Monday, September 29, 2008

Vasculitis and Acute Cecal Infarct

A 27 year old female presented with 24 hours of severe, acute right lower quadrant abdominal pain. She had a white count, focal RLQ peritoneal signs and she simply looked ill. The CT scan was read: "peri-cecal inflammatory changes and thickened appendix, all consistent with acute appendicitis." Again, she was 27 and had no known other medical conditions. It seemed like yet another clear-cut case of appendicitis. So we booked her for a presumed laparoscopic appendectomy.

Once inside, it immediately became obvious that the intial diagnosis was incorrect. The appendix was normal; pale-pink and supple and striated with healthy blood vessels. Her cecum, however, appeared to have sustained some sort of hemorrhagic infarct; bright red, edematous, almost like a smashed tomato. So I switched gears and performed the ileocecectomy laparoscopically. At the top of my list was Crohn's disease or typhlitis (cecal inflammation usually seen in immunocompromised patients). The final pathology surprised me; severe mesenteric vasculitis with segmental colonic infarcts.

Vasculitis is a general term to describe a multitude of disorders characterized by an autoimmune-mediated inflammation of blood vessels. Basically, the body attacks the proteins in our vascular system and causes destruction, thrombosis, and ultimately tissue death of the supplied organ. Here's a good link that reviews systemic vasculitides.

Examples of systemic vasculitides include lupus, Wegener's granulomatosis, polyarteritis nodosa, and Takayasu's arteritis. Rarely, there can be gastrointestinal manifestations. In this case, the patient did well after the resection. She resumed a regular diet and went home by post op day #3. But she still has an elevated CRP and ESR and there was evidence of vasculitis at the resection margins. Rheumatology is involved and and the autoimmune work-up is pending. My concern is that the segmental, systemic nature of these diseases puts her at risk for future events.

If anyone has any ideas/experience with this, please let me know.

My first internet stalker

Back in April I posted about my initial foray into the 33% tax bracket and the shock associated with getting that first bill from the IRS. Add up the local and state taxes and I paid close to 40% of my income to governmental entities last year. The point of the post was to posit the question: how much is enough? When have my societal obligations have been filled? Why is the solution to our nation's ills to raise taxes on individual families while corporations pay next to nothing?

Since then an internet troll named "Jon" has been posting comments on this blog where he calls me an elitist and various other uncomplimentary names. Big deal. But then today this "Jon" went a little too far. On the SurgeXperiences post he writes, "I did a little research", and proceeds to expose my address and the price of my house here in Cleveland (as some sort of asinine explanation for why I need to pay more taxes). Then, inexpicably, he uses my wife's name.

That doesn't happen, buddy. If anyone on this site ever uses my wife's name again or inquires into her private life I will expend all my energy and all my disposable income (according to Jon, this is substantial) to bring the perpetrator to the proper lawful authorities. Now let's all be nice.

Sunday, September 28, 2008


Welcome to another scintillating edition of SurgeXperiences. It's my 2nd time hosting, which is cool. Jeffrey Leow has done a terrific job in establishing this thing as the definitive Grand Rounds for surgery. Next time anyone sees him around the neighborhood; buy him a drink.

We'll start with a few posts from Bongi. Anyone who spends any amount of time browsing through medblogs is familiar with his wry and insightful takes on medicine in South Africa. First is a harrowing tale about a time he was on the other side of the sterile drapes giving anesthesia. Next is a story about a Cesarean section gone horribly wrong. (Fortunately, the South African John Edwards didn't hear about it.) Finally, he relates a story about a time he was moonlighting as an....African killer bee exterminator. Apparently, there were no shift openings for "lion tamer" that would fit into his surgical schedule.

Keeping it on the continent, Eishmadiskakhi (buddy of Bongi) gives us an amazing checklist that will prove you are indeed a Saffa doctor.

No surgical grand rounds would be complete without a few takes from Ramona Bates. First, she draws much needed attention to an issue that often gets swept under the rug; physician depression and suicide. Here's a link to information on the documentary she highlights. I also liked her review of a recent article from the plastic surgery literature investigating the psychological consequences of post-bariatric surgery patients undergoing subsequent body contouring surgery. It's important that patient expectations are tempered with a dose of reality before proceeding with post bariatric body contouring.

