The Fall of the Invincible One

Not to delve too far into the realm of hyperbole, but I had the case of a career recently. The patient was a 77 year old vasculopath. CABG. Carotid endarterectomy. Fem-pop bypass. Basically every major blood vessel was afflicted with some degree of advanced atherosclerosis. Patient X had been admitted several times over a four week period for early satiety and abdominal pain. A CT angiogram of the mesenteric vasculature revealed a near complete occlusion of the celiac artery and a high grade stenosis of the superior mesenteric artery. It was a textbook case of chronic mesenteric ischemia. The plan per vascular surgery was to bring patient X in at some point for elective angiography and stenting of the SMA.

Well the patient apparently hadn't read the playbook. Showed up one day in the ER with severe, unrelenting abdominal pain and hypotension. For some reason, an ultrasound was ordered in the ER and the patient was admitted with a diagnosis of "cholecystitis". And that's how I got involved. Well I went to see patient X and frankly I was appalled. Patient X was in some serious trouble. Looked like hell. Tachycardic. Confused. Diffuse peritoneal signs on physical exam. This is more than just a gallbladder problem, I told the family.

I stepped out for a moment and reviewed the blood work and the previous investigations that had been done. The lactate was elevated to 6. The WBC count was 27k. Other than the ultrasound, no other imaging had been done in the ER. I scanned through the CT angiogram of the mesenteric vessels from a month ago. And this is when things started to move quickly. I called the vascular surgeon to inform him of patient X's admission and current decompensation. He rushed right over and concurred with my assessment. Within fifteen minutes patient X was on the angio table. This time, the angio showed a near complete occlusion of the SMA as well as the celiac. Somehow, they cannulated the take-off of the SMA and were able to dilate and stent it. Instantly, blood flow was restored to the mesenteric circulation. The previously hazy, indistinct fluoroscopy screen lit up with a florid, interlaced arterial arcade.

But the patient still looked like hell. There was peritonitis on exam. We went directly from the angio suite to the OR. Anesthesia was given and I entered the peritoneal cavity. I immediately encountered bilious contamination. I started at the Ligament of Trietz and ran the small bowel all the way to the cecum. The bowel was pink and peristaltic and completely non-pathologic. The colon likewise appeared grossly normal. At this point, my suspicion was for a perforated duodenal ulcer but close inspection of the pylorus/duodenal area failed to demonstrate an injury. The only thing left was the stomach. The left lobe of the liver was retracted out of the way and the rib cage was gently elevated to better display the subdiaphragmatic area. What I saw was shocking. The entire stomach, and only the stomach, was black and gangrenous, and there was a large ischemic perforation on the greater curvature. I was forced to do a total gastrectomy with a super-tenuous esophagojejeunostomy reconstruction. At midnight. On a sick old patient with a billion medical issues. God, it's great to be a general surgeon.

The stomach is the supposedly invincible organ of the GI tract, like the queen in chess. It's supposed to be impossible to devascularize the stomach because it gets it's blood supply from so many different sources. The left gastric artery comes right off the celiac trunk. The right gastric artery is a branch of the hepatic artery. The gastroepiploic artery is fed by branches from the SMA and the celiac. The short gastric arteries siphon blood from the splenic artery. It's hard to necrose the stomach even if you're feeling especially reckless and/or malicious. When we pull the stomach up through the chest as part of an esophagectomy procedure, three of the four main arterial trunks are tied off but the stomach does just fine.

What happened in this lady was quite interesting. She already had a near occlusive lesion of the celiac trunk. That knocks out flow to the right and left gastric feeders. Previously she was noted to have a stenosis of the SMA as well. Presumably this SMA stenosis then progressed to the critical point whereby blood flow via the celiac/SMA collateral system was insufficient to maintain perfusion of the end organs. In addition to gastric gangrene, her gallbladder was compromised (I guess the ER was right all along!), and her liver enzymes were greatly elevated post-operatively (indicating ischemic insult to the liver parenchyma). Without the pre-op angioplasty/stenting of the SMA, my surgical intervention would have been for naught. Fortunately, Patient X is plugging right along, doing much better than I would have ever thought....

The Choice

There's a fascinating book from 2004 called "What's the Matter with Kansas: How Conservatives won the Heart of America" by Thomas Frank that explores the irony of how middle class, blue collar Kansas became a solid red state, consistently voting for conservative policies that are contrary to its own best economic interests. By using such "hot-button" issues like gay marriage and terrorism and abortion, the Republican Party was able to capture the hearts of Americans who didn't stand to benefit economically from fiscal policies aimed to appease the wealthy.

As this momentous election draws to a close, I find myself in the same position, only for opposite reasons. My wife and I are both physicians. Our combined income will put us in that subset of wage earners who will have to pay the piper with an Obama victory. You know, because we're "rich" and have to "spread the wealth". Even though we didn't start to make anything until we were in our thirties and have a mortgage and owe close to $300,000 in school loans and reimbursements are tumbling and the threat of malpractice always looms, we're the "lucky ones". That's the perception. There's not much I can do to change it. So why on earth would I consider voting for the candidate who aims to take more money out of my pocket and spread it around throughout various aspects of an expanded byzantine federal bureaucracy?

By nature, I have conservative leanings. I believe in individual responsibility. I believe that individuals need to be held accountable for their actions. I believe that increased government involvement in our daily lives leads to stagnation, complacency, and mediocrity. There's a reason this country has led the world economically, politically, and morally for the past one hundred years. Free markets and free exchange of ideas leads to an environment conducive to innovation and creativity. Granted, such a system is susceptible to greed and intransigence but for every Ivan Boesky or James Cayne, there are a hundred more like Bill Gates and Steven Jobs and Sergey Brin. Government intrusion in the form of higher taxes and increased regulation may help to "spread the wealth" but at the cost of hindering risk taking and innovation.

