Monday, December 31, 2007

No chance

Horrible case Saturday night. A 65 year old dialysis patient with CAD/DM/HTN came in through the ER hypotensive following a dialysis treatment. He intitally complained of some abdominal pain with nausea. As the day progressed, the abdominal pain increased, becoming intolerable by the evening. I was consulted at that time and when I looked at the above CT, I knew it was game over. But the guy was totally coherent. We chatted about the Browns. He was making puns. Just a happy, regular guy. I said, listen, it doesn't look so good for you. He wanted me to do everything though; he had a new girlfriend and he wasn't ready to die yet. So I agreed. I took him for OR and I found gangrene of the the entire stomach, duodenum and 75% of the small bowel. The colon was compromised but not necrotic. I did a quick Mattox maneuver, just to see how bad the abdominal aortic branches were, and I couldn't feel anything in the SMA or celiac artery at their origins. The aorta itself was hard and stiff, like a bamboo shaft. He must have either tossed an embolus to both or had concommitant acute thrombosis. Basically an unsalvageable situation. I've never seen pneumatosis that involved mainly the stomach and duodenum like this. There are fewer organs in the body as well vascularized as the stomach. Ischemic gangrene of the gastroduodenal complex requires an extensive vascular compromise.

So I anticipate the inevitable "why the hell did you operate" question. Why would I operate on someone with CT scan that showed basically dead stomach and duodenum? It's not like I was going to be able to resect the third and fourth parts of the duodenum safely. Well, maybe I shouldn't have. He had no chance. But I propose two reasons:
1. The guy wasn't gorked out on a vent when I saw him. He was awake and coherent, even charming. He wanted everything done. We were giving him morphine every five minutes, significant doses. He was going to die no matter what and it was either going to be in that ICU room, conscious and in pain, or after a quick trip to the OR, sedated and intubated and unaware of the catastrophe ravaging his system. The latter seemed more humane to me.
2. Practice. Sounds ghastly, I know. But you don't get to do a Mattox maneuver very often. It was clear 30 seconds after opening the peritoneal cavity that I was just going to close. The Mattox added six or seven minutes to the case. Maybe some day a young trauma victim will roll into the ER with a belly full of blood and I'll have to do a similar vascular exposure to repair some injury to the SMA or Celiac. You could say I performed unnecessary, gruesome surgery on this guy; I prefer to think I was able to use the terminal event in the guy's life as a gift, in order to hone a skill that could someday save someone else's life.

Saturday, December 22, 2007

SurgeXperiences 111

Hey, let the good times roll! Welcome to the ultimate blog carnival for all things surgical! Exclamation points! Things have been a little hectic, being the end of the year and all, but I hope you enjoy a sampling of submissions from surgical stories around the world. I suppose the theme ought to have something to do with Christmas, but most of the submissions I received were a little on the somber side. So just pretend that there's a holiday cheer vibe coursing through the proceedings. Since case studies were a lacking this month, I decided to post one. Guess the diagnosis and treatment by the end of this carnival and I owe you some sort of super duper prize: 52 year old guy with a history of hepatitis C and B who presents with LUQ pain. He appears non-toxic, is afebrile and hemodynamically stable. He's uncomfortable with palaption of the left upper quadrant but without peritoneal signs. Abnormal labs include WBC of 1400 and hemoglobin 8.0 and platelets 48,000. Liver function tests are normal. CT abdomen/pelvis shows edema and fat stranding around distal pancreas and splenomegaly. That's all you get. And no cheating.

On to the Carnival:

Bongi gets the holiday season off to a rousing start with a post about the thrills of spending Christmas taking care of drunken revelers in the trauma bay. He also posts a potentially controversial story about "practicing" on a hopeless patient. Very compelling stuff.

The Monash medical student submits a nice review on the science of music in the OR. I love it that people are doing research and writing papers about something like this. In my OR I find I get agitated easier if there's no music. I like Coltrane or something mellow like Moby/Grateful Dead/Phish (but not classical, puts the rest of the OR team into a soporific trance) for long or difficult cases. For shorter, end of the day cases I like something with a little more tempo. The IPod shuffle is surprisingly not as satisfying; too much variety in genres. You're all over the place; Barber's Adagio for Strings followed by Metallica. Too jarring. I pick a CD and stick with it to the end. Anyway, those are my thoughts on OR tunes.

Great review of the history of artifical implants in medicine by Lakshmi from the blog Nanoscience.

Suture for a Living continues her consistently strong work with a highly informative post detailing the difference in anatomy, technique, and coding between panniculectomy and abdominoplasty. There's also great historical and technical review of reduction mammoplasty from a couple days ago. So many medical blogs are off the cuff and spontaneous, it's nice to read one that is so well researched and honed. Check it out.

Amusing little feature from Plasticizer about a "special" wine glass on sale for Christmas. If you have a long, unsightly nose, please forget it was me who linked this.

White Coat Rants reminds us all that the things we wear beneath our clothes aren't always private; you never know when you'll end up in a trauma bay.

Dr. Bruce Campbell, an ENT specialist from Wisconsin, writes about the way a veteran surgeon visualizes a major operation; not from beginning to end, but in retrospect. Very insightful. Plus, he quotes Kierkegaard at the beginning, thereby ensuring that you add a couple points to the old IQ by the end. He also has a great post about the "collaborative" nature of decision making in the modern physician/patient relationship, especially with regard to cancer treatment options. Younger patients, especially women with breast cancer, studies show, are more likely to be active participants in decisions. I have found this to be true myself. Conversely, older patients tend to be more passive; a whatever you think is best, doctor, sort of attitude. This is spot on as well. Old guys with colon cancer invariably shrug and say "you're the doctor. You tell me what to do" after you go through all the options and risks.

