Monday, January 21, 2008

Sid Crosby

14 year old boy slashed in the belly at a hockey game the previous night. Came to ER, sent home. Up all night, can't sleep, severe abdominal pain. Mother brings him back to ER in the morning. He's pale, diaphoretic, HR 95, BP 105/75. CT abdomen/pelvis is done (see above). Obviously, the kid has sustained a major splenic injury with resultant massive hemoperitoneum. Now in the old days, you don't think twice, do not pass go, straight to the OR and whack out the spleen. Nowadays, you have to do a lot of thinking. Non-operative management of splenic trauma has become the standard of care, especially in children. Complications of splenectomy include the entity "overwhelming post-splenectomy sepsis" with an attendant mortality of close to 50%. The spleen actually has a useful immunologic function; helps us to clear the bloodstream of the "encapsulated" bacteria (streptococcus pneumoniae, haemophilus influenzae, etc). People who lose their spleen require lifelong immunizations to lower the risk of acquiring post splenectomy infectious complications. We've found that close to 90% of kids with blunt splenic injury can be managed conservatively without an operation.

So how do you decide when it's time to take a kid to the OR? Three main indications:
1. Hemodynamic instability
2. Diffuse peritonitis
3. Transfusion requirements (greater than 6-8 units of packed red cells over a 24 hour period.

Predictors of conservative failure:
1. Grade of splenic injury
2. Evidence of a vascular "blush" on CT scan

Why did I take this kid? The radiologist called and said he was was worried about a possible concommitant splenic artery transection in the area of the pancreatic tail with a suggestion of pancreatic injury. He also has a belly full of blood and was pretty tender, diffusely. Could I have waited a little while? Given him 4 units of blood and see what happened? Sure. He was hemodynamically stable. Even though he looked like a ghost. I could have tried conservative therapy for a short period of time. But I work in a community hospital. There's no "trauma team" to watch the kid. No chief resident to perform serial exams to make sure he wasn't deteriorating. It was just me. What if he decompensated at 3am? Given the CT report and the way the kid looked, I didn't want to mess around. So I took out his spleen. His belly had several liters of old and fresh blood. The spleen looked like a grenade had gone off inside it. Completely ruptured, with several areas of active bleeding. The pancreas was fine. The case took 15 minutes. He'll probably go home in a couple days. No more slap shots this year, but he should be good for next season.

There is data to suggest that this scenario is quite common; kids who come to a community hospital are more likely to get a splenectomy versus a kid who goes to a free standing pediatric hospital with pediatric trauma teams. And that makes sense. Specialized pediatric trauma units have a full contingent of doctors to watch these kids like hawks. I'm ok with that. I did the right thing, I'm sure. You have to practice safe surgery and the safest course is going to be different depending as much on where you practice as how you do it.

Friday, January 18, 2008

Sir, I need to place a finger in your anus

A lot of hoopla regarding the construction worker from Brooklyn who is suing the trauma unit who performed an "unauthorized" rectal exam during his initial evaluation. I hate to be a "doctor apologist" but when you find yourself being rolled into a Trauma Bay, your "inalienable rights of man" are temporarily suspended. I'm sorry, but that's just the way it is. The approach to trauma resuscitation is completely protocol driven. Everyone gets essentially the same work-up every time, all the time, in every level I trauma unit across America. The reason is, evidence suggests outcomes and 30 day survival numbers to be superior in centers that employ an algorithmic, protocol based approach. First you do ABC's. Then mental status exam/glasgow coma score, then a brief history, and finally a complete head to toe, back and front physical exam. So many of these patients roll in with severe head injuries or compromised by drugs/alcohol on board that you can't trust anything they say, initially. You can't afford to. Removing a c-collar too early, or skipping a rectal exam can be disastrous. The Brooklyn guy supposedly fell and sustained a head injury at the construction site. What if they found blood at the anal verge? Is it just hemorrhoids? Or maybe a shard of lumber that lacerated his rectum as he fell back unconscious? You don't know, but your interest is piqued and further work-up is warranted.