The Sterile Eye describes the difficulties of filming transvaginal repairs of vesicovaginal fistulae so that surgeons in Africa can adequately learn the procedure. He also has a nice post on surgical history about Alexis Carrel and the technique of triangulation for vascular anastomoses. Plenty of general surgeons also use triangulation for intestinal anastomoses.

From Inside Surgery is a great interview with the noted pancreatic surgeon, Dr Charles Yeo.

Make Mine Trauma runs the show at the terrific blog IntraopOrate and she's also a consistently valuable contributor to the medical blogosphere. Reading her posts and you can't help but appreciate her enthusiasm and dedication to being a surgical first assistant. She's the kind of professional any surgeon would want to work with. Here's a story about her persistence in learning the steps of a total knee replacement. Not one to simply go through the motions, she devised a way to get a cheat sheet sterilely into the OR so she could better anticipate the steps of the case. Also, she alludes to some old Seinfeld lore with a take on the benefits of having, um, well developed hands.

Here's a blog I hadn't heard of before called Head and Brain Injuries. It's described as the "comprehensive resource for survivors and their families" and there's a lot of good stuff on it. For instance, check out this review of the different types of surgery performed for traumatic head injuries.

There were several submissions from nursing blogs, which was nice. Here's a helpful guide to managing your own health care. And from RNCentral is a compendium of the 100 best medical blogs for nursing students. (Unfortunately, Buckeye Surgeon did not make the cut. Alas.)

Laika, a medical librarian, reviews a paper from the infectious disease literature that highlights the relative unimportance of patient temperature measurements in the post-op period. I agree that most fevers in the first 24 hours after an operation are simply a reaction to the trauma of surgery. But not always. I like my vital signs on my patients. I don't think I'll be getting rid of them anytime soon.

Hey, here's a cool story from White Coat Rants about a rapidly closing airway in the ER.

Here's a blog (by way of Ramona) called Surgery, Passionately. She's a hand surgeon in New York City who gets reminded of how good we have it after an encounter with an unfortunate guy with a chronic, festering finger infection.

There's a new surgical blog in the neighborhood called Ant Ears. He's a surgical resident in Pennsylvania and is interested in a career in rural general surgery (and if that continues to be the case, he certainly won't lack for job offers). The first link is to a story of health care delivery in small town America. When home health care is not available, it's up to family and friends, even strangers, to pick up the slack. One wonders how this would work in large metropolis. He also writes a thought provoking post on the notion of case number inflation. Good stuff in there.

Now let's go to the two minute drill:

From ShockMD- A post about the paucity of women who actually perform self breast exams, and whether it matters.

From DrCris- The ways surgeons can use something called Evernote. (I'm the guy who doesn't understand Twitter; of course I don't get this.)

From Plastic Surgery 101- The utility (or lack thereof) of routine MRI screening of silicone breast implants.

From Medical School of Hard Knocks- A student's description of his first day in the operating room (ah, the memories!)

Aggravated Doc Surg gives us an entertaining little review of enterovesical fistulae and an unforeseen, rather simple, treatment.

And I couldn't pass up the opportunity to end this SurgeXperiences with a story about a man who went in for a circumcision and ended up having his rod whacked off. Hopefully it grows back. Reminds me of a joke I heard this week:
Two guys are having a beer to celebrate the birth of the first one's baby.
-How big is he? the friend asks.
-Well it depends.
-Depends? Whatcha mean it depends?
-Well he was 27 pounds when he first came out. But by the time we got him home he was only 8 pounds.
-Huh? What the hell happened? Didn't the hospital feed him?
-Nah, it was the circumcision.

Thanks to everyone who submitted. And happy new year to our Jewish colleagues.

Thursday, September 25, 2008

Dr A Show

Thanks to Dr. Anonymous for having me on his show. I only mumbled and rambled half as much as I expected. Anyway, his show is a must-listen on Thursday nights.

Check my bracelet, please

From today's NY Times:
New York’s 11 public hospitals are at the forefront of a national movement to standardize color coding of hospital wristbands to designate patient conditions, in which purple — the color of amethyst — means “Do Not Resuscitate.” Red, or ruby, indicates allergies, while yellow — call it amber — marks someone at risk for falling.