That being said, the Republican Party, ostensibly the steward of conservative principles, has lost it's identity. The past 8 years has witnessed a party hijacked by a fringe contingent of righteously indignant social crusaders. Somehow, the party of Abraham Lincoln and Theodore Roosevelt became the party of Rush Limbaugh and Rick Santorum and Karl Rove. Politics trumped policy. Instead of proposing reality based solutions to the nation's ills, they resorted to meaningless, abstract, somewhat menacing (in an Orwellian way) stock phrases like "country first" and "patriotism". Extraneous right wing causes like gay marriage and gun control issues assumed a prominence in Republican discourse above more substantive concerns. Republican support for the Medicare reimbursement reduction this summer further alienated the party from a reliable ally in physicians.

The Bush administration, moreover, has been an unqualified cataclysm. An ill-advised war prosecuted under false pretenses and conducted with an ineptitude of historic proportions. The prodigal expenditure of American moral authority and international influence through arrogant unilateralism and third world torture tactics at Guantanomo. The Katrina disaster and the delayed, inadequate response. And now, the financial crash on Wall Street, with the inevitable trickle down effect to Main St. George W. Bush has clearly demonstrated that he is a man who lacks intellectual vigor and curiosity. Under his watch, the country has gone from being the unquestioned hegemonic leader of a post-cold war world to an isolated pariah, marginalized in the world's eyes by the failures and embarassment of financial ruin and the debacle of Iraq. His claim to fame was national security. But Afghanistan is spiralling out of control and the Taliban lurks, waiting to pounce on the power vacuum developing in nuclear armed Pakistan. Are we really safer than we were 8 years ago?

Now I like John McCain. But I liked him a whole lot more in 2000. He was the independent, moderate Republican back then. The Straight Talk express. But that campaign was sabotaged by unsavory, deceitful insinuations made during the North Carolina primary by the Bush apparatchiks. The McCain of 2008 is now 72 years old. He made a move to the right, assuaging the Christian Coalition of Ralph Reed and Jerry Falwell. His thinking on issues such as the economy and national security seem very regimented and partisan. I don't sense that McCain, for all his personal valor and strength of character, is much of a consensus builder anymore. And the ludicrous selection of Sarah Palin as a running mate has to be one of the more short-sighted and cynical moves by a candidate for the Presidency in the history of American politics. Her bumbling performances over the past 6 weeks raise serious doubts about McCain's decision making and judgement.

Barack Obama leads this race confortably with less than a week left. He's going to be our next president. But he will ascend to that position despite having a resume thinner than pretty much anyone else who's ever run for the high office. He has no experience in an executive capacity. He is the junior senator from Illinois who has passed no legislation of note. Who has proven to be one of the most liberal voters in the Senate. Who slithered his way through the Chicago political machine unscathed, betraying allies along the way and doing absolutely nothing to clean up one of the most corrupt political establishments in the country. Barack Obama the factual man is extremely unimpressive. His record is sparse. Based on the facts, all we can predict is that he will raise our taxes and implement policies to increase government intrusion into our lives. His campaign is built on vague promises and empty appeals. Change, he says. What's going to change? And how?

And this is the essense of the election. Obama the man has become irrelevant. Obama the concept, however, has swept into the hearts and souls of this country and has attained an unstoppable momentum. This country is hungry for something fresh. The anticipation of his anunciation is a palpable thing. There is an energy and lifeforce to his campaign that is solely lacking from McCain's. He is youthful and a first rate intellect. He presents himself as a man who is guided by reason and fairness. His thinking is refreshingly non-dogmatic. His nuanced reply to the Reverend Wright controversey this summer was one of the most impressive things I've read from a politician in my lifetime. There is a curiosity and intellectual humbleness to Obama that we have not seen from a President in a long time. For some reason, I don't see Obama approaching the Presidency with a strict liberal "agenda". For some reason, I can see him paradoxically acting more moderately than everything in his history would suggest. If he wins as resoundingly as is predicted, I'm willing to give him that chance. The question remains though: are these reassuring qualities by themselves predictive of a successful Obama Presidency?

I still haven't made up my mind. A part of me thinks that maybe it would be a good thing for McCain to lose. Perhaps a resounding defeat would send a message to the Republican Party loud and clear that we have truly entered a new era. Out of the shambles of defeat, hopefully the party could regroup and find itself again. Voting for Obama would be an act of insanity for me, financially. But it's kind of like rooting for your favorite team to lose when the season is already lost, because a worse record will net you a better draft pick. The Cleveland Cavaliers pretty much tanked the 2002 season. The following year, they chose a local kid named Lebron James with the first pick in the draft.

Obama will be inaugurated with a clear majority, an unquestioned mandate to govern, and a legislative branch accomodating to his liberal stances. Time will tell. After all, 2012 is only 4 years away....

K-II

Kellen Winslow Jr., the all-pro tight end for the Cleveland Browns, has always been a little hard to take. The son of a Hall of Famer has had a career marked by controversy and playing field achievement. I've never been a huge fan. He was the villain in the 2003 title game between Ohio St. amd Miami. He has that crazed rant (see above) about being a soldier playing the game of football (while hundreds of American servicemen were dying monthly in the killing fields of Fallujah). Still rehabbing a broken leg his rookie year with the Browns, he foolishly blew out his ACL speeding on his motorcycle. Currently, he's embroiled in a contract dispute with Browns management even though he has several years left on the signed deal. He can be insufferable and incredibly self-absorbed. But, as painful as it is for me to say, I think he's getting a raw deal in this latest flap.

Winslow was hospitalized last week for three days at the Cleveland Clinic Foundation (world renowned, most advanced institute of higher medical performance) under mysterious circumstances. Rumors on the internet suggested a horrifying case of, um, orchitis. Winslow himself broke the silence this week, saying he was afflicted with another staph infection, his second in the past two years. Where and how severe were not identified. Winslow claimed that the Browns "encouraged" him to keep the details of his infection private. When his GM didn't call him in the hospital, his feelings were hurt and he angrily opened up and intimated that his workplace environment is possibly unsafe: “There’s obviously a problem and we have to fix it. Just look at the history around here.”

