Wednesday, May 28, 2008

Saying you're sorry

The NY Times ran a story last week about a "full disclosure" policy some hospitals are implementing. Rather than trying to conceal the circumstances of medical errors or poor outcomes, hospitals and doctors at the University of Illinois-Chicago are disclosing all the details and even apologizing to patients. As a result, malpractice claims have dropped by half since the policy was instituted.

This correlates with what we already know about the likelihood of malpractice suits. A patient's decision to sue often has more to do with some deficit in the patient-physician relationship rather than with some perceived technical or diagnostic error. Doctors who are inattentive, who rush through office visits, who blame the patient for untoward outcomes are more likely to find themselves sitting in a courtroom. Listen to your patient. Be empathetic. Communicate from the beginning the risks and benefits of any scheduled procedure. These are the skills we as physicians need to cultivate.

I operated on a lady a few weeks ago for recurrent diverticulitis; she'd been hospitalized several times over the past year for recurrent attacks, and she had had an abscess drained percutaneously during the most recent attack. I had planned on performing a laparoscopic sigmoid colectomy. I told her that generally patients tolerate it well and are able to go home in 2-5 days time. Let's do it, she said.

Well the case was a disaster. I had to open. The colon was stuck to the uterus. There was pus in the pelvis and the inflammatory changes extended quite low down onto the distal rectum (usually diverticulitis is a disease of the sigmoid colon). The anastomosis ended up being just above the lower sphincter mechanism. I always get worried about low pelvic anastomoses, especially in the setting of acute inflammation. Consequently, I protected it by diverting her fecal stream with a loop ileostomy. So she ended up with a much bigger incision, an extended hospitalization, and a stoma (which will be reversed with another operation in 4-6 weeks). Understandably, she was initially quite disappointed. Not that I did anything wrong. I have no doubt that my intra-operative decision making was appropriate. But the outcome was unexpected.

As we neared discharge, she started to feel better and one morning she sort of opened up to me. Doctor, she said, I understand you did the right thing for me. I'm okay with the bag on a temporary basis. But I wish you would have been more forthcoming prior to the operation that something like this might have happened. You know, I signed up for several art shows this year (she paints in water colors and displays her work at shows all over the midwest) and those entry fees are non-refundable. I'm going to lose all that money. If I'd known that something like this was even possible, I would not have made any plans this summer.

Hell, I felt terrible. I told her I was sorry. In retrospect, looking at some of the old CT scans, maybe I ought to have anticipated a tougher case. She was right. And I told her that. I apologized and offered to write letters to the art shows on her behalf. As soon as the word "sorry" left my lips, I could almost detect a physical change sweeping over her. Her shoulders relaxed. She smiled warmly. The lines in her face smoothed out. She had heard what she needed to hear. It's OK, she said.

I think there is some merit in open communication and admitting culpability in adverse or unexpected outcomes. But it isn't a panacea. You have to be careful. I thought this article gives an interesting counterpoint to the NY Times story.

Friday, May 23, 2008

Never? Really?

This case has been modified for obvious reasons.

When I was an intern, there was a patient who came in for gastric bypass surgery. This was in 2001 before reimbursement for bariatric surgery took a dive, and we usually had four or five patients at various stages of recovery from Roux-en-Y bypass in the hospital. This patient was a 35 year old male who weighed over 700 pounds. That's 700 pounds. His BMI was greater than 100. He had all the usual co-morbidities one would expect; diabetes, severe sleep apnea, pulmonary hypertension, etc.

Because of his body habitus, his bypass was done via an open laparotomy. Unfortunately, his ventilatory parameters were suboptimal at the end of the case and anesthesia kept him intubated, given the difficulty of placing the tube under duress. He never weaned. He acquired pneumonia. The tube stayed in for weeks. Ultimately, a tracheostomy was placed and he was eventually transferred to a long term care facility. His recovery was long and slow but he finally went home after several months of rehab. He lost close to 400 pounds over the next several years. His diabetes resolved. His heart function improved. And then the hospital and the attending physician (and, by extension, all the residents involved in his care) received a notice from a plaintiffs lawyer notifying of intent to sue for a ridiculous sum of money....

