the attending physician either has to be standing right next to the young doc or at least somewhere on the premises. So all those central lines and chest tubes and code blues that happen in the middle of the night have to be handled by older residents.

Ah, the slow death of general surgery....

What Does Dave Weigel have to do with Sermo?

2010-06-27T13:21:00.006-04:00

Dave Weigel is a libertarian, right-leaning blogger who had been writing for the Washington Post. Although his politics veer right of center, he has no tolerance for the radical, wacky wing of the Republican Party (think Tea Partiers, Glenn Beck, Sean Hannity, etc.) Weigel was a member of the liberal-leaning listserv called JournoList (a private, by-invitation-only email group comprised of professional journalists and bloggers). JournoList provided a forum for these guys to exchange ideas with one another in an off the record fashion. Weigel, this week, in a moment of reckless writing, posted a thread on JournoList implying that the world would be a better place if Matt Drudge suddenly decided to self immolate.

Someone read the post and decided to break protocol. Ultimately, several of his off the record email posts were published for the general public on both the Daily Caller and FishbowlDC. Weigel subsequently resigned his position as a writer/blogger for the Washington Post.

The embroglio got me thinking social media and professionalism, in general. On places like Facebook and private blogs and Twitter accounts, people often present a far different characterization of themselves than the one they perhaps proffer in the office, at the hospital etc. Perhaps we sometimes trust too much that these two versions of ourselves do not overlap, that our secret rebellious, outgoing selves are secure behind passwords and restricted access walls. (This is why I don't do Twitter or Facebook--- Buckeye Surgeon is the sole source of learning about Dr Parks; no contradictions or duplicity. As long as I keep writing honestly, I don't feel any need to worry about reprisals.)

Sermo is a social network restricted to physicians (you have to give a verifiable medical license number in order to join). It's a great resource for docs. I've run cases by strangers on Sermo in real time while trying to decide upon an appropriate treatment plan for a difficult patient and have been aided immeasurably by the advice and comments I've received. But there are also posts about the political aspects of medicine and complaints about other specialties and rants about difficult patients and malpractice claims. And not everyone on Sermo chooses to be anonymous.

What if someone obtained access to Sermo for nefarious purposes? Perhaps a physician-turned-hospital administrator who went looking for dirt on a trouble-making internist. Or a malpractice attorney who used his brother-in-law's log-on ID to troll for cases.

Dave Weigel lost his job over a careless post on what he thought was a secure, private listserv. You figure it's not a question of if, but when, something similar will occur to casually flippant doc on a site like Sermo....

Drug Testing Docs?

2010-06-25T13:15:00.014-04:00

I got this link from Sermo. Lucian Leape MD, a public health professor at Harvard, wants to subject doctors in America to strict random and periodic drug testing to help identify those physicians who are impaired. All in the name of patient safety, of course:

"I'm very much in favor of random testing," Dr. Leape says. "We have a responsibility to identify problem doctors and bring them into treatment." And to protect patients in the process.

Ok, I get it. Impaired physicians are bad. We don't want strung out cokeheads and stumbling alcoholics roaming the halls of our hospitals. But random drug testing? Listen, it's hard to argue with someone like Dr. Leape without appearing to be some uber-lefty, bleary eyed, tie-dye wearing hippy freak. But consider:

1) A doctor who is on vacation with extended family in the Outer Banks. After a day of surfing and tanning and several cold frosty beers, one her cousins busts out a joint late night on the back deck while the ocean rolls into shore. And let's say she partakes in such activities 3 of the next 4 nights in similar fashion. That THC will be floating around in her system for the next 30 days, potentially. What if she is called to give urine a week after the trip?

2) Let's say an internist goes to a Super Bowl party with friends. The day turns into an all night fiesta as they celebrate the Browns' first ever world title. Many beers are consumed. Knowing that it was going to be a long night of carousing, the doctor had cancelled his office hours for the following Monday morning, planning to just drop by the office in the afternoon to do some charting. The next morning, his office manager calls at 8 AM sharp and tells him he has to have his urine/blood sample in by 10AM. He stumbles out of bed, still hung over, and rushes into the hospital. The result shows his blood alcohol is 0.09 (enough to get you a DUI). What do you do with him?

What are the consequences? Do you lose your license? Are you reported to the medical board? Are your privileges at hospitals suspended? Does your name wind up on the police blotter section of your local Sunday paper?

To be clear-- I am strictly against the idea of physicians practicing medicine while impaired. But this totalitarian encroachment on what a man or a woman chooses to do in his/her free time is rather disturbing. As a professional class I think it is our own responsibility to identify and report those doctors who have a problem. An impaired physician cannot hide for very long. We just need to stop being such timid cowards and do a better job of self-policing ourselves.

Work Hour Reform Redux

2010-06-23T14:34:00.006-04:00

Kevin has a good article in the USA Today about the negative consequences of resident work hour reform. In it, he notes that patient "hand off" errors and the lack of operative exposure a surgeon-in-training gets during residency can adversely effect both patient care and the ability of future doctors to handle complex situations.

I also just read a crappy paper in Archives about the effects of the 50 hour work week limitation currently in use in Switzerland. The overwhelming majority of attending and resident physicians stated that the reforms negatively affected operating room experience and overall patient care. Who would have thought that working as much as a middle manager at a Toyota plant would adversely effect a surgeon's training and performance.

If you live in the Atul Gawande world, none of this bothers you. In this world, sub-sub specialist physicians are only responsible for a tiny sliver of medical knowledge and so there's really no reason to be spending 100 hours a week in a hospital during your training. A fully integrated, multidisciplinary "system" will take care of everything. You won't need a general surgeon. The thyroid guy will take out your thyroid gland. The biliary guy will remove your gallbladder. And the colorectal guy can take care of your hemorrhoids. Don't you worry.

Yes!

2010-06-23T12:34:00.004-04:00

Happy Father's Day

2010-06-20T19:29:00.003-04:00

Ok, so I've obviously decided to continue churning out a mixture of pithy anecdotes and other assorted detritus on Buckeye Surgeon. Thanks to all who commented, either on the post or via email. As my buddy Goose wrote: "nice to see you've snapped out of your early mid life crisis and are back blogging."

