Why it matters....

The recent revelations of the American torture policy have obviously struck a nerve with me. A week has elapsed since the release of the OLC memos detailing the horrific legal justifications for institutionalized torture and I still can't yet let it go. Now that the sensationalistic aspects have had a chance to mature, I find myself less appalled by what occured than by what has been the subsequent response of the American people. It's shocking to me that there is not a national unanimity in condemning what was, in essence, a state sponsored and organized torture program. For some reason, the national response has not been one of collective embarassment and mourning. You read the op-eds from national newspapers, the blogosphere, and you find, maybe not a 50-50 split, but nowhere near the overwhelming majority of Americans you'd expect who denounce this national travesty. The talking heads on Fox News. Glenn Beck. The opinion pieces from the Weekly Standard and the National Review. Michael Hayden and Rush Limbaugh. We have the ludicrous Mike Huckabee joking about how "he's stayed in hotels with scarier bugs than the ones Zubaydah had to deal with". (HAHAHAHAHA!) And of course, there's the incredible Peggy Noonan dismissively saying that some things ought to "remain mysterious" and that we ought to just "walk on by" without looking.

That we don't have a unanimous stance on these revelations is simply mind boggling. You see, this torture issue represents a benchmark of sorts for how we gauge our relative moral standing. It isn't just the latest 24 hour tabloid phenomenon a la Craigslist med student killer! or Obama kneels before an Islamic ruler! What's happening now is actually quite rare. The torture revelations must make us pause, look under the hood so to speak, and make sure that the hidden moral engine that has kept American life humming along without much critical examination for so many years is worthy of continual operation. How we manage the aftershocks of Gitmo and Abu Ghraib is extraordinarily important. Rarely does life present us with an event that challenges those fundamental principles upon which we base this thing called western civilization. Resorting to cliched partisan motifs would be disrespectful to those who have lived, thought, and struggled with the same philosophical difficulties over the past two thousand years.

Philosophy is not just some esoteric activity that occurs behind ivy covered walls amongst elitist intellectuals. Philosophy is all around us, invisible, the ghost in the machine that keeps the machine from breaking down. It determines how we interact with one another, our conduct and how we agree to govern our behavior. It's about what it means to be a human being on an integral level. How do you think it all holds together otherwise?

So I'd like to get inside the torture apologist's head for a moment; to try and discover what rational principles are driving their vitriol. When dealing with questions of moral conduct, we can simplify the various systems into those that focus on the Action (normative ethics) versus those that attribute more weight to the Effect of said action. Means and ends. It's the simplest way to organize moral philosophy. Action-dominated moral codes are best represented by Plato's Forms, Kantian categorical imperatives, and even most religious dogma (i.e. the Ten Commandments.) The Act of an individual determines one's relative moral standing, irrespective of the outcomes of said act. Murder is wrong. Theft is wrong. Thou shalt not commit adultery. Of course, not all Act-dominated systems are so inflexibly black and white. There is a spectrum, from situational ethics to iron-clad dogma. Nevertheless, normative moral codes are obviously ill-suited to the goals of the torture apologists. No one would try to make the argument that torture is ok, in and of itself. Your only recourse is to deny that torture occured, to alter the language of the discourse. It isn't actually torture, we've been hearing. Alternative procedures. Enhanced interrogation methods. Torture-lite. Choose your own euphemism. Of course this evasion of reality crumbles upon closer inspection. Torture is clearly defined. The United States tortured. Therefore, the apologists have no choice but to resort to consequentialist justifications.

Utilitarian or consequentialist ethical systems are not so concerned with one's behavior. The determinant of moral worth instead rests on whether or not the Act leads to a positive result, i.e. "the greatest happiness for the greatest number of people". The argument then becomes: torture, or whatever you want to call it, is justified because it "saved lives" and prevented future attacks on American soil. This is what Dick Cheney is trying to tell us. He wants memos released that will demonstrate unequivocally that information gleaned from torture led to actionable intelligence which helped protect America. That's his ace in the hole.

But does this reasoning satisfactorily justify the Act of torture? Cheney's rationale represents the simplest, most superficial interpretation of utilitarianism imaginable. He is basically promulgating the conjecture that any means will justify the stated end, arbitrarily defined as "American security interests". The reality of the situation is that consequentialist moral codes are much more complex and nuanced. An Act will inevitably have a variety of effects. Arbitrarily focusing on the effect of "improved national security" ignores other consequences that arise from nationalized torture: international condemnation, violation of the rule of law, its function as a propagandistic recruiting tool for Al Qaeda and other radical Islamic sects, the untrustworthiness of the intelligence gathered via such methods, and the betrayal of American ideals. Taken all together, how well did torture actually "work", from a pragmatist perspective? If this is Cheney's only argument, I feel bad for him. It's inane, intellectually trifling, and almost insulting to any average person who would take five minutes to think about it. And now we are hearing from front line FBI interrogators (Ali Soufan, Robert Mueller) that the torture campaign was neither reliable nor especially effective, when compared to classical, legal interrogation methods. There were no ticking time bomb plots that were foiled. It seems now that much of the torture was used on detainees in order to establish a now discredited link between Al Qaeda and Iraq. You're damn right Zubaydah was waterboarded 183 times! We have a war to justify!