The problem in this area is one of proper triage. If I walk into my PCP's office and decline a rectal exam, it would certainly be assault if I were held down and forcibly rectalized. Trauma is a different animal. It's like when you were a little kid and had to be cajoled and bossed around by your parents. You didn't have a choice in brushing your teeth because it was "good for you." Same thing in trauma. The cost of missed traumatic injury far outweighs the momentary loss of dignity of having somebody put a finger in your anus for 1.5 seconds. Obviously this guy probably didn't need to be sent to trauma bay; he sounded completely alert and oriented and without obvious physical injury. But that's where he ended up. And we're much safer, in the long run, knowing that the guy got his inevitable rectal exam.

Wednesday, January 16, 2008


If you haven't seen it yet, take 7 minutes of your life to watch the Glenn Beck post-op hemorrhoid surgery video. Now, I generally frown upon making light of anyone's perception of physical pain. There's a neurologic component to pain that is very real and should never be minimized. However. This rambling, incoherent diatribe is absolutely ridiculous. And amusing. It's funny, doctors see patients like this all the time. They're the patients who torture family members with incessant personal illness stories, the lady who calls you every week because she's "concerned" about her hernia incision (looks fine), the guy who lugubriously asks "am I gonnna make it, doc" as you take him back for gallbladder surgery. These are the people who think the world has cursed them with incurable illness and suffering and, god willing, they may just pull through. Almost universally, what they suffer from is something routine and non-life threatening (hemorrhoids, hernia, gallbladder, etc.) They take weeks off from work. They call for multiple refills of pain meds. They even make Youtube videos while unshaven and zonked out on painkillers. Patience and empathy are the keys. Eventually, they "heal" and, as a surgeon, you dont have to see them anymore. Thank god I'm not primary care.

Hemorrhoid surgery is literally a pain in the ass. Think about it. You're subjecting yourself to sharp objects being used around your anus. That's going to hurt, right? Perhaps even for days afterwards.

Here's the deal with hemorrhoids. They're basically vascular plexi underneath the anal mucosa. Importantly, hemorrhoids are not innately pathologic. Everyone has hemorrhoids. They actually function to provide some resting anal pressure and also have a sensory function to help differentiate between gas and stool. (Therefore allowing one to cut a little cheese without soiling oneself). They cause problems only when engorged or swollen. They come in two flavors: internal and external. The picture above helps delineate the difference. Presentation is different for each one.

Internal hemorrhoids cause painless bleeding. Their location above the dentate line renders them insensate. Usually patients are treated conservatively for as long as possible (stool softeners, metamucil, etc). Surgical intervention is indicated for refractory bleeding. In the past this meant either rubber band ligation or formal hemorrhoidectomy. Nowadays, more surgeons are using the PPH hemorrhoidopexy device. This is a stapler that resuspends the anal mucosa and essentially cuts off the blood supply to the hemorrhoidal plexus. The benefit is that is allows you to treat multiple hemorrhoid bundles simultaneously, with much less post-operative pain.

External hemorrhoids are right at the anal verge. These babies are well innervated and when thrombosed, cause significant pain. I suspect a thrombosed external hemorrhoid was what brought Mr Beck to a surgeon. After surgery, you're going to be sore as hell for several days. I hate these cases because patients aren't always pleased with how they feel afterwards. The key thing to to properly prepare the patient for what is going to happen and how they're going to feel after. As always, patient expectations are associated with patient satisfaction.

Also, a lot of patients present with combined internal and external hemorrhoids. When conservative measures fail, operative intervention can include PPH along with concommitant excision of the external component. You don't want this. You're going to be sore as hell and you're going to curse your surgeon. Plan on seven days of discomfort and some bloody spotting on the toilet paper, but it should get better.

How do you avoid complications of hemorrhoids? The best evidence we have seems to suggest that chronic constipation and straining at stool contribute to engorgement of the vascular plexi. If you're going every three days, that's a problem. Mix in a little prune juice or metamucil if you can. And when you do go, if your legs are going numb by the time you're finished, you've probably been sitting there too long. You shouldn't be able to finish the NY Times crossword puzzle during a BM session. Sit down, do your business and get off the toilet. Just a little public service announcement from your friendly anal specialist.