I've been reading William Shirer's Rise and Fall of the Third Reich lately. (It's long, but reads like a Tom Clancy thriller. Just fascinating that an entire nation could fall under the spell of a complete and utter lunatic.) Anyway, there was a part describing one of the speeches Hitler gave to the Reichstag in 1938. He used the occasion to respond to FDR's official query into his intentions with regards to several of the other remaining free nations in central and eastern Europe. Hitler had already secretly obtained declarations (in the gentle, diplomatic Nazi way, you can be sure) from those countries announcing that none of them had any fear of further German aggression. He then proceeded to mock Roosevelt in faux indignation. How dare the President of a country that just ended slavery a generation ago, a country that liquidated/relocated the native population to allow for the Manifest Destiny of its white pioneers, how dare they lecture Germany on good behavior. Apparently this set off thunderous applause and laughter throughtout the Reichstag.

Hitler hadn't really scored any real points with this line of thought, of course. One doesn't lose all moral credibility just because of past transgressions. You don't lose the right to call out someone for immorality or an ethical lapse just because you have sinned in your own past. You only lose it when you fail to ackowledge your past failures. Atonement is impossible without an honest self-interrogation. And I guess that was the point of my little blog sabbatical and the subsequent to be or not to blog post. As my fantasy football friend Jeff said: it's about time you wrote a self critical post contra the shiny white knight of compassion you've created on the blog. What took you so long? What kind of self-loathing post-modernist would you be otherwise?

I guess that's part of it. But not all. I'll be honest---I write this thing for my little baby girl, mostly. I want her to have a way to find out what I was like and what I thought about when I was younger man. It's corny, I know. But I dont care. Go read Kevin MD if you dont like it.

Gawande on the Matrix

2010-06-20T08:37:00.005-04:00

Atul Gawande gave the commencement address at Stanford medical school this year. I thought it might be fun to rip-off a Bill Simmons schtick and do a retro-diary of my thoughts as I read through it. So here goes. (Text borrowowed from the New Yorker.)

Many of you have worked for four solid years—or five, or six, or nine—and we are here to declare that, as of today, you officially know enough stuff to be called a graduate of the Stanford School of Medicine. You are Doctors of Medicine, Doctors of Philosophy, Masters of Science. It’s been certified. Each of you is now an expert. Congratulations.
(Frank Drackman additionally received a Masters of His Own Domain upon graduation)

So why—in your heart of hearts—do you not quite feel that way?
(Because we just finished the entirely useless, waste of time, summer vacation known as fourth year of medical school!)

The experience of a medical and scientific education is transformational. It is like moving to a new country. At first, you don’t know the language, let alone the customs and concepts. But then, almost imperceptibly, that changes. Half the words you now routinely use you did not know existed when you started: words like arterial-blood gas, nasogastric tube, microarray, logistic regression, NMDA receptor, velluvial matrix.
(I use the word 'microarray' at least 17 times a day)

O.K., I made that last one up. But the velluvial matrix sounds like something you should know about, doesn’t it? And that’s the problem. I will let you in on a little secret. You never stop wondering if there is a velluvial matrix you should know about.
(When I was 11, my older cousin Chris told me all about his girlfriend's velluvial matrix. I acted like I knew exactly what he was talking about.)

Since I graduated from medical school, my family and friends have had their share of medical issues, just as you and your family will. And, inevitably, they turn to the medical graduate in the house for advice and explanation.

I remember one time when a friend came with a question. “You’re a doctor now,” he said. “So tell me: where exactly is the solar plexus?”

I was stumped. The information was not anywhere in the textbooks.

“I don’t know,” I finally confessed.

“What kind of doctor are you?” he said.
(Now come one. Solar plexus? Did this anecdote really happen? And was Gawande truly upset that he didn't know the location of a solar plexus? Did he crack open his anatomy textbook, frantically leaf through the index searching? In the words of my pretentious feminazi freshman English comp instructor---it just doesn't "ring true".)

I didn’t feel much better equipped when my wife had two miscarriages, or when our first child was born with part of his aorta missing, or when my daughter had a fall and dislocated her elbow, and I failed to recognize it, or when my wife tore a ligament in her wrist that I’d never heard of—her velluvial matrix, I think it was.
(Damn. Don't I feel like an ass after all those anti-Cost Conundrum posts. I hereby retract all jokes re:Gawande. The dude's had a tough life.)

This is a deeper, more fundamental problem than we acknowledge. The truth is that the volume and complexity of the knowledge that we need to master has grown exponentially beyond our capacity as individuals. Worse, the fear is that the knowledge has grown beyond our capacity as a society. When we talk about the uncontrollable explosion in the costs of health care in America, for instance—about the reality that we in medicine are gradually bankrupting the country—we’re not talking about a problem rooted in economics. We’re talking about a problem rooted in scientific complexity.
(Now we get into the meat of his point--that the complexity and depth of modern medicine is "too much" for the individual physician. More on this later.)

Half a century ago, medicine was neither costly nor effective. Since then, however, science has combatted our ignorance. It has enumerated and identified, according to the international disease-classification system, more than 13,600 diagnoses—13,600 different ways our bodies can fail. And for each one we’ve discovered beneficial remedies—remedies that can reduce suffering, extend lives, and sometimes stop a disease altogether. But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures. Our job in medicine is to make sure that all of this capability is deployed, town by town, in the right way at the right time, without harm or waste of resources, for every person alive. And we’re struggling. There is no industry in the world with 13,600 different service lines to deliver.
(Service line? Why are we using corporate jargon all of a sudden?)

It should be no wonder that you have not mastered the understanding of them all. No one ever will. That’s why we as doctors and scientists have become ever more finely specialized. If I can’t handle 13,600 diagnoses, well, maybe there are fifty that I can handle—or just one that I might focus on in my research. The result, however, is that we find ourselves to be specialists, worried almost exclusively about our particular niche, and not the larger question of whether we as a group are making the whole system of care better for people. I think we were fooled by penicillin. When penicillin was discovered, in 1929, it suggested that treatment of disease could be simple—an injection that could miraculously cure a breathtaking range of infectious diseases. Maybe there’d be an injection for cancer and another one for heart disease. It made us believe that discovery was the only hard part. Execution would be easy.
(This part seems forced and a little disingenuous. The multitude of diagnoses and treatment options available to doctors today does not necessarily demand instantaneous memorized command of all facets of medicine. I have no problem using these things called the "internet" and "medical textbooks" to read about topics I don't know or have forgotten. For big cases I prepare by reviewing the surgical atlas and reading up on the latest literature. For management of hypertensive crisis in the ICU, I quickly log on to UpToDate and then call back the nurse with an answer. It doesn't take long. Just because the answer to a patient problem initially eludes you, it doesn't mean you have to throw your hands up in the air and retreat to the safety of the "50 or so diagnoses you are comfy with".)

