Gastric Ulcer

In this day and age of everyone and their brother being on protonix or nexium or some variant thereof, we rarely see patients present with peptic ulcer disease to such a degree that surgical intervention is necessary. The glory days of general surgery had to be back in the late seventies when guys like Phil Donahue MD (not Marlo Thomas' husband) were snipping vagus nerves in a highly selective fashion left and right. The old surgical textbooks had throngs of chapters on all the permutations of ulcer surgery. Vagotomies and Billroth I and Billroth II and roux-en-Y gatrojejunostomies and all the post-gastrectomy complications like dumping syndrome and gastroparesis and roux stasis. My god, I killed myself trying to memorize everything as a junior resident. And then.... I find out no one ever does surgery like that anymore except for the occasional graham patch for a perforated duodenal ulcer. Looking through the old Cameron and Schwartz textbook chapters on peptic ulcer diease is like reading an old scroll from Galen or Hippocrates. Interesting but not particularly relevant to modern surgical practice.

But every once in a while we see someone like Patient X. 50 years old, alcoholic, non-compliant with previous medical interventions. He smokes 2 packs a day and said that whenever he would "cough up blood" he could usually treat it by running out to Walgreens and scarfing down a bunch of Tagamet and/or Pepcid. He was admitted for weakness and his hemoglobin in the ER was noted to be 4.6. The upper endoscopy confirmed a large gastric ulcer (3x6cm) on the lesser curve of the stomach that was not actively bleeding. Further questioning found that he had a first degree relative who had died from a "stomach tumor". So he got transfused up to a normal level and was placed on a Protonix IV drip. Then what?

Peptic ulcer disease (PUD) encompasses ulcers in two distinct locations: duodenal and gastric. Duodenal ulcers are much more common. 95% of duodenal ulcers are associated with chronic H Pylori infection and nearly all are observed in the setting of acid hypersecretion.

Gastric ulcers are a slightly different animal. Gastric ulcers are further broken down into 4 categories:

Type I- Most common type, usually a single ulcer on the lesser curve, not typically associated with hypersecretion of acid, seen in patients infected with H Pylori or NSAID abusers.

Type II- Two ulcers present (duodenal and lesser curve of stomach), strong association with hypersecretion of acid.

Type III- Prepyloric ulcers, also have an association with hypersecretion of acid

Type IV- ulcers near the gastroesophageal junction, not associated with acid hypersecretion.

The classic indications for surgery for gastric ulcers are similar to those for duodenal ulcers: perforation, bleeding, obstruction, and intractability. In addition, gastric ulcers are a risk factor for the development of gastric adenocarcinoma. Therefore, all gastric ulcers need to be biopsied and followed over the course of time. Giant gastric ulcers (>3cm) have a 30% incidence of harboring a cancer.

Back to my patient. Non compliant borderline alcoholic male. Giant gastric ulcer. Strong family history of stomach cancer. Presents with significant blood loss and massive transfusion requirements....what would you do?

Well I did a distal gastrectomy with Billroth II reconstruction. No need for vagotomy because his was a true Type I ulcer (non-dependent on acid hypersecretion). He's doing well so far. The ulcer seemed smooth and rounded (more consistent with a benign etiology) but we'll have to see what the pathology shows in a few days. Surgery on the stomach is actually quite fun. You feel like a goddam surgeon when you're in there doing it. Sometimes futzing around with laparoscopes and tiny instruments all the time can be tiresome. Good to get your hands dirty every now and then....

Healthbeat

Maggie Mahar over at Healthbeat was nice enough to feature a couple of my posts from this past month. Her blog is top notch. Definitely on my short list of med blogs I try to check 5-7 times a week.

