Friday, July 22, 2011


I took care of a trauma patient a few months ago who was in a motor vehicle crash on her prom night. Initial imaging showed some left sided rib fractures and a broken leg. She was admitted to the regular nursing floor for further observation. When I saw her in the morning (4 hours after arrival) I found that she had one of those classic "seat belt signs". She was also was quite tender on abdominal exam. Her labs revealed an elevated white blood cell count, in itself not necessarily a concerning thing as young trauma patients with broken limbs will often mount a reactive leukocytosis. But her abdominal exam bothered me. I reviewed the CT with the radiologist. She didn't see anything unusual. So I repeated the CT and the blood work 2 hours later. Her WBC count was now over 20. The CT scan, however, was again read as "normal". When I examined her, she had frank peritonitis.

I took her to the OR and found she had perforated her proximal jejunum. Enteric contents were actively leaking into her peritoneal cavity. Everything else looked OK. We lopped out the damaged intestinal segment and put everything back together again. She did very well afterwards.

Blunt injury to the intestinal tract is a terrifying diagnosis in the world of trauma surgery. The CT image you see above is from the young lady's 2nd scan. What you don't see is anything that would ordinarily mandate an operation. There is no free air. No ascites. No obvious evidence of bowel injury. You just have to be patient with these cases. Examine the patients frequently. Don't be comfortable with negative CT scans. It also helps to have a firm grasp on what is meant by the term "peritoneal signs".

These are the cases where you simply have to know what the hell you are doing, individually. Collaborative care won't get you anywhere. You won't receive an award for just removing the patient's foley after 24 hours. Your Accountable Care Organization won't send you an Olive Garden gift certificate for limiting the total inpatient costs. It's all on you, buddy. Prom night 2012 is ten months away.

Sizemore Opts for "Sports Hernia" Surgery

Washed up Indians center fielder Grady Sizemore was just put on the disabled list following surgery for a "sports hernia". This news came as a bit of a surprise to those of us masochists who follow the Tribe because press releases last week indicated that Sizemore would be out of action for a few days due to a "bruised knee" sustained while running the bases. Apparently, he had also been suffering from groin pain and his doctors felt that, as long as he was going to be out with a knee injury, he might as well undergo the procedure on the groin.

Sizemore hasn't played a full season of baseball since 2009. He had microfracture knee surgery last Spring. He was batting in the .230's and striking out every three trips to the plate this year. The guy is clearly going to pieces. I feel bad for him. But sports hernia? I hope to God Sizemore isn't thinking this is going to help him rediscover the art of actually making contact with the baseball.

The sports hernia craze is nothing short of amazing. It truly amazes me that such a procedure is being done so commonly on world class athletes. I've read the literature. I've done the research. And I still have no clear idea what a "sports hernia" is. I've read that it is everything from a "weakness" or a "bulge" in the inguinal floor, to a torn adductor muscle, to an entrapment of the obdurator nerve. What is it? Is it simply a Syndrome of Pathology? Is it multifactorial?

And what exactly is being done in the operating room? It sounds like most of these repairs involve placing a synthetic polypropylene mesh in the inguinal area, either via an anterior Lichtenstein approach or a laparoscopic, preperitoneally placed mesh in the Space of Retzius. I found one randomized trial on PubMed comparing conservative therapy with laparoscopic surgery. The mystery and lack of uniformity surrounding the technique certainly raises a few questions.

The mesh repair seems a little dubious to me. In true hernia repairs, the mesh acts as scaffolding, to allow natural scar tissue to form and strengthen the fascial defect. The mesh actually bridges the fascial defect. There are no anatomic fascial defects in the sports hernia. It's not clear to me, therefore, why exactly one needs to be implanting mesh in these patients. If you tear a muscle in your calf and I take you to the OR, stitch a piece of mesh over your muscle and tell you not to do anything strenuous for three months, there's a real good chance you'll feel pretty darn good after three months. But if you rest anything for 3-6 months, I suspect most will see significant improvement with or without surgery.