All that aside, I would like to grant for a moment Cheney's claim that torture preserved American security for the past eight years. Let's say Jack Bauer broke up a plot to explode a nuclear bomb in Cleveland, Ohio in 2005 by torturing a terrorist to get the vital information. Is this sufficient? Is Cheney off the hook, morally?

The problem with strict consequentialist morality is that it allows for any Act, as long as the desired End is achieved. But all results, all effects are inevitably darkened a bit by the shadows cast by Acts which give rise to them. The shadow cast by torture is much darker than most. It is one of those intrinsically evil acts that poisons our lives, no matter what fruit is produced by its labor. If it's ok to torture to protect American lives, then everything is permitted. The equation becomes sadistically simple. As long as it "works", the CIA/military has carte blanche to do what will. The same argument can be used for rape and child abuse and the murder of innocents. Whatever it takes to maintain "national security". Let Cheney come forward with his memos. Let him show us what his evil has wrought.

On previous posts on this subject, anonymous commenters have asked me what I would do if someone broke into my home and threatened my family. (Not that this is in any way, shape, or form analogous to illegal state-sponsored torture). I would do whatever it took to protect them, obviously, including killing the intruder. But I wouldn't feel good about. I would be angry that I had been placed in the unwinnable position of being forced to either watch loved ones be harmed or to violate my moral principles. Although justified, the murder would defile me to some extent. I would feel diminished, a lesser human than the one I had been before. But it would be a burden I bore on my own, through my own doing. Cheney is asking us to bear an indefensible moral burden for far more abstract, depersonalized, and uncertain reasons. We are bearing it despite never being asked. It was thrust upon us. And this is why accountability is crucial. What Cheney et al did was an unconscionable betrayal of the public trust. We cannot just simply "turn the page". There must be punishment. It's too important. The fabric of human society is precariously thin; once you start allowing threads to unravel, it isn't long until the entire structure comes undone. That is all....

The dying art of physical exam

I got called about an older lady to evaluate for a possible bowel obstruction. When I saw her, she looked fine. She denied nausea or abdominal pain. She was hungry. She'd been in the hospital for over a week, recovering from dehydration and a bad bout of pneumonia. On exam felt an obvious large, soft, mobile mass in the left lower quadrant. So I got a CT scan, seen above.

She'd been in the hospital for over a week. I was the fifth and latest consultant on the case. Reading through the chart, I kept seeing the same description of the abdominal exam in the progress notes of the various doctors involved: soft, non-tender, non-distended. This thing ended up being a complex ovarian neoplasm.

(Responses along the lines of "I've had surgeons who miss obvious cardiac murmurs/pulmonary edema/want to take a gallbladder out of a patient who just had a stroke" are appreciated and welcomed. We all miss things. Talking about it makes us better, right?)

The Machines

I saw a middle aged foreign woman the other day who had been in the hospital for several days. Her chief complaint was "right sided abdominal pain". It had started after a meal of chorizo at her home. I reviewed her chart. She'd had a CT scan, an upper endoscopy, a HIDA scan and an ultrasound. The data seemed to be pointing toward gallbladder pathology. When I walked in her room, she was standing, arms akimbo. She didn't look happy. There was a jug of golytely on the night table, presumably preparation for an impending colonoscopy.
-You're the surgeon, she said?
-Yes, Ma'am.
-I called my doctor in Colombia. He told me it is my gallbladder. He said this two days ago.
I pushed on her belly. She was mildly tender in the RUQ. The ultrasound had shown gallstones.
-He may have a point, I said.
-You doctors in America. Too much you do with the machines.

She's right, you know.

It's Unacceptable

Torture Timeline (From Andrew Sullivan)

A comprehensive review.

Enhanced alternative techniques of aggressive information seeking.....

Official proclamation from the White House in 2003 (via TNR):

The United States is committed to the world-wide elimination of torture and we are leading this fight by example. I call on all governments to join with the United States and the community of law-abiding nations in prohibiting, investigating, and prosecuting all acts of torture and in undertaking to prevent other cruel and unusual punishment. I call on all nations to speak out against torture in all its forms and to make ending torture an essential part of their diplomacy. I further urge governments to join America and others in supporting torture victims' treatment centers, contributing to the UN Fund for the Victims of Torture, and supporting the efforts of non-governmental organizations to end torture and assist its victims.

Oopsy-daisies

A surgeon in Minnesota removes a sliver of tissue on a patient, thinking it was the appendix. It wasn't. The pathologist informed the operating surgeon that it was just a chunk of fat. So he brought her back to the hospital and removed what, by then, had become a perforated appendix. I hate when that happens.

I can understand how it could have occured. Advanced appendicitis can cause an intense inflammatory reaction, obscuring the normal anatomy. But you have to be extra-vigilant in these cases. Make a bigger incision if you need to. Be sure of the anatomy; follow the tenia coli of the cecum to their coalescence. For God's sake, open the specimen on the back table if you're uncertain. Ultimately, it seems that this particular patient recovered and resumed a normal life. But it just doesn't look good to have to treat appendicitis on the second try; we like elegance and precision when we operate....