Seven Browns have now been infected with MRSA (methicillin resistant staphylococcus aureas) infections over the past few years. LeCharles Bentley, recovering from bilateral patellar tendon repairs, developed a MRSA infection that required multiple trips to the OR for washouts and there was talk at one time of the possibility of an amputation if the infection didn't clear. Clearly, there is something going on. Winslow expressed his (understandable) concern to the press and the Browns responded by suspending him for a game and fining him $235,000. The case is currently being appealed by Winslow.

Even in the quasi-fascist realm of the NFL where players are routinely fined for endzone celebrations or having the wrong color socks and are governed by the vaguely menacing and Orwellian "personal conduct code", this is going a little too far. Even Roger Goodell can't legislate what comes out of K-II's mouth. Phil Savage, the Brown's GM, then awkwardly tried to invoke HIPAA laws to justify why the Browns wanted Winslow to keep silent. Of course HIPAA laws don't apply when the patient in question willingly decides to discuss the case publicly himself. The maneuver by the Browns was a bullying, mean-spirited tactic meant as retribution against a player who would dare to speak ill of the "organization".

In the bigger picture, we are starting to see an epidemic of MRSA-related infections in NFL players, especially those in the immediate post-operative period. Recently in the news, there have been stories about staph infections following operations on Peyton Manning and Tom Brady. It isn't just the Cleveland Clinic. And I'm not surprised. From my lowly perch as a general surgeon, I see almost exclusively MRSA related soft tissue infections. Even in community acquired boils/abscesses, it's rare to see one that isn't caused by MRSA. I don't even bother writing for Keflex anymore; doxycycline or bactrim is the choice for presumed staph. Years of inappropriate antibiotic use has led us to the brink of this new epidemic. And there's no better milieu for the rapid spread of a contagious organism than the locker room/weight room setting. It will be interesting to see what measures are implemented to reduce future occurences in the NFL. MRSA is here to stay, however. Secrecy and misinformation campaigns are ill advised coping mechanisms for an issue that will only become more prominent in the days ahead, and can only serve to further alienate athletes from the monolithic organizations that employ them....


Update from 10/25: The Browns have announced that the fine/suspension has been rescinded. Apparently, the Winslow camp presented evidence to the Browns in the form of a text message from a Browns PR representative instructing him to "keep quiet" about the MRSA aspects of his hospitalization... Or maybe Phil Savage just read this post and realized his mistake.

More never event absurdity

Just when I was starting to calm down about the controversy surrounding "never events", the New York Times unloads a masterpiece of naivete and contempt. Reading this, my eyeballs almost popped out of my skull. One would think that the editorial staff of such a renowned, prestigous newspaper would exhibit a little more intellectual rigor when composing such a denunciatory op-ed piece. I almost thought Diane Suchetka had infiltrated the NY Times hierarchy.

And now, from the other side of the political spectrum, comes a piece from the National Review (arch conservative publication)that uses the concept of never events in such a way to elucidate the danger of government managed health care delivery. (Thanks to Alice at Cut on the Dotted Line)

To review: "never events" are a new designation for "avoidable" complications that arise during hospitalization. Certainly, wrong site surgery ought not to happen. But the list of never events includes such things as urinary tract infections, surgical wound infections, falls, pressure sores, c difficile colitis, delirium, deep venous thromboses and other similar such events that often arise in the setting of critical illness. Interestingly, you will not find a publishable work of science that describes how to reduce the risk of these events to zero. Why? Because it's impossible. If you put a rubber catheter into your bladder, I don't care how sterilely it's done, eventually a certain percentage of them will cause a urinary tract infection. It's a foreign body, for godsakes. And DVT's are not entirely preventable. Everything we know about prophylaxis with Lovenox/heparin/compression hose talks about risk reduction. There are no magic formulas or medicines or healing balms that will completely eliminate the risk of blood clots. It's absurd. The entire concept is absurd.

Basically, this an attempt to cut costs and distribute blame under the guise of "patient safety". And the ironic thing is, it won't cut costs at all. If anything, we're going to see doctors ordering more tests to prove that the patient had a pre-existing condition prior to admission to the hospital. The rise of community acquired MRSA and even c diff infections mandates this.

Furthermore, these viewpoints articulated by two prestigious national publications illustrate a shocking lack of understanding of the terminology with never event proposals. It attempts to lump together true medical errors (wrong site surgery, blood transfusion reactions) with undesired outcomes that occur despite preventative measures. A bad outcome should never be assumed to be a consequence of a "mistake". It's like sending Josh Beckett down to the minor leagues just because he gives up a home run to a good hitter. Take for example decubitus ulcers. All it takes is 30 minutes of unrelieved pressure from a mattress against your buttocks to compromise capillary blood flow to skin and subcutaneous tissues. Now imagine a 500 pound post op gastric bypass patient flat on her back on an air mattress. It takes 6 people to rotate her every two hours. She gets a pressure sore anyway. At what point was her care compromised? Please demonstrate the error. Ought we to have zero gravity chambers available for such scenarios?

The other fallacy has to do with this idea of "physicians making money off their own errors". Give me a break. Let's say I note a wound infection after a colon surgery. I open the incision a bit and drain the pus. I don't charge for it. The patient goes home with wound care instructions and gauze. Or let's say I diagnose a DVT after a low anterior resection. I put the patient on anti-coagulation and maintain the INR at 2-2.5 for 6 months. I don't charge for it. It all falls under the post operative global billing period anyway.

So let's dispense with this idea that physicians are just racking in the dough taking care of typical post op complications. The entire argument is fallacious and disingenuous. And as long as respected publications like the NY Times and the National Review continue to promulgate this nonsense, the sooner the general public will accept it as the conventional wisdom. Very frightening indeed.....

The Dwindles

There's nothing more frustrating than a dwindler. You get the 83 year old lady with free air to the OR expediently (3am). The operation proceeds quickly and smoothly. You promptly get her off pressors and restore renal function with timely and appropriate resuscitation. Post op she gets extubated by day 2. The stoma looks pink and fleshy and starts putting out stool by day 4. You get her up in a chair. She smiles. Her labs all normalize. Things are progressing swimmingly.