I was amused by a comment from someone named Chris Johnson who had responded to my post about the distinction between surgeons who "own" the patient versus those who sort of "hit and run" after the procedure is done. Now Chris Johnson MD ,for all I know, may very well be the world's greatest pediatric intensivist but I don't think I've ever come across such an unintentionally pompous and condescending statement about the role general surgeons ought to play in the post operative period of a patient he/she has just operated on. Check this out:

I have to say that, from my prospective, Buckeye Surgeon represents an example of the kind of problems I encounter every day. For those of us who work in the ICU, the irritation of dealing with surgeons who truly believe they know everything I know (as an intensivist), and they can do surgery, too. On the other hand, I do appreciate the kind of proceduralist, be it surgeon, cardiologist, gastroenterologist, or whatever, who stops by regularly after they have done whatever they needed to do to see how the patient is doing and if we need any more of their help

That's nice that he appreciates when a "proceduralist" stops by occasionally just to make sure that the brilliant intensivist doesn't "need any more of their help". That's not patronizing in the least bit. Wait a second... yes it is. I write all the orders after a perforated bowel case, buddy. You can write your note and make your extravagant rounds with 16 people following you around (pharmacists, residents, students, social workers, etc) at 1pm (after the grand rounds lunch presentation) and I'll read it and implement anything I find beneficial to the patient and we can talk face to face about whatever issues you have, like professionals, but don't think I'm not going to be the Big Lebowski on the case. We're actually trained to take care of post-operative issues as general surgeons. Actually, we spend the majority of our time as residents learning and mastering pre and post-operative care of the extremely ill. So thanks for your help, Dr Johnson. I do appreciate your insight. But excuse me for a second... I have to go write orders for IV fluids, TPN, wound care, electrolyte replacement, and anything else that the sick patient down the hall needs....

Blunt force trauma

For the most part, the sort of cases you see at a suburban level II trauma center are rather banal. The old ladies who fall and come in looking like Rocky Raccoon. The guy who breaks a leg trying to clean the leaves from his gutters. The kid who falls of the monkey bars at recess. But every once in a while I see something interesting. The other day I was called about a young guy who had been ejected from his car at the time of a high speed MVC. He showed up tachycardic and hypotensive, but sort meta-stabilized after the initial resuscitation maneuvers were implemented. This enabled the ER doc to get him quickly to the CT scanner. When I first saw him he was still tach-ing away in the 130's and he looked pale and ghostlike. And he had peritonitis. I called the OR and got the blood infusing while I reviewed the images. For one thing he had a hilar splenic injury with massive amounts of hemoperitoneum. Hence the initial shock and peritonitis. The other interesting finding is portrayed in the image above....can you guess what it is?


Well, I'm not in the mood to be coy and let you play guessing games. It's a traumatic rupture of the diaphragm and it's not an injury seen very frequently, even in large tertiary care centers. The amount of blunt force necessary to cause the diaphragm to blow out is substantial and often these patients present with multiple injuries. No exception in this case. In addition to the splenic rupture, this kid also had a complicated pelvic fracture that ultimately had to be addressed at downtown level I trauma center.

Traumatic diaphragmatic injuries can be tricky to diagnose, especially when the injury is isolated. Diagnostic peritoneal lavage, laparoscopy, and thoracoscopy have all been utilized in recent years in algorithms to help facilitate the early identification of even small diaphragmatic tears. Isolated diaphragmatic lacerations from penetrating wounds are notoriously difficult to diagnose early; often the patient will show up years later with a symptomatic chronic diaphragmatic hernia. The repair itself is pretty straightforward. Several interrupted non-absorbable sutures will usually do the trick. You also have to worry about pleural contamination, especially if there has been a concomittant bowel injury. Lavage and drainage of the pleural space with a chest tube is sometimes warranted....

Weekend Rounds

I actually like coming in for rounds on weekends. I usually start early, around seven or so. The drive in is quiet and pleasant and I keep the windows rolled down and the fresh morning air all around me. The parking garage is nearly empty at this hour on a Saturday. I don't wear a tie; sometimes just a short sleeve Polo collared shirt under my white lab coat. The halls and lobbies are devoid of people. It's quiet. The bustle of action and people passing and trying to get somewhere fast is gone. There is a distinct lack of pace and urgency to the hospital that is quite refreshing. Remember when you were younger and you had to go into the middle school after hours for a practice or a meeting? How different and strange and interesting it seemed without the usual regimented fuss and human traffic? Weekend hospitals are similar...