The goal is to prevent potentially dangerous mistakes, like giving the wrong food to an allergic child, or allowing a patient with balance problems to walk unescorted down a freshly waxed hallway. The drive was spurred, in part, by a notorious 2005 Pennsylvania case in which a patient nearly died because a nurse used a yellow band thinking it meant “restricted extremity” (don’t draw blood from that arm), as it did at another hospital where the nurse sometimes worked, when at this hospital it meant D.N.R.

"Good morning Ms Smith. I'm Dr Buckeye and your internist wanted me to see you regarding some abdominal pain you've been having.."
"Well hello Dr Buckeye. Ive been waiting breathlessly for you. Breathlessly."
"Um... ok. Before we begin, I can't help but notice that you have hundreds of little plastic bands around both your arms."
"Oh these? These are my color coded hospital wristbands that will hopefully reduce the risk of me suffering from some medical error that you guys are notorious for."
"Oh. Interesting. I see this red one indicates a penicillin allergy, but I must say, I don't recognize most of the others. I didn't realize there were so many designations."
"It's a new thing. And I'm very specific in my desires and goals. You can't be too careful when you're in a hospital. Did you realize that medical errors are the seventh leading cause of death in this country?"
"Um, that's not true, actually.."
"For instance, this mauve one indicates that I'm a germophobe. You're going to have to put on that body suit and airtight helmet before you touch me."
"That looks very hot and uncomfortable."
"Oh it is. And this periwinkle band means I have a sensitive rectum so they need to change the toilet paper to triple ply Charmin and make sure the bedside commode has a padded seat. Speaking of accomodations, this plaid band means I have allergies to most fabrics and textiles; all my hospital gowns have to be from either the 2008 or 2006 Vera Wang line."
"Not 2007?"
"God no. Those are embarassing. I can't stand tackiness. Along those lines, this checkered black and white band requires someone to adjust my television set so that there is no chance of the channel alighting upon a NASCAR race. And this Aquamarine band reminds the nurses to play Barbra Streisand continuously as a soothing background music. Achooo!!!"
"Opsy, looks you didn't see the burnt siena band; indicating to you that I prefer 'God Bless you' when I sneeze."
"God bless you then."
"Thank you. And make sure you note the red, white, and blue band. That will remind you to write an order for an American flag to be unfurled every morning at 7 so I can recite the Pledge of Allegiance. Wait a second, what are you doing?"
"I was just going to listen to your lungs."
"Is that stethoscope pre-warmed?"
"Obviously you didn't see the Navy wristband. Cold stethoscopes against my skin give me the Willies. And the yellow ochre band reminds the maintenance people to keep my ambient room temperature between 72-75 degrees fahrenheit. Ow! Why are you touching me there?"
"I was just examining your abdomen."
"Well someone wasn't paying attention to this wristband right here."
"It's a crude drawing of a human body., What am I supposed to do with that?"
"Duh. It's supposed to remind you to review my chart before examining me so you know where my trigger points are from my fibromyalgia."
"I see. What about this green one?"
"That's hunter green. It signifies that I'm environmentally conscious. All paper products that are used on me have to be recycled."
"And why does this one have a picture of Colonel Sanders on it?"
"I'm allergic to fast food and anything made in a hospital. People with this wristband are supposed to get a special diet delivered from the higest rated (per Zagat's) Italian trattoria within ten miles of the hospital. My baked ziti is supposed to be here any minute, by the way"
"Sounds delicious. What about this purplish one with a broken wedding band on it?"
"That's Han blue, actually. And it's a warning to keep any doctors away who look anything at all like my cheating, good for nothing ex-husband. 6'2", salt and pepper hair, wonderful moustache, a tendency to rub his chin when he's thinking..."
"Fortunately I'm quite short. And sans facial hair."
"And the carmine bracelet, which is right next to the Han blue, is a warning that I'm at extremely high risk for breaking down and crying for hours at a time if any hospital personnel resembling my ex's secretary enter my room; young, blonde, perfect calves...."
"Um, what about the one with the giant eyeball."
"That just means I've had hidden cameras installed in every corner of the room. My people are watching your every move, even as we speak."
"Terrific. What about this one around your ankle? It appears to be filled with pentagrams and other symbols of demonology."
"Oh. You're weren't supposed to see that one. That's why I keep it under the covers. It has my attorney's phone number written in Wiccan so only I can read it. You know, just in case any of those "never events" I read about happen to me."
"How convenient. Fortunately it doesn't appear that you have appendicitis. I guess I'll be seeing you. Good luck with everything."
"Thank you Dr Buckeye. Make sure you take off that body suit before you leave."