But then she won't eat. She refuses to participate in physical therapy. She lays in bed all day. The smile fades. You enter the room and she barely looks at you, a blank gaze, dull-eyed and lifeless. You try to keep her spirits up. You encourage family members to get involved. But every day you see yet another full tray of cold, uneaten food. She starts to cough a little. You have to commence tube feeds via a nasogastric tube to supplement her nutrition. Then one night you get a call from the nurse. "Dr. Buckeye, Mrs. Dwindles is short of breath and her heart rate has jumped to the 130's. She looks like hell." You send her down to the ICU. CT scans are done. Labs are drawn. She looks septic. The white count is elevated. There's an infiltrate in the lower lobe of the lung. She spikes a fever overnight and continues to deteriorate. She's saturating 89% on a non-rebreather mask. The family opts for intubation and that seems to help for while. Antibiotics are started and she begins to semi-stabilize as the pneumonia clears up. But she never really gets over the hump. She just doesn't seem to have the heart for it anymore. Maybe she stabilizes enough to be transferred to an LTAC, maybe not. Either way, she isn't anything like the woman she used to be. Everything good and vibrant and distinctive about her as an individual has already dissipated. She simply dwindled away.

These sorts of patients can be very frustrating. No matter what you do, no matter how textbook the operation, no matter how perfectly you manage the recovery phase, sometimes the patient fails to progress. You bang your head against the wall searching for an underlying reason. But the explanation is quite simple. A patient needs to want to get well. They have to want it with every ounce of their being. It doesn't matter how hard you work or how many tests you order. Once a patient loses the heart for the good fight, the ultimate outcome is inevitable. For a young surgeon, this can be one of the most difficult pills to swallow...

Employee based health insurance

Here's a thought provoking piece from the Boston Globe arguing that the traditional link between employment and health insurance ought to be severed. Now I won't pretend to be an expert on the complexities of health insurance policy and tax codes but the article makes a couple of interesting conjectures (especially with regard to third party payors), even for an amateur like myself.

After all, we don't rely on employers for auto, homeowners, or life insurance. Those policies we buy in an open market, where numerous insurers and agents compete for our business. Health insurance is different only because of an idiosyncrasy in the tax code dating back 60 years - a good example, to quote Milton Friedman, of how one bad government policy leads to another.

During World War II, federal wage controls barred employers from raising their workers' salaries, but said nothing about fringe benefits. So firms competing for employees at government-restricted wages began offering medical insurance to sweeten employment offers. Even sweeter was that employers could deduct those benefits as business expenses, yet employees didn't have to report them as taxable income. For a while the IRS resisted that interpretation, but Congress eventually enshrined the tax-exempt status of employer-based medical insurance in law.

Result: a radical shift in the way Americans paid for medical care. With health benefits tax-free if they were employer-supplied, tens of millions of Americans were soon signing up for medical insurance through work. As tax rates rose, so did the incentive to keep expanding health benefits. No longer was medical insurance reserved for major expenditures like surgery or hospitalization. Americans who would never think of using auto insurance to cover tune-ups and oil changes grew accustomed to having their medical insurer pay for yearly physicals, prescriptions, and other routine expenses.

We thus ended up with a healthcare system in which the vast majority of bills are covered by a third party. With someone else picking up the tab, Americans got used to consuming medical care without regard to price or value. After all, if it was covered by insurance, why not go to the emergency room for a simple sore throat? Why not get the name-brand drug instead of a generic?

This complete disconnect between consumers (patients) and knowledge of the cost of the delivery of health care is a major issue. What would happen if we made grocery stores covered by a "national food insurance initiative" and we ran it the way we run medicine, where only a third party is aware of what we spend? You could saunter into your local Giant Eagle (or Safeway or Kroger or whatever) and start loading up. Why buy generic sliced cheese when you can fill your cart with the ultra cool hunks of gorgonzola and gouda? Why buy three boxes of Cheerios for $5 when you can get three different, significantly more flavorful brands? Count Chocula and Lucky Charms! Why buy a loaf of boring wheat bread when you can get frshly baked french baguettes straight from the oven? It's all the same. Someone else pays for it.

At some point, this "moral obligation" to provide health care for all Americans needs to become more of a two way street. Maybe not two lanes in each direction. More likely four lanes one way and a dirt road going the other. But at some point the consumers (individual patients) need to assume some responsibility. With third party payors, there's no incentive to contain costs on the consumer end. On the provider end, physicians' urge to contain costs is trumped by a fear of litgation.

Cost containment, then, needs to be addressed at both ends of the stick. Tort reform is the first obvious step. Once the fear of fruitless lawsuits is removed, then we can hold doctors accountable for the ordering of unnecessary tests and changing a patient's perfectly effective generic hypertensive pill to the latest flashy new combo med that costs ten times as much. On the other hand, perhaps we need to involve patients more in the decision making process. When you go to get your oil changed, those mechanics are always trying to scam you into replacing your air filter or serpentine belt or whatever as well. Even when it's not technically recommended. (I love how they have to always take out the filter and show you how incredibly filthy it is, even when it just got replaced three weeks ago). But the choice is yours. And it isn't hard to say no.

Maybe in medicine the same rules ought to apply. If you want the most expensive medicine, the body scan, the dubiously indicated MRI, then you have to contribute to the costs individually, outside the coverage parameters of your insurance plan. Having a tiered distribution of resources is not a foreign concept in this country. Those who can pay, generally are more apt to receive the most extravagant and limited options. As long as the standard of care is not compromised, those of limited resources ought not to be eligible for certain tests/procedures if not clearly indicated. Rationing, unfortunately, is going to part of any conversation we have going forward on health care reform.

Now someone could make the argument that having a nationalized health care delivey system would solve the problem of third party payors; under one omnipotent banner, decisions on tests/medicines could be made unilaterally without input from doctors or patients. But I don't think we really want to toss all our marbles in the basket of a completely government-run system. The history of bloated, behemoth government bureaucracies is not so reassuring (see the VA system and county charity hospitals).