In the immediate post-operative period, the patient was vented and bed ridden in the ICU. Nursing records make note of skin breakdown and eventual development of a sacral decubitus ulcer, despite the use of an air mattress and preventative maneuvers to shift him every few hours. The chart describes 6,7, and sometimes 8 people being required to assist in rolling him one way or the other. Appropriate dressings were applied. Necrotic tissue was debrided when necessary. It never progressed to the point of being a septic wound. During the recovery phase, a plastic surgeon covered the resultant open wound with a tissue flap.

And this is what the suit is about. A decubitus ulcer in an extremely ill patient who weighed so much that the entire ICU staff was needed to roll him in such a way to take pressure off the skin and subcutaneous tissues of his ass. Well, the Herculean efforts of dedicated nursing personnel and doctors wasn't enough in this particular case..... But now we have "never events" as described by Medicare and Cigna and soon to be many other insurance companies. Line infections and UTI's and delirium and c diff colitis and decubitus ulcers aren't supposed to happen anymore. It's the doctor's and nurse's fault. Coincidentally, this lawsuit was posted shortly after this new designation came out. Never events. Is this the sort of vocabulary we want to be using? Never? I can't wait for the avalanche of lawsuits soon to be coming down the pipeline for the elderly lady with pneumonia who develops c diff or the old guy who goes into delirium after his Whipple....

Thursday, May 22, 2008

Letting Go

There's no protocol in the United States for the process of making a patient DNR. I don't mean the simple act of writing "DNR-CC" (Do Not Resuscitate, Comfort Care) in the chart after a long discussion with family members. What happens next? Do you open up the "death playbook" and run the offense with morphine and benzodiazepines? It doesn't exist. Palliative intervention varies from hospital to hospital, from doctor to doctor. It's something you make up as you go along.

As a surgeon, I get involved in futile cases more often than I would like. As the population ages, we find more and more 80-90 year olds in ICU's who develop acute abdominal emergencies, such as ischemic bowel, toxic megacolon, neoplastic colon obstructions, and perforated ulcers. Often, they show up without family or contact information. Dementia and/or toxic encephalopathy precludes an honest discussion of how aggressive the level of care will be. The patient will die without an operation. However, the concomitant coronary artery disease, COPD, and heart failure make any surgical intervention fraught with hazard. What do you do?

Sometimes surgery is life saving. That can't be denied. I've seen it with my own eyes; elderly patients smiling as they are wheeled out to the rehab facility, a week after being on death's door. There are few things as gratifying in a general surgeon's practice. Another year on earth. More time to be spent with loved ones. Some aren't ready to be done with this thing called life.

But there are others who don't do well no matter what you do. You can do the perfect operation in an expeditious manner and it's all for naught. They won't wean from the vent. They go into heart failure. Multiple organ failure develops. An inevitable, ineluctable downward decline hurtles them toward oblivion despite your best efforts. The futility of the situation eventually becomes obvious to all and the time comes for "the talk" with the family members.

I've had two patients in the last month who presented in extremis with peritnotis and/or ischemic bowel. One was an open and close case; entire length of small bowel gangrenous. The other was an incarcerated hernia with dead sigmoid colon that had perforated into the peritoneal cavity. Both patients were octogenarians. Both had lived full, enriched lives according to the respective families. It was time to say goodbye.