Here's what I propose to those who are advocates of sports hernia surgery:

1) Someone write an expository paper with pictures or intra-operative video footage detailing the exact technique of the repair.

2) I would love to see a randomized controlled trial comparing a sham surgery with real surgery in patients who have experienced 6 months or more of refractory groin pain despite conservative management. If something like this demonstrated statistically significant improved outcomes, I could be persuaded that maybe, just maybe, sports hernia is a real live entity.

Sunday, July 17, 2011

Irrational Death

My mind has been wracked by this story of a man falling out of the stands at a Texas Rangers game while trying to catch a game ball tossed into the crowd by star outfielder Josh Hamilton. He was a 39 year old firefighter and a husband and a father. He had driven his 6 year old son Cooper three hours to the game to watch their beloved Rangers. By all accounts he was a great fireman; fearless and a leader of men. He was a husband and a father. He took his son Cooper everywhere with him, to the fire station, community events, to baseball games at Rangers Ballpark.

He fell on his head reaching for a baseball. In the end, that's what it comes down to. The injury was probably an epidural hematoma that expanded rapidly. By the time he got to the emergency room, he was probably already on the verge of brainstem herniation. He didn't have much of a chance. Again, he died reaching for a goddam baseball. Sports columnists and writers will try to spin this as a "tragedy at the ballpark". They will dress it up in the narrative of fathers and sons and how baseball is a metaphor for life and fatherhood and growing up and all that Field of Dreams nonsense. But it's all bullshit. This wasn't a tragedy, not in the Greek sense of tragedy describing a character's fall from grace due to an unrecognized, fatal moral flaw. He didn't fall as a result of some fatal moral flaw. It was momentary lapse of judgment. A split second of reflex reaction, the excited boy in the heart of a man reaching out for a real live ball at a game. To give to his son. He died stupidly, and I don't mean that as an attack on Shannon Stone. I'm not saying Shannon Stone was a stupid man; just that the circumstances of his death were absurd, in the existential, Albert Camus-sort of way. There are plenty of stupid deaths that happen every day. Rarely does such a death reflect on the intrinsic worth of the individual who succumbs to it.

The difficult part is how this death doesn't easily lend itself to any rational narrative. Humans have a natural inclination to tell stories about the things we don't understand. We tell ourselves stories to make sense of a seemingly random, brutal existence of winners and losers and arbitrary suffering. A death, especially a premature one, has to be explained in a way that makes it meaningful. Otherwise the pain of meaninglessness is intolerable. When the ones we love slip away into the eternal darkness of the great unknown, we grasp feebly for a narrative that can show the natural progression of a Life and how the end came "in good time". We strive to demonstrate that it was "meant to be."

In the ICU I see such narratives play out every day. These little old ladies who fall and strike their heads and spiral into oblivion. The bedside is adorned with pictures of earlier, healthier times. Surrounded by grandchildren and everyone smiling, a cake in the foreground, inter-generational gatherings, the completeness of a life captured on film. Those primitive drawings from children. Get Well, grandma. Everyone can gather and celebrate a life well lived.

My grandfather had one of those textbook "perfect deaths". He was in his mid-eighties and every morning he swam at the YMCA before work. Yes, he still worked with my Dad. The morning he died, he met my Dad for coffee and then went to the Y for his morning exercise. According to Y attendants he was in his usual good spirits, smiling and wishing everyone a great day. He swam his laps and then, in the shower, he suddenly collapsed and died instantly from a massive stroke. He had lived a full life. He had watched his children grown up. He had been in a fifty year marriage. And then he died just after doing something he loved. You couldn't have scripted it any better. There was no bewilderment at his funeral. You didn't look around and see blank, baffled faces mottled with grief and confusion. Death had simply come. No one could quibble about the timing. It was a reasonable death.

