Friday, July 30, 2010

Letting Go

Atul Gawande has a great piece in the New Yorker this week about the difficult and complex management of end stage disease in terminal patients. (See, I don't always criticize the guy. He writes good stuff.) What happens when we reach the point where further treatment is futile, when death gathers momentum, threatens to overwhelm at any moment? What do we do with these brittle, emaciated, broken human beings, bodies riddled with cancer, when all the latest toxic chemotherapy options have been exhausted and there's no more surgery to offer? What do we do when these patients don't want to hear about "palliative care" and "hospice", when they get angry or accuse you of abandonment when you tell the truth about their prognoses? There has to be something else, they plead, some new trial, some miracle cure. That faint sliver of light is what they grasp for when the darkness begins overtake them. Gawande:

There is almost always a long tail of possibility, however thin. What’s wrong with looking for it? Nothing, it seems to me, unless it means we have failed to prepare for the outcome that’s vastly more probable. The trouble is that we’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets—and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win. Hope is not a plan, but hope is our plan.

It's a great weekend read.

Thursday, July 29, 2010

She Chose (b)

Awesome summary from Deborah Tornello.
2. If, while attending this conference, you experienced leaking amniotic fluid and felt early contractions on the morning before you were scheduled to speak, would you (a) hand the speech to someone else, ask him or her to give it on your behalf, and go straight to the nearest hospital--one that was equipped for handling high-risk mothers, premature births, and special-needs infants--and get yourself checked out by a doctor or (b) continue with your day and give the speech anyway?

Sarah Palin chose (b).

Tuesday, July 27, 2010

Laparoscopic CBD Stone Extraction

This case was sort of fun. The patient presented with abdominal pain, localized in the epigastrium and RUQ. The US demonstrated gallstones and a thickened gallbladder wall. His amylase and lipase values were extraordinarily elevated, suggesting an element of gallstone pancreatitis. Furthermore, his bilirubin and transaminases were abnormal, raising the possibility of a common duct stone. So I sent him for an MRCP which was rather unremarkable, other than showing some edema around the pancreas.

My policy on gallstone pancreatitis is to remove the gallbladder once the pancreatitis abates---on that same admission. That way there, you don't have to worry about relapse if they pass another stone while waiting to get their outpatient surgery done. So I took this guy to the OR and his gallbladder was predictably inflamed. My initial intra-operative cholangiogram (see top pic) demonstrated a meniscus sign in the distal duct and non-filling of the duodenum.

Usually this warrants a post-op ERCP to fish out the stone. But in this case, the patient's cystic duct was quite dilated (even the large clips wouldn't extend across the lumen; I had to secure it with an endoloop). So I decided to make a run at it myself. I slid a fogarty catheter through the stump and into the common duct, all the way into the duodenum. Then you inflate the ballooon and slowly bring the tip back, adjusting for tension as you go. So I did that and boomski, out popped a little yellow stone. The second pic shows a pristine biliary tree with the folds of the duodenum filling in like a coral imprint.

Monday, July 26, 2010

Gut Check

So it's a Saturday morning and you're making leisurely rounds when a consult comes in for an ICU patient. You show up at the same time as the GI guy who was also consulted. The patient is at the extreme terminus of age. You and the GI consultant review the data together. He had come in through the ER from a nursing home with mental status changes and fevers. His WBC was elevated. A CT scan done the night before showed thickening of the colon from the splenic flexure all the way down to the distal rectum. You walk in and the guy is about to be intubated. He's on three pressors, all maxed out. His belly is soft but you can't really trust your exam. The nurse states that he "just had a seizure".

-Looks pretty bad, you say.
-Yeah. I think I ought to do a quick flex sig to see if he has any pseudomembranes (a sign of c. difficile colitis)
-Ummm...doesn't really matter either way, you offer.
-Yeah, but it would be nice to know. Then we can at least start vancomycin enemas. And with you on board, depending on what the family wants...
-This guy won't be undergoing any surgery, you say. You give him one of those looks, a look that is supposed to transmit a deeper, unspoken meaning---a look that always seems to work in the movies or in bad crime novels, but never in real life. He is already paging his endoscopy team to come in with the equipment.