But how is this done? We agree to withdraw supportive care. Antibiotics are stopped. Vasopressors are halted. Directives are given not to run a code when the patient starts to deteriorate. There are no chest compressions. No epinephrine. The primary objective is palliation. Make the patient comfortable. In this synthetic environment, where some semblance of life is propped up with machines and tubes and drugs, it isn't ethical to merely "turn everything off". They've decompensated beyond the stage of self-sustaining life. Unplugging everything and stopping all the drips is about as cruel a thing as I can imagine. I never terminally extubate a patient. There's nothing more gruesome than watching a patient suffocate after terminal extubation. A wise old nurse made me experience it when I was a resident. No reason to pull that tube out. The dead bowel or the fecal peritonitis is going to stop the heart soon enough. No reason to expedite the death with unnecessary agony.

Here's my ICU orders for these cases:
-Do not extubate
-Morphine 4 mg IV q 15 minutes
-Propofol drip titrated to complete sedation/unconsciousness
-Turn down the sound on all monitors.

People don't die on cue. Sometimes it happens right away, as soon as the levophed is unhooked. But not always. I've seen patients linger for hours, heart rates in the 30's, blood pressure barely registering. The families are in the room, keeping vigil, together for the last moments of the loved one's life. The patient is peaceful looking, sedated, unrushed on his journey toward death. We cannot control the inevitable end, but we can control how gently we allow these poor souls to land.

Thursday, May 15, 2008

Unforeseen Consequences

Over a 100,000 weight loss operations are performed in the United States every year. It is an operation that is the only proven solution to the complications of refractory morbid obesity, aka the "metabolic syndrome". There are many surgical options including lap bands, laparoscopic roux-enY gastric bypass, duodenal switch, and sleeve gastrectomy.

The most common one performed for morbid obesity is the Roux-en Y, usually performed laparoscopically. As everyone knows, this is a difficult operation and the learning curve is steep. In the wild west early days, the complication rates were astoundingly high. Leak rates of 8-20% were described. Patients died. It was a dangerous endeavor. Nowadays, as residents and fellows are learning the procedure from seasoned specialists, the morbidity of the operation is much more palatable.

But it's still a rather new operation, relatively speaking. Long term complications are still being delineated. I saw a young woman yesterday ER who had a Roux-en-Y done in Oregon exactly one year ago. She presented with an acute onset of severe abdominal pain and nausea. A CT scan suggested free air. I took her for emergent laparotomy and the perforation was at the anterior surface of the gastrojejunostomy. She had formed a "marginal ulcer" after the surgery which, over the subsequent months, ultimately eroded through the full thickness of the jejunal limb. Since the gastric pouch was already so small, I had to simply Graham patch the hole, as if it were a perforated duodenal bulb ulcer. I also placed a gastrostomy tube into the gastric remnant, in case she needs enteral feeding access in the future. Drains were placed in the upper abdomen and I got out. I didn't do it laparoscopically, but I think it was the right thing to do. Long term, she's going to need treatment with proton pump inhibitors and endoscopic surveillance of the ulcer. Stricture is a definite possibility in the future.

Even though most general surgeons do not actually perform weight loss surgery, it's important to be familiar with the anatomic alterations of all the bariatric variations. You never know when someone is going to turn up in your ER with free air.

Monday, May 12, 2008

Thyroid Cancer

I read a couple of weeks ago about the Arizona Diamondbacks pitcher, Doug Davis, who was diagnosed with thyroid cancer and underwent a thyroidectomy on April 10th. Last week I performed a partial thyroidectomy on a young woman who had an equivocal needle biopsy of a thyroid mass but the frozen section pathology on the right lobe fortunately was benign. So I decided the time had come for a post about thyroid mind works in a simple fashion.

The thyroid gland sits atop our trachea like a shield. It is an endocrine organ that synthesizes and maintains our supply of thyroid hormone. (It also helps with calcium homeostasis, but that is perhaps a little too indepth.) About 37,000 new cases of thyroid cancer are diagnosed a year. Risk factors include goiter, Graves disease, family history, and female gender. But the biggest risk factor is a history of radiation exposure during childhood. Believe it or not, kids used to be radiated as a treatment for such conditions as acne, thymus enlargement, and tonsil/adenoid problems. Good thing Clearisil was invented. Nuclear fallout exposure is another biggie. People exposed to fallout from the Chernobyl accident have a significantly higher risk of developing thyroid cancer (something to keep in mind when your patient is a relatively recent immigrant from Russia or the former Soviet Republics).