Torture Doctors

This article from ProPublica focuses on an aspect of the torture scandal that has, for the most part, escaped notice; the role of physicians and medical providers in the "enhanced interrogation techniques". From the beginning of the Bush/Cheney era of torture, the CIA's Office of Medical Services (OMS) personnel "were involved in designing safeguards for, and in monitoring implementation of, the procedures used on other high value detainees", according to the recently released OLC memos. Isn't that nice? Here are a few choice quotes from the article:

Perhaps the most chilling aspect of the memos is their intimation that medical professionals conducted a form of research on the detainees, clearly without their consent. "In order to best inform future medical judgments and recommendations, it is important that every application of the waterboard be thoroughly documented," one memo reads. The documentation included not only how long the procedure lasted, how much water was used and how it was poured, but also "if the naso- or oropharynx was filled, what sort of volume was expelled....and how the subject looked between each treatment." Special instructions were also issued with regard to documenting experience with sleep deprivation, and "regular reporting on medical and psychological experiences with the use of these techniques on detainees" was required.

The memos describe the techniques in highly precise and clinical detail, befitting a medical textbook. During water boarding, in which a physician and psychologist were to be present at all times, "the detainee is monitored to ensure that he does not develop respiratory distress. If the detainee is not breathing freely after the cloth is removed from his face, he is immediately moved to a vertical position in order to clear the water from his mouth, nose and nasopharynx." Side effects including vomiting, aspiration and throat spasm that could cut off breathing were each addressed: "In the event of such spasms...if necessary, the intervening physician would perform a tracheotomy."

While physician assistants could be present when most "enhanced" techniques were applied, "use of the waterboard requires the presence of a physician," one memo said, quoting the OMS Guidelines.

Joseph Mengele would be so proud!

Yes, I know, that's three posts in one week on the torture scandal. But it cannot be emphasized enough, in my opinion. We live in a country where a sitting U.S. President was impeached in 1998 because he lied about getting a blow job from a lowly intern. I think we'd all agree that what we're dealing with now just might be something a little more worthy of such intense public scorn. What we have now is a situation where an executive branch unilaterally defied international law and the US Constitution by designing and codifying a program, yes a program, of torture, kept it secret, justified it with bad faith legal arguments from hacks like Jay Bybee, and then lied about it when the harrowing details began to leak out ("the United States does not torture!"). And even now Dick Cheney has the gall to go on Fox News with Sean Hannity and sneer in his condescending way about how President Obama has put us in danger by rescinding the illegal torture policies he now unabashedly claims "prevented any more terrorist attacks on American soil since 2001".

But that's not the point, you see. Leaving aside all teleologic arguments for the justification of torture (and if there are documented cases of the effectiveness of torture in this program, I also want to know to what degree torture could be expected to be effective, i.e. was it 80% effective, 20%, 0.2%, and did we have to waterboard detainees 100 times or 10 before they coughed up the goods, it all needs to be exposed in all its gory detail because if you're going to implicate me as an American in this heinous, pre-meditated torture policy, I deserve to know what I'm buying into) leaving aside all that (those arguments are weak anyway), the point of the matter is that what Bush/Cheney did was I-L-L-E-G-A-L. It's very simple. We live according to a rule of law in this country. No matter who you are, breaking the law has consequences. Bill Clinton wasn't impeached because he cheated on his wife or some other such personal moralistic conundrum. He was impeached because he lied in a deposition about his relations with Lewinsky. Think about that. And, based on Obama's initial response, it seems the perpetrators of easily the most appalling American scandal in at least thirty years will go unpunished. We can't let that happen. We cannot afford to sweep this under the rug. Our collective national conscience is at stake.

The Radiologist with a Heart

This feature from the NY Times about Dr. Yehonatan Turner, a radiology resident in Israel deserves a read. A couple of days ago I cracked down on radiologists and the degree to which they are held accountable for their findings. This story paints them in a far more favorable light.

Dr. Turner found during his residency that, by virtue of spending all his time interpreting radiographic images completely disconnected from the actual humans that the images corresponded to, he was missing something ineffable and yet fundamental about being a physician. So he tried something unusual; he attached a photograph of each patient to their film jacket.

“I was looking for a way to make each case feel unique and less abstract,” said Dr. Turner, 36, now a third-year resident at Shaare Zedek Medical Center here. “I thought having a photo of the patient would help me relate in a deeper way.”

I think that's cool. He even put together a journal paper to describe the effects of his little experiment. Besides a heightened sense of connectiveness, the investigation found that the reports done on photograph-available patients were more thorough and comprehensive. So beyond the warm and fuzzy angle, there is a practical benefit in terms of improving the level of health care provided to patients.

In a questionnaire that was also part of the study, the radiologists said that the photos helped them relate better to the patients and that they themselves felt “more like physicians".

Part of the story is also a little bittersweet. This kid is exactly the sort of young compassionate physician who would thrive in a primary care setting where there is direct contact with patients. Instead the poor guy sits in a darkened room all day looking at fascimiles of patients, just starving for the sort of intimate human contact that makes the doctor/patient relationship so unique and privileged. It's too bad medical school is so expensive and, even worse, that radiologists get paid three times as much as family practice docs and internists. It makes you wonder how many more Dr. Turners there are in this country that primary care loses to subspecialties.

Torture?