Dr Val writes about an unsatisfying experience with an orthopedic consultant for a mysterious elbow ailment. Every other week or so I'll get a lady with chronic abdominal pain in the office who has bounced around from PCP to GI doc to OB/Gyn without a diagnosis. It can be very frustrating for patient and doctor.... just goes to show, the human body isn't a car that you can simply run through a diagnostic computer. Some things, we'll never figure out.

From the blog Ten out of Ten comes a post about an ER doc trusting his instincts and relentlessly chasing down the true diagnosis; excellent job!

Dr Alice
blogs about her first awkward experience telling a patient that he has cancer. We've all been there. It doesn't come naturally, breaking awful news to someone.

Bright Lights, Cold Steel relates an unfortunate bad outcome after a gastrectomy/vagotomy. Leaks happen; the lesson, as always, is that survival correlates with identifying them early.

Counting Sheep recounts a story about enduring a five hour hopeless vascular surgery case, raising the important question: if what we're saving isn't compatible with dignified life, then is it worth the cost and effort to go through the exceedingly complex motions of saving it? Incidentally I like the phrase "mis-surgeonist". Pretty clever.

Panda Bear and myself also address the issue of futile care in posts from last week. Draw your own conclusions, or at least think about the ramifications of our ability to salvage patients from what had historically been death sentences with advances in critical care and increased understanding of the pathophysiology of SIRS/multiple organ failure.

On a lighter note, a cool little anecdote from Donorcycle about the distractible surgeon and how sometimes everyone is better off if you just stick a scalpel in his hand. My thoughts exactly!

No surgical carnival would be complete without at least something from Sid Schwab at Surgeonsblog. Although he hasn't posted anything new lately, here's a link to the "Sampler" post that gives an organized platter of great writing, insight, and humor.

Some other random tidbits: Orac on the Blue Man. Cameras built into light handles, allowing better filming of operations. A goofy simulation of what to do when a fire breaks out in the OR; my wife (an anesthesiologist) found it somewhat ridiculous. Someone also sent me a submission that basically was an add for mesothelioma screening; no thanks. That was part of the reason why I got rid of my AdSense; after I posted the inguinal hernia review, the little box at the bottom kept advertising for a law firm that specialized in Kugel Patch recalls and how to go about suing your horrible surgeon for malpractice. Yeah, I think I can do without the extra 26 cents a month that AdSense brings in. Anyway, Season's Greetings and Happy New Year to everyone. And thanks for all the submissions. Hosting the carnival is a great way to get introduced to all the medical blogs out there you wouldn't normally get to peruse. I strongly encourage those who haven't hosted to do so. No word on who's doing edition 112; volunteer if you can.

And the answer is: Splenic Vein Thrombosis, likely secondary to pancreatitis. No gastric or esophageal varices on endoscopy, but the pancytopenia of splenic sequestration would be the indication for splenectomy. The GI guy, however, is concerned about distal pancreatic neoplasm (doesn';t look like it to me) and wants to get endoscopic ultrasound/biopsy done first. Doesn't seem to me that EUS would change the plan, but whatever.

Thursday, December 20, 2007

Hot Rod

This is priceless. Apparently some "surgical staff member" felt compelled to make an anonymous phone call to the newspapers, thereby creating a media frenzy. Now the stupid chief resident who took the picture with his cell phone faces suspension or even termination, and possible future legal recrimination. Obviously a dumb, spur of the moment thing to do, but I think anyone who participates in operations for a living can relate a similar scenario where an unconscious patient is exposed and something humorous is revealed; the fat guy with pubic hair shaved in a thin strip, x-rated tatoos on an elderly lady's buttock, etc. Everyone chuckles, but you move on. Not a word is spoken after the case to the patient or anyone else. Taking a picture...... a line gets crossed when you try to capture a vulnerable moment in the OR and share it with others outside the actual case. Just a dumb, dumb thing to do.


I was in the ER yesterday seeing a consult when I noticed a goddawful odor in the slot next to me. Nurses were actively spraying the hall with deodorizer as I asked what the hell was going on. Oh, it's actually a guy you know, I was told. The nursing home sent him over. I read the chart and realize it's an old guy I had operated on about 6 months prior for fulminant c diff colitis. I did a total colectomy and end ileostomy. He was a demented old guy, but in relatively good overall health. Somehow he survived the c diff episode and recovered and was transferred to a long term care facility. Apparently he had developed sudden hypotension and tachycardia and the nursing home sent him right over. No mention was made of the sickening odor the poor guy was emitting on any of the transfer forms. I say hello to his wife, who was sitting ever vigilantly by his bedside, and examined him. The belly looked fine. Stoma functioning well. The nurse helped me roll him over and the sight was something out of Night of the Living Dead. I've seen some nasty decubitus ulcers in my time, but this was absolutely horrifying. The skin and subcutaneous tissue had almost liquefied and a black dead escar extended almost to his lumbar spine like a glaze. His WBC 24k. Lactate 2.8. Pressors already started. We carted him to ICU and I got three nurses to help roll him over again. In these situations you don't need anything fancy. A clamp to grasp tissues and something sharp to cut it with. I found a hemostat and a scalpel in the supply room and went to work. And by "work" I mean literally filleting chunks of dead flesh from his sacral area. Two nurses had to leave secondary to near fainting or extreme nausea. I could feel the odor seeping into my pores. You cut and cut until you get tissue that bleeds. Must have been a pound or two of gunk on the bed by the time I was done. He didn't feel a thing. I hadn't done something like this since early residency; senior level surgical staff always tries to pawn off the crapola decubitus cases on juniors. But the guy needed it. He was septic and dying from an ulcer. He's doing much better today.