Monday, January 14, 2008


Two similar cases recently, with different outcomes. A 60 year old lady apparently was in a minor car accident the previous week, but didn't seek medical treatment. She had horrible back pain and, according to family members, she self medicated by popping aspirin and motrin. She develops abdominal pain. Three days later, her husband brings her into the ER because "she isn't acting right". She takes two steps into the triage area,stumbles, babbles incoherently, and basically arrests on the floor. The nurses note that her toes and fingers are blue as the code starts. Evetually she is resuscitated and intubated and vitals return. They run her through the CT scan and an enormous amount of free air is seen. At this point her labs trickle back. Extreme metabolic acidosis. Potassium 7.2. BP 80/30 on three pressors. This is point where Buckeye Surgeon is called. The nephrologist is already there when I arrive (at 2AM! nice work!)frantically trying to get the potassium corrected with bicarb, insulin, etc. The woman is mottled blue in all her extremities. Her eyes are fixed and dilated. She basically looks like a corpse hooked up to machines. I tell the daughter, who's a wreck, that the prognosis is extremely grim. She wants everything done, though. I get a quick head CT to make sure there's no obvious infarct or impending uncal herniation. It's normal, so I book the case at 4am. The anesthesiologist is just furious. What do you hope to accomplish, she hisses at me. We'll see, I say. I end up putting in all the lines and then we get started. Whoosh of air as the peritoneal cavity is entered and then a tidal wave of liquid green succus. Ten minutes are spent evacuating the contamination. I have an idea what the problem is going in, so I target the foregut. Sure enough, there's large anterior perforated duodenal ulcer. And this baby has been like this for days. Strands of fibrinous exudate span the peritoneal cavity like melted mozzarella. Chunks of corn and other vegetation float by in the irrigation fluid. The omentum, unfortunately, is a shriveled, near necrotic, mess. Usually for perforated duodenal ulcers, the move is to do a Graham Patch with a tongue of omentum to seal the hole. That wasn't possible in this case. the omentum was like used tissue paper. So I used a little trick a guy at Cook County Hospital taught me. I liberated the falciform ligament and boom, I had a nice strip of well vascularized adipose tissue to cover the hole. Graham patch in the standard fashion. Hole closed. We irrigated with ten liters of saline, closed, shipped her to the ICU, and crossed our fingers. We dialyzed her that night and were able to slowly wean the pressors. Amazingly, by ten the next morning, she was off pressors completely and was opening her eyes and following commands. Nice save, I'm thinking. But then around 4pm she starts throwing some PVC's and then suddenly drops her pressure. Troponin comes back over twenty. She goes into Vfib, codes, and dies. Basically she died from a massive post-op MI/ventricular arrythmia. Sometimes you can do everything right, but the patient's ticket is already stamped. Sucks to come that close though, to bring someone back from the dead, only to ultimately lose them. You wonder what the hell took her so long to come into the hospital. She'd been curled up in bed for days, apparently. Well, we gave it a shot. Definitely not wasted resources. Anyone with an acute abdomen (peritonitis, free air) deserves at least a shot in the OR, if that's what family/patient want. You just aren't going to win all those battles.

The other lady was about the same age, with a similar co-morbidity history(CAD, COPD,DM). She came in with vague lower abdominal pain and was admitted to the floor after an intial negative work-up. The pain worsened over the next several hours and she started dropping her pressures and became anuric. They called me while I was at the movies. Stat repeat CT scan was done which showed diffuse free air. When I arrived in the ICU, she was pale and deathly. Her pressure was 64/40 and she had obvious peritonitis. I resuscitated her with saline, pressors, etc. and booked her for OR. Now I've done a lot of operations for free air/perfed bowel and it's always satisfying to get that whoosh of air as you slice open the peritoneum. But this case was a little different. This was no little whoosh. This was more like Mount St. Helens blowing its top. It was like a poop grenade had gone off in our faces. Good times! Especially at 1 in the morning on a Friday. The assistant and I scrubbed out, re-gowned and got to work. After scooping and sucking out about 3 gallons of stool we could finally see. The pathology was a perforated cancer in the rectosigmoid area, the hole the size of a golf ball. I resected the left colon and gave her a colostomy. Again, we irrigated with ten liters of fluid. At the end of the case she was on levophed and vasopressin and nothing was coming out of the foley. Back in the ICU, I slammed her with fluids all night. By daybreak, her BP was holding steady, vasopressors were off, and there was a faint trickle of urine output. Within 24 hours she was extubated and was making copious urine. The stoma is working and she's bugging me about when she can eat. Now that's the way it's supposed to work out.....