Wednesday, September 24, 2008

Dr Anonymous Show

Well, I'll be on the Dr A show tomorrow night. Tune in if you like. Just don't expect 90 minutes of oratorical brilliance from me. I am a surgeon, after all. Anyway, the chat room is fun and it's worth a try if you haven't listended to his show yet.

Also: I need more submissions for the SurgeXperiences Carnival...submit here.

Monday, September 22, 2008

Virtual Reality

Last week, The New England Journal of Medicine published a study evaluating the efficacy of CT colonography (virtual colonoscopy) compared to standard optical colonoscopy. 2600 patients received CT colonography with a follow up standard colonoscopy on the same day. The results show that virtual colonoscopy identified 90% of adenomas/cancers greater than 1cm in size.

As KevinMD suggests, this could instigate a turf war between radiologists and gastroenterologists as both specialties fight to tout their procedure as the surveillance technique of choice of colorectal cancer. Because virtual colonoscopy is completely non-invasive (no long black tube up the rear, elimination of the risk of perforation) one can certainly see the appeal to the general population as the preferred screening method, but I'm not necessarily convinced that that will be the case because, ultimately, this may be a turf war the radiologists don't want to win.

The current theory of colorectal cancer development is one of step wise progression from polyp to dysplastic polyp to frank invasive cancer. The reason polyps are removed at colonoscopy is that polyps are thought to be pre-cancerous lesions; therefore take out the polyp before it has a chance to transform into a cancer, the thinking goes.

However, there's a kink in the theory. This year in JAMA, a study was published by the folks at Palo Alto called "Prevalence of nonpolypoid (flat and depressed) colorectal neoplasms in asymptomatic and symptomatic adults." It's a cross sectional study of over 1800 patients who underwent colonoscopy at a California VA. What they found was a 9.35% prevalence of non-polypoid lesions. Furthermore, after biopsies were performed, these lesions were found to have a higher incidence of harboring invasive cancer regardless of lesion size. Now, flat polypoid lesions are difficult to spot on normal optical colonoscopy. You have to proceed much more slowly and make sure you thoroughly inspect the entire mucosa of the colon. Even so, these lesions can be easily missed. With virtual colonoscopy, there's no chance of spotting them.

So even though the public may demand more CT Colonographies, all it's going to take is a couple of missed flat lesions or even peduncular polyps (10% miss rate in the NEJM article!) that turn into a stage III cancer and the turf war will come to a very quick ceasefire. I don't think GI guys have too much to worry about yet.....

Friday, September 19, 2008

Carnival of Surgery

I forgot that I'm hosting SurgExperiences on September 28th (or round about there, depending on how efficient I can be). Please submit your posts here. Thanks.

Thursday, September 18, 2008

Duodenal Diverticulum and Jaundice

Elderly lady comes in with recurrent RUQ pain and jaundice. US shows gallstones and a dilated common bile duct. No stones seen in the CBD on MRCP. The GI consultant attempts an ERCP but the common duct cannot be cannulated secondary to a peri-ampullary diverticulum, noted to be full of food matter. I obtain the Upper GI barium study shown above.

Intermittent jaundice has been described in association with peri-ampullary duodenal diverticula, although it's quite rare. Options include formally excising the diverticulum versus simply bypassing the distal segment of the CBD with a biliary-enteric anastomosis.

My stance is always to do the safest surgery when feasible. This diverticulum was on the mesenteric aspect of the duodenum, bulging into the pancreas. Formal excision and sphincteroplasty would have been a complicated, potentially dangerous, operation. Even in the hands of the experts at Mayo, there is a substantial mortality/morbidity rate with such an endeavour. So I simply did the cholecystectomy and bypassed the obstruction with a choledochoduodenostomy. Post-operatively, her liver function tests normalized. Five weeks later she's still symptom free.