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The Rationale Behind Mammosite

Breast conservation therapy (lumpectomy + axillary node dissection + whole breast irradiation) is an accepted alternative to modified radical mastectomy for the treatment of breast cancer. This determination is based on over twenty years of data. BCT is equivalent to MRM in terms of survival. This is what we tell our patients. The data from multiple randomized controlled trials is incontrovertible. MRM is still a preferred treatment modality in the following clinical scenarios: pregnancy, prior irradiation to the breast, two or more gross foci of cancer in separate quadrants of the same breast,
mammographic findings of diffuse areas suggestive of malignancy, failure to obtain negative margins despite several surgical attempts, collagen vascular diseases. But not every woman needs to undergo a potentially disfiguring mastectomy. The option for less extensive surgical intervention is not only more palatable, but scientifically justified.

But we always like to push the envelope, especially in medicine. The biggest problem with BCT is the necessity for whole breast irradiation. The rationale for radiation therapy is that local recurrence rates after BCT alone were unacceptably high (although survival rates are the same). The NSABP B-06 trial showed that the addition of radiation reduced 10 year local recurrence rates from 53% to 12%. Subsequent studies confirmed the survival benefit of this reduction. So adjuvant radiation therapy is an integral aspect of the BCT trifecta. A surgeon who treats a breast cancer with just a lumpectomy and sentinel node/ax dissection is doing a disservice to his/her patient.

The problem is that radiation therapy is rather inconvenient. It's given over the course of 6 weeks. Every morning, before work, you have to drive into the rad-onc department and get zapped. For some people, this inconvenience outweighs the theoretical benefits; recent studies show that 10-15% of women don't complete the full course of radiation therapy.

So the envelope gets pushed. How can we make radiation therapy shorter and more tolerable? Researchers started looking at where those local recurrences occured in patients who had had BCT. What they found was that 70% of ipsilateral recurrences after BCT were in the neighborhood of the original tumor. So the gears started grinding. And someone came up with the idea of "partial breast irradiation", i.e. just irradiate the breast tissue around the residual tumor bed and you will likely derive an equivalent benefit to whole breast irradiation. Seems reasonable, no?

The Mammosite Balloon is a type of partial breast irradiation delivery system. A balloon catheter is left in the lumpectomy cavity and, after confirming placement with CT scan and US, radiation doses are applied through the balloon over the course of 5 days. At the conclusion of the 5th session, the balloon is removed. And that's it. One week and you're done.

Preliminary evidence is encouraging but we won't have level I evidence (in randomized controlled trials) to support Mammosite-like partial breast irradiation until 2014. So for now, it's strictly an experimental, albeit highly appealing, treatment option.

My question: If local recurrence after BCT seems to be occuring predominantly in the area of the original tumor bed, then why is the solution to use an extremely expensive partial irradiation delivery system instead of just, you know, maybe doing a better, cleaner initial surgery? In breast cancer we talk about the need to get "negative margins" when excising a tumor in a lumpectomy specimen, but we don't put a number on how negative it needs to be. In other words, should you get 1cm clean margin? 2cm? 3mm? Should it be a 1cm gross margin or a full 1cm microscopically? The data is not clear on this point. As long as there is no tumor at the cut edge of the specimen, we are satisfied. In other forms of cancer, expected resection margins are more explicit. If I am doing a right colectomy for cancer, I want at least a 5 cm clean margin. Low rectal tumors need at least a 2 cm distal margin or you aren't doing the patient any good.

So before we dive headlong into a very expensive, labor intensive new technology like Mammosite, shouldn't we first determine the optimal surgical approach to early stage invasive breast cancer? Shouldn't we compare local recurrence rates in specimens with 1cm margins vs. those with 2mm margins? Wouldn't that be a good thing to know? It just seems logical to me; after all, breast cancer is first and foremost a surgical problem.

Whose Responsibility?

Kevin MD links to a post from Dr. Amy Tutuer about her father's unfortunate demise from lung cancer. He had presented with hemoptysis (coughing up blood) and an X-ray confirmed a giant lung mass, later confirmed to be a highly aggressive cancer. He died 8 weeks later. But that's just the beginning of the story. Apparently, 7 months earlier he had had a minor urologic procedure performed. As part of his pre-operative testing for the urology case, a chest x-ray had been ordered. This CXR demonstrated a mass, much smaller, which the radiologist commented on and suggested follow-up. All the doctors involved in his care assumed someone else would inform the patient. No one ever did.

Kevin Pho is predictably outraged:

An ordering physician always needs to take responsibility for the results of the test, even if it doesn't fall under his specialty.

I get it. Another overpaid proceduralist neglecting to take care of anything other than making sure the lucrative procedure gets done. But let's take a moment, shall we? Do we really believe that some urologist is going to be the one who coordinates the appropriate follow up for an abnormal chest X-ray? A urologist? God help us all if that's the honest solution.

As a surgeon, I send all my elective patients for pre-operative testing. This usually involves some combination of blood work, an EKG, and sometimes a chest X-ray. The determination of what is needed is often left up to the pre-testing center, the primary care doctor, and the anesthesiologists who will be doing the case. On the day of the surgery I glance through the chart, make sure everything is copacetic, and then we proceed. Sometimes the lab will call a few days prior to surgery with an abnormal value and I will look into it dutifully. I'll be honest; I don't pay much attention to a CXR report unless I'm specifically concerned about something beforehand (patient with COPD, hsitory of lung resection etc). Sometimes the official report on the CXR doesn't end up on my desk until a week after the procedure has already been done. But my name is on the CXR and I have to go through a pile of reports every couple of weeks. If anything jumps out, I will contact the PCP.