Sunday, January 13, 2008

No country for old men

I'm probably going out my realm of expertise here, but it's just something I have to try to articulate. The wife and I saw the movie "No Country for Old Men" this past Friday. Now, judging by the nearly unanimous rave reviews the movie has received from expert movie critics, you'd think that this was the second coming of Citizen Kane or the Sistine Chapel or something. Phrases like "work of art", "darkly poetic", "modern masterpiece", "cathartic", and "flawless" can be lifted from literally hundreds of positive reviews. I admit, I was excited to see it. I hadn't read the Cormac McCarthy novel of the same name, but I enjoyed his latest offering (The Road) quite a bit. When it was over, however, I walked out of the theater feeling completely empty, detached from what I had just witnessed. I wasn't moved. I didn't feel anything. Nothing. It was like going out to a highly recommended restaurant and having them serve a plate of thin air. A strange sensation to have after watching, ostensibly, "one of the great American movies of the decade", indeed. And that bothered me. Why was I feeling nothing when the rest of the country was apparently swept up in rapturous delight?

Was it a bad movie? No. It was actually entertaining and extremely well made. The acting was top notch. Javier Bardem just nails the role of the remorseless sociopath. Nails it. But when the credits rolled, I stood up and left without a pause. Within 2 minutes my wife and I moved on to other conversational topics. Isn't a "work of art", a "masterpiece" supposed to ingrain itself into your psyche just a wee bit longer? What was my problem? I liked the movie; don't get me wrong. The scene where Bardem makes a poor gas station clerk call heads or tails to determine whether or not he lives is a masterful combination of humor and horror. I just don't get why critics are falling over themselves with praise and adoration, as if the Coen brothers have contributed to the aggrandizement of the collective human mind.

For one thing, I think there's an important distinction between "technical excellence" and "art". No Country for Old Men is certainly flawless in its construction. The scenes are taut and steely. The dialogue crackles. The characters are developed with a minimum of exposition. The cinematography is occasionally breathtaking. No denying the superiority of the film in these regards. But is it art? Did it force me to look deep within, to acknowledge a truth that perhaps I hadn't realized? Was there a hidden human beauty, carefully delineated, that became steadily more manifest as the film reached its conclusion? What edifying idea was transmitted?

The film is about a bizarrely hilarious psychopath, Anton Chigurh, who spends the bulk of his time on screen mercilessly gunning down innocents with a compressed air gun, usually used to subdue cattle prior to slaughter. Chigurh's inexorable, inevitable killing rampage is conducted on a barren, craggy south Texas landscape almost completely devoid of anything soft or gentle. Tommy Lee Jones as the aged lawman with lines in his face like a dry, cracked riverbed, can only follow the carnage, always showing up a little late, helpless to stop it. Josh Brolin is the everyman, suddenly thrust into the crosshairs, who decides to challenge the ineluctability of his own death, unable to overcome the temptation of easy money. In the end, evil triumphs. The last twenty minutes elapse quickly in retrospect. The violence, so meticulously portrayed in all its gory detail in the frst half of the film, is elided at the end, the Coen brothers leaving to our imagination the senseless concluding butchery. I suppose that was nice of them.