Sports Hernia Redux

I've written about this topic before. But here we go again. Jeremy Shockey, the New Orleans Saints tight end, is upset. It seems he's still feeling pain in his groin following surgery for a "sports hernia". He feels that the team made him return to the playing field too soon. Moreover, he thinks the team doctors screwed up by not diagnosing his "hernia" sooner:

`I'm worried that this thing could have been taken care of in camp, like it should have been,'' said Shockey, who the Saints acquired from the New York Giants in July for two draft picks. ``If it wasn't misdiagnosed in camp like it was there'd have been no problems. ... Next time I know. When I get hurt I'll get three or four opinions besides just the team's.''

That quote pretty much encapsulates everything that's wrong with the concept of "sports hernia". No clear diagnostic tests. Multiple medical opinions often sought. No clear time frame on the recovery period. Shockey is like the sixth or seventh professional athlete this year I've read about who had surgery to fix an alleged sports hernia. Kevin Curtis, the Philadelphia Eagles WR, had surgery way back in August and he still isn't due to return to the team for several more weeks.

If you present to me with an actual inguinal hernia and I fix it in the standard fashion, I pretty much remove all restrictions by week 3 or 4 post-op. The Kevin Curtis situation is simply outlandish. Three months off just because some expert surgeon tacked a piece of mesh to your strained lower abdominal muscles? It's absurd. Hopefully, these kinds of undesired outcomes will lead to NFL players thinking twice before subjecting themselves to future sham surgeries.....

Soft Eyes

The title of this post is another reference to "The Wire"; this time from season four. I know, I just used a clip from "The Wire" last month. I acknowledge that. I'm a repetitive son of a bitch. But it's the best thing this country has produced in terms of the visual arts (TV, movies) in a long time. Anyway, there is an episode in season four where Greggs, a rookie female homicide detective, gets stuck with a seemingly unsolvable case; dead drug dealer turned informant on some back alley with no witnesses. Greggs pieces it together by going to the scene and picking up on the little details. Her senior partner sees the perpetrator in the interview room and he's dumbfounded. How'd you do it? he asks. Soft eyes, she says.

You have to look at things from different perspectives. It's those hard eyes that get you in trouble. An inability to see things beyond the clouded distortion of past experiences. Surgery, in a way, is quite similar to breaking down a crime scene. We're taught a technique. We know the anatomy. We have xrays and ultrasounds and other data to use going into an operation. But you can never anticipate the contingencies. Unfortunately, we don't all look exactly alike on the inside and it's the subtle variations that can sabotage an operation. If you go into an operation thinking it's going to be just like the other hundred you've done before, you're going to get someone hurt.

The laparoscopic cholecystectomy affords plenty of opportunities for surprise. Aberrant ducts. Posterior branches of the cystic artery. And all the adventures associated with acute inflammation. More than any other operation, the lap chole requires your utmost vigilance. You can't go through the motions. You can't flip on the autopilot switch like you can for say, an inguinal hernia or a lipoma excision. You better keep those eyes as soft as you can.....

Ascending Cholangitis

There are few emergencies in biliary disease. Run of the mill biliary colic can be managed as an outpatient. Even patients with acute cholecystitis can be cooled down for 24-48 hours with fluids and IV antibiotics prior to definitive surgery. But a patient presenting with ascending cholangitis is another matter. Delays in intervention can be life threatening.

The fundamental problem with cholangitis is some obstruction of the common bile duct. Most commonly, the cause is from a gallstone that trickles out of the gallbladder and lodges itself in the distal duct. Other etiologies include strictures and tumors. The bile flow is stanched and the patient will become jaundiced. Pooled bile is a terrific medium for bacterial overgrowth and gram negative organisms such as e. coli and klebsiella can superinfect the biliary system. The end result is purulent bile under pressure and, with the common duct obstructed, it decompresses back into the liver, accessing the systemic bloodstream via the portal triads. Bacteremia and rampant sepsis ensues.

I saw a patient the other week who had been admitted through the ER with a diagnosis of "sepsis". When I walked into the room she was in extremis. She was frankly jaundiced and had one of those wide-eyed looks of horror on her face. Her systolic blood pressure was in the seventies and she was breathing 40 times a minute. Her thighs were mottled bluish-black in a marbled pattern and her fingers and toes were dusky and cold. She was maxed out on levophed and vasopressin. Her white count was 20k and her bilirubin was over 10. On exam she could only mumble incoherently on questioning. Her abdomen was distended and she had diffuse peritoneal signs. We rapidly obtained control of her airway and pondered the next move.

For most patients with ascending cholangitis, the best initial move is an ERCP (endoscopic retrograde cholangiopancreatography). ERCP is both diagnostic and therapeutic. A sphincterotomy can be done to open up the ampulla and stones impacted in the distal duct can be scooped out with a basket retriever. Relief is often immediate. Much like a boil that feels better after it's lanced, ERCP will usually lead to rapid improvement in the patient's condition. Subsequently, the patient can then undergo a laparoscopic cholecystectomy to remove the source of the problem.

This patient was a different situation. Not too many GI interventionalists are going to be too excited about doing an ERCP on an unstable patient. Although we could have placed a PTC drain (percutaneous transhepatic cholangiography)for immediate decompression, I was concerned about her diffuse peritoneal signs. I wanted to have a look inside myself. Sometimes the safest course of action in these situations is to get a very ill patient on an OR table with some general anesthesia. Upon entering the peritoneal cavity I encountered bilious ascites and the gallbladder was frankly gangrenous. After washing everything out and doing a quick cholecystectomy, I performed a Kocher maneuver (mobilization of the duodenum)and I could palpate several hard stones in the distal common bile duct. A choledochotomy was made and I used a Fogarty balloon catheter to extract several stones. A cholangiogram conformed clearance of the duct and I closed the choledochotomy around a T-tube. Anesthesia was able to get her almost completely off the levophed by the time I was done.

This was a very unusual case. We seen patients jaundiced with common duct stones quite frequently in surgical practice but it's quite rare for a patient to progress so quickly to septic shock. Charcot's Triad (RUQ pain, fever, jaundice) is the classic descriptor of ascending cholangitis. It's the question every medical student rotating through a surgical service gets asked. Lesser known, and more ominous, is Reynaud's Pentad. In addition to pain/fever/ jaundice, hypotension and mental status changes are seen in this more severe variety of ascending cholangitis. This was the first time I've seen manifestations of Reynaud's Pentad in an actual patient.....