So who is responsible for an abnormality on a pre-operative CXR? What is a surgeon/orthopod/urologist supposed to do if they get a CXR report on their desk a few weeks after operating on someone (whom they barely remember) that states something along the lines of "right lower lobe mass, well circumscribed, 1.1 cm, clinical correlation/follow up images recommended"?

What about the DOCTOR who actually provided the expertise in reading the image? I know it's outlandish to expect a radiologist to (heaven forbid) actually interact with a patient over the telephone, but is it really that unreasonable to expect a specialist to follow up with the consequences of his/her determinations? If a family practice doc refers a patient to me for an abnormal mammogram and I see the patient and recommend a stereotactic biopsy, whose responsibility is it to make sure that biopsy gets done? Ought not the surgeon, the ostensible expert, assume the primary burden?

For some reason radiologists are immune to the usual expectations of physician responsibility. It must be nice to just have to dictate an addendum in your report about "follow up" and "clinical correlation" in order to exonerate you from all future culpability. A subtle liver or lung lesion gets passed off to the "ordering physician". Because you can't expect a radiologist to care about what happens to patients whom they have been consulted to provide radiologic expertise on, right? Right? Am I missing something here?

Someday, we will have a national data base of patient information via a centralized EMR and concerning lesions on routine screening films will get red flagged automatically. Until then, shouldn't we be able to trust that the physician who deems such lesions as "concerning" will be the one who is in the vanguard of doctors who make sure that said lesion is addressed properly?

Torture

The release today of the Office of Legal Counsel memos from 2002-2005, which provided "legal" justification (i.e cover) for the "alternative interrogation techniques" implemented during the Bush Adminsitration's War on Terror, will leave you speechless. Take ten minutes and read this legalistic morass from Judge Jay Bybee. It's chilling. You'll read about how waterboarding doesn't technically meet the suffering criteria of torture, but rather it is merely a "controlled acute episode". What the hell is that? Was George Orwell exhumed so he could write 2184? I'm embarassed. This was our government, our country which authorized the torture of other human beings (bad people, granted). But we tortured people and hired lawyers to re-interpret the Geneva Convention and international law and the universal unwritten statute of decent moral conduct in such a way to justify it. We tortured these people. And medical personnel/doctors were present to monitor vitals and oxygen saturations, to make sure the operatives didn't "go too far". The whole thing makes me sick.

Yesterday I ranted about high taxes and back-up quarterbacks making millions. It seems so petty and small now. Even the cecal volvulus post seems a tad frivolous. We tortured people under a Presidential directive. Things have changed. This is the world we live in now; one where our national conscience is heavy with a collective guilt. It stains us all. The only way out, from this point forward, is a policy of absolute accountability and transparency. Let the atonement begin now....

More Tax Fun!

I couldn't resist. Ari Fleischer says we need to be realistic about funding President Obama's government expansion. In this WSJ article, he makes the case for raising taxes on all Americans, not just those in that magic highest 2% bracket. Cutting taxes on 95% of the Americans who will most benefit from the American Safety Net is unfeasible and, honestly, borderline irresponsible. He wants even the poor to "get some skin in the game". It's worth a read.

I promise, no more tax posts until next April. We just sent our check out today. So here are my final thoughts and recommendations on this rather desultory topic:

1) I'm all for a true progressive tax scheme. But let's be honest about it. Let's define "rich" in a realistic fashion. We have rich people in this country, over 3 million millionaires. We have backup quarterbacks in the NFL pulling down seven figure salaries. The stars of lousy network television sitcoms (I looking at you Charlie Sheen) are raking in hundreds of thousands of dollars per episode. I say, bring back the 90% tax bracket. Anything over $2 million/year gets taxed at 90%. Why not? At the very least, it might spare us another ten years of Two and a Half Men.

2) Why shouldn't those who pay in the higher tax brackets get to partake in the fruits of the national safety net? If I am working from January till June for the US government, shouldn't I be able to get my health care paid for? That's the difference between the US and the European model of free market socialism.

3) I've found it's best not to look at the final tally on your tax bill. Trust your accountant. Send him a blank check and enjoy your blissful ignorance.

Large Bowel Obstruction

I've had a run of large bowel obstructions (LBO) lately. The images above are illustrative. When we talk about "bowel obstruction", usually we're referring to small bowel obstruction (SBO), generally caused by adhesions and scar tissue from previous surgery. SBO's can be managed non-operatively about 75% of the time.

LBO is a different animal. Adhesions don't (in general) cause an obstruction of your colon. Cancer, volvulus, and hernias are the usual culprits and an operation is often mandated. A colonic obstruction is technically a surgical emergency. The cecum is very thin walled and, with the ileocecal valve, can form a closed loop situation with a distal obstruction. Ischemia and frank perforation are eventual consequences. The resultant poopy belly is not in anyone's best interest.

The first picture shows a dilated cecum secondary to a hepatic flexure tumor. Pictures 2 and 3 demonstrate a LBO caused by a splenic flexure cancer. Both patients had formal resections with primary anastomoses.