Decubitus ulcers are a problem in institutionalized patients. Studies suggest that all it takes is 32 mmHg of pressure applied to an area for two consecutive hours to overcome capillary pressure and thereby impede perfusion of cells. The typical mattress applies 150mmHg of pressure. Pressure sores are an epidemic in certain patient populations: para/quadraplegics, the demented, institutionalized patients, and patients on vents in the ICU. Precautions such as off loading and frequent rolling of the patient and some of the newer air mattresses can help, but the work that goes into prevention can be taxing to nursing personnel. Especially in nursing homes. It's troubling though, nonetheless, that an institution in the United States of America would allow an ulcer to progress to this level of rancidness. I'm certain that odor didn't acutely present itself.

Wednesday, December 19, 2007

San Antonio Breast Cancer Symposium

Medpage is a good site to check out. This month it gives a good review of several of the articles presented at the San Antonio Breast Cancer Symnposium. Over twenty articles are available for review and free CME credit is given after you read each one (just answer two or three questions based on what you read). A couple of highlights:
1. As breast conservation therapy has increased, the use of breast irradiation has not risen accordingly; troubling in that lack of radiation after lumpectomy doubles your risk of recurrence.

2. An interesting study detailing the arbitrary five year cutoff for Tamoxifen; ten years may be beneficial. Of course, with the enthusiasm now for aromatase inhibitors, the argument may become obsolete.

3. Speaking of aromatase inhibitors, there's an article that describes an extended benefit past completion of treatment with Arimidex.

4. A good meta-analysis on the negligible benefits of high dose chemotherapy for advanced breast cancer.

5. Another study that questions the use of antracyclines (long a primary agent) as adjuvant therapy for all women with breast cancer.

Monday, December 17, 2007

Futile Care

The idea of futile care is shockingly new in the American health consciousness. The fact that it has become controversial is a testament to the amazing advances we've made in critical care and the preservation of life in the face of multiple organ failure and overwhelming sepsis. Patients are now surviving hemodynamic insults that, 30 years ago, would have been obligatory death sentences. It's truly a remarkable feat in scientific and technological innovation. Critically ill patients are leaving hospitals mere weeks after being almost completely supported by machines. Dialysis and mechanical ventilators replace native organs temporarily, allowing for kidneys and lungs to recover. New antibiotics are able to strike at highly resistant "superbugs". ICU's provide a setting of heightened vigilance so that every change is noted. Highly specialized intensivist teams are there to catch the slightest perturbation in patient performance. It's labor intensive, stressful, and extremely expensive; but it often works. We're literally bringing people back from the dead. The question is: how do you know when the situation has become "futile" and what do you do when you reach that threshold?

In the Panda Bear Blog, this issue is addressed at great length in the unfortunately titled post, "Putting Granny Down". Much of the piece is well written and insightful but the essential point is that we spend far too much money on patients who don't derive any benefit from such intervention. He speaks of the 90 year old nursing home patient, demented and incontinent who gets admitted with urosepsis every two months or so, lacks a DNR order and ends up in the ICU with 15 consultants on board managing his/her multiple organ failure, but in the end, merely delaying the inevitable. Point taken. Not a good situation. Not a good use of limited resources. But put Granny down? Did granny ask to be in this situation? Is it her fault that she's "such a burden" to society? Isn't there a more dignified way to handle the last days of a human being? The reality of the situation is that most ICU's aren't filled with 90 year old demented bags of bones. Believe it or not, there's actually humans in those rooms. Humans across the age spectrum with families and and lives and pasts and even hopes for the future. That hope depends on the efforts of the doctors and nurses providing meticulous, round the clock care. And it ain't cheap. Good outcome or no.

I won't pretend to have all the answers. ICU's will always be expensive. The latest chemotherapy drug will always be expensive. The newest titanium product in hip replacement surgery will always be expensive. The idea that innovation in medicine will be rewarded financially drives much of the research and development that goes on in BigPharm, biotech, and engineering firms. This is a good thing. The high cost of American health care is more a function of the high quality of cutting edge American health care, rather than of wasteful spending on barely conscious Gomers. The problem isn't granny getting too old. The problem is we don't have a system in place to handle this emerging paradigm of how people die. The days of grandpa passing away peacefully at the family homestead of "natural causes" is becoming more and more rare. The elderly are dying with increasing frequency in hospitals and nursing facilities. Death has become a public burden, witnessed by nurses and aides and doctors, and, as a result, has become much more expensive. So what can we do?

1.Make a law requiring every American to have power of attorney/living will/advanced directive documents complete by a certain age. You can't drive without car insurance; why is it ok to enter the twilight of life unprepared for the inevitable decline? At age 60 or so, you sit down and decide what you want to happen when you become ill or are unable to make conscious decisions on your own. Seems simple enough, right?

2. Patients who are deemed unsalvageable, but not close to death (think of the 75 year old guy with good cardiac function who has suffered a major stroke, is dependent on the ventilator, has bed sores, and requires dialysis three times a week but has no idea who or where he is anymore) need to be evaluated by some sort of hospital ethics board. If deemed that ongoing care in the ICU is "futile" then further continuation of such care will need to be paid out of pocket by family members. Major questions arise, obviously, over who this "ethics board" is and why and how they arrive at their decisions. It can be standardized though. If x number of criteria are met, the patient qualifies as a "futile case" and appropriate designation is relayed to the insurance company. The sense of guilt and responsibility is removed from the shoulders of hospitals and health care providers and transferred to involved family members. And maybe that's where it belongs. It may seem cold-hearted, but it's certainly better than "putting down granny".