Wednesday, September 17, 2008

Not everyone can be Cliff Lee

I read with interest the recent, and highly blogged about/commented-on, article from JAMA about the career leanings of fourth year medical students. The stunning finding from the paper is that only 2% of graduating students plan to become primary care internists after completion of residency. Another 5% are ticketed for a family practice career, while another 12% plan to pursue primary care pediatrics. Add it up and it means that 82% of graduating medical students are looking to stay far, far away from the very field of medicine where there is the most need. Moreover, 70% of general surgery chief residents are doing super-specialty fellowships rather than taking jobs as bread and butter community general surgeons

Very interesting. And with the possible ascension of Obama to the presidency, and his promise to bring health care to all the uninsured in some vaguely defined fashion, the problem of physician access becomes even more pronounced. So why are our talented, bright students from this generation opting out of primary care?

The reasons have been reviewed ad nauseam: poor pay (relative to the subspecialties), increased paperwork, hassle from insurance companies/Medicare, lack of perceived autonomy, overall sense of dissatisfaction. I get that. And I applaud those who do choose primary care. Primary care represents in its purest form what the concept of "doctoring" is all about. Patients are followed over the course of a lifetime and an astute clinician can diagnose and treat illnesses of acute and chronic nature. Long term relationships are established. Ideally, it can be one of the most rewarding careers available to a motivated and intelligent prospective young doctor.

I don't necessarily buy the premise that all we have to do is pay primary care docs a little more and the problem will be solved. The article in JAMA suggests this to be the case as well. Certainly the debt load that a young doctor has to shoulder is a factor but I think the reasons for the primary care shortage are deeper. I think there is a generational component involved that doesn't get addressed as much as maybe it should.

We live in the era of "work hour reform". Surgical residents are forced to go home following a night on call, irrespective of work to be done. In a few years, new restrictions may limit residents to 57 hours in the hospital per week. And the only uproar and dissent you hear is from the old guard of established attendings. Residents and medical students almost universally support the new measures.

Anticipated lifestyle has become a major factor in determining career choice of younger medical students. I'm not going to stand in judgement of anyone who decides that spending time with family and being able to go to the opera and symphony on weekends is more important than slaving away in a grungy hospital late into the evening or going into the OR to do an emergency colectomy at 3AM. But this is medicine. You are a doctor. Disturbingly, medicine has become a default pathway career choice for high achiever types who don't want to become lawyers or financiers. Magna Cum Laude? Oh, you ought to go to medical school. You'll make six figures and earn the respect of your community.

There is this sense of entitlement that comes with such thinking. A sense that "I've earned the right to do what I want and enjoy my life" just like those guys from college who weren't as smart but have been bringing home solid coin for ten years as "consultants" while you scrimped and deferred gratification on your resident salary. Younger doctors expect, even demand, both financial compensation and the ability to work the same hours as the CPA guy down the street.

As an analogy, think of an All-Star Little League team. The first day of practice, everybody tells the coach they want to play shortstop or pitcher. That's what they did on their regular teams. But not everyone can be the shortstop. You can't have 9 starting pitchers. Somebody has to be the catcher. Somebody has to trudge out to the lonely post in right field. Otherwise, your team will get crushed. Similarly, we have all these medical students who want to be dermatologists and radiologists and plastic surgeons. Well guess what? We need more right fielders in medicine. We need more motivated medical students who want to throw themselves into primary care and general surgery. Frankly, I'm not sure why students are allowed to choose whatever they like. If we need more primary care docs, them we ought to mandate that a certain percentage of graduating seniors have to go into IM or family practice. Mandate that only a select few can obtain fellowships in GI or plastic surgery or pulmonology.

Like most problems, the solution involves some sort of compromise between rival factions. Something needs to be done about the ridiculous debt burden that students must assume. And the pay discrepancy needn't be so extreme. But younger doctors need to do their part as well. This job, being a doctor, isn't like any other job. It's a privilege and certain obligations come with the privilege of wearing the white coat. You're going to have to do some scut work. You're going to have to work more weekends and evenings than you thought. You're simply going to have to give more of yourselves to your patients if you want to earn the entitlements you want.