There are other good deaths. The Army private who dives on a grenade to save his buddies. The father who dies protecting his family during a robbery. The secret service agent who takes a bullet for the President. I read recently about a Thomas VanderWoude in Virginia who died in 2008. His youngest son, Josie, had fallen through a septic tank cover into a deep pit. Josie had Down's Syndrome and he was an adult and lived with his parents, semi-independently. Mr VanderWoude immediately jumped into the septic pit, immersed himself in eight feet of raw sewage and propped his son's head above the surface until he could be rescued. By the time Josie was safely extricated, Mr. VanderWoude had already died from the asphyxiating fumes. This was his seventh and youngest child, a boy with Down's Syndrome and he didn't hesitate to put his own life at risk. There was no moral calculus in the decision, no weighing of the costs and benefits---just instinct and love. This is what we mean by a heroic death.

But it doesn't always have to be an act of heroism. Sometimes death is reasonable if it just alights upon us gently. Even the cancer death can be a good one. Usually one dies from cancer slowly. Slowly one wastes away, after all the surgery and chemotherapy and experimental treatments. The end presents itself. But at least it's an honest end. There are no surprises. One cannot deny that Death beckons. One look in the mirror will shatter all those illusions--- the sunken cheekbones; the amber-tinted, dulled eyes; the protruding skeleton; the wasting away of vitality and slow erasure of prior Being. One cannot hide. But there is solace in finality. One cannot procrastinate any longer. The end is near, inevitable, but there is still time to make amends, to heal old wounds, to express love, to say things you were saving for an indeterminate denouement, to make peace with God, soul, life. You have time to touch up the narrative of your life. Although the end is premature, you are given the gift of writing the final chapter. You have time to make sense of it all, to reconcile yourself to extinction.

But there is another kind of death that we don't like to discuss. There are deaths that don't announce themselves. Deaths that ambush us suddenly and without warning. The 18 year old valedictorian who dies in a graduation night car accident. Len Bias. The five year old who is abducted and murdered. The 44 year old father of five who dies of a massive MI during his seventh marathon. The 32 year old who is struck by lightning while golfing on his honeymoon in Bermuda. The 13 year old Afghani girl killed by a Predator drone strike. The 18 year old high school senior with a full ride football scholarship who dies on spring break in Panama City after drunkenly falling backwards off a third floor hotel balcony. The four year old who runs out into traffic after a ball and is struck dead right outside his house. I remember this patient from medical school while I was on a trauma rotation. They announced him as a motor vehicle crash (MVC) and when they wheeled him in, he was already intubated. He wasn't moving anything and they hadn't given him any sedation. The story was, he was sitting at a stop sign in a Topaz or whatever, awaiting his turn to go. He was an IT specialist, or something along those lines, for a local industrial behemoth and he was on his way home from the grocery store. He was a bigger man, but he seemed soft and doughy, like a high school math teacher. The worst part was that he was completely conscious when he rolled into the trauma bay. I remember looking into his terrified eyes. I was a green and arrogant student then, completely out of my league. I guess I had never seen true Fear before. This was the real deal. Anyway, he was sitting at that stop sign, just another day in an anonymous life, when a pickup truck, piloted by a drunken repeat offender, plowed into him from behind. The impact whipped his neck forward with a violence that snapped his cervical spine at C2 and C3. The CT scan was obscene. There was nothing to be done. I recall being forced to attend the meeting with the man's wife in the consultation room. This was for our edification, as medical students. His wife was there by herself, surrounded by about 8 people (Trauma surgeon, Neurosurgeon, residents, students, etc). I remember the look on her face as the Neurosurgeon methodically explained that her husband was condemned to a life of quadraplegia, as a best case scenario. She had this look on her face like someone who sneaks into a Harvard mathematics class where the professor is lecturing on how 2+2=5, while everyone nods their head and takes notes. The anger and incredulousness on her face betrayed all decency. They had a three year old girl at home. He died within the week.

Let me now venture into a prohibited zone for just a moment. You know, while we're on the subject of unjust deaths that are redeemed by narrative. The mother of all examples is, of course, the story of Jesus of Nazareth. Let's review: God watched us for two centuries. He tried Law and Covenants and Promises. Over the eons, we continued to disappoint Him and betray Him. God was pained beyond understanding. But His love for us was infinite. So He sends down his Son, Incarnate in Man, as a final offering. This Son is to live and suffer and ultimately die for all mankind's sins. He dies violently on the Cross and rises again on the third day. Man, if he chooses, is redeemed through Grace and Faith.