I think the topic carries with it major philosophical implications. What is life. When is a being not the being he/she was prior to such catastrophic event. The very process of dying has been altered; rather than a quick deterioration and "dying in your sleep", we now face the distasteful possibility of long, slow, drawn out loss of function, viability, and Self. Machines filling in the blanks as your body breaks down. The tissues succumbing to entropy despite the best efforts of science and technology. No one wants to end up like these poor souls who do little more than metabolize in ICU's across the country. Let their unfortunate sufferings be a lesson for our generation. Perhaps dignity and goodness can be salvaged for the future.

Sunday, December 16, 2007

Once again

I hate to be the sort of blogger who harps on the same damn thing over and over. But it happened again. 78 year old lady comes in Friday afternoon to ER with 24 hours of severe lower abdominal pain. Worse when she moves. She can't eat and vomited when they made her drink the barium for CT scan. WBC is 19,000. She's dehydrated. The CT scan is read as "ileus versus bowel obstruction." Admiited overnight to the medical attending on call. Saturday morning I get the consult. I browse through the chart, noting that my GI colleague has also been consulted. The WBC count makes me nervous so I see her as soon as I arrive at the hospital for rounds. I'm thinking SBO as I walk into the room, given the ER records and the CT read. Turns out, she has focal peritoneal signs in the RLQ and suprapubic area. "That makes it hurt all over", she says as I press on McBurney's point, exhibiting classic peritoneal signs. Moreover, she'd never had any abdominal surgery done. Adhesive obstruction would be highly unlikely. Hold on for a second, I say. Let me go look at that CT scan. I scroll through and damn if it doesn't look like appendicitis to me. Dilated tubular structure in the RLQ that doesn't seem to connect to anything else. Now, general surgeons who have come out of residency programs recently (like myself) may not be able to whip through a highly selective vagotomy, but we can certainly read abdominal CT scans. (Be aware of pompous statement coming up...) I can read a CT abdomen/Pelvis for certain diagnoses better than a lot of radiologists. With the new PACS machines, CT scans are readily viewable with a point and click. On call as a resident I'd sit up and look at all the scans that had been done in the ER, just for something to do to kill the tedium. By the time I was a senior resident I'd be catching appendicitis and going down to the ER before they even paged me. For this particular lady, I went downstairs and reviewed the scan with the in-house radiologist. He agreed. Appendicitis. At night, there's a "Nighthawk" system in place. All scans after hours are outsourced over the internet to some radiologist in Pakistan or India or Australia or whatever. (Are these guys even certified by an American Board? If not, aren't radiologists risking an awful lot in terms of liability just for a few hours of shut eye?)

Once again we have a case of a surgical problem undiagnosed until seen by the surgeon. In the meantime, multiple consultants are called to give an opinion. As a way to restrain myself from revisiting this topic over and over in a self-congratulatory fashion, I should probably at least try to diagnose the problem and provide a remedy. Appendicitis in the elderly is a notoriously difficult diagnosis, sometimes. You don't expect it. The literature shows that complications are higher in the elderly, primarily because of delayed presentation and delayed diagnosis. I get that. It's hard sometimes. But I think too often our fine colleagues down in the ER rely a little bit too much on a CT report. I understand it gets busy down there; you have no beds, you've got five patients waiting on reports, an acute MI who's not doing so well, charts to sign, a drunk frequent flyer causing a ruckus, a minor MVC in trauma bay and everything else. If the scan is positive call the surgeon, if not, admit to medicine. Formulaic. I'm right with you on that. But this lady presented with ABDOMINAL PAIN as her chief complaint. The CT scan suggested ileus/bowel obstruction but she'd never had surgery before. And her WBC was 19,000. Something was off. The clinical picture didn't correlate with the almighty CT report. Call the surgeon early, I guess is the answer. In this era of PA's and nurse practitioners, sometimes the ER attending won't lay hands on the patient. He/she listens to the story, agrees with proposed treatment plan and waits for test results to trickle back. It isn't good doctoring. I'm sorry.

I took her for lap appy that morning. Her appendix was gangrenous and perforated. I was able to finish it laparoscopically, wash everything out and leave a drain. Would she have perforated had I seen her 24 hours earlier? You never know. Today, she's doing great. WBC almost normal. Will probably go home Monday. No harm, no foul, I guess......

Saturday, December 15, 2007

SurgXperiences, 111th edition

I'll be hosting the next edition of the surgical blog carnival on December 23rd. Please submit your essays/cases before then. In the meantime, check out the 110th edition over at Cut on the Dotted Line.

Friday, December 14, 2007

Mass Health

Here's a link to the Wall St. Journal health blog detailing the cost overruns with the Massachusetts model of "universal health care". It seems doctors and hospitals are being targeted for reimbursement cuts as a way to make the bottom line look a little more palatable. I loved the comment from "Anne" at the end asking why administrators aren't asked to take cuts in reimbursement when plans implemented by said administrators go awry....