I take my time. I visit with the nurses on the floor. Review the morning labs and vitals on the computer, sipping a large starbucks. There's no rush. I can spend some time with the patients. There're no cases to be done, usually. No office appointments. I can afford to review old CT scans, lab trends, variations in vital signs, the sort of things you sometimes miss or forget to check during the week when you're always running a little behind. It's a way to get caught up, reacquaint myself with all the little details on the patients.

Rounds are enjoyable. I usually examine patients a bit more thoroughly. I even use that thing that internists have hanging around their necks...a stethoscope, right? All dressings come off. Wounds are inspected. Stoma appliances are removed so I can see the cloaked beefy red bowel exposed at skin level. I look for erythematous IV sites and forgotten triple lumen catheters and foleys that have been left in too long. It's my chance to leave no stone unturned.

A lot of times, I'll pull up a chair after the exam is done. You can get a sense of how someone is doing, how he/she is really doing, by moving the conversation beyond the usual litany of "do you have pain, are you nauseous, have you pooped yet"...It's fun to shoot the breeze. Find out what interests them. What they like to do outside the hospital. The Nascar fanatic. The single parent divorced lady going to night school for her masters degree. The kid who works at the corner Subway. The guy who brags that his wife never had to buy a tomato from the grocery in 50 years of marriage because of the fecundity of his yearly backyard garden. I especially love finding out what old guys did before they retired. Policeman. Pharmacist at the drug store where I frequent. Math teacher at the local high school. The people who used to be all around us every day, the ones that time has passed by. I'm reminded that all these people stuck in the hospital on the weekend have lives, families, places and things they'd rather be doing. The least I can do is listen to them for a few minutes. You see, I get to eventually drive home in my truck. They don't. The weekend isn't a time to escape and relax for everyone. And that can be frustrating as hell. There's the lady on post operative day #6 after a colon resection with an ileus and the annoying nasogastric tube who thought she'd be home three days ago. She needs me to sit there in that chair holding her hand for an extra fifteen minutes, telling her she's not unusual, that everything is going to be all right. I owe her that. To a certain degree, there's a loss of one's dignity during hospitalization; all the shiny wood floors and smiling faces and fresh architecturally exquisite hospital lobbies can't mask the fundamental fact that you've been institutionalized temporarily. And the weekend can sometimes make it seem worse. Too often, I've seen docs try to whip through rounds on weekends in a half hour or so. Kids soccer game to get to. Or a barbecue. Or a Browns game. Weekend rounds are an underrated duty but I think the patients appreciate a doc who takes it seriously and it's one of my favorite parts of being a surgeon....

Well duh

Sometimes it's necessary to dress up the obvious as science in order to remind people (surgeons) of certain fundamental truths. The Archives of Surgery this month published an article entitled "Early Laparoscopic Cholecystectomy is the Preferred Management of Acute Cholecystitis". Whoa! Stop the presses! Alert the Nobel committee in Stockholm!

Seriously though, it has to be done every so often. We've seen this nefarious idea of "cooling down hot gallbags" creep into general surgery culture over the past several years. Admit the patient, put them on broad spectrum IV antibiotics (Zosyn) and if they feel better the next day, bring the patient back in several weeks or months for an elective cholecystectomy. Although this article isn't particualrly strong (retrospective, non-randomized), there is a wealth of recent surgical literature supporting earlier surgical intervention for acutely inflamed gallbladders. Hospitalizations are shorter. Accrued costs to the patient and hospitals are less. Fewer complications are seen. It's a no brainer.

So why are we cooling off gallbladders instead of whacking them out? Several reasons. In the early days of laparoscopy, it was felt that acute cholecystitis was a contraindication to lap chole. We now know that not to be true; in fact the operation often proceeds much more easily because the edema facillitates dissection of the tissue planes. But that initial thinking has carried over for some older surgeons who learned lap chole on the fly as attendings. Another reason, I'm embarassed to admit, is one of convenience. Sometimes it's hard to get a lap chole on the schedule at the end of a long day. Or maybe you just don't feel like waiting around until 8 at night to get it done. As opposed to appendicitis, there is a perception that hot gallbladders can be delayed and put off as long as the patient is feeling better with antibiotics. Finally, it's a resource issue. Especially at county or charity hospitals, OR time is limited and it's hard enough to get your appendix and perforated bowel cases on in a timely fashion. My skin starts crawling even now just thinking about the hassle and frustration involved in trying to start an emergency case at Cook County Hospital in Chicago.