Now that's a good death, no? To die as the sacrifical lamb for all mankind, the vessel through which all can be saved from eternal damnation. It's a beautiful story. A father sacrificing his only son for a greater cause. A supernatural diety trying to connect with his creation in terms that they can identify with. But then I start wondering. Why did old Jesus have to die such a violent, unjust, horrifying death? The Passion of the Cross is certainly dramatic. There's no doubt about that. Just ask Mel Gibson. But does the mode of His death somehow overshadow the ultimate message? Would it have mattered if old JC had died of typhus or malaria or leukemia in some clay hut in Palestine? If He had succumbed to famine or flood or pestilence? What if He had simply tripped over a rock after 40 days in the desert with Satan and fallen down a cliff? What if He had sustained a massive heart attack ten minutes after delivering the Sermon on the Mount? What if He had drowned while bathing one morning in the river Jordan? Would it have mattered? Would the stupidity of His death detracted from a lifetime of everyday suffering? Did it have to be so dramatic? Would the story have been any less compelling without the Passion? (I know, there's probably something to be said for Original Sin and how Man's Fall from Grace during the Edenic phase mandated that humans were wholely responsible for the Savior's death. But still. It bothers me. Sort of an abrogation of responsibility, in my mind. And I hate the Original Sin argument anyway, especially when it's used to justify the death/suffering of innocent children. Tangent ends.)

We humans need a coherent narrative, not just for those whom we choose to worship, but for the flesh and blood we share our lives with. Death disconnected from narrative is intolerable. It's too much of an obstacle, even for a great Faith.

I don't know the answers to these questions. I'm no theologian. I'm a traveller through the inexplicability of life like anyone else. But I think we should all pray,or something along those lines, for Cooper Stone. He is a child now without a father. But he has a long ways to go (hopefully) before his time on earth expires. He has time. He will grow into a man someday. He will exercise a free will. And he will tell himself stories about a father he barely remembers. He has time to construct a meaningful narrative for a father who missed the bulk of his life. And there is Hope in that. There is Hope in the possibility that somehow, someway, Cooper Stone can eventually explain his great loss to himself through a fictive amalgam of memory and imagination. Perhaps his mind is seared with images of going to the fire station with his daddy, playing catch in the hot Texas afternoon, the way his daddy smelled when he came home from work, the prickliness of his unshaven, up all night face. This is all we have. The dead are lost to us otherwise. They die in a multitude of ways. They are extinguished like flickering candles in a November wind. The way they die is immaterial. It won't always make sense. The story just begins. They leave fragments and remnants and shattered pieces of a life. It's just lying there, fluttering in memory and anecdote, evanescent snippets of reality. And it is up to us, the living, to put those fragments back together again when we finally choose to speak of the dead we have lost and loved. I think this is the essence of a True Faith--- to believe these assuaging stories with all our hearts, in spite of all the evidence to suggest otherwise, in spite of the irrationality....

Sorry for the heaviness.

Monday, July 11, 2011

Pancreatic Pseudocyst

One of my long time patients came to see me a while back with a complaint of abdominal distention, pain, and early satiety. A few years prior to this visit I had taken care of him during a prolonged bout of severe necrotizing gallstone pancreatitis. The scan above shows a giant pancreatic pseudocyst. A pseudocyst lacks a true epitheliazed wall. After an episode of severe pancreatitis involving parenchymal destruction and damage to branches of the pancreatic duct, pancreatic juices leak out into the surrounding retroperitoneal tissues. Once the flow of pancreatic secretions is tamponaded off (the ultimate size of the cyst is a function of the degree of ductal damage or obstruction) it will organize itself into a discrete cystic collection. Symptoms generally arise due to the mass effect of the cyst. Pseudocysts can also become superinfected leading to sepsis. Pseudocyst rupture is another rare complication.