Friday, September 5, 2008


I've become a huge fan of the Wire. The wife and I have churned through seasons 1 and 2 in a few weeks and now we're on to season three. Best show I've ever seen. It's not even close. In the clip above, we have the old veteran detective Freamon teaching the incorrigible McNulty a little lesson about the difference between the life we lead at the "job" (whatever that may be) and the time we spend at home; our hidden, often unacknowledged life. It could just as easily be an old surgeon like Sid Schwab giving a young guy like myself some wisdom.

In medicine, it's easy to get caught up in the Job. It's a rush. It's exciting to come into the hospital most days. Every case is a new adventure. You can change someone's life either by making a crucial diagnosis or performing a timely procedure. There are few career options that are so privileged. It's the best job in the world, as far as I'm concerned.

But in the end, it's still just one facet of my life. As Freamon says, "how do you think it all ends?" There will always be another case. Another sick patient. Another complication. Another chance to to do some good. But it never ends. And it keeps going long after we've shuffled off this mortal coil. Life is more than the Job. It has to be or else you'll eventually be overwhelmed by despair, as you realize that you can't fix everyone. There has to be something else outside the hospital, something that is an alternative source of edification. Life goes on when you turn off your pager. It's all around us, everywhere we go. Sitting here writing this, it's happening to me right now.

Eventually there will be no Job to save us. And it's up to us to make something of those rainy Saturday afternoons, the quiet Wednesday night in winter, the 16th anniversary dinner date with your wife, the lonesome retirement, the empty house when the kids have grown and moved on. These aren't just events to fill the gaps between the hours you spend working as a doctor; this is the essence of life itself. As Lester eloquently states, "life is the s*** that happens while you wait for moments that never come."

Anyway, sorry to get all corny and depressing on everyone. I suppose I do need a vacation. Fortunately the rental house has WiFi so I may post a story or two from the beach...

Monday, September 1, 2008

Small Bowel Volvulus

I was called to see this patient emergently for sudden abdominal pain. He was a 65 year old alcoholic, tall and thin and gaunt-faced. He drank a liter of Vodka a day, a refugee in our ER that day from the VA system. He had peritonitis on exam and his lab work was rather discouraging. Severe metabolic acidosis. White blood count over 25k. Creatinine 5.1 (new onset ARF). He was a mess. Buddy, we need to try to find out what's going on with an operation, I told him. Whatever doc, he said. Just get me some more pain medicine.

Look at those images above. That's a high grade bowel obstruction with extensive pneumatosis intestinalis and retroperitoneal air. You always think about perforated duodenal ulcers in alcoholics with retroperitoneal air but there was no free fluid and no evidence of peritoneal free air. Whatever. He needed an operation but I figured it was probably too late. That degree of pneumatosis is usually an ominous and end-stage sign

He'd never had an operation before and with his body habitus it was easy and fast opening him up. The proximal jejunum looked purple and the associated mesentery bubbled with the retroperitoneal air. The loops of bowel proximally were grossly dilated so I did what I always do when operating for a bowel obstruction. I found the cecum and marched my way backward toward the ligament of trietz. The ileum was pink and peristaltic and completely decompressed. As I approached the jejunum, I sort of got stuck. It seemed things were arranged weirdly. It seemed the jejunum had somehow flipped around on its vascular axis, kinking both the lumen and the blood supply. So I flopped the bowels around a couple times like a twisty tie and amazingly the jejunum started to "pink up". I spent a lot of time screwing around with an extensive duodenal dissection (take down ligament of trietz, Kocher maneuver etc) just to make sure there wasn't any frankly necrotic bowel. But it all looked fine. Dilated as hell and edematous. But viable. I didn't know what else to do, so I closed him up. Fortunately, he did quite well. The kidney failure resolved within a couple days. The acidosis resolved.....but he spent the next three weeks going through some serious DT's.

Small bowel volvulus is a rare cause of bowel obstruction. Here's a good review from the medical literature. I don't know why my patient suddenly volvulized his intestines. It wasn't a case of adult malrotation (which I've also seen)and it wasn't a sequelae of a primary cause, like adhesions from previous surgery or internal herniation. It just.... sort of....happened. Anyway, he's better now. I'm just lucky I detorsed the volvulus when I did; dead duodenum and proximal jejunum aren't compatible with any surgical cures.....