HIDA Scans: A call for a moratorium

We can all agree that baseball games last far too long. One of the biggest reasons for these protracted snoozefests are all the extraneous time waster crap that occurs. Batter stepping out of the box to adjust their wristbands and gloves. Or pick-off attempts, for example. Now I don't mean the quick move to first when there's an actual basestealer taking a big lead off first. I'm talking about those lazy, lobbed soft tosses to first when the slow, lumbering clean-up hitter is standing 7 inches from the bag. It's like the pitcher is saying, " you know, I'm really not ready to pitch to the batter. I think I'll kill some time by needlessly lobbing one to my first baseman." I can't stand it. It wastes time. It doesn't add anything. Nothing is gained. Ban it.

With health care costs spiralling out of control, it would be prudent to re-evaluate the American way of ordering test after test on patients who come into the hospital. We need to start asking ourselves: What can we eliminate? HIDA scans, in a way, are the general surgical equivalent to the lobbed pick-off throw to first. For the most part, they don't add much to the proceedings. Here's the typical scenario: Patient presents to ER with RUQ pain and nausea. An ultrasound is performed which shows multiple gallstones in the neck of the gallbladder. Some wall thickening of the gallbladder is noted. The patient is admitted to the internist on call (happens more often than you'd think). The internist then reads the official US report in the morning. Invariably, there will be sentence at the end of the report along the lines of this: "Recommend HIDA scan if there is concern for acute cholecystitis". So, the dutiful internist orders the "recommended" HIDA scan and gets a general surgery consult. General Surgeon comes to see patient but patient not in room. Down in nuclear medicine, the clerk says. So general surgeon leaves, comes back in an hour or two. Still no patient. Still in nuclear medicine for delayed images. General surgeon silently swears into his head. Returns at the end of the day. Patient clearly has RUQ tenderness, a positive Murphy's sign. The US shows stones. The HIDA hasn't been read yet. Doesn't matter. He books the patient for lap chole as soon as OR time available, which likely will be the following day. So now, the patient gets an extra couple days and an unnecessary test added on to his/her final bill.


A HIDA scan (hepatobiliary iminodiacetic acid scan) is an imaging procedure that involves injecting a radiotracer into a peripheral vein. The tracer gets picked up by the biliary system of the liver and is excreted via the common bile duct into the gallbladder and duodenum. A HIDA scan that shows non-filling of the gallbladder after a certain amount of time is diagnostic of acute cholecystitis; cystic duct obstruction being the sine qua non of the calculous biliary disease.

Sounds all well and good. But acute cholecystitis is, for the most part, a clinical diagnosis. RUQ pain. Nausea/bloating. Often developing after eating a fatty meal. Positive Murphy's sign on exam. An ultrasound demonstrating gallstones pretty much confirms the diagnosis. You really don't need anything more. A HIDA scan may or may not be positive, but the result is irrelevant. You already have a strong clinical suspicion of cholecystitis; so take out the gallbladder!

There are plenty of scenarios where a HIDA is warranted and useful:
-The demented old lady with gram negative sepsis who is a poor historian and has an unreliable physical exam.
-The ill patient in the ICU who has been on TPN for weeks and has an unexplained leukocytosis.
-Patients with symptoms of biliary dyskinesia (another blog post altogether)
-Evaluating for the possibility of a bile leak after biliary surgery

But straight-forward acute calculous cholecystitis in a reasonably healthy, alert patient should be obvious enough without biliary scintigraphy. Let's save ourselves the $1500 a pop that HIDA scans cost. Ultrasounds are cheap and highly sensitive. Enough is enough. Starting now, let's all try to limit how often we send our patients down to the basement of radiology for time-consuming, expensive, needless, and ultimately useless, testing. We can do it; I have faith.

Mammosite

Prior to the early 1990's the standard of care for a woman diagnosed with Stage I or II breast cancer was to perform a modified radical mastectomy. That all changed with the publication of two major randomized controlled studies (National Cancer Institute in Milan,Italy and the NSABP B-06 in the USA) comparing mastectomy with the three headed attack plan of lumpectomy/axillary lymph node dissection/whole breast irradiation (Breast Conservation Therapy, or BCT). Ipsilateral recurrences were slightly higher with BCT but overall survival was shown to be equivalent between the two treatment methods, even out to twenty years.

This paved the way for the acceptance of the minimalist approach to breast cancer and gave women a viable alternative to the potentially disfiguring and psychologically disturbing option of mastectomy. Not only was BCT more cosmetically appealing, the accrued science had proven that it could stand confidently next to modified radical mastectomy as a legitmate standard of care in the treatment of breast cancer.

A recent problem has developed, however. We are finding that of the women who opt for BCT, 10-15% of them are not completing the recommended treatment cycle of whole breast irradiation. The most plausible reason for this is that radiation therapy is extremely inconvenient and time consuming. Most regimens mandate daily treatments over the course of 5-7 weeks. Imagine that for a moment. Every day, before work, you have to drive into the hospital and spend an hour in the radiation oncology department. For 6 weeks. Now imagine that the hospital is far away or your workplace is on the opposite side of town or you have to get your kids to day care by a certain time or maybe you're all alone and you don't get around as well as you used to.

Now certainly, these issues ought to be addressed by the surgeon performing the definitive operation. Inability to comply with the demands of radiation therapy is a valid counterindication to BCT. But the non-compliance issue has prompted a search for alternative strategies. Radiation is given to reduce recurrence rates to a level comparable to mastectomy. Omission of radiation doesn't necessarily worsen survival, but recurrence rates are unacceptably high without it. New data has suggested that 70% of recurrences after lumpectomy occur in the area of the resected tumor bed. Furthermore, the incidence of recurrence in other quadrants of the breast is equivalent when comparing BCT with or without post operative radiation. This raises the question: Can we simply irradiate the tumor bed and thusly achieve local control with longterm recurrence rates equal to the standard of whole breast irradiation.