In the Blink of an Eye

Nick Adenhart, the young Anaheim Angels pitcher, was killed by a drunk driver last week. He was 22 years old and had just thrown six shutout innings for the Angels hours before Andrew Gallo drunkenly drove his van through a red light and slammed into Adenhart's sports car. It's a horrible loss, obviously, and our thoughts go out to his family. He was 22 years old. A pitcher in the Major Leagues. Young and athletic and full of confidence. His whole life stretched out as far as the eye can see. And now he's gone, all that potential and youthful vigor down the drain.

The tragedy prompted a memory of mine from medical school. I was a third year med student on trauma call. It was midday, like 3pm, when a patient rolled in on a backboard, collared and already intubated. All we knew was that a male driver had been struck from behind at a stop sign and EMS on the scene had had to intubate him because he wasn't breathing. As students, we did all the dirty work during a level I trauma; place the foley, do the blood gas stick, make sure there was IV access, etc. I had Foley duty and I wasn't too happy about it because the patient, he seemed to be about a thirty year old male, was sporting a massive erection. At first, I started to smile, formulating jokes in my mind in a typically juvenile medical student way, but I noticed no one was smiling or laughing in the way people do in the operating room when a patient spontaneously becomes erect under general anesthesia. This was different. The trauma attending was shaking his head. I heard fragments of chatter about "spinal cord" and "IV steroids" and it dawned on me what was really happening. He wasn't moving at all. Even though he was intubated, he was awake and blinking his eyes, these wide white terrified eyes, desparately trying to follow the instructions someone kept shouting in his ear; "wiggle your toes, sir!" and "squeeze my hand!". His toes weren't wiggling and his fingers lay motionless on the gurney. I put the Foley in and stepped back against the wall.

The films showed a transection of the cord at C3. He was lucky to be alive but clearly there was little hope of any meaningful neurologic recovery. He was going to be a quadraplegic. Later on his wife showed up. She was dressed up in some sort of work uniform, Sears or Montgomery Ward or something, and she had this harried, almost angry look on her face. We met her in the consultation room and the neurosurgeon bluntly and unequivocally informed her that her husband would never walk again, would never use his hands again, likely would never breathe again on his own. He wanted to do a cervical stabilization procedure to limit the damage already done but there wasn't anything he could go to reverse what had already occured. He told her he was sorry and then he left.

The details of the accident had started to trickle in. The woman's husband had been idling at a stop sign, waiting for the other cars to pass. He was at a standstill, zero velocity, when struck from behind by a pick-up truck. He never saw it coming. The force of the impact caused such a violent whiplash effect that his cervical spine just snapped. Just like that. An ambulance happened to be driving by when it occured; otherwise he would have suffocated and died at the scene.

In the consultation room, the wife was inconsolable. She wailed all hunched over, her back shuddering while we all sat there uncomfortably. What am I supposed to do? she sobbed. What am I supposed to do now? They had three young kids at home. She gathered herself eventually. She sat up straight. She told us that her husband was an accountant who never took chances. He kept two hands on the steering wheel at all times. He always wore his seatbelt and kept a notebook on all the repairs and maintenance work on their cars. He never drove fast. He drove like an old man, she said, almost with a bitter laugh. She shook her head. She went off to find her children.

Flutter

This parody pretty much sums up my take on the "micro-blogging" application Twitter.

Image of the Day

Another Cecal Volvulus

Watch Out Middle Class

Here's a good article from Clive Crook at the Financial Times. President Obama has made clear his intentions to expand the role of the federal government in our lives to an extent not seen before in our history. Even better, he avers that the middle class won't pay a "single dime" more in taxes. Universal health care, cradle to cubicle subsidized education, the green revolution-- all will be paid for by tax increases on only those 2% of Americans who make more than $250,000 a year. Here's Crook:

Mr Obama intends to squeeze the rich, but the scope for this may be more limited than US liberals would wish. Few Americans seem aware that the US income tax code, as a recent Organisation for Economic Co-operation and Development study showed, is already one of the most progressive.* Even before the rise in top marginal rates promised by Mr Obama, the US income tax collects 45 per cent of its revenues from the highest-income decile. Compare that with Britain at 39 per cent, Canada at 36 per cent, France at 28 per cent, Sweden at 27 per cent and an OECD average of 32 per cent.

This difference is only partly explained by the less-equal US income distribution. The fact that the US has no broadly based national sales tax – value added taxes make Europe’s overall tax codes less progressive still – only underlines the point. The US tax system raises comparatively little revenue; what little it raises already comes disproportionately, by international standards, from the rich.

Wait a second. You mean that wealthier Americans already bear a heavier tax burden than wealthier people in every other country in the world, countries that have much more extensive social safety nets? What about the Obama rhetoric of the rich "doing their fair share" and "leveling the playing field"?

The truth is that raising taxes on just the wealthiest 2% of Americans will not be sufficient revenue to cover this audacious expansion of the federal government. Health care reform alone will cost at least $2 trillion over ten years (of which only $600 billion will come from tax increases on the rich). The bottom line is, we are all going to have to pay for this American Safety Net. It won't just be the "rich". He's coming for you too, middle class. It may not come in the form of higher income taxes, but via more insidious methods; national sales tax, carbon taxes, energy taxes, etc. Just you wait....