We usually adopt a stance of watchful waiting with regards to pancreatic pseudocysts. Most will spontaneously regress as the duct/parenchymal injuries heal. Those cysts that persist past 6-12 months are unlikely to ever go away. Furthermore, cyst size is predictive of regression--- those greater than 6cm are less likely spontaneously resolve.

This cyst was over 20 cm. I watched it for a while but it never got smaller and his symptoms persisted. Treatment options include endoscopic vs. percutaneous vs. surgical decompression. Percutaneous drains are generally a poor choice because you simply convert a contained internal pancreatic fistula into an uncontained external fistula with all the attendant fluid/electrolyte sequelae. Endoscopic drainage of pseudocysts into the stomach utilizing endoscopic ultrasonography is an exciting new option but it isn't universally available and long term results are lacking.

The standard treatment has long been surgical decompression of the cyst into either the stomach or small intestine. I performed a cystogastrostomy on this patient. It's a nifty little procedure. By the time you operate the cyst wall has densely adhered to the posterior wall of the stomach. So all you do is open up the stomach anteriorly, palpate the bulging cyst through the posterior wall and excise a wedge of the gastric/pseudocyst confluence. Classic teaching is to send off that specimen to the path lab to rule out a neoplastic process. The image below represents the 3 month follow-up appearance of the upper abdomen.

Thursday, June 9, 2011

The Cancer Racket

News of a new weapon in the "War of Cancer" raged across the internet last week with the publication of a paper in the New England Journal on vemurafenib, an immune system-targeting drug used in cases of advanced melanoma. Heretofore, prognosis of patients with stage IV melanoma has been dismal, at best. Most die within 6-10 months. Various attempts over the past 15 years to improve survival with the likes of chemotherapy or immune-modulating drugs such as interferon have miserably failed to meet expectations. Paul Chapman's group at Sloan Kettering trumpets the fact that, at 6 months, 84% of participants using vemurafenib were alive compared to 64% who took the chemo agent dacarbazine.

This paper was presented at the American Society of Clinical Oncology and the resultant fanfare would have you believe Jonas Salk himself had announced a cure for the common cold. Here's a sampling of headlines from major media outlets covering the presentation:
'Time to Celebrate'; New Metastatic Melanoma Agent Wows ASCO
---Medscape News
Drugs hailed as a 'major breakthrough' in treating deadly skin cancer
---LA Times
The Biggest Skin Cancer Breakthrough In 30 Years
----Business Insider
Skin cancer 'wonder' drugs that could offer years more life in biggest breakthrough for 30 years
---Daily Mail (UK)

Pretty exhilarating, no? But let's take a look at the actual data. At six months, 84% of patients on vemurafenib were alive compared to 64% on the other standard chemo agent, dacarbazine. Based on this modest 6 month improval, the patients in the dacarbazine group were then switched over to vemurafenib for "ethical" reasons. So there is no data on longer term efficacy or median survival. Since the patients were switched, we'll never know if survival at 12 months, 18 months, or even two years is any different between the two drugs. Isn't that something that would be interesting to know? Furthermore, the results show that less than 50% of patients even responded to vemurafenib. And close to 40% of patients experienced toxic side effects incapacitiating enough to mandate dose modification or even outright temporary cessation of the vemurafenib.

The cost of the drug has not been released but a similar medication, Yervoy, retails for close to $120,000 for a one year course of treatment. Presumably, verumafenib will cost somewhere in this neighborhood.

Now I don't want to belittle the scientific achievement that vemurafenib represents. Being able to manipulate the expression of certain viral and neoplastic proteins at the genetic level is an exciting new frontier. But let's not confuse modest, incremental scientific advancement with real life efficacy. The headlines suggest a quantum leap in medical insight and intervention; which is misleading at best and perilously close to fraudulent misrepresentation at worst.

When it comes to late stage cancer, these pharmaceutical firms and the doctors doing the research have a major financial stake in promoting these newer drugs. Billions of dollars are in play. But this misleading propaganda campaign shamefully exploits a very vulnerable, desparate patient population....