I've done four colostomy takedowns in the past 10 days. One of those weird streaks. All of them had had Hartmann's procedures done. Three had perforated diverticulitis and peritonitis and the fourth presented with an incarcerated inguinal hernia (gangrenous sigmoid colon.) The Hartmann's procedure involves doing a sigmoid colectomy and then bringing out the descending colon as an end colostomy. Patients who are sick or have a lot of fecal contamination of the peritoneal cavity are more safely treated with diversion because primary anastomoses in the pelvis are almost doomed to fail (leak) in such situations. The treatment plan is two-staged. Divert, recover from sepsis, and then bring them back in a few months for colostomy takedown. Patients are always disappointed to wake up and find they have the dreaded "bag" attached to their belly. It's understandable, of course, and you just try to reassure them that once they heal, re-establishing intestinal continuity is possible. They like to hear the word "temporary".

The problem is, not all colostomies are temporary. After Hartmann's procedures, only about 75-80% of patients are able to have the bowel reconnected. The long term effect of fecal contamination of the peritoneal cavity is severe scarring, disruption of normal tissue planes, and, often, transformation of pelvic anatomy into something unrecognizable. Colostomy takedowns are fraught with hazard. You spend over an hour sometimes just lysing adhesions and identifying what exactly the anatomy is. It's a major abdominal operation. Few cases make me as nervous. There's a disconnect between patient expectation and the reality. No matter how many times you tell the patient that the procedure is risky and could potentially make things worse, they want the "bag" to go away, no matter what. Luckily, none of the four leaked and are doing quite well......

Wednesday, December 12, 2007

Kevin Everett

Pretty cool profile on the Buffalo Bills tight end who was temporarily paralyzed duing a game earlier this season on Apparently he's walking now and is slowly regaining much of his previous strength. The ortho-spine doc who initially managed his care at the game instituted hypothermic therapy to keep his core temperature at 91 degrees. This is still a bit controversial; the level I evidence in a trauma setting simply isn't there to recommend it as a standard of care but certainly things have worked out remarkably for this young man.

Inguinal Hernia

We see a lot of referrals for inguinal hernia in private practice. Other than lap chole, inguinal hernia repair is the most common operation done in America. What people don't realize is the anatomic complexity that must be understood and navigated when undertaking the repair. Surgical residents don't really "figure out" groin hernias until sometime in the third or fourth year. It requires thinking three dimensionally in a small space. Suddenly, something clicks and everything makes sense. You could watch three colon resections and have a good handle on how to do the case, but inguinal repairs need to be watched over and over. It's very subtle.

Given that surgeons have a hard time grasping groin hernias, it's no surprise that patients struggle to articulate what is happening to them. I hear various descriptions of something going on that isn't quite right. "I got a problem 'down there'". "My ball is swollen." "Something keeps jumping out when I cough." "It pinches when I work." "Something keeps going in and out." "My doctor says I got a hernial." I've heard it all. So let's do a question and answer session and clear some things up.

What is an inguinal hernia?
Hernia comes from the Latin for "rupture". It's basically a defect in the strong fascial component of the abdominal wall. The inguinal canal contains the spermatic cord and its associated blood vessels. The testicle starts out embryologically up near the kidney. As the fetus develops, it migrates from the abdominal cavity through the abdominal wall via the inguinal canal into its final resting place in the scrotum. The membranous connection to the peritoneal cavity is called the processus vaginalis. If this remains patent, one is susceptible to indirect inguinal hernias. Indirect inguinal hernias occur lateral to the inferior epigastric vessels. Conversely, direct inguinal hernias are not congenital. They occur through attenuated tissue medial to the inferior epigastric vessels. These are the hernias of "wear and tear" and heavy lifting. Differentiating direct from indirect is not always possible pre-operatively, but the approach is the same for each one.

Why should I worry about my groin hernia?
Several reasons. Number one, you worry about bowel slipping into the hernia and getting trapped (incarcerated). This can lead to bowel obstructions and even gangrene of the affected bowel. Fixing hernias in the setting of bowel obstruction or ischemic intestine can be quite problematic and morbidity/mortality rates are substantial. So it's wise to consider repair on an elective basis; before such complications arise. Number two, hernias don't improve with time. They get worse. If you're having a hard time now, it's not going to be any better in two years.

So should all hernias be fixed?
This is a little controversial. Asymptomatic inguinal hernias can probably be watched in most men. There's a good study from the Hines VA in Chicago that addresses this. Any symptomatic groin hernia should be repaired. Symptoms can vary from patient to patient. Anything from a dull ache at the end of a work day to a sharp, acute pinch with lifting can be described. Any hernia that you see bulging yourself should be repaired. All hernias in women should be repaired. Hernias in children ought to be repaired with high ligation of the sac.

How are you going to fix my hernia?
Inguinal hernia repairs have undergone quite an evolution over the past hundred years or so. Bassini perfected a technique that still bears his name in 1887. This involved suturing the conjoint tendon/internal oblique/transversalis musculature laterally to the inguinal ligament. McVay modified the technique by adding a relaxing incision in the rectus fascia and utilizing Coopers ligament for some of the sutures. The Shouldice repair is another tissue repair that closes/reinforces the inguinal canal in four running suture layers. The problem with all of these tissue repairs, however, can be summed up in one word: Tension. Tissues brought together under tension are doomed to breakdown. Recurrence rates with tissue repairs are as high as 50-60%. Tension also substantially increases post-operative pain. Patients were often hospitalized for 4 or 5 days after hernia repair in the days prior to the use of mesh.

So you use mesh?

Absolutely. Mesh allows for tension-free repair of the defect. Tension free repairs have reduced recurrence rates to around 1-5%. Post operative pain is now manageable on an outpatient basis; 95% of patients go home the day of surgery.