Rationing

A 97 year old guy was admitted recently to the trauma service following a fall, a face-plant actually, with a resultant broken nose and sinus fracture. Otherwise he was fine. He was 97 years old and he didn't take any medications, had never had surgery, and he lived independently in the same house he raised his kids in.

-How'd you fall, I asked.
-Tripped over a rug or the carpet, he said. My cane snagged on something. I was visiting my wife.
-Where was your wife?
-The nursing home. I visit her as much as I can. It's not far.

His wife was 95 years old. Last year he had had to admit her to an assisted care facility because she "had got the dementia".

-Does she recognize you? I asked.
-Yes. She remembers me. She remembers parts of our life together.
-That's good, I said.
-Yes, but she doesn't remember much else. She forgets things I told her even twenty minutes ago. And she remembers things that never happened. Like a third son. You see, we only had two boys, John and Richard. But she always talks about a third son. Always asks me how he's doing. Paul. She even has a name for him.

He looked out past me. There was a scabbed bandage across the bridge of his nose and he was bruised under his left eye. That day's NY Times was splayed out across his lap. A Teddy Roosevelt biography was bookmarked on his nightstand.

-That must be difficult for you, I said.
He nodded.
-My kids are all passed. I had a brother in Oklahoma but I don't know what happened to him. There's no one else. It's just me and Esther.
-I'm sorry, I said.

I sat down in the chair next to his bed. It was a Friday afternoon. It was warm in the room and he was bundled up in several blankets. Some time passed and I absent-mindedly read the Times headlines upside down.

-She gets the dialysis three times a week, he said. Her kidney doctor told me last week that he didn't think the dialysis was doing any good. ...
-I understand.
-He wants me to think about stopping it. The dialysis.

I nodded. I leaned back in the chair. It was raining outside and windy and the thinner boughs of the trees bent in curved arcs with the wind. The old guy kept staring ahead, a blank TV screen.

-Anyway, I'll have to decide. I'll miss her. Even though she's not the same, I like going to see her. It's like when a baby smiles at you. It makes your day...

I sat there for a while. And then I had to go do some work. He went home the next morning but I've had a hard time forgetting him. I understand, as we move forward on health care reform, that rationing will play a larger and larger role. Given our technology and the rapid rate of innovation in health care, the amount of money we could conceivably spend on individual patients is infinite. At some point we will have to draw lines in the sand; enough is enough. I understand that. I've been an advocate for rationing myself, having experienced first-hand the wasted effort and financial drain of providing futile care to elderly patients in the ICU who aren't really "sick" but are actually just going through the dying process.

This case in particular is exemplary of an irrational health care expenditure. I mean seriously, hemodialysis on a 95 year old demented lady? It's crazy, right? Think of the money saved if we had a system in place that restricted or denied the possibility of nonegenarians receiving dialysis. No one in their right mind would disagree that the redistribution of resources from the provision of futile care to the elderly in order to make more preventative and life-saving care available for younger people is a solid moral stance. But then you see the consequences. These are real people who will have to be told "no more". When I drove home that night, a part of me was hoping that they'd keep that old guy's wife on dialysis just for a little while longer....

Non-Profit?

In the Cleveland Plain Dealer today is a front page report on the amount of charity care provided by the three main private (but non-profit) hospitals in the metro-Cleveland area. On average, the Cleveland Clinic, University Hospitals, and Sisters of Charity spent just over 2% of their revenue on the provision of charity care in 2007.

Because of the work of Senator Charles Grassley, all non-profit hospitals will be required to disclose information on how much free care they provide, starting in 2009. These large institutions have come under fire recently because of the tax breaks they receive from being "non-profit" hospitals. Particularly in Cleveland, where the safety net hospital (MetroHealth) had to cut jobs and services just to break even, this sort of transparency will be crucial to ensure that such tax breaks are justified and that everyone is (in the words of President Obama) "doing their fair share". It seems to me that 2% is a rather paltry number, especially given the other expensive projects that The Clinic seems to have the funds for, in Las Vegas and Abu Dhabi.

In this era of federal bailouts and car company executives being fired by our President, it doesn't seem unreasonable anymore for a "non-profit" hospital to be required to allocate a little more than 2% of revenue toward charity care if they want to continue to be exempt from the prying fingers of the IRS....

Lap Chole Tips

In General Surgery News (a free throwaway publication we get monthly in the mail), there's an opinion piece from one Arnold Seid, MD, a general surgeon in California who discusses his own personal "five key rules" to avoid potential bile duct injury during a laparoscopic cholecystectomy. Dr. Seid is a veteran surgeon; he's done thousands of lap choles over the years and he has been serving as an expert witness in LC malpractice cases for the past 15 years. So it's worthwhile to read his take. Here're his rules:

1) Never perform a lap chole without a skilled surgeon as your assistant. (He always books his LC cases with his partner, another board certified general surgeon.)

2) Slow Down (He claims that he never finishes a LC in less than an hour.)

3) Knowledge is power, don't be afraid to open.

4) Don't try to repair a bile duct injury. (Place a drain and refer to a specialist.)

5) Don't ignore post-operative complaints. (Pain/fevers/nausea/etc deserves a thorough evaluation to rule out bile leak or CBD injury.)