We like our violence in America, I get that. We also love our psychopaths. But just because talented filmmakers are able to package that recipe into a well-made movie, that doesn't necessarily mean that ripples have been made in the river of historical aesthetics. Maybe I'm a little biased, given what I do for a living, but I see plenty of suffering and needless pain almost every day. It's very clear that the 45 year old woman with stage IV breast cancer didn't do anything to deserve her plight. Or the guy who comes in with perforated diverticulitis. Or the elderly lady with a massive myocardial infarction. I don't need to watch a goofy looking sadist leave a trail of horror for two hours to illustrate the vicissitudes and randomness of the human condition. Most of the beauty of art isn't in the actual work itself, but rather in the discussion and soul searching and enlightenment that the work of art triggers in each individual and the subsequent sharing of such insight. It's sad commentary that in this modern age, it takes someone like an Anton Chigurh to rouse us from our cruise control ennui and complacency. It shouldn't have to be like that. Suffering is all around us. In our neighborhoods, within the walls of our own homes. Even when we look in the mirror. No Country for Old Men is merely well made escapist fare with cool characters (a la Pulp Fiction)that satisfies our national fetish for violence. That isn't art. So let's all get down from our cultural purveyor thrones (I mean you Roger Ebert, AO Scott, Peter Travers, etc), wipe the blood from our lips, and save the awards for something a little more ennobling.

Tuesday, January 8, 2008

Not Again!

I want to put to rest the notion that "the SEC has superior athletes" and the "slow, plodding Big Ten" just can't physically compete. Last night had nothing to do with speed or strength. Every year, Ohio St. has any many guys picked in the first few rounds of the NFL draft as anyone. They have plenty of speed. Last night was about toughness, mental and physical. The Buckeyes posted a quick ten points on the board and LSU didn't flinch. 31 straight points later, the Buckeyes were done. Just a sickening display. I never thought I'd see such an undisciplined Jim Tressel-led squad. Four personal foul penalties! Roughing the kicker! Missed tackles! Just another embarassment on the national stage.

Meanwhile, we have a two-loss national champion. That's just great. I'm sure fans of USC and Georgia and West Virginia are thrilled. A playoff just makes too much sense for the geniuses of the BCS.

Monday, January 7, 2008

Learning for next time

I didn't want to operate on this guy. He's 86 and suffers from emphysema and CHF. In the past year I've operated on him three times. The first time I was covering for my partner who had removed a large basal cell carcinoma from his back earlier that day. He came back later in the middle of the night with a giant hematoma and I drained it, placed a JP in the OR. Two months later he came into the ER with an incarcerated right inguinal hernia. I took him emergently to the OR and fixed it, resecting about 8 cm of small bowel that had become ischemic. He recovered nicely and by this time we had become buddies. He had a left inguinal hernia as well, and I told him he needed to have that one fixed too, as soon as he recovered completely. So, we set a date for elective repair, but he shows up in the pre-op area tachycardic and basically looking like hell. The hernia looked to be incarcerated and the overlying erythematous skin, leukocytosis, and acidosis was suggestive of advanced bowel ischemia. How long has it been like this, I increduously asked his wife? All weekend, she said. He didn't want to come in though. I found incarcerated, gangrenous sigmoid colon in the hernia and performed a sigmoid resection with end colostomy, in addition to fixing the hernia. This time he was sick as all hell. Respiratory and renal failure. Prolonged ICU stay. Pneumonia. But eventually he recovered. He went to a rehab facility. Ultimately, he went home. He gained weight. His cantankerous humor returned. He came to see me in the office every few weeks or so, not because he needed to, he just liked coming in to see me. You're like a son to me, he said one time, breaking down and crying right there in the little exam room in front of his wife. I liked him. He was more than just a patient. He was my buddy. We'd been through a lot together. But he wasn;t happy. The colostomy was "killing" him. He hated it. He told me he'd rather die than live the rest of his life with it. I went through the risks. I told him that another operation might very well be the end of him. He'd been through too much at 86 years old. But he was relentless. I half-heartedly referred him to a cardiologist and pulmonologist for preoperative clearance, fully expecting them to put the kibosh on any further surgical intervention. To my surprise I got letters from both saying, as long as he understood the high risk nature, he would be cleared for surgery without need for further testing. So there he was, about 8 weeks ago, sitting in my office, eyes beaming, adamant, asking when his surgery could be arranged. You really want to do this, I asked him? At the risk of death? At the risk of maybe never seeing your wife again? Yes, he said. Please get rid of this colostomy. So I scheduled him. The surgery went beautifully. Post op day #1, however, his lungs sounded like an evening tide had rolled into his alveoli. He was intubated within hours. He'd gone into heart failure and developed pneumonia shortly after being mechanically ventilated. He went into ARDS. I watched his eyes go blank, the muscle mass he'd rebuilt slowly waste away. Every day for a month it was the same. I studied his anastomosis and it was intact; his bowels started to function normally after five or six days. Eventually, his lungs started to bounce back but not before I had to place a tracheostomy and a feeding gastrostomy tube. He's almost ready for transfer out of the hospital to a long term care facility, which is a minor triumph. But every time I go into his room, I say good morning Bill and he turns his head and looks away. He looks out the window with his glassy, sunken eyes. I shouldn't have done this to you Bill, I think. I should have been stronger in saying no.....There are different degrees of failure in surgery; technical errors, laziness, lack of foresight. Judgment failures are the ones you can't prepare for in textbooks. You have to learn them on your own.