You move on to the next patient on your list. A little while later a code blue is announced over the intercom as you pass the endoscopy nurse wheeling the unwieldy endo cart toward the ICU.

-You might as well put that thing away, you say.

Work Hour Reform Ctd.

More from the work hour reform beat (via Health Science Blog):
The researchers reviewed 2,908 laparoscopic cholecystectomies, in which the gall bladder is surgically removed through a small incision in the abdomen, and 1,726 appendectomies to remove patients’ appendixes that were performed at Harbor-UCLA Medical Center from July 2003 to March 2009. These are the two most common operations performed by residents, and the two surgical procedures are often performed at night when residents are more likely to have worked a long shift.

The researchers compared outcomes in these two operations when they were performed during the day by surgical residents who had worked less than 16 hours and at night by surgical residents who had worked 16 or more hours. The researchers concluded that “appendectomy and cholecystectomy operations performed at night by less rested and possibly sleep-deprived residents have similar good outcomes compared with those performed during the regular work day.”

So are you telling me that surgeons do not, in fact, require nappy time if they have been awake for 16 hours prior to performing a cholecystectomy? Really? Who knew? I can't believe it. What about the cookies and milk? Has anyone done a RCT studying the effects of a bellyful of cookies and ice cold milk on a surgeon's competence? Why hasn't the Institute of Medicine investigated this? And don't be trying to pass off a Nilla Wafer as a cookie.

Thursday, July 15, 2010

Gastric Volvulus

This elderly guy presented with acute renal failure due to vomiting everything he tried to eat or drink for a week. He was rehydrated and decompressed. The images above demonstrate a complete foregut obstruction secondary to herniation and volvulus of the stomach through a large hiatal hernia. On the coronal view, you can actually see the pylorus and dilated 1st part of duodenum in the thorax.

I reduced his elephantine stomach and repaired the crural defect. I also did a pyloroplasty and affixed his fundus to the abdominal wall with a gastropexy. He was eating lukewarm hospital chicken casserole by day three. Fun case.

Tuesday, July 13, 2010


Glenn Greenwald has done a bang up job of exposing the cozy, compromising relationships that the elite press corps has developed with the very Washington DC politicians and insiders they are ostensibly supposed to be covering. In this era of blogging and open source media, the public doesn't necessarily have to seek political news and opinions from the old guard of mainstream media. The elites no longer have a monopoly on defining what is news and how the news ought to be interpreted. So they cling to the one thing that the bloggers will never be able to touch---their sources, connections, and inside contacts.

As a result we get travesties like the Joe Biden party where reporters engage in squirt gun fights with the Vice President and other White House staffers. You get Chris Wallace "interviewing" Dick Cheney without asking a single uncomfortable question about torture and waterboarding. You get Sarah Palin running for Vice President without having to endure a single unscripted press conference. The presentation of "news" becomes merely a propaganda show where journalists and reporters subserviently regurgitate what the politician wants them to say, unchallenged. Because if they don't, guess what? No more access! No more "private sit down" sessions with Mr. VIP! And so the journalist/reporter simply stops doing the job he/she was hired for, i.e. holding governmental persons in postions of power accountable. Getting at the truth isn't so important as maintaining an open relationship.

Similarly, in medicine we often compromise ourselves for nefarious purposes, especially financial. We bitch and moan about tort reform and the insidious malpractice situation but we refuse to hold one another accountable. When another doctor makes an error, no one says anything. It's "too awkward" to say anything or "it creates an antagonistic environment" will be the explanations you hear. And of course this is true to some extent. But a larger reason has to do with the way private practice is constructed. Referral patterns are based on relationships and habit. You refer to a certain surgeon because he seems nice and the patients like him. You refer to a certain endocrinologist because she went to your medical school. Rare does it have anything to do with the quality of care delivered. And as these referral patterns and relationships ossify, it becomes harder and harder to change them. One thing that will change a referral pattern mighty quick would be "tattling" on a referring doctor for providing substandard care. Or receiving a notice in the mail from your QA committee that another physician has submitted several examples of cases where you delayed an intervention.