Wednesday, June 8, 2011

So Fast

It sneaks up on you. One day your little girl clambers up for story time before bed and you realize that she just doesn't quite fit in your lap the way she used to. She sort of overflows the confines of the rocking chair and spills across your torso, legs dangling, everything suddenly awkward and cramped. You have to look around her head to see the words on the page. She has to keep shifting to find a comfortable spot. On the one hand you're happy; your child is healthy and growing, becoming a little person. But it still doesn't change the fact that it sort of stings when it happens.

Monday, June 6, 2011

More Checklist Consequences

One of the SCIP protocols involves removing foley catheters post op within 48 hours to reduce hospital acquired urinary tract infections. UTI's acquired during a hospitalization, of course, are a "never event" and hospitals are loath to subject themselves to reimbursement penalties therein. One way to control this is to program the Electronic Medical Record (EMR) for Physician Order Entry (POE) such that all foley catheters are automatically removed by post op day #2 no matter if the surgeon wants it or not. By making foley removal the default pathway, you improve foley removal rates and, presumably, lower rates of acquired UTI's. The doctor is removed from the decision-making process altogether.

My partner operated on someone with an incarcerated hernia not too long ago. The patient was an older guy and he had to perform a limited bowel resection. A foley was placed prior to incision. The guy had a history of severe BPH and it was a struggle to get the catheter in. In his post-op orders he checked the standard box on the POE for Foley care (usually a bag to free gravity).

Unbeknownst to him, the "Foley care" order contained a drop-down box (accessible by clicking a separate tab) mandating that the catheter was to be removed on post-op day #2. In the evening of post op day #2, my partner received a phone call from the nurse---your patient hasn't been able to void since the catheter came out.

"Why is it out? I never wrote that. The guy has a prostate the size of a tennis ball."
"I don't know doctor. But he's having a lot of pain. The lasix you wrote for worked though. The bladder scanner says he's retained 700cc of urine."

And of course the house officer couldn't get the Foley in. Urology had to be consulted, urgently. The guy ended up getting another catheter placed, this time without the benefit of deep anesthesia. According to one of the nurses on that night, it took about 30 minutes of penis stabbing to get it in. But at least the hospital's SCIP data will look good.

Friday, June 3, 2011

The Unintended Consequences of Algorithmic, Bureaucratic Medicine

Whenever someone is scheduled for an operation, the assigned nurse is required to fill out a "pre-op checklist" to ensure that all safety and quality metrics are being adhered to. Before the patient is allowed to be wheeled into the OR we make sure the surgical site is marked, the consents are signed, all necessary equipment is available, etc. One of the most important metrics involves the peri-operative administration of IV antibiotics. SCIP guidelines mandate that the prophylactic antibiotic is given within an hour of incision time to optimize outcomes. This has been drilled into the heads of physicians, health care providers, and ancillary staff to such an extent that it occasionally causes total brain shutdown.

Let me explain. For most elective surgeries (i.e. hernias, lap choles) I give a single dose of antibiotics just before I cut. For elective colon surgery, the antibiotics are continued for 24 hours post-op. This is accepted standard of care. You don't want to give antibiotics inapprpriately or continue them indefinitely.

But what about a patient with gangrenous cholecystitis or acute appendicitis? What if, in my clinical judgment, I want to start the patient on antibiotics right away (i.e. several hours before anticipated incision time) and then continue them for greater than 24 hours post-op, depending on what the clinical status warrants? I should be able to do that right?

Well, you'd be surprised. You see, at two different, unaffiliated hospitals I cover, the surgeons have seen that decision-making capability removed from their power. If a young patient comes in with acute appendicitis and I feel that it would be prudent to continue the Zosyn an extra couple of days, an automatic stop order is triggered in the department of pharmacy and the antibiotic is stopped after 24 hours, no matter what. Unless the surgeon specifically writes "please do not stop this antibiotic after 24 hours; it is being administered for therapeutic purposes, not prophylaxis", the antibiotic will not be sent to the patient's floor for administration. As a result, patients end up being treated sub-optimally, and potentially harmed, due to an over-emphasis on "protocol" and "quality care metrics".