But this could not be further from the truth. Diagnosis and treatment of most conditions require complex steps and considerations, and often multiple people and technologies. The result is that more than forty per cent of patients with common conditions like coronary artery disease, stroke, or asthma receive incomplete or inappropriate care in our communities. And the country is also struggling mightily with the costs. By the end of the decade, at the present rate of cost growth, the price of a family insurance plan will rise to $27,000. Health care will go from ten per cent to seventeen per cent of labor costs for business, and workers’ wages will have to fall. State budgets will have to double to maintain current health programs. And then there is the frightening federal debt we will face. By 2025, we will owe more money than our economy produces. One side says war spending is the problem, the other says it’s the economic bailout plan. But take both away and you’ve made almost no difference. Our deficit problem—far and away—is the soaring and seemingly unstoppable cost of health care.
(Yes, occupying three countries half way around the world is a mere drop in the pan of federal spending!)

We in medicine have watched all this mainly with bafflement, even indifference. This is just what good medicine is like, we’re tempted to say. But we’d be ignoring the evidence. For health care is not practiced the same way across the country. There is remarkable variability in the cost and quality of care. Two communities in the same state with the same levels of poverty and health can differ by more than fifty per cent in their Medicare costs. There is a bell curve for cost and quality, and it is frustrating—but also hopeful. For those getting the best results—the hospitals and doctors measured at the top of the curve for patient outcomes—are not the most expensive. They are sometimes among the least.
(Aha! It seems the good doctor has backed off a bit from his conclusions in the Cost Conundrum article that communities that spend more per capita on healthcare have worse outcomes. Now he hedges a bit, using the modifier "sometimes" to describe discrepancies in health care spending as they relate to outcomes. See this for details.)

Like politics, all medicine is local. Medicine requires the successful function of systems—of people and of technologies. Among our most profound difficulties is making them work together. If I want to give my patients the best care possible, not only must I do a good job, but a whole collection of diverse components must somehow mesh effectively.
(For now on, all doctors who practice in a hospital setting need to meet for three hours every other Monday morning with representatives from ancillary care, hospital administration, nursing, physical therapy, food services, patient transportation, the candy stripers, the old lady who brings around the gentle giant siberian husky petting dog for patients to touch, janitorial services, etc for a collegial intradiscplinary staff meeting to discuss ways of enhancing hospital teamwork.)

Having great components is not enough. We’ve been obsessed in medicine with having the best drugs, the best devices, the best specialists—but we’ve paid little attention to how to make them fit together well. Don Berwick, of the Institute for Healthcare Improvement, has noted how wrongheaded this is. “Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,” he says. He gives the example of a famous thought experiment in which an attempt is made to build the world’s greatest car by assembling the world’s greatest car parts. We connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo: “What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.” Nonetheless, in medicine, that’s exactly what we have done.
(And if you take the engine of a Pinto, the body of a Edsel, the transmission of any 1980's era Chevrolet you get: a very cheap and ugly piece of shit.)

Earlier this year, I received a letter from a patient named Duane Smith. He was a thirty-four-year-old assistant grocery-store manager when he had a terrible head-on car collision that left him with a broken leg, a broken pelvis, and a broken arm, two collapsed lungs, and uncontrolled internal bleeding. The members of his hospital’s trauma team went swiftly into action. They stabilized his fractured leg and pelvis. They put tubes in both sides of his chest to reëxpand his lungs. They gave him blood and got him to an operating room fast enough to remove the ruptured spleen that was the source of his bleeding. He required intensive care and three weeks of hospital recovery to get through all this. The clinicians did almost every single thing right. Smith told me that to this day he remains deeply grateful to the people who saved him.

But they missed one small step. They forgot to give him the vaccines that every patient who has his spleen removed requires, vaccines against three bacteria that the spleen usually fights off. Maybe the surgeons thought the critical-care doctors were going to give the vaccines, and maybe the critical-care doctors thought the primary-care physician was going to give them, and maybe the primary-care physician thought the surgeons already had. Or maybe they all forgot. Whatever the case, two years later, Duane Smith was on a beach vacation when he picked up an ordinary strep infection. Because he hadn’t had those vaccines, the infection spread rapidly throughout his body. He survived—but it cost him all his fingers and all his toes. It was, as he summed it up in his note, the worst vacation ever.

When Duane Smith’s car crashed, he was cared for by good, hardworking people. They had every technology available, but they did not have an actual system of care. And the most damning thing is that no one learned a thing from Duane Smith. For we have since had the exact same story occur in Boston, with an even worse outcome. Indeed, I would bet you that, across this country, we miss the basic, unglamorous step of vaccination in probably half of emergency splenectomy patients.
(Ok. Now we have to interrogate this line of thinking. No more jokes. Gawande seems to be advocating for an algorithmic, systems-based paradigm of medicine, one in which the parts, i.e physicians, are mere cogs in some sprawling, evidence-based machine of health care delivery. There are too many diagnoses, too many treatment options, and too much innovation to be apprised of, as individual doctors. Therefore, we need to limit our spheres of responsibility. A specialist for every facet of health care. Blood pressure too high? Go see a cardiologist. That rash you got after hiking in the woods? Go see this dermatologist. Need your thyroid removed? Go downtown to see the endocrine surgeon. This is an attack on generalists, an attack on the idea that an individual doctor, dedicated and intellectually curious, can provide optimal care for his/her patients. And the example he provides of Duane Smith seems to paradoxically repudiate his entire theorem. All these good doctors working together but somehow they all forgot to prescribe the necessary vaccination. Gawande would say that the problem lay in an inappropriately designed and monitored 'system'. I would counter that the component parts, the doctors, individually failed the profession and henceforth the patient. How do you forget to give Pneumovax after taking out a spleen? That's simply bad doctoring. That's a general surgery 101 exam question.)