Thyroid cancer usually presents as a painless, hard mass in the neck. Most people are euthyroid. Things to ask about include voice changes, trouble swallowing, and a sense of not being able to get enough air when the arms are stretched high above the head.

All suspicious thyroid masses get a Fine Needle Aspiration (FNA) on the initial office visit. I also like to ultrasound the gland myself. Other tests that an endocrinologist might order would be CT scans and nuclear medicine scintigraphy.

There are two major determinants of the course and prognosis of thyroid cancer. One is the degree of differentiation of the tumor. The other is the age of the patient.

Well differentiated = good
Poorly differentiated = bad

Patient <45 years old = good
Patient >45 years old = bad

Well differentiated cancers are reasonable cancers. These are the follicular and papillary cancers. The cells are malignant but they follow the rules to some extent. They spread in a fairly predictable fashion. They don't replicate like rabbits in heat. They're like an incorrigible child who gets in trouble at school, gets detentions, C student, but he's not going to embarass the family name. He's a good kid, just a little misguided. Poorly differentiated cancers, conversely, are the kids who torture animals in the basement. The kid who runs a drug ring out of his black wall-papered bedroom. They don't follow the rules. Poorly differentiated cancers are aggressive and fast growing and outcomes are much worse.

Age, interestingly, is also a big prognostic factor. If you're less than 45 years old, you can't be any worse than Stage II. Even with distant metastases, there is no such thing as Stage III or IV cancer for young patients with well differentiated thyroid cancers. Getting the disease at an older age protends worse outcomes.

Overall, however, well differentiated thyroid cancer is one of the best cancers to get. Ten year survival of early stage disease is over 90%. Unusual subtypes such as medullary thyroid cancer and anaplastic tumors have poorer survival rates.

Definitive treatment of well differentiated thyroid cancer is surgical. Specifically, total thyroidectomy (removing the entire gland) is curative and allows one to monitor for recurrence. Several weeks post op, one can perform a "thyroid scan" in nuclear medicine to see if there is any residual thyroid tissue. Then you can specifically eradicate it with radioactive iodine (I-131), with is taken up solely by thyroid-like cells. Patients are kept on synthetic thyroid hormone (Synthroid) for the rest of their lives, with the dose titrated to such a level that Thyroid Stimulating Hormone (TSH) is down regulated (high TSH levels will stimulate growth of any residual cancerous cells).

This is a fun operation. Generally, it's well tolerated and patients go home the next day. The procedure is pretty standardized, by the book. Incision in a skin line in the neck. Raise the platysmal flaps. Open the strap muscles in the midline. Note the gland, red like cranberry sauce, veins and arteries splayed across its surface and pulsating. Free the gland from the undersurface of the strap muscles. I go for the superior pedicle first. This is a branch of the external carotid artery that I always tie. Most of the rest of the vessels can be coagulated with the small, hand held Ligasure device. Two main structures to tighten your anus over. Have to preserve the parathyroid glands (control the body's calcium levels), especially if a total thyroidectomy is done. They look like carmelized little lima beans residing posterior to the thyroid. Sometimes they're hard to find, because embryology can take them in weird places. The other thing to ALWAYS find is the recurrent laryngeal nerve. Cutting one leaves the patient with a raspy, hoarse voice, usually for the rest of their lives. Cutting both sides will paralyze the vocal cords in the midline of the trachea, leading to respiratory compromise and often, an emergent tracheostomy. Never Bovie or cut or Ligasure anything near the trachea until you find it. It looks like a piece of vermicelli cut in half travelling deep in the neck, along the posterior aspect of the trachea.