Conservative management of acute cholecystitis may initially be successful but it's more expensive and leads to multiple and prolonged hospitalizations. Moreover, when the acute inflammation subsides, the gallbladder and porta hepatis heal by forming scar tissue which can distort normal anatomy and make the surgery much more dangerous. Most surgeons will tell you that some of the most difficult cholecystectomies they have seen are the ones done for patients with a long history of multiple gallbladder attacks.

Acute cholecystitis is one of the more common causes of "acute abdomen". The ideal treatment is surgical. Sometimes it's good to be reminded of that, no matter how obvious it seems.....

It always feels good when an operation goes perfectly: the ten minute lap appy, the flawless inguinal hernia, the 45 minute mastectomy. But nothing in the OR has ever given me the sort of rush I got when I was able to replace the sump pump in our basement. One day my wife was down there doing the treadmill thing and she noticed some discoloration of the carpet over by the far wall. It was completely saturated and we had to rip up a 10 x 10 foot section.

Water in the basement! Basically a newbie home owner's worst nightmare. We called a plumber who came out and told us our sump pump was busted and to fix it we had fork over 800 bucks. Now I dont know too much about furnaces or water heaters or car engines or sump pumps or any of that stuff. I'm actually sort of an idiot when it comes to handy-man activities. But I wasn't going to write out a panic check to some random plumber dude. So I got on the internet. I went to Lowe's about sixty times. I bought what I figured I needed. I wrenched the rusted old machine out of the pit and, because it was an old model, I had to attach adapters and cut PVC pipe to fit and apply this crazy hallucination-inducing liquid cement and use some tools I'd seen before. After about 6 hours of labor (and cursing and kicking things and dejectedly staring at the walls) I was able to get the son of a bitch in the ground. I plugged it in and damn if all that excess water didn't get sucked whoosh up into the drainage pipe and out of my basement. I screamed like I'd just struck out the last batter in a World Series game. I almost can't wait until our water heater breaks down.

One more thing....the global period

Lots of great feedback from everyone regarding my post on the MedPac/general surgeon controversy. Shadowfax submitted an interesting response in the comments section about the idea of certain procedures being "over-reimbursed". Why should an ankle fracture be reimbursed far more than the hour he spends sifting through the critical care complexities of a patient in the ICU?

It's a good point but not an entirely fair one. First of all, let me back up for a second. There is a tendency to group all physicians who perform procedures together under one banner. GI, general surgery, ortho, vascular, dermatology, plastics, cardiology, etc. But they aren't all the same. Far from it. I see two distinct categories of "proceduralists".

1) The "Hit and Run Bandits": You're the PCP. You consult Specialist X. Specialist X sees the patient, books the case for the next day, does the case, says thank you very much, and signs off as soon as the patient gets wheeled out of the procedure room. Ortho is quite good at this. As is GI. In and out. No hassles. Easy billing.

2) The "You Operate, You Own It Crew": These poor saps (general surgeons) tend to get sucked into being the primary care provider for all the patient's needs as soon as the scalpel is unsheathed. Patient admitted to internist from ER with "nausea". CT shows volvulus. Surgeon consulted. Emergent, life saving operation. Patient to ICU, attending physician changed to "Dr. Buckeye".

Now I wouldn't have it any other way. I operate, I own it. That's the way I was trained. I run the show. I correct the electrolytes. I manage post op hypertension and pain. I write my own TPN. I order my own insulin drips. I make most of the critical care decisions for my sick patinets in the ICU. That's the way it is. My part doesn't end when I take off my mask. Often, it's only just beginning.