Isn't mesh dangerous? What about recalls?
Mesh infection rates are usually quoted as being less than 1%. I do these operations sterilely in the OR and peri-operative antibiotics are always given. The Kugel Composix Patch was the one recalled. I never used that particular brand.

What are the kinds of mesh repairs?
There's the Lichtenstein repair, the Plug and Patch technique, and the pre-peritoneal repair. All of them involve returning any indirect sacs to the preperitoneal space and reinforcing the inguinal floor with a non-absorbable, inert mesh. For open repairs I generally utilize the Modified Millikan technique (a Robbins/Rutkow modification) using a plug inserted through the internal ring into the preperitoneal space and fixed to the internal oblique, conjoined tendon and inguinal ligament with non-absorbable sutures. The floor is then reinforced with an onlay patch.

What about laparoscopic repairs?
There are two techniques to consider when discussing the laparoscopic approach: TEPP and TAPP. TEPP stands for total extraperitoneal patch. TAPP stands for transabdominal peritoneal patch. The best way of thinking about the laparoscopic approach is to imagine a hole in your windshield. Patching that hole from the outside is comparable to what happens during an open, anterior approach. The laparoscopic approach is like fixing that hole from the inside of the car. Same end result, just a different way of approaching it. We now have good evidence that laparoscopic inguinal hernia repair is comparable to the open approach in terms of recurrence rates. Moreover, there is also accumulating evidence that patients recover much quicker with the laparoscopic approach and are able to resume activities sooner. The problem is that you have to give the patient general anesthesia for these operations. It's also more expensive.

So who do you offer laparoscopic repair to?
Recurrent hernias and bilateral hernias are the best candidates for the laparoscopic approach. You don't want to have to dissect through previously disturbed tissue planes in recurrent hernias; the laparoscopic approach allows one to address the defect through fresh, undisturbed tissue. Bilateral hernias can be fixed simulataneously through the same laparoscopic incisions without much added operative time. I also consider laparoscopic hernia repair at patients request. Young athletes who want to get back to training as soon as possible seem to bounce back quicker with the laparoscopic technique. For run of the mill, unilateral inguinal hernia, I find it hard to justify laparoscopic repair. It's costlier and cardiovascular events are certainly increased anytime you subject a patient to general anesthesia. The open approach has a low recurrnce rate, allows the patient to go home the same day, and utilizes fewer resources. That's a tough combo to ignore.

How am I going to feel afterwards?
You're going to be sore. I usually write for prescription-strength pain medications for the first three to five days. Everyone recovers a bit differently. Some guys are ready for work in three days. Others need a bit more time. Some other things to expect: scrotal swelling, numbness over the incision, burning with urination, and prickling sensations that radiate into the upper leg. Almost universally, these issues are self limited and will resolve with time.

Any restrictions afterwards?
No lifting anything more than 25 pounds for at least three weeks. Other than that I encourage resumption of normal activities as soon as possible. At six weeks, the scar tissue that forms will be about as strong as it ever will be, so until that time avoid power lifting or any similar ultra-strenuous activities.

Friday, December 7, 2007

Friday Night Relaxing

I recently acquired Sirius satellite radio and I must say: how did I use to deal with drives to and from hospitals before? Imagine being able to control your listening environment completely as you navigate traffic lights, jams and off ramps. Here's my top 5 settings:
1. Channel 32, Grateful Dead radio
2. Channel 26 Left of Center
3. Channel 35 Chill
4. Channel 72 Jazz
5. Channel 17 Jam Bands

I also listen to Jim Rome as a guilty pleasure. In general, though, listening to regular radio is barely tolerable anymore. We've entered the era of optional commercials. You don't even have to watch your favorite TV show with commercials anymore; just watch it the next day on the internet, or wait for the entire season to come out on DVD.

Anyway, there's a terrific article in the New Yorker this week by Atul Gawande. Dr Gawande is a surgeon from Harvard who is also a rather prolific writer. His books "Complications" and "Better" were best sellers. He also writes regularly for the New Yorker as a medical correspondent. Now I have to admit, a few years ago I wasn't the biggest Atul Gawande fan. I suppose I was just jealous of the dude. He is a scientist, a compassionate physician commited to excellence, and a decent man who had endured some personal tragedies. But I focused on his occasional over-earnestness and tendency toward sententiousness in his writing. He was Dr Harvard and the quintessential "academic surgeon" and I was just sick of hearing about him. But I've come around. He's genuinely an intellectually curious guy. His prose is lucid and coherent. I like his stuff.

The article this week is entitled "The Checklist" and it's mainly about the efforts of a intensivist from Washington DC named Peter Pronovost to standardize protocols of care for ICU patients. There's plenty of science to show that unsterile technique leads to higher central line infection rates. That maintaining patients on prophylactic heparin/lovenox will reduce DVT rates. That early enteral nutritional support reduces morbidity in the critically ill. What Provonost found was that most American ICU's weren't consistently following these relatively simple guidelines. His radical idea was to standardize intensivist practice via the use of clinical checklists. Each central line placed had to be done according to protocol; mask, gown, gloves, sterile drapes, chlorhexidine scrub. Nurses made sure residents and attendings followed each step. Ultimately, infection rates were reduced 66%, saving millions of dollars and countless lives. Such a simple idea; but more effective than the billions of dollars pharmaceutical companies spend each year on the development of drugs that provide marginal and sometimes dubious benefit.