We specialists don't want to disrupt our profitable and essential referral patterns. So we don't say anything when an internist puts a patient on full strength lovenox 24 hours after a colon surgery. At most we perhaps off-handedly mention to the physician that maybe it would be a better idea to allow the surgeon to decide when to re start anticoagulation. The GI doc doesn't report the surgeon who always calls him for his all too frequent post-lap chole bile leaks. We don't report the internist to QA who prescribes massive doses of IV steroids to a patient with a rash (probably from morphine reaction) who was admitted with diverticulitis, who then decompensates and becomes septic with peritonitis. We just kinda, sorta mention that altering the patient's immunity with corticosteroids maybe wasn't such a great idea. Or maybe we don't say anything at all. Because it would just create an awkward situation.

Thursday, July 8, 2010


"Thank you all for coming tonight. Special thanks to my sponsors, Rubbadub Latex Gloves Inc. and ShankRite Scalpel Ltd.

After considering all my options I have decided to remain here in Cleveland, Ohio for the prime years of my surgical career. Numerous suitors have approached me over the past 6 months and, frankly, my soul has been wracked by guilt and self-doubt. It's been incredibly humbling. There was the practice in South Beach which offered to provide authentic Shojo Zen back massages during all my laparoscopic cases, while maintaining a steady stream of polysymphonic chill music in the background. There was the group outside Georgia that promised I could operate barefoot (or flip flops at the most) and would never have to wear a tie while in the hospital. And then of course the practice in Omaha that told me they would install a miniature indoor soccer field in my office. And how could I forget the hospital group in Poughkeepsie that told me I would be allotted ten minutes to rifle through all the anesthesiologist's wallets in the locker room between my own cases without reprisal (security cameras turned off, my call) and wad whatever I could gather into my scrub pockets. Again, I was profoundly moved by what others would willing to do to acquire my services. The temptation to leave snowy, decayed, broken-down, riddled with crime and unemployment Cleveland was high.

But I've always been about winning. Perks have no effect on me. I am a winner. I don't take out gallbladders for the reimbursement. I don't come in at three in the morning for an incarcerated hernia just to fill out sixteen duplicate copies of Medicare forms. No. It's about winning, baby. Conquering that diverticular stricture. Whacking out that burst appendix in record time. Victory. Glory. It all awaits me here on the shores of Lake Erie. I can smell it."

/taped delayed interview of above transcript available on local cable access channel 324 on August 23rd.

/screw you Lebron

Complex Diverticulitis

This is about as bad as it gets. I saw an elderly lady with a chief complaint of frequent urinary infections and passage of stool per her vagina. The images above demonstrate obvious colovesical and colouterine fistulae. The CT also demonstrated significant left ureteral obstruction at the level of the pelvic inlet. What ensued was a complex multi-specialist procedure involving a sigmoid resection, hysterectomy/oophorectomy, and ureteral stenting. Good stuff.

Sunday, July 4, 2010

Happy Fourth of July!

Despite the unemployment, the corruption, the imperialistic foreign wars, the social inequality, the increasing fundamentalism and anti-intellectualism of my conservative party, and the overall uncertainty of what the future holds --- despite it all, there's no better place to live and work and raise a kid than the old US of A. Fire up the grill. Down a few pints. Have a great weekend.

(What song did you think I would use??)

EMT Loses Lawsuit for $10 Million

(via White Coat and Kevin MD)

I was incredulous to read about the case of the EMT service sued for negligence for transporting a pregnant woman to a tertiary care center in Florida. The woman went into labor in the ambulance and the heroic paramedics had to deliver a breeched 25 week-old baby and then resuscitate him en route to the hospital. The boy lived but ended up with cerebral palsy secondary to prolonged hypoxia during the delivery. The doctors and hospitals had both settled the case for $1.4 million. The EMT company didn't feel it needed to settle, thinking there was no way they could lose at trial. They lost. And the verdict was for 10 million buckaroos.

Apparently, the plaintiffs attorney was able to successfully argue that the paramedics ought to have performed a thorough, independent evaluation of the pregnant mother prior to departure and then refused to transport her; in essence, they should have overruled the judgment of the physicians involved in the case. And they also ought to have resuscitated the child as well as any tertiary care NICU. Even though they weren't physicians. While in a speeding ambulance.

But we don't need tort reform, right?