Similarly, the 60 minute timeline for preoperative antibiotic administration can be problematic. I have had patints come into the ER with appendicitis or cholecystitis and, in my pre-op orders, write for Zosyn or whatever, to be started ASAP, no matter what time the operation is scheduled. Not too long ago, I admitted a gallbladder over the phone at 2am. I gave the nurse admitting orders which included one for a broad spectrum antibiotic.

When I saw the patient in the morning, I added her on to the OR schedule. By the time a room opened up, it was about 1030AM. The OR nurse asked me if I wanted to give an antibiotic for the case. I told her that the patient was already on antibiotics as part of her admit orders for treatment. The nurse shook her hand. It had never been given; the floor nurse held it so that it wasn't administered until 60 minutes before the scheduled OR time, just like the algorithm dictates--- despite the fact it had been ordered nearly 8 hours prior to the case, not for peri-op prophylaxis, but for treatment of an established pathology. And there it was, the cefotetan, hanging on her IV stand. Now nothing bad happened but here you have a situation where health care providers are so terrified of violating Quality Assurance Protocol that they end up withholding necessary treatment. It's just astounding.

As surgeons, we have bitched and moaned. You would think that these issues would be quickly rectified. But no. It is the responsibility of the surgeon to write qualifying statements for therapeutic antibiotics because the default mode is to override a licensed physician's clinical judgment. This is what I'm talking about when I say that blind allegiance to a top-down, systems analysis-driven algorithm can turn everyone involved in health care into a bunch of mindless drones.

Errata- In a previous iteration of this post, I mistakenly substituted NSQIP for SCIP. I mix them up all the time. The above version is now correct.

Thursday, June 2, 2011

Macho Man!

The very driven Maggie Mahar has a sweet takedown of little old me over at her Healthbeat blog. Please go check it out pronto. I've read through it a couple times, in addition to the attached comments, and I must say I honestly feel thoroughly Tressel-ized. I learned quite a few interesting facts about myself of which I was heretofore previously unaware. According to Ms Mahar I am pretty much an asshole who manifests a "macho" attitude toward patient care. I exhibit paternalistic and faintly misogynistic chracteristics. I have no compassion, in fact I have "contempt", for the poor and uneducated patients of America. I'm also not very eloquent, an assertion I wouldn't ordinarily object to, but it certainly isn't because I haven't been "a regular contributor to the New Yorker". Adam Gopnik is horrible. And I can't stand Hilton Als and Sasha Frere-Jones. Tom Junod at Esquire writes circles around everyone at the New Yorker. But anyway.

The bottom line is this. I agree with Atul Gawande on some things and disagree (vehemently) on others. We can have a back and forth debate like gentlemen. But that wasn't the point of my previous blogpost. The point was to draw attention to the fact that the commencement address was lame and uninspiring and completely inappropriate, given the context. I mean, this was a medical school graduation speech! The graduating students had just spent the past 12 years grinding through a very rigorous and exhausting phase in their lives. And now they are to embark upon a life of selfless labor, dedicated to the well being of their future patients. To use that moment as an opportunity to give a wonkish health care policy speech is entirely self-serving and, well, boring.

In fact, Dr Gawande was in the area last weekend when my little sister got married. I saved the transciption of his wedding toast:

"Jen and Brandon, congratulations on your recent betrothal. I know it's exciting and all but please beware of indulging your romantic fantasies too much. The truth is, we Americans don't do so well at the institution of marriage. Over half will end in divorce. Domestic violence is on the rise. Children can be emotionally scarred by the fallout from broken homes. I would advise you to throw away your Shelley and Lord Byron, your Shakespearean sonnets, your anachronistic Valentine's Day traditions. Such mindlessness is old school and inappropriate in the modern age of love and marriage. Instead, I would encourage you two to engage one another in more actionable displays of a solid married life. Instead of random weekend getaways, consider a more robust, algorithmic approach to love. Those warm fuzzy feelings you get from time to time are completely unpredictable. Do not trust them. It is a cowboy mentality to lose yourself in a sappy loving brain goo. You have to collaborate in a pro-active, value added fashion. My wedding gift to you is a special Love Checklist that I have released to you, free of charge, prior to its intended publication date in the fall. Please review it and implement its tenets and re-purpose its structure for your own needs. Thank you. Again, my heartfelt congratulations."