The point is that medicine has become too complicated for a single person to remember all the details that ensure its safe and efficacious delivery. The idea of a checklist eliminates the possibility (hopefully) of a crucial forgotten step. All well and good. But I always get wary of medical practice than relies too much on algorithmic thinking. You have to be careful not to try and implement formulas in all areas of medical care, especially surgery. It certainly works in trauma care and the safe placement of central lines. But you don't want to lose the element of flexibility. Sometimes a particular patient won't fit into the paradigm. You could standardize the laparoscopic cholecystectomy if you wanted; mandate that each resident trainee learns the steps in an organized, checklist-type fashion such that by the time he/she graduates, the procedure proceeds without even thinking, one step naturally leading to the next in a robotic, automatic fashion. But I don't operate that way. Each case is always just a little different. Anatomy, body habitus, little quirks always seem to arise that require a bit of improvisation. Sometimes I'll put the subxiphoid port in first, other cases require the subcostal ports to be first. Sometimes you have to take the gallbladder out of the liver bed first, in order to see. I do cholangiograms most cases, but not always. I leave drains in when I feel it's warranted. Sometimes I keep the patient on Zosyn post-operatively, sometimes one dose of antibiotic is all they get. Certainly the overall goal and concept is unchanged, but the route of accomplishing it varies. Algorithmic medicine relegates patients to the status of "object"; a thing upon which to execute a process. Never forget that that body sleeping under the sterile drapes is an individual; with subtleties and variations that just may not fit into your "scheme".

Thursday, December 6, 2007


When I was a resident, all I had to do was show up at work everyday and patients would magically materialize on my list. Usually, it was annoying because longer lists meant more work. The OR schedule was usually full as we covered cases of multiple attendings. As a chief resident, it's fun; you round in the morning and then operate all day. It never really crossed my mind to think about where all these patients came from. They don't arise out of a vacuum. Someone had to be referring them to our surgeons.

General surgeons depend on primary care doctors and internists for business. We don't post ads in the newspaper or phone book. You won't see me on television touting my laparoscopic skills or announcing a year end close out on hernia repairs. The system is set up such that a patient must go through his/her PCP gatekeeper to get in contact with a surgeon. Ideally, this means that a referring doctor, using wisdom and experience, will refer a patient to the surgeon he/she trusts. And sometimes that's exactly what happens. An internist will develop a relationship and a level of trust with a specific surgeon and will refer most patients his way. But in this era of managed care and large multispecialty groups, the ideal isn't always realized. A lot of internists don't have a choice which surgeon to refer to. You simply give the patient the phone number of the surgeon in the group or the one part of the correct insurance plan, irrespective of said surgeon's capability or performance. I work in a small group that is completely independent of the two major medical behemoths in the Cleveland area so I get shut out of the patient base that is underneath those umbrellas. Every once in a while I'll take care of a patient from the Cleveland Clinic system who comes in late through the ER and I'll take out the appendix or whatever and follow up with the primary care doc over the phone, but no matter how well the patient does, or how quickly he recovers, I won't see any more patients in the future from that primary care doc because I'm simply not part of his "system". And that can be frustrating for a young general surgeon building a practice. Referral patterns, in an ideal world, would be based on surgical excellence, clinical outcomes, and personal relationships. Unfortunately, the reality is far from that. There is no absolute meritocracy in American medicine anymore. Most people's insurance plans restrict access to certain physicians. At some point, it may be necessary to join the giant group paradigm just like everyone else.

Wednesday, December 5, 2007

Retrocecal Appendix

I got called late last night by a very insistent ER Attending regarding a young gentlemen with midline suprapubic pain for a week. He had a low grade fever and apparently was having severe pain with the rectal examination. The official report from the CT scan was negative for appendicitis or any significant intra-abdominal pathology. The ER Attending, however, was convinced that this was a case of "retrocecal appendicitis" because of the severe rectal pain. Now, I get this story a lot from the ER and the there's no scientific or anatomic foundation to it whatsoever. The term "retrocecal" implies that the appendix is located retroperitoneally, behind the cecum. The only way this can happen is if the tip of the appendix is pointing superiorly toward the liver. Certainly, the presentation may be a little different from an anteromedially located appendix (back and flank pain, pain with flexion of the psoas muscle) but there would be no reason for pain elicited on rectal exam, unless there was a perforation with resultant pelvic abscess. But this ER guy was adamant. I even got the "I've seen this lots of times before; its a retrocecal appendicitis" bit. When I saw him, he was certainly tender on digital rectal exam. I reviewed the CT on my own and I thought there was a suggestion of perirectal inflammation posteriorly in the pelvis. Then when I talk to the guy I find out he's being treated with high dose Cellcept and Prednisone for Lupus. Of course, no mention of this was made to me over the phone by the ER. So he's an immunosuppressed guy with severe rectal pain and questionable inflammatory changes on the CT scan. Evolving perirectal sepsis is number one on my differential. I'll probably examine him under anesthesia in the OR later today.