So what does this have to do with Shadowfax' point about the overcompensation of proceduralists? Well, there's this little thing called the 90 day global period in medical billing. Basically that fee you collect for the cholecystectomy or the cataract or the Whipple is supposed to include the cost of all the post operative care (with a few exceptions) that the patient receives for 90 days. If you're the GI guy and you do a negative colonoscopy for anemia, you could care less; you'll never see the patient again once the procedure is done. You collect your fee and that's the end of it. But imagine a perforated diverticulitis that comes into the ER and you do the left colectomy/end colostomy routine but the patient is septic and limps along in the ICU for a week and you're writing TPN and managing hyperglycemia ruling out pulmonary embolisms and your pager is always going off and its three and a half weeks until she/he finally leaves the hospital. Suddenly, that fat fee for the intial procedure doesn't look so great when you add up all the hours of work and stress you've put into the patient's recovery.....

Perhaps general surgeons are being dumb about the whole thing. Maybe we ought to just be like the orthopods and refuse to have anything to do with the care of patients outside the operating room. Just dump it all on the internists/hospitalists.

I don't see it happening though. The problem is I kinda like what I do. I actually like being, you know, a doctor. I don't see myself as a "proceduralist". Maybe I'm a dying breed. Maybe the concept of the "general surgeon" is becoming an anachronism. But until it actually happens, I'm going to continue doing things the only way I know how.

Let's assume for a minute that we are dealing with a zero sum game. There's only so many dollars to go around and the PCP's are scrambling to pay their bills and it's apparent some redistribution of funding is necessary. Should general surgeons be the first target? Really? We're ok with radiologists and dermatologists raking in half a million bucks a year? Maybe if these hit and run proceduralists weren't so "overly compensated", more of our bright medical students would opt to go into primary care and alleviate the growing shortages in that area.....

Physician owned and operated

One response physicians have had over the years to the battle over dwindling reimbursements has been to seize the reins of health care delivery themselves, by building physician owned and operated hospitals and/or surgicenters. By controlling the means of health care delivery, doctors regain a certain sense of autonomy in an era where big government in America desperately tries to neuter our political voice. After all, aren't we just "providers"?

Recently, I was approached by group looking to build a physician owned facility a little south of me. They were looking for investors from all the subspecialties to assist in the construction of a unique health care facility that would be postioned to compete for those patients located between the giant Cleveland behemoths and the hospitals in Akron. For the most part, it would be entirely physican owned, with the internists/primary care docs getting in on the ground floor. It sounded interesting, I had to admit. But then I came across an article in the NY Times today that made me pause.

Apparently, there has been a steady, driving force from Democratic circles (Hi Pete Stark!) over the years to restrict the existence of physician owned facilities. The assumption is that when doctors own a hospital, they will order more unnecessary tests and procedures because there exists a financial incentive to do so. In other words, you can't trust those unscrupulous docs in such ethical dilemmas. Now I understand that not all physicians are angels sent down from the Mount. Think of the orthopedic guy who buys an MRI for his office and next thing you know, everybody in town gets magnetized. Or the General surgeon who buys an ultrasound machine and basically does a full body exam (breast and thyroid ultrasounds included) on all office consults (even when the patient is sent over for a hemorrhoid). Or the family practice doc who has his own lab and ends up ordering twice as much blood work as the guy down the street.

I'm not naive enough to think this doesn't happen. Doing the right thing for the patient always takes precedence over any financial gain. But at the same time, isn't this a market driven, capitalistic country? Just playing the devil's advocate, but why should physicians be excluded from playing the game? Or a better question: what drives physicians to feel the need to play such a game? And what if the doctor who buys his own ultrasound uses it justifiably? Like only when a patient comes in for a breast mass or a thyroid nodule? Why shouldn't he be able to bill for expertise in using a specialized instrument? Why should he have to send the patient off to the radiologist for an ultrasound that may be more expensive, and certainly wastes time? If you don't trust him, create a way to audit his billing records; if there is any question a third party arbitrator can determine whether the test is or isn't justified.

I just think the Pete Starks of Washington have it in for us. Once again, it's an attempt to demonize physicians as profiteers looking to wring everything they can out of the system. As if we are the source of the profligate waste of our country's health care dollars. Of course, as long as your local democratic politician (I mean you, Patty Murray!) is on your side, there is always the chance a "special dispensation" will get written into the law...