Post operatively, you have to worry about bleeding. You end up tying off or Ligasuring a ton of vessels and any bleeding in the resultant closed space will collect and press on the trachea. I actually had to do an emergent neck exploration and tracheostomy on the floor on a post op thyroidectomy when I was a resident (the night before the rehearsal dinner of my wedding).

Medullary Cancer
Special side note on medullary cancer. These tumors only comprise 3-8% of all thyroid malignancies. Although 80% are sporadic, a good proportion are associated with the inherited endocrine cancer syndrome of MEN (multiple endocrine neoplasia syndrome). It's important to rule out the concommitant presence of things like pancreatic tumors and pheochromocytomas prior to definitive treatment of the medullary tumor. Outcomes are worse compared to well differeniated cancers, mainly because they are not susceptible to treatment with I-131. Furthermore, central compartment and sometimes modified radical neck dissections are indicated, in addition to total thyroidectomy, depending on presence or absence of local spread to regional lymphatic basins.

Anyway, I read the other day that Doug Davis has started throwing again, and may be due back to the team in a month or so.

This is what happens when you're the junior surgeon at a community hospital. Today was one of those mornings where there happened to be three laparoscopic cholecystectomies scheduled at the same time. Apparently there's not enough video equipment to make this happen. When I arrived in the room, the surgical assistant was wheeling in this rickety looking video monitor that looked like it had last been used for some middle school study hall presentation.
-Where did you find that thing? I asked
-In the basement. It's all we have left.
-Oh. I see.

Meanwhile, two rooms away, the senior surgeon is toiling away happily with the latest in HD technology. Whatever. That's what you get when you're low man on the totem pole. So we flip the thing on and there's no color. It's a black and white monitor. It's like watching an episode of Leave it to Beaver, only with human organs and surgical instruments instead of Jerry Mathers. Fortunately, everything went well; routine chronic cholecystitis. The patient was never compromised. By the end of the case, I was starting to like the black and white look. In fact, I requested that for my next case they dust off the sterile rabbit ears. And to look around the basement to see if they had any hickory dissecting instruments.... Anyway, I'll always remember it as my "I Love Lucy Gallbladder".

Saturday, May 10, 2008

Proud to be an American!

This story is made me forget for a moment that we actually live in the 21st century. And it's shameful that Hillary Clinton has chosen this segment of the population (uneducated working class whites!) to pander to as a last ditch effort to salvage her failed campaign. Yeah Hillary, keep wearing that green John Deere hat when you crawl back to your fall sabbatical in the Hamptons.

Wednesday, May 7, 2008

Surgeon Tryouts

I'm not a huge fan of this drive to designate hospitals as a "Center of Excellence" in some surgical sub-specialty. Bariatrics was the first to champion the idea. On the surface it sounds super-duper. Center of Excellence! That's where i want my surgery! Obtaining such designation, however, usually requires jumping through multiple hoops and making sure all the boxes are checked on an application form. It doesn't hurt to be affiliated with an institution that that can afford to fund the added resources required to meet the prerequisites. The emphasis is less on outcome measures, more on program compliance. For instance, a bariatric program needs to document that they have nutritionists, weight loss specialists, specialized equipment for the operating room and afterwards, and other ancillary services available for potential patients.

It seems like a good idea but now we're starting to see a push for other kinds of surgery to be restricted to such designated "Centers of Excellence". Some surgeons (i.e. academic ivory tower big shots) would like to restrict operations like Whipples and advanced laparoscopic procedures (colon resections, Nissens) to the big tertiary referral centers. Isn't that nice. Let all the community surgeons handle the gallbladders and hernias and butt pus. We'll handle the big cases, they say. Despite the fact that volume actually correlates poorly with reduced morbidity in major operations like pancreatic resections. Other factors like quality of the individual surgeon, nursing staff, and chracteristics of the hospital where the surgery is performed contribute to outcomes as well. Volume is sometimes an arbitrary number.