Tuesday, December 4, 2007

Friday night special

The last case of the day Friday was a classic. She was an 80 year old lady who'd been suffering from biliary colic for a number of years who finally decided to have her gallbladder taken out. Preoperative liver function tests were normal, but there was a suggestion of mild intrahepatic biliary dilatation on the CT scan. I repeated the LFT's in a week and, again, they were normal. So we prepared for laproscopic cholecystectomy. The gallbladder was jam pack full of hard stones and it was difficult to get a good grip on the fundus. There were a lot of dense adhesions, but I went slow, teasing away the tissue strand by strand. I identified a thin tubular structure coming out of what appeared to be the distal infundibulum of the gallbladder. I made a nick and inserted my cholangiocatheter. Under fluoroscopy, the dye seemed to flow easily into the duodenum but I couldn't get the proximal ducts to opacify. Based on the cholangiogram, one would have to conclude one was in the common duct. So I pulled out the cholangiocatheter and started to work a bit more on the dissection. There was a giant stone in the infundibulum, which made retraction suboptimal, but I was able to free things up a bit more and I thought I saw another ductal structure posteriorly. This is where the anal sphincter tightens up a bit. With retraction, the stone in the distal infundibulum started to break through the wall and it wasn't clear to me where the cystic duct was at this point. So I opened. I took the gallbladder down and it became apparent that there was a ping pong ball-sized stone lodged 1/2 in the common duct, 1/2 in the distal infundibulum. There was no cystic duct. I cut across the distal gall bladder and popped out the stone, leaving me with a fairly good sized defect in the lateral common duct. I closed the cholangiocather site with a single stitch of 3-0 PDS. Then I closed the common duct transversely around a 14f T-tube. A Jackson-Pratt drain was placed and I got out of Dodge. The intraoperative cholangiogram through the T-tube showed.... normal filling of all the intrahepatic radicles. Currently, she's doing great. LFT's are normal. No bile in the JP. I clamped off the T-tube. Plan for T-tube cholangiogram in 6 weeks.

The lesson in this case was: Trust Your Cholangiogram. Misinterpretation of a cholangiogram is one of the leading causes of severe biliary injury during lap chole. It isn't enough to simply "do the cholangiogram in the standard fashion." Think about what you see. It would have been easy to attribute nonfilling of the right and left ducts to a wide open sphincter of Oddi and just finishing the case. Especially on a Friday night. If the pictures you're receiving on the cholangiogram don't correspond to the mental image you have about what the anatomy is, then further investigation is necessary. You don't want to end up with this.

Thursday, November 29, 2007

Efficient use of resources

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

The County

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

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

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

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

Wednesday, November 28, 2007

NFL tragedy

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

Tuesday, November 27, 2007

Bad News

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

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

Wednesday, November 21, 2007


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

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

On a brighter note, Happy Thanksgiving.

Monday, November 19, 2007

Chemotherapy = Poison

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

Sunday, November 18, 2007


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

Thursday, November 15, 2007

Too many doctors?

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

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

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

Monday, November 12, 2007

Not just appendicitis

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

Friday, November 9, 2007


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

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

Thursday, November 8, 2007


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

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

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

Wednesday, November 7, 2007


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

Wednesday, October 31, 2007

A new Paradigm?

Surgical dogma has long dictated a Hartman's procedure (sigmoid colectomy, end colostomy) for complicated acute diverticulitis requiring surgical intervention. A one stage procedure was considered substandard care in the acute phase. Ideally, a patient responds to antibiotics, has an abscess percutaneously drained, and then, 8 weeks later or so, returns for an elective laparoscopic sigmoid colectomy with primary anastomosis. That's the playbook I studied when I was a resident while preparing for oral boards. Then I started hearing stories from community general surgeons about draining an abscess, cooling the patient down for a few days with antibiotics, and then doing a one stage procedure on the same admission. I reviewed the surgical literature. It was apparent that people are certainly challenging the so-called standard of care. So I had an unfortunate woman come in a couple weeks ago with diverticulitis and a peri-diverticular abscess. I had interventional radiology place a drain. She got better and went home. Four days later she returns with worsening pain, fevers and a WBC of 24,000. Repeat CT scan sugested another abscess, more lateral to the original one. She clearly wasn't doing well. She hadn't been eating, she simply looked miserable. IV antibiotics were reinstituted and I considered my options. Surgery was obviously going to be necessary; she had failed conservative therapy, but what was the right surgery? Options: 1) Open sigmoid colectomy, end colostomy 2) Laparoscopic colectomy, end colostomy 3) Laparoscopic one stage procedure 4) Laparoscopic colectomy, primary anastomosis and diverting temporary ileostomy. She wasn't too thrilled to hear the word colostomy but I prepared her for the possibility. 50/50 chance. I started with a scope and of course the sigmoid looked lousy, but there wasn't gross contamination of the peritoneal cavity. There was a well contained abscess on the lateral side wall where the sigmoid was stuck and that was about it. I went about the usual business of medial to lateral mobilization of the colon, found the ureter, took down the IMA, and prepared the rectum. The splenic flexure was a bitch, but it came down. Going into the case I had prepared myself for some sort of ostomy, but now...... as I washed out the left lower quadrant I started thinking, reconsidering. It didn't look so bad. The rectum was nice and clean and pink and healthy looking. Same with the descending colon. I made the colorectostomy with the EEA stapler and then stepped back and thought a good three minutes about doing a diverting ileostomy. She was septic. Hadn't been eating well for over a week. But she was young and otherwise healthy. You hate these moments in an operation. Self doubt. Wanting to do what's best for the patient. You're always taught in surgery to take the "safe" option over anything heroic. Guess what? I skipped the ileostomy. It just seemed right. I left a couple drains in and closed up shop. Post op day #3 I get called because her heart rate has spiked to 135. Ah hell, I'm thinking. She's leaking. I send her down for CT abdomen and chest and, miraculously, the pelvis looks fantastic. No air out of place. No free fluid. She did have a small pulmonary embolism (despite compression boots and lovenox) to explain the tachycardia. Currently she's doing great. Just waiting for INR to be therapeutic and she'll go home. Did I just get lucky? Was that truly the right operation? In this case maybe it was. Not always. There are no cook books in surgery. Patients are individuals, not automatons. They don't always behave and react the way they're supposed to. I suppose that's where the "art" comes into play.