Those evil surgeons

I've been wanting to write about this for a while. Recently, the Wall St Journal Health Blog highlighted a letter the American College of Surgeons sent to MedPac, the advisory group that makes recommendations to Congress with regards to Medicare funding. Essentially, the ACS objects to a plan to raise Medicare pay outs to primary care physicians in a "budget neutral" manner. What does this mean and why is the surgical community outraged? Because "budget neutral" is a code phrase for "take money from from those evil, greedy surgical specialists and give it to the family practice docs".

The headline of the WSJ article is frankly disingenuous. Surgeons aren't opposed to primary care docs getting more money. We're all for that. But don't obtain that funding from the already dwindling surgeon's piece of the pie. Many surgical procedures have seen reimbursements cut 40-60% over the past 20 years. And that's not an adjustment based on inflation; those are real, bottom-line dollars. If you want all specialties to be paid the same, that's fine. But if that's the case, then we all better share in the liability and the risk. You want part of my earnings? Then make sure we all pay the same malpractice premiums. Oh, and make sure that I get paid like an attending during my fourth and fifth years of residency and any additional years of fellowship I might pursue, to ensure my salary is equal to the family practice doc from the get-go. It's all about equality, right? It would only be "fair".

I believe Sid Schwab touched on this earlier, but it bears repeating. This is a perfect scenario for the federal government and the insurance companies: doctors from different specialties fighting each other for the piddly scraps of revenue that they decide to dole out to us. I don't need to write a treatise to defend the concept that some specialties ought to be paid more than others. It would be insulting to everyone's intelligence. Let's get beyond that. Primary care certainly needs to be better remunerated. Being forced to see 50 patients a day just to break even isn't a sustainable business model, nor is it good medicine. But the fault doesn't lie with the surgeons. We're right there in the trenches with you.

As an analogy, imagine major league baseball without a players union or a collective bargaining agreement. Owners with their multi-billion dollar TV contracts could dictate player salaries to be whatever they chose. Maybe the power hitting first basemen gets a lucrative contract because he produces and is a gate attraction. But what about the slick fielding shortstop who steals a lot of bases and hits for a high average? Maybe he doesn't hit a lot of homers, but he is arguably just as valuable as the first basemen. It wouldn't be fair to pay him a pittance for his efforts. Would he begrudge the power hitter his salary? Of course not. He might be jealous, but he would never demand that the first baseman fork over a portion of his salary to "make things more equitable". He knows the owner is sitting on a pile of cash. He'd call the owner and say, Pay me what I'm worth, dammit.

There's plenty of money to go around. The discrepancy in pay between the GI doc and the PCP is not the reason why health care is so expensive. The giant HMO's and the pharmaceutical conglomerates would love to have you believe that. There's a reason both are multi-billion dollar industries. Let's not nickel and dime each other. A united front is our only hope of ensuring that the backbone of the American health care system, i.e. the physicians, does not deteriorate into a collection of second- rate, infighting, backstabbing special interests.

Sleep

Tough weekend. Trauma and ER emergencies kept me scrambling. I think I slept four or five hours Thursday, Friday, and Saturday combined. (Don't tell the work hour Nazis.) It happens every once in a while. The pager won't stop. Rounds go on forever. As soon as you get home, something else shows up and back you go. Waiting around in the office for a case to start at three in the morning, mindlessly playing TextTwist on Yahoo games......

So I've been a bit of a zombie the past couple days. A few nights of solid sleep should recharge me. In the meantime some random bits....

Nice post from the Pallimed blog about withdrawal of care. Interesting perspective from a non-surgeon. I still think my idea of leaving the endotracheal tube in, along with snowing the patient with propofol/morphine, is the way to go. Love to hear other opposing viewpoints...

I tuned in to Dr Anonymous' podcast last Thursday for the first time. He interviewed Bruce Froedtert MD, an ENT doc from Wisconsin. It's actually a cool thing he's got going. There's also a chat room where you can interact with other med bloggers and pose questions for the guest. Be sure to check out the next installment.....

Hillary roars to a win in Puerto Rico. Now, if only she can sweep the Grand Cayman Caucuses and the Aruba Primaries, she may yet win the nomination...

One of the hardest things about being a younger attending? Getting used to calling older physicians by their first names. Addressing silver haired guys who look like my grandpa as "Rich" or "Mike" is just a little bizarre. I'm getting used to it though....