Sunday, January 6, 2008


Surgical intervention for Crohn's disease is generally a very satisfying experience. The patients are usually young. They've been in and out of hospitals, suffering from the effects of acute flare-ups for a number of years. Side effects from the high doses of steroids sometimes necessary can be debilitating, physically and psychologically. By the time a surgeon gets involved in a case, the patient is exhausted and almost mentally defeated by the disease. The possibility of alleviation of suffering via the knife is welcomed as a respite of last resort. Surgery is deleayed as long as possible in Crohn's, as opposed to Ulcerative Colitis (UC), because, whereas in UC the disease is continuous and restricted to the colon and rectum, in Crohn's the disease can afflict anywhere in the gastrointestinal tract. Proctocolectomy for UC is curative; in Crohn's, you've merely removed a "hot zone" of the disease. It may very well strike again in other places. The more you remove, the less bowel is left for nutritional absorption. Short bowel syndrome is a very real entity in the long term outcomes of Crohn's. So all attempts at medical therapy are exhausted before a patient sees a surgeon. Classically, we're taught that the indications for surgery in Crohn's are as follows:
1. Perforation
2. Stricture/Obstruction
3. Fistula
4. Refractory symptoms

The last indication is obviously a little more subjective, defined differently by different gastroenterologists. A 21 year old male was referred to me recently who had been admitted to the hospital four times over the past three months for bowel obstructions caused by acute flare-ups of terminal ileitis. He'd developed an allergy to asacol and was being maintained on Imuran (immunosuppressive medicine originally used in transplant patients). High dose steroid pulses were able to relieve the bowel wall edema for each of the prior hospitalizations but he came in this last time already on a high oral dose (60mg) of prednisone. The poor guy was at the end of his rope. As the CT demonstrates, the terminal ileum was already starting to develop significant stricturing. We discussed all the options, but he was adamant; I want surgery. Surgical intervention in Crohn's is a double edged sword. On the one hand, you're dealing with relatively young patients who haven't developed significant cardiac or respiratory co-morbidities. On the the other hand, the effects of steroids go beyond attenuation of the inflammatory response. Wound healing is compromised. Infection rates are higher. Anastomotic leaks lurk. This was all explained to the kid and he agreed to proceed. I was able to laparoscopically resect the involved ileum and the cecum. Extracorporeally I did a two-layer hand sewn anastomosis (makes me feel better than staples). There was a transplant surgeon in Chicago where I trained who showed me a hand sewn technique he always used for his roux-n-Y cases. He said he never had a single leak out of hundreds of cases (despite a patient population of malnourished, immunosuppressed, steroid-infused patients). That was good enough for me.

The kid is doing great so far. And he's thankful as hell. In our business, nothing is more satisfying than to be able to help someone who is truly grateful for your work. Unfortunately, however, this isn't the end of this kid's travails. For now, the disease is quiescent. But the monster merely slumbers. Where will it strike next? We'll meet again, I'm sure. Hopefully, not until many years in the future.