Anyway, I do actually like this idea. (See page 7 of the link) General surgeons in the Boston area have agreed to take the Fundamentals in Laparoscopic Surgery (FLS) exam in order to maintain laparoscopic operating privileges at hospitals such as Massachusetts General and Beth Israel Deaconess. Basically you show up, take a written exam, and then have to perform a series of timed maneuvers using a laparoscopic training module. Meritocracy in the purest sense. If you have the goods, the skills, then you get to stay in the game. Doesn't matter whether you practice at a vaunted "Center of Excellence" or not. It's based entirely on individual performance and proficiency. Now there are some things I dont like about the FLS test. For instance, moving a bunch of rubber balls from one cup to another or being able to tie a knot in a piece of styrofoam does not necessarily translate into real life excellence. It's like drafting a quarterback based on how fast they can run the 40 yard dash and how many footballs they throw through a tire in a 60 second period. Surely we can do better than rubber balls and styrofoam bowels. Perhaps an in vivo exam on an animal would be a better indicator..... just don't tell PETA.

Monday, May 5, 2008

Sorry for the inconvenience

Sort of an amusing tale from the office last week. I removed an appendix a couple weeks ago from a young "au pair" here in the States from (let's say Paraguay) on a work visa. Very straight forward case. Laparoscopic appendectomy. Went home the next day. She works for a family in one of the foo-foo sections of the east Cleveland suburbs. I usually see post-op patients 10-20 days after discharge just to make sure everything has healed well and there aren't any further problems. I had to cancel this young woman's initial post op appointment because of an emergency that arose. Within minutes the "lady of the house" (LOTH) calls the office and is just outraged. How dare we cancel the appointment of her au pair. Didn't we realize that she was vital to the smooth functioning of the household? My office staff, as always, was quite apologetic and made arrangements for me to see her between cases the following day.

They arrived twenty minutes early the next day and I raced upstairs to see her between gallbladders. The patient looked fantastic; smiling, pain-free, completely back to normal. Her incisions had healed perfectly and I told her to remove her steri strips the next time she was in the shower. Standing in the corner, hovering almost, was the LOTH. She didn't acknowledge me when I said hello to her except with one of those dismissive upward turned arched eyebrows you give to someone you pass in the hallways. She stood next to the high end stroller shushing the cute baby during the exam. She looked to be about 30-35 years old. Not an ounce of fat on her. Prada bag dangling off her shoulder. Dolce Gabbana sunglasses perched atop her head. Dressed like a female correspondent on Fox News.

I gave the patient my usual spiel. No specific restrictions other than avoiding activities that caused pain. You're not going to hurt anything, but you may find certain activities make you uncomfortable (muscle soreness, scar tissue, etc). The young au pair smiled and thanked me. And it was "au pair". Not nanny. Not babysitter. Au pair. In Cleveland, Ohio.

That's not going to be good enough, the LOTH hissed at me. Excuse me, I asked? I need to have explicit instructions. If she can lift the baby, then you need to write that down. I have been trapped in my own house for two weeks doing all the things that we're paying her to do! I've missed yoga. I don't see my friends. I haven't been sleeping at night. And I have no recourse until we get clearance from the doctor. So if she doesn't have any restrictions, you need to make that clear in writing.

Her cold steely gaze was one of pure contempt. I was incredulous. The poor Paraguayan girl was blushing silently on her chair. The baby started whimpering.

What I just said is what I'm going to write, I told her, slowly, standing from my stool. She may have pain when she does certain activities. If that happens she should stop what she's doing. Most of the time, people don't have any problems after appendix surgery. But I have to prepare her for the possibilities. It would be prudent for you to give her a little leeway and empathy in this matter.

Fine, she hissed. Are we done?

Yes, we were done. Amazing. Hopefully the poor girl is only there on a one year contract. And hopefully the LOTH has no plans to add to her brood. I should have written "no lifting anything heavier than toilet paper for 6 months".