/cue electric slide.

Monday, May 30, 2011

The Most Uninspiring Med School Graduation Speech Ever

Atul Gawande's recent commencement speech to Harvard Medical School is here. Read it if you like. It won't exactly send chills down your spine, to say the least.

His essential message is this: Healthcare is far too complex for any one doctor anymore. So gear up to be an interchangeable part, a faceless drone who performs menial tasks according to checklists and algorithms that Really Smart People will provide for you. Don't be a Cowboy (in the romanticized, individualistic sense of a bygone era) unless you want to be like a real live lower-case "c" cowboy in Wyoming who functions as part of a team and follows protocols (Dr Gawande talked to one himself, it's true!). All that debt you've taken on to be a physician? It's so you can be an anonymous member of an integrated Team. Like a Pit Crew. Who doesn't get jacked up to join a pit crew? I sure do!!!

Is it any wonder that Dr Gawande is the very Messiah of future healthcare delivery to people like Maggie Mahar and Ezra Klein? Not a word about being a better physician, about recapturing the old ethic of patient ownership. Nothing about the challenges individual doctors face to stay on top of new medical developments and how they can be surmounted. Nothing about personal accountability. Nothing about putting your heart and soul into this noble calling.

Friday, May 20, 2011

Weekend Surgery Puzzle

So a patient comes in with hypotension, tachycardia. His family found him down on the bathroom floor laying in a pool of dark maroon stool. In the ER he is immediately intubated and we resuscitate him with saline and PRBC's. An orogastric tube is placed and massive amounts of blood is evacuated from the stomach. The stomach is then copiously lavaged with saline until clear. An upper endoscopy is subsequently performed that morning which shows 4-5 large duodenal ulcers. But none of them are actively bleeding. No visible vessels are present.

He goes to the ICU on a protonix drip and stabilizes his hemoglobin for 48 hours. Then one Sunday he drops his pressure and starts passing large amounts of blackish-red stool. The GI doc and I are there simultaneously. His blood pressure is tenuous, despite aggressive resuscitation. It seems like he has re-bled from his duodenal ulcers and may need emergency surgery.

But the orogastric tube is putting out bilious contents. The GI guy quickly slips an endoscope into his stomach. And then there's no blood. The ulcers appear stable. Bile washes back from the duodenum.

What is the next step? What operation do you think the dude will need?

Thursday, May 19, 2011

Rules for Case Blogging

Last week Kevin Pho wrote about a physician in Boston, Alexandra Thran, who was disciplined by both her hospital and the state medical board for writing about a trauma patient she had seen. Although Dr. Thran hadn't divulged the patient's name, enough information was conveyed that allowed others in the community to identify the patient in question.

That story really freaked me out. Because, as you know, I sometimes write about my adventures in general surgery. Am I a dead man? Is the Ohio State Medical Board going to give me the Bradley Manning treatment? Am I destined to working the night shift at a CVS minute clinic in five years?

As with most ethical issues, there is a lot of gray and nuance. But in general, I think you are safe writing about personal cases from your practice if you exercise a certain degree of reasonable restraint. Write about your experiences, not as a form of personal aggrandizement, but as an attempt to share, educate, and converse with laymen and other professionals about disease processes and treatment options in the open forum that is the Internets.

Here of some general rules of thumb:

1) If someone famous comes under your care, just don't write about it. If the patient is famous enough, some aspects of his/her clinical condition will leak out. There may be understandable angst and resentment that Celebrity X's privacy isn't guarded as well as anyone else's. If you write about the celebrity's case, even if you conceal it, there's too great a risk that details will overlap with leaked information from other sources. Then a giant HIPAA target forms on your