Why does anyone receive suboptimal care? After all, society could not have given us people with more talent, more dedication, and more training than the people in medical science have—than you have. I think the answer is that we have not grappled with the fact that the complexity of science has changed medicine fundamentally. This can no longer be a profession of craftsmen individually brewing plans for whatever patient comes through the door. We have to be more like engineers building a mechanism whose parts actually fit together, whose workings are ever more finely tuned and tweaked for ever better performance in providing aid and comfort to human beings.
(This resigned attitude to the impossibility of staying up to date on the latest medical developments is saddening. I don't know what to say. Maybe I'm just a 37 year old dinosaur.)

You come into medicine and science at a time of radical transition. You have met the older doctors and scientists who tell the pollsters that they wouldn’t choose their profession if they were given the choice all over again. But you are the generation that was wise enough to ignore them: for what you are hearing is the pain of people experiencing an utter transformation of their world. Doctors and scientists are now being asked to accept a new understanding of what great medicine requires. It is not just the focus of an individual artisan-specialist, however skilled and caring. And it is not just the discovery of a new drug or operation, however effective it may seem in an isolated trial. Great medicine requires the innovation of entire packages of care—with medicines and technologies and clinicians designed to fit together seamlessly, monitored carefully, adjusted perpetually, and shown to produce ever better service and results for people at the lowest possible cost for society.
(Yikes. That last sentence evokes an uneasy Orwellian utopia. Do I have to report to room 101 for a session with O'Brien if I write for Nexium instead of Prilosec for GI ulcer prophylaxis on a post op patient??)

When you are sick, this is what you want from medicine. When you are a taxpayer, this is what you want from medicine. And when you are a doctor or a medical scientist this is the work you want to do. It is work with a different set of values from the ones that medicine traditionally has had: values of teamwork instead of individual autonomy, ambition for the right process rather than the right technology, and, perhaps above all, humility—for we need the humility to recognize that, under conditions of complexity, no technology will be infallible. No individual will be, either. There is always a velluvial matrix to know about.
(Subsume the individual into the Great Intradisciplinary Whole! The Maoist in me is feeling warm and fuzzy right now. But seriously, it's one thing to encourage greater communication between different specialists and to penalize those docs who are doing unnecessary procedures just for the compensation; it's quite another to throw in the towel on individual accountability and the ideal of the dedicated, astute physician who always strives to do the right thing for his/her patients. Kierkegaardian Individual Ethos trampled under foot by Henry Fordian mechanization and interchangeable parts! Listen, we don't need a brand new system or a restructuring of some quasi private/public healthcare bureaucracy. We need better doctors. We need to inculcate a stronger ethic of personal responsibility, both to our patients and to the health care system as a whole. I've said it a million times in this blog--- becoming a doctor ought not to be some default pathway for high achieving college kids who can't decide what else they want to do. It's a hard job, but rewarding as hell when you approach it with the right mind frame.)

You are joining a special profession. Doctors and scientists, we are all in the survival business, but we are also in the mortality business. Our successes will always be restricted by the limits of knowledge and human capability, by the inevitability of suffering and death. Meaning comes from each of us finding ways to help people and communities make the most of what is known and cope with what is not.
(I can't argue with those sentiments.)

This will take science. It will take art. It will take innovation. It will take ambition. And it will take humility. But the fantastic thing is: This is what you get to do.
/mass of students toss grad hats and gowns in the air and charge out of locker room screaming and yelling like banshees into the Pacific Ocean and swim for an undeteremined hospital in China.
Read more: http://www.newyorker.com/online/blogs/newsdesk/2010/06/gawande-stanford-speech.html#ixzz0rObG9PKa

Hedging

2010-06-19T10:57:00.000-04:00

Pathologists and radiologists don't have the luxury of spending time with actual patients so they have to render professional judgments and determinations based on indirect data (radiographs, a mashed up slice of breast tissue, etc.) I don't envy them; the utter detachment from patient care would make me miserable. But they do have a tough job. They get one shot at getting it right. There's no patient follow up. They never get the opportunity to explain a missed diagnosis to a patient, to soothe things over. Once they stamp their name on the final report, there's no turning back. They can't afford to allow a sliver of a chance that they haven't "covered" themseleves.

And so they hedge. The radiologist will write "cannot rule out possible neoplasm" on an incidentally seen 4mm white blotch on a CXR and recommened "follow up CXR in 6 months advised." I understand it. I get it. But there are consequences to this hedging. And nowhere in medicine do we see this more than in mammography and the pathological analysis of breast biopsy specimens. We are prodded into far too many needle and open biopsies by mammography reports that "can't rule out cancer, biopsy strongly encouraged". Often, these reports come across the desks of primary care docs and they have to call them on the phone and inform them that "something was off on your mammogram; we need to do a biopsy. Please make an appointment with the surgeon as soon as you can."

My initial encounters with breast lesion patients are always emotionally charged. They've been crying, or are on the verge of tears, wrapped in their flimsy exam gowns. Often, a terrified-looking spouse is sitting uncomfortably next to them. They are in a surgeon's office. For an abnormal mammogram. It's every couple's worst nightmare. The first ten or fifteen minutes are spent defusing the situation, reassuring them that the overwhelming majority of abnormal mammograms end up being much ado about nothing.

The pathology reports are similarly hedged. Fine needle aspirations are notoriously non-specific. A result of "cellular atypia" could mean anything. More tissue needs to be obtained, you inform them. Another biopsy needs to be performed. The whole waiting process has to be repeated. You may as well have told them they have to walk non-stop from Cleveland to Buffalo carrying an anvil. I had one younger woman recently (35, no risk factors) whose OB/Gyn had ordered a mammogram for a palpable mass. The palpable lesion ended up being a benign-looking cyst but nearby was a cluster of calcifications that were deemed "suspicious". I sent her for a stereotactic core needle biopsy. Three days later the pathologist filed his report. Most of the core specimens were benign. Unfortunately, on one slide, at the edges of the specimen, there was a small area of cellular atypia. The pathologist noted that, given the location of the area of concern, this most likely represented an artefactual effect of crushed tissue during preparation of the slide. Nevertheless, underlying neoplastic change "could not be ruled out".

What do you do with that information? Well, you call the patient and you explain that despite overwhelming evidence to suggest a complete absence of cancer, the pathologist felt that he could not definitively rule out the possibility of a small focus of neoplastic change. She was 35 years old. Do you tell her to not worry, that the pathologist is just covering his ass? You can't say with 100% certainty that I don't have cancer, she asks me? No, I say. We'd have to do a formal open breast biopsy. There's always a pause on the other end of the line. You can hear a kid playing, laughing somewhere else in the house, the television blaring too loud. My son is five years old, she whispers, her voice cracking. I know. I'm sorry, I say. It's going to be fine. I promise you.

Robbed!

2010-06-18T17:47:00.002-04:00

What a comeback, but that call (and it's still not clear if offsides or a foul was called, even now, 6 hours after the game) goes down as one of the worst I've ever seen in any sport.

Watch the World Cup! I know soccer gets a bad rap in America but it's the Beautiful Game, dammit! Turn off the NASCAR. You won't get the valium-induced fugue of baseball. You won't be forced to scratch at your own eyeballs after watching Kobe Bryant go 6-24 in a game seven. This is the sporting event you can't miss. It's time for Americans to get on board. Soccer! Soccer!

/Resigned to watching tape delayed MLS games on ESPN 7 in 2015.....

Appy Tips

2010-06-18T08:36:00.005-04:00

I always look at my own CT scans on rule-out appendecitis cases. (We surgeons arrogantly fancy ourselves as board certifiable in radiology, didn't you realize?) When I see a scan like the one above, i know the case is going to be a bear. Probably 90% of my lap appies take 10-25 minutes. What you see above is a classic retrocecal appendix. You can tell by how high it is (tip extending toward liver rather than down toward pelvis) and by its location directly behind the cecum (hence retrocecal!). Plus the patient was a rather large, bulky dude. So you know you're going to have to roll up your sleeves and go to work. You find you often have to mobilize much of the entire ascending colon just to see the damn thing and then you have to dig it out of indurated, inflamed retroperitoneal fat. I actually had to place an extra port to finish the case. Took me an hour.

In America....

2010-06-16T09:23:00.005-04:00

The Nobel prize winning NGO Physicians for Human Rights (PHR) has published a widely circulated white paper detailing "experiments" conducted by physicians and other medical personnel on detainees at Guantanomo. Read the paper. It's a grisly, soul-sapping compendium of state-sanctioned, state-organized human experimentation.

Remember those OLC torture memos that war criminals John Yoo and Jay Bybee wrote, alleging that the US policy of "enhanced interrogation" was both legal and safe? Well, the "safety" of the techniques was determined based on results of "studies" conducted by medical personnel on actual human beings. The effects of waterboarding and extreme sleep deprivation and sustained severe pain were all meticulously recorded and studied. Conclusions were then drawn. Just like a happy little science project! Only instead of making acetaminophen in the lab and determining the yield of product (the only actual science experiment I remember from college), these criminals were distorting the scientific method for totalitarian, undemocratic purposes.

To wit:
1) Experimenters were able to conclude that saline was a far safer liquid to pour over the faces of restrained inmates, rather than pure water. The simulation of drowning wasn't altered (thank god!) but the higher sodium concentration of saline helped prevent the unfortunate side effect of severe hyponatremia and subsequent brain edema seen with the forced swallowing of large amounts of pure water.

2) Clinical investigators determined that combination of techniques that cause severe pain did not lead to an overall increased susceptibility to the perception of severe pain (someone please feel free to interpet whatever the hell that means). Consequently, researchers felt comfortable recommending that Gitmo torturers could freely combine walling, stress positions, and other pain eliciting techniques. In other words, the detainee felt equally shitty whether you just rammed his head into a wall or combined that with forcing him to also stand on his right leg for three hours without moving.

3) Researchers concluded that sleep deprivation up to 180 hours (that's about 8 days of sleeplessness for the math impaired) did not lead to any long term psychological or physical consequences. And then as long as you let the subject sleep uninterruptedly for 8 hours, you could resume another 180 hours of wakefulness! Sweet!

Yes, this happened in America. This is what even the Obama Administration defends to its core. We don't look back in this country. We gaze only toward the future, wide eyed and full of hope. With our blinders on. No one is held accountable for lawlessness and immoral actions. We invade countries under false pretenses. We torture suspects. We detain indefinitely "suspicious Muslims" for years at a time only to release them without any charges. We send unmanned Predator drones into Pakistan and Afghanistan, strafing villages, collateral damage be damned. Our former President can smugly proclaim, "hell yeah I waterboarded KSM....and I'd do it all over again!". We have government employed doctors who conducted illegal, immoral experiments on human subjects, not for some greater good, mind you, but to provide a sham scientific cover for the inhumane torture and abuse of completely subjugated prisoners.

Maybe the AMA could advocate for some transparency on this issue. I realize they are busy fighting the good fight for the doctor fix and against the special tax on plastic surgery procedures. But perhaps it would be beneficial to their moral standing and ethical credibility to update their statement on the torture doctors from April 2009....

Enough Already

2010-06-14T13:49:00.003-04:00

Aren't you all sick and tired of hearing about the impending 21% cut in doctor reimbursements on Medicare patients? This farce of a story has been cropping up in the news every couple of months. I'm sick of it. At the last minute, the "doc fix" will get tucked into the back pages of some unrelated Congressional bill and the problem will be deferred till the next fiscal year. Does anyone doubt that this won't happen?

Just like i don't care about whether Brett Favre ever plays football again or retires to raise cattle and alpacas on his Mississippi ranch, I could care less about the impending Medicare cuts. It isn't a story until something substantive is done. All else is just frenzied speculation. The minute I hear the words "Brett Favre" on ESPN, I flip the channel. Same when I see him tossing footballs to randoms dudes in that Wrangler commercial. Enough is enough.

As far as I'm concerned, the "Brett Favre Rule" is in effect for the Medicare Doc Fix. I don't want to hear about it anymore.

To blog or not to be

2010-06-07T19:54:00.011-04:00

I've been struggling lately with the raison d'etre of this blog. I tend to write about a variety of topics, usually medically related, but it seems the best posts have been the ones based on actual patient encounters in my practice. And I've been wrestling with the significance of that fact to such an extent that I had to just shut things down for a while.

Blogging is by nature an extraordinarily solipsistic expression of individuality. It isn't enough for the blogger to privately fill notebooks with his ramblings---no, he must publish them to a world wide audience. It takes a certain degree of pompous audacity, let's be honest, to embark on such a task. One has to believe that what one is writing is unique, interesting, important enough to be read by strangers. I've always hated this implication of blogging. To blog is to cry out for attention.

The stakes are much higher for medical bloggers who go beyond writing about healthcare policy and reform. To write about a meaningful patient encounter is to cheapen it somehow. And I have become increasingly uncomfortable with the exploitative, self-aggrandizing solipsism inherent in writing about patients. I grown tired of Myself and the Voice I provide on Buckeye Surgeon. I'm always constructing these narratives where I'm some super-compassionate doctor of mercy, unique in ability to identify those anecdotal moments of human connection. I'm tired of the narrative, the underlying message of I'm a nice guy and a superb clinician that runs through the thread of posts. The blog dangerously veers toward being more about me and my supposed superior compassion and diagnostic acumen rather than about the patients or functioning as some sort of edifying source of inside medical information. It's irritating as hell. I'm a real person, with real shortcomings and faults. I ought to be writing more posts about how I was rude on the telephone late night with some nurse or how I was impatient with a patient's relative because she kept asking the same damn question over and over or the time I made a delayed diagnosis. It wouldn't be such a glowing portrait of me, but at least it would be an honest one. (But then you ask yourself, why do I even need to be painting accurate self portraits for strangers to peruse on the internet? Wouldn't that hurt my career? Isn't it better to concoct some alternative personality that people can read about on line?)

I feel this blog has unintentionally created a Doppelganger Dr Parks who is always kind and wise and decent, who never makes errors, who always sees the little streaks of humanity glimmering under the veil of illness in his patients. I mean I have tried to write honestly about things over the past three years. I wasn't intentionally trying to manipulate facts. But you cant help writing in such a way that makes you look maybe better than what you really were, in retrospect. In the act of writing, I'm able to capture my life and my experiences in such a fashion that I see myself as an agent of good. That isn't a bad thing I suppose. We all have our private little forms of solace as we navigate through unwieldy, unpredictable life. But a blog isn't private. It ends up being a slanted representation of a real person. I can do the same thing and derive the same benefit in a private journal, just perhaps more honestly and with more perspective.

The one good thing about the blog is that its mere existence has forced me to contemplate my life as a surgeon on a more consistent basis. A blog is always starved for material and the experiences I've had have been a fruitful fodder to fill the hungry beast. My reflections on specific encounters have changed me more than the encounters themselves. But I don't want to keep repeating myself. I don't want Buckeye Surgeon to devolve into a bunch of sappy, regurgitated tales from the front lines of the hospital. That's not what this was supposed to be about. It was supposed to transcend its author, a medium through which author and reader alike could possibly make some sense of illness and death and human fallibility.

One thing I've discovered on these travels is this idea that the patients don't so much need me as I need them. The authenticity of a meaningful patient encounter fills some indescribable void in my life (pathetic as that sounds). I need them. I need the 88 year old guy recovering from a perforated bowel surgery who tells me he prayed last night for the first time in 50 years. I need to see the lonesome mother holding the hand of her prodigal son, suffering in the ICU with severe alcohol-induced necrotizing pancreatitis, whispering for him to open his eyes. I need the brash 77 year old Senior Olympian (diskus and hammer throw) recovering from a bowel obstruction who gives me shit every morning about how I played soccer in high school instead of wrestled. But I don't want to exploit them or splash their vulnerability all over some public blog anymore. Conversely, if I dont write about them, I lose them; they slip from the tenuous realm of my active memory. They strike me like those big beautiful snowflakes in early November that quickly melt and dissipate on your sleeve. I want to keep as many of them frozen and crystalline and perfect for as long as I can. I want to be like that kid in the book Snowy Day who hides a snowball in his pocket, hoping it will be there when he wakes in the morning.

I'm not entirely certain what will happen with Buckeye Surgeon. I'm still grappling.

Believing in what you do

2010-04-06T13:16:00.025-04:00

This story (from the NY Times) about the young palliative care physician in New York who died at age 38 from metastatic breast cancer is pretty harrowing. Dr. Desiree Pardi was a rising star, apparently, in the field of palliative care medicine. She was first diagnosed with cancer at age 31 and battled the recurrences with surgery and chemotherapy while maintaining a full work schedule over the subsequent 7 years. As a palliative care doctor, she spent her days having frank conversations with patients who had no chance for recovery and helped guide them down the road toward a resigned acceptance of death.

About a year ago, she was asked to speak to a young woman who refused to accept that her life was limited. Dory Hottensen, a social worker who was there, later recounted how Dr. Pardi sat down and held the woman’s hand.

“I could see that Desiree had an unusual connection with her,” Ms. Hottensen said. Dr. Pardi spoke kindly, and “told her that she was not going to get better. In fact, she was going to die very soon. What did she want for her last days? How did she want to die?”

In her own battle with cancer, however, Dr Pardi chose to pursue every means of aggressive treatment, no matter how futile, up until the very end. When it became apparent that there was nothing more to be offered and doctors broached the possibility of hospice, she vehemently refused to cede the hopelessness of her situation.

A doctor asked if she would like a palliative care consultation. She was shocked; she interpreted the question to mean that she had been identified as someone who was dying, and she did not think of herself that way.

She had crossed to the other side of the mirror, from doctor to patient, and she no longer saw an orderly path to death.

It's easy to sit here and condemn Dr Pardi as a poor soul in denial, as someone who turned her back on the very principles of the field which had made up her life's work. I mean, she counseled patients to accept the inevitability of forthcoming death while refusing to consider the possibility that her own terminal illness had reached a stage of futility. It just doesn't seem very consistent does it?

But I would caution against standing in judgment of this unfortunate woman. We all make a thousand little betrayals to ourselves every week. We all have those grand visions of the Ideal Life we hope to lead. But real life has a way of trashing our best laid plans. We're never as courageous or ethical or as kind as we envision ourselves to be lying in bed at night, staring at the ceiling. We fail to live up to our standards. We compromise our goals and aspirations to an alarming degree. I'm not always the father, the husband, the surgeon I aspire to be. We do the best we can but it isn't always easy. Life rarely conforms to the neat little algorithms of personal conduct we've laid out in our minds.

Those who have read this blog for any length of time will know that I am staunchly opposed to absolutism and inflexible ideological fervor. The contingencies and tribulations of life demand a reasonable pragmatism that allows for some flexibility in choosing unexpected pathways. Don't condemn Dr Pardi for turning her back on her life's work when the chips were down and her own life was at stake. Maybe in her own private moral computations it was more honorable to fight her cancer until the very end. She was too young to die. It wasn't fair. Perhaps the bigger betrayal in her mind would have been the acceptance of an arbitrary early death. Who knows. But we owe her the respect and the autonomy to make those tough decisions for herself.

Medical School Debt

2010-04-05T09:13:00.005-04:00

From the AMA:

Student debt statistics
*$156,456 – According to the Association of American Medical Colleges (AAMC), the average educational debt of indebted graduates of the class of 2009.
*79 percent of graduates have debt of at least $100,000.
*58 precent of graduates have debt of at least $150,000.
*87 percent of graduating medical students carry outstanding loans.
Source: AAMC 2009 Graduation Questionnaire

Why medical education debt has increased
Medical education debt is driven by rising tuition. AAMC data show that median private medical school tuition and fees increased by 50 percent (in real dollars) in the 20 years between 1984 and 2004. Median public medical school tuition and fees increased by 133 percent over the same time period. Other recent 20-year periods show similar trends.

Tuition is just one source of increasing debt burdens. Other causes include:

Interest accrued on loans over time significantly adds to the total cost of student debt.
Students are now entering medical school with more education debt from undergraduate education.
Increasing numbers of “non-traditional” students who have children to support.

Those are the numbers. The road to being a physician in this country is long and arduous enough. Factor in the absurd debt load one must take on to obtain that degree and it becomes very clear why many young docs are electing to pursue careers in the higher paying specialties. It's an unsustainable track.

We just passed Obamacare. 30 million uninsured people will have affordable health care. You won't get denied coverage for a pre-existing condition. But what are people supposed to do when they find out there aren't enough primary care doctors to handle the workload? The negligent attitude of Obamacare toward this forthcoming crisis is just astounding. So much political capital was expended throughout the year long battle. And to think it could all come crashing down because nothing was done about lessening the debt burden of medical school. Oh, and there's no tort reform either. And reimbursements are going to get cut. So who wants to sign up for medical school, kids? Anyone? Someone?
/crickets

Weekend Image

2010-04-02T13:31:00.005-04:00

Yeah, it's a femoral hernia with a loop of transverse colon incarcerated in it. We get to operate on these.

Self Regulation and Tort Reform

2010-03-29T00:53:00.002-04:00

John Yoo and Jay Bybee were the lawyers who provided the sham legal cover for the Bush/Cheney torture machine. The original draft of the Office of Professional Responsibility (OPR) report had determined that Yoo, Bybee, et al had committed grievous misconduct in their legal reasoning and advice and recommended that they be remanded to their state bar associations for possible discipline and/or disbarment. Of course, in the final version of the OPR report, Yoo and Bybee, although severely reprimanded by Associate Deputy Attorney General David Margolis, were ultimately cleared of providing "intentionally false arguments that they knew to be wrong". In the original OPR report, Yoo and Bybee were determined to have failed "to exercise independent legal judgment and to render thorough, objective, and candid legal advice." Apparently this basic standard of professionalism was deemed by Margolis to be too high a bar. Margolis instead argued that since Yoo was an ideologue who truly believed in what he was saying, then it wasn't his fault that the advice he gave was factually and legally false. Intention to harm is all that matters to Margolis. This is the low standard of professional conduct that an accused lawyer can always appeal to when his or her license is on the line. The blogging lawyer Jack Balkin has an excellent review of this fiasco here:

It's not about what people should do, but about how badly they have to screw things up before they are subject to professional sanctions.

Instead, Margolis argues that, judging by (among other things) a review of D.C. bar rules, the standard for attorney misconduct is set pretty damn low, and is only violated by lawyers who (here I put it colloquially) are the scum of the earth. Lawyers barely above the scum of the earth are therefore excused.

This got my mind revving about medical malpractice reform. It's very clear that malpractice litigation, as currently constituted in this country, is harmful to doctors, patients, and the country's fiscal well being. Frivolous lawsuits lead to defensive medicine and all its attendant costs, in addition to creating an uneasy, antagonistic dynamic in the doctor/patient relationship. Patients who are harmed by bad doctors generally are not compensated for their injuries. (One study determined that only 2% of negligent adverse events occuring in a hospital resulted in a med mal claim.) It's a bad system. The only ones who seem to benefit are the plaintiffs attorneys and the defense lawyers for the big med mal insurance companies. It's a cash machine.

From the perspective of a practicing physician I would like to see reform take several iterations. I think these cases need to be tried in specialized "health courts", with the evidence weighed by independent panels comprised of physicians and lawyers and a judge familiar with medical standards. This way, you eliminate the wild west system of the "show" where hired gun physician expert witnesses argue that "obvious negligence" has occured while others argue the exact opposite. I think any potential malpractice litigation ought to be screened by an indepedent advisory board that would determine the validity of said claim. This would create a mechanism for weeding out those frivolous cases that a doctor has to address via his defense attorney in our current system. It would reward physicians who follow best evidence guidelines and shield them from the lottery system of a med mal trial. I'm also in favor of altering the evidenciary standard in medical malpractice cases from "preponderance of evidence" (which merely implies that malpractice was more likely than not to have occured) to one of "clear and convincing" evidence (a standard just below "beyond a reasonable doubt" in criminal cases.) I'm not so attached to the idea of capping damages. For one thing, caps only benefit insurance companies. Ask any doctor--- it doesn't matter if you're sued for a million bucks or $50,000, the mere fact of "being sued" alters one's future practice patterns rather than the gross dollar amount of the judgment. So I don't think capping the damages will have any appreciable effect on the scourge of defensive medicine. I do, however, like the idea of pre-determined awards that victims are slotted into based on the kind of injury sustained, victim age, and lost wages. This would all be calculated as part of the compensatory aspect of the verdict. The unlimited punitive damages phase of the verdict serves no purpose other than to line the pockets of the plaintiff's attorney.

Those are just a few ideas. I have a future post brewing that goes into more detail. But for now, those are my preliminary thoughts.

The point of this post is to correlate the Yoo/Bybee nonsense with med mal reform. As physicians, we have particular interests and goals with regards to medical malpractice reform. Overall, I think there is broad based support for what physicians desire. But we have to be reasonable about our entreaties. We have to approach the negotiating table in good faith. What can we do in return for arriving at some judicious accomodation? (You know, sort of like what the AMA ought to have been doing all last year instead of stridently, but vaguely, screaming about tort reform tort reform tort reform!)

Here's what we can offer: A renewed dedication to improving professional accountability. Via the state medical boards, medical societies, hospital QA committees, and intra-departmental morbidity and mortality meetings, we need to do a better job of holding those doctors accountable who fail to meet basic standards of care. Our ranks are infested with our own Yoos and Bybees. We need to police ourselves better. And not merely by using some statistical rubric devised by some hospital risk management executive. (Stats don't tell the whole story. Doctors who realize that they will be judged solely on outcomes will seek to eliminate those patients who are more likely to result in bad outcomes, i.e. the suburban hospital that shunts all redo CABG's to the main tertiary center, thus improving their "statistical superiority".) It needs to be done on a case by case basis. It will be labor intensive. Bureaucracies will need to be created. There will be errors and missed opportunities for intervention. But we need to do something. To serve as a practicing physician is a privilege, not a god given right, no matter how many diplomas you have hanging from your wall. You have to re-earn it every single day, with every new patient who walks through your door.

To lose your medical license, or even to be suspended or face disciplinary measures for failing to meet the bare minimum standards of care happens far too rarely in this country. You basically have to show up drunk or drug addled, repeatedly, or to have so many complications that the local newspaper does a story on you and your injured patients in the metro section for there to be any consequences. The bar is set too low, in other words. Denial doesn't help matters (ask the Vatican right now). We need to subject ourselves to a higher standard than what we've held our members heretofore. The surgeon who has four bile leaks in a year maybe needs to have another board certified surgeon watch his technique for his next ten cases. The internist whose diabetic patients develop an inordinately high rate of foot ulcers and have elevated hemoglobin A1c levels perhaps ought to be forced to enroll in some didactic session or a CME course on proper diabetic management.

I don't have the exact plan for how all this is to be enacted. I'll leave that to the AMA, hospital QA committees, and perhaps even federal oversight to determine how we self-regulate ourselves. But the point is that we have to make a move toward greater transparency and better quality assurance. This is the price of any meaningful tort reform. The standards we as physicians hold ourselves to have to be higher than the low bar set by trial lawyers, right?

Spring in the Rust Belt

2010-03-26T12:19:00.004-04:00

Hey look---it's a bunch of hippies jamming in the sun. Who doesn't love that? Finally warming up here in Cleveland. Hope all have a satisfactory weekend.

Thiessen Repudiated

2010-03-26T10:01:00.003-04:00

The must read piece of the week is Jane Mayer's almost effortless smack down in the New Yorker of torture apologist extraordinaire Marc Thiessen's ridiculous new book "Courting Disaster". You almost feel bad that such a prominent, well-regarded actual journalist like Mayer is forced to wade through Thiessen's compendium of lies, falsehoods, and distortions in order to set the record straight. But somebody had to do it; Thiessen's revisionist history sits atop the NY Times best seller list.

The more interesting question is--- when is President Obama going to start "looking backward" to find out the truth surrounding America's dark torture secrets and hold accountable those who implemented and carried out a shameful program of barbaric, ineffectual, and illegal torture and indefinite detention.

By now I think we can all acknowledge that Obama's greatest strengths are his tenacity and his patience. This HCR triumph took a hell of a lot of courage. He spent an enormous amount of political capital. But he won the long battle. I hope his intention is not to bury the Cheney embarassment, but to revisit it at a later time, once he rings up another couple of victories, i.e. financial market reform. I hope he wins the long battle against the Bill Kristol/Cheney/Thiessen cabal as well.

As Mayer writes:

By holding no one accountable for past abuse, and by convening no commission on what did and didn’t protect the country, President Obama has left the telling of this dark chapter in American history to those who most want to whitewash it.

Palliative Care: An Overused Subspecialty?

2010-03-24T10:56:00.007-04:00

The #1 Dinosaur has a provocative post from last week about palliative care medicine. Her point is that, too often, primary doctors neglect their duties as physicians and pawn off the undesirable aspects of comprehensive care (end of life issues, vague abdominal pains, constipation, depression/sadness) onto specialists.

Excuse me: why do you need a brand-new "Team" to treat symptoms and talk to families?

True palliative care -- the management of symptoms -- is part and parcel of everyday medicine. Itching; nausea; constipation; pain. Work them up to make sure there is no serious underlying problem, of course, but for crying out loud, don't tell me you now need another specialist to actually come TREAT them! This is fragmentation of care taken to outrageous extremes.

Her argument is compelling. And the dialogue that ensues in the comments to the post (from Palliative Care docs like Christian Sinclair and Eric Widera) is equally persuasive. I fall somewhere in the middle. I agree with Dinosaur to a certain extent that primary care docs need to be more aggressive in addressing end of life issues, even when the patient is ostensibly healthy. You don't want to wait to discuss hospice plans until you're intubated in some random ICU with numerous liver metastases wracking your body. The problem isn't entirely the fault of internists and family practice docs lacking the courage to compassionately address terminal issues, however. Most doctors simply aren't certain of how to navigate this senstive terrain. Medical students aren't exposed nearly enough to the philosophy and psychology of death and dying. (Do we really need to spend four weeks during the second year memorizing the differences between Freudian, Jungian and Piagetian psychobabble?) Furthermore, all residencies, no matter what the specialty, need to incorporate either a rotation on a palliative care floor or multiple intensive didactic sessions dedicated to end of life issues and pain palliation options. (General surgery residents would especially benefit.)

On the other hand, sometimes it's nice to have a palliative care "team" available for those truly futile cases to give the patient and their family additional perspective. I have a tendency to stay optimistic about a case for too long sometimes--- I'm always strategizing ways to "make the patient better", longer than what the objective clinical data warrants. When futility is too obvious to ignore it's sometimes very difficult to make that transition, as a surgeon, from aggressive advocate of healing to the voice of realistic resignation. It's hard for me and it's hard for the families involved. It can seem as if I've too suddenly changed my mind, which can trigger doubt (in my judgment, my clinical expertise, etc) in the minds of the patient and his loved ones. So I have found it is constructive to say to a patient's family, "you know, things don't look so great right now. It's becoming apparent your mom is not pulling through the emergency surgery the way we had hoped. I think it would be helpful for you all to speak with the people from our palliative care team, to hear a different perspective, and maybe then we can reconsider our options." It just helps smooth the transition from the full-court press of intensive treatment to the more realistic phase of saying goodbye.