Accelerated partial breast iradiation (APBI) can shorten the length of radiotherapy to five days and it comes in a couple of different flavors.
1. Interstitial Catheter-based Therapy:

-This technique is highly user dependent and requires a technical expertise that has limited its applicability to a wider population.

2. Balloon-based Intracavitary Radiotherapy
-Examples of this include the Mammosite balloon
-A catheter is placed in the resultant lumpectomy cavity either at the time of the surgery or shortly thereafter (once margins and lymph node staus has been determined) and radiation is given via the balloon catheter twice a day over 5 days.
-Easier to learn and perform; better opportunity for widespread use
-Preliminary data suggests that locoregional control and recurrence rates comparable to whole breast irradiation.


What are the Exclusion Criteria for APBI/Mammosite?
-Primary tumor must be less than 3cm
-Cannot have positive lymph nodes
-Margins of lumpectomy specimen must be clean
-At least 7mm of skin spacing to avoid skin necrosis

Can you describe the process of Mammosite Balloon placement?
First, we determine suitability of the patient for APBI with Mammosite. (See above exclusion criteria) Then the definitive BCT surgery is performed (usually lumpectomy/sentinel node biopsy.) At the time of the intitial operation we leave the Cavity Evaluation Device (CED) in situ as we wait on final pathology and margins. The CED helps to hold and maintain the space for the actual Mammosite balloon. Once margins and pathology is clarified we exchange the CED for the Mammosite balloon either in the OR or in the office. An ultrasound probe is used to confirm placement and to check skin spacing and cavity conformity. Next, the radiation oncologist will often obtain a CT scan of breast to further elucidate targeting strategies and cavity conformity. If all goes well, the treatment commences shortly thereafter.

What is the bottom line?
At this point, although the preliminary evidence for APBI with the Mammosite Balloon is encouraging, we do not yet have definitive, level I evidence to support its use as standard therapy. At this point, it's still an experimental treatment modality that cannot be routinely recommended for all women with early stage breast cancer. The ongoing NSABP B39/RTOG 0413 trial is a randomized controlled trial comparing conventional whole breast irradition with APBI in patients with Stage 0,I,and II breast cancer. Results will be available in the year 2015. In the meantime, I cannot in good conscience recommend APBI until the level I evidence is there to support it.

Now there are scenarios where it may be appropriate. I will always recommend whole breast irradiation as the standard of care when discussing BCT, but I have had patients who research partial breast irradiation on their own and then ask me about its utility. These are patients who would likely fall into that 10-15% category of non-compliance anyway. They are adamant about not going through 6 weeks of treatment. And they don't want a mastectomy either. As long as we discuss the science behind the decision making and the risks of proceeding with a treatment regimen that is not currently the accepted standard of care, I will place Mammosite balloons on occasion.

On Disclosure

About a month ago I decided to reveal my true identity on this blog. For a year I had been known simply as "Buckeye Surgeon". I didn't make a big deal of the change. No announcement. It just happened that one day I published a new post with my name and picture in the upper right hand corner of the screen. Now why would I do a crazy thing like that?

There are a variety of reasons, actually. On a personal level, I just felt that if you're maintaining a blog and you're taking strong stances on certain issues, whether it be the politics of medicine or management strategies of certain disease processes, then you owe it to yourself, and your readers, to stand behind that stance with your identity. One of the biggest criticisms (and entirely valid, I might add) of the blogging endeavour is that anonymous blogging can lead to an undisciplined, hypercritical, sneering style of writing that devalues the oftentimes valid points you're trying to make. There's no hiding when the cloak of anonymity is removed. That's my name up there in the corner. If I write something snide or uncomplimentary, or if I come at an issue with a poorly thought out line of reasoning, then I have to live with the consequences. In essence, you put yourself on the firing line without the shield of anonymity. There's a higher standard of accountability. So you better bring the goods.

Also, I have found (via sitemeter) that people are visiting my blog for answers to their medical questions. If you google "anal fissure" or "hartman's procedure" or "fournier's gangrene" or "jackson pratt drain", a post from Buckeye Surgeon will usually be on the first page of the search. Maybe I'm being naive, but I think this modest little thing of mine can potentially be a useful source of information, especially as we move deeper into an era where patients rely on the internet more and more often as a "second opinion" with regards to their individual health issues. If that's the case, perhaps the knowledge that I'm a real general surgeon, and board certified at that, will allay the fears of some anonymous visitor from Malaysia of whether I'm reasonably trustworthy and legitimate.

Furthermore, I still think we are in the infancy of med-blogging. I think the sky is the limit. Barack Obama's intuition of this fact allowed him to trounce the seemingly unbeatable old school Clinton political machine via online fundraising. The failure of Revolution Health notwithstanding, I think that web 2.0 will play more, not less, of a role in the way Americans approach their personal health; we just haven't figured out the intricacies of how that's going to work. Nevertheless, having an internet presence will be crucial for physicians as we move forward.

Beyond patient care and education, I think medbloggers have a role to play in how physicians represent themselves as a group in the political realm. Listen, the AMA has been the only real representative body we've had for the past twenty five years and look where we're at: more infighting, worse pay, less professional satisfaction. There has to be a new way to make our voices heard. And if medblogging is going to part of that "new way", then the fastest way to legitimize it is by publishing with our real names and locations. Why perpetuate the stereotype that doctors are "always trying to hide something" and "are out for themselves"? What effect on American politics would Slate or the National Review on line have if all the opinion pieces were published anonymously? Would anyone pay attention? Look at Kevin Pho from KevinMD. He's now a member of the USA Today's board of contributors and frequently writes op-ed pieces. I don't think that happens if he's FacelessMD.com.

We all blog for different reasons. I'm not going to sit here and moralize on how it ought to be done. But I think we underestimate our ability to to change public perception via the internet. This is the new media. This is the forum for idea exchange and it's wide open. Imagine a interconnected network of physician blogs, maintained and vetted by physicians who are open and completely legitimate. It's like California in 1848! The Wright Brothers at Kitty hawk! Neil Armstrong on the Moon! Yes we can!