Now I'll grant him the last three rules. Opening ought not to be considered a "complication". If you're not progressing, if there's any doubt, NEVER hesitate to put the tiny tools away and open the patient. To some extent I agree with rule #4 as well. If you've injured a bile duct, best to cut your losses, place a drain and let someone with expertise correct the problem. Most of time, you only get one chance to repair a bile duct injury. And I strongly support rule #5. Anytime a patient calls me after a LC with complaints of seemingly excessive pain they get a stat HIDA scan and blood work. 99.9% of the time it's overkill but you just can't afford to miss anything.

I'm not so sure about the first two rules however. With all due respect to Dr. Seid, having two board certified general surgeons scrub into every LC seems almost absurd. The idea of course is that two sets of eyes are better than one. But that logic is self-defeating. Why not get three surgeons in there? Why not have the entire surgical staff come into the room when everything is exposed and have everyone vote on whether or not it's safe to clip and cut? An infinite number of eyes are better than two sets right? Ultimately, the attending surgeon needs to take responsibility for what he/she sees and make the correct call. It's very simple. We have to be able to trust that, given appropriate exposure and technique, that any board certified general surgeon will be able to interpet the anatomy correctly.

As for rule #2, I have a hard time understanding how one could spend 60 minutes on EVERY SINGLE laparoscopic cholecystectomy. I don't rush. I don't cut or clip anything until I'm 110% certain of what I'm looking for. I do a cholangiogram on probably 95% of my cases. Even with all that, my LC cases invariably take somewhere between 20-45 minutes. I have done LC that took over an hour (adhesions/extensive inflammation/etc) but those are the rare cases.

I love LC. If I had to do 3-4 a day for the next 20 years I would be a happy general surgeon. It's an elegant operation. I haven't done thousands, but I've done enough where it's become almost automatic. I try not to waste any moves. Every act is purposeful. Rarely is there struggling or the sort of futzing around that can occur when doing a laparoscopic colon resection. So here are my tips:

1) Never use a Veress needle. Why blindly stick a needle into your patient's belly? It's ridiculous. I do an open Hasson insertion. It's not slower. It's definitely safer. It's a no brainer.

2) Don't use cautery while doing the initial dissection. I gently tease down first the peritoneum, then the fibroadipose tissue with a Maryland dissector. Don't do it roughly. Don't rip things. Be patient. A single strand at a time if you have to. It will reveal itself to you.

3) Don't forget to do a posterior dissection. In other words, flip the infundibulum to the patient's left and open up that peritoneum and space behind and to the right of the cystic duct/infundibular interface.

4) Cholangiogram! Really no excuse not to do one. You'll feel better about the case if you make cholangiography a routine part of your technique. I didn't do many at all as a resident (attending choice) but since I've been in practice I plan to do one on every LC. It doesn't add much time. It really doesn't. And the more you do, the faster it goes. Anymore, if I don't do a cholangiogram for some reason (dye leakage, patient body habitus, etc.) I feel like you would if you went to work one day and realized at noon that your zipper had been down all day. A nice cholangiogram just makes me feel all warm and fuzzy inside.

5) I use the 10mm clips on the duct. I just don't like the 5mm clip devices. Maybe I'm using the wrong product, but I just feel that the smaller clips don't go on as well. The subxiphoid incision I make is consequently a little larger, but it's worth it to my sense of well-being.

6) Hook cautery when dissecting the gallbladder out of the liver bed. It's better than the spatula. You can actually sort of dissect with the hook, which allows you to get into the exact tissue plane, thereby minimizing bleeding/bile spillage.

7) I use a bag to retrieve the gallbladder on every case. Studies suggest that at least 20% of gallbladders (even non-inflamed ones) are colonized with bacteria. So why pull a potentially dirty, devascularized specimen out through a clean umbilical incision?

8) I'm pretty conservative when it comes to placing Jackson-Pratt drains. I leave one in for 24 hours for nasty, pus-filled gallbags or if there's a lot of bile spillage or bleeding. Also, if I'm worried about the cystic duct stump (friable, inflamed, ischemic). The drain helps me identify an early stump leak.

Safety Nets with Holes

MetroHealth System in Cleveland, Ohio is supposedly the safety net hospital of northeast Ohio. Or at least it was, before last summer's move to restrict the provision of free care to only those patients who have an address within the confines of Cuyahoga County. This excludes all the people in Lake and Geauga counties (population close to 400,000) without health insurance.

As a result we are starting to see more of the following:
1) 50 year old gentlemen with rectal cancer laid off from his factory job, without any insurance. He underwent neoadjuvant chemoradiation and then I did an abdominoperineal resection. HCAP (hospital care assurance program) will help him with his in-hospital costs but the medical oncologist, the radiation oncologist, and myself are not likely to be compensated. The burden of providing free care, because of the decision of Metrohealth, falls not on "society" but instead on individuals in the community who feel obligated to "do the right thing".

2)47 yo woman with melanoma who needs a wide excision and sentinel lymph node biopsy. She has no insurance. She lives alone, is unmarried, and has no family in the area. She showed up in my office for the initial consultation with some crumpled up dollar bills. It's heartbreaking. I tell her to put her money away and worry about getting well.

I don't know what the answers are. But I do know that safety net intitutions can be a valuable resource. Diminishing how wide that net gets cast for the sake of improving the county budget bottom line is borderline irresponsible. Someone has to take care of these people....

Frequent Flyers

This news item out of Austin, Texas probably won't be all that surprising to most ER docs.