Anyway, that's enough bombast; those are my rambling thoughts on anonymous blogging. My obscure blog does what it can. Go Bucks.

Needle Stick

Bongi recently had a post about an experience getting stuck by a needle while operating on an HIV positive patient. It reminded me of a time during my residency I had forgotten.

I was a second year resident on the transplant service and it was out of control busy. My program had just added a new liver transplant surgeon who had quadrupled the surgical volume in the 6 months he had been at Rush. Unfortunately, our program still hadn't changed the resident distribution to account for the extra work so there was just a PGY-1, a PGY-2, and a PGY-3 taking care of over thirty patients. We absolutely got killed but it was fun because, as junior residents, we did a lot of operating. Not many second year residents in American surgery programs get to first assist on a liver transplant and put all the stitches in on a portal vein anastomosis.

I was post call and there were seemingly a thousand AV fistula cases to do before I could go home. I'd been up all night during the call doing a kidney transplant. The third year was stuck in a liver case and the intern was running around like a headless chicken trying to take care of the patients in the ICU and on the floors. It was around four o'clock in the afternoon when I introduced myself to the last AV fistula case.

Initially, I thought I'd entered the wrong room. The patient was on an oxygen mask and he was curled like a wounded calf on the bed. He appeared to weigh somewhere between 60 and 67 pounds. He looked at me with these dead black eyes. He wouldn't talk, just nodded his assent to my queries. His skin hung like an ill-fitting rubber mask from his protruding facial bones. He was a skeleton, thinly clad in papery, translucent skin. I reviewed his chart. He was HIV positive. His last CD4 count was less than 50. He was on five different medications. The note from his ID doc indicated that he had a "highly resistant strain" of HIV. And he had renal failure. He needed a fistula.

As a second year resident, I didn't question anything. Somebody had decided he needed a fistula. So be it. I wheeled him back to the OR. Of course now, looking back, the whole scenario is absurd. An AV fistula takes months to mature. You can't even consider using them right away. What were we thinking? This man needed dialysis access? He needed a bed at hospice.

In those days, the attending would scrub in briefly, make sure the anastomosis was lined up properly, and then we were on our own. The case actually went quite well. There was a nice thrill in the venous limb when I released the clamps and I proceeded with the closure. As the attending was leaving, he asked me a couple questions about patients on the floor. I wasn't paying close attention, my eyes off the operative field when I felt a sharp prick on my index finger. Looking down, my heart sank; the creamy white of the glove was rapidly staining red from the inside. I ripped the glove off and blood was pouring from a deep wound. It hurt like hell. I felt it to the bone. I started dumping betadine on it, then wrapped it in gauze. The attending sent me down to employee health.

When you sustain a needle stick injury, you get plugged into the "system". You get your blood drawn. You meet with the nurse practitioner. An incident report is filed. You basically spend three hours in employee health. Then I met with the ID specialist. This was the same guy, coincidentally, who took care of my patient. He shook his head, reading the chart. Of all the people to get stuck by, he said. That night he started me on three different HIV drugs. Nothing beats gagging down three horse pills four times a day. Back at employee health, I met with a counselor. She was very nice and gentle and everything, but she made me feel like I was already infected. I was given literature on "dealing with HIV". I was encouraged to attend local HIV support group meetings. Lots of pamphlets. Thanks, but no thanks, I told her.

Once I finally got home, I was in shock. I hadn't slept in 36 hours and my finger still throbbed and I had fifteen jawbreaker-sized pills to swallow. I felt like my life had suddenly veered into a brick wall. I had just gotten engaged. I was going to be a surgeon. I was living in Chicago. I wanted a family and a nice life and to be a good father to a couple of rugrats. And now everything seemed to be in jeopardy.

In retrospect, my fears were exaggerated. The risk of HIV transmission after getting stuck by a hollow bore needle is 0.3%. I was hurt by a suture needle, which further reduces the chance of transmission. Furthermore, there has never been a documented case of a surgeon acquiring HIV from a needle or scalpel. But at that time, I was a basket case. The rapid HIV test wasn't available then, so I had to wait the full four months to assess for possible seroconversion. Intially, the days crawled by painfully. I couldn't stop thinking about it. About three weeks after the incident I developed a horrible cold. Granted, it was winter in Chicago and everyone was getting it and I hadn't been sleeping or eating well, but I wondered; is this the prodromal HIV flu? I refused to acknowledge the possibility. It was the only way to get through the days.

After I got my blood drawn four months later, I didn't call the lab for the results for two weeks. I figured if it was positive they would have contacted me. But I was also terrified. I didn't want the burden of knowledge. I wasn't ready.

Finally, I got off early one day post call while on trauma. I went to some sleazy bar and gunned down a couple of beers. Courage restored, I went to employee health and requested the results. When they told me it was negative I felt lighter than air. This invisible, oppressive burden I'd been hauling around for months had finally been lifted. I could breathe again. My reprieve had come through. I made a lot of promises to myself that day. How I would be the most dedicated and empathetic surgeon on earth. How I was going to be the best husband to my wife. How I was going to make the most of time, wringing every last drop of utility and meaning and enrichment from my remaining waking days. Philosophy and kindness and charity and all that rigamarole. It would start that afternoon and last the rest of my life.

After a couple weeks, I forgot my vows. It didn't take long. I started getting pissed off again at stupid inconveniences. I wasted time watching sports and surfing the internet. Once again, I was consumed with the minutiae of my narrow, regimented life. The years rolled by and I forgot about the whole episode.

Reading Bongi's post brought it all back. And strangely enough, a small part of me sort of misses that time. There was something powerfully existential and substantive about it all. Rarely do we visit those dark places of the soul where our ultimate weaknesses are exposed. Rarely do we acknowledge our ineluctable mortality. It's too much. It throws us off our fragile equilibrium. There's too much to do in the here and now. But the time will come for all of us. The day of reckoning is unavoidable. Whether it's lump in the breast or a heart attack at age 47 or a sudden stroke or a car that runs a red light. Eventually, there's a needle stick that gets us all. And I think it hurts, initially, no matter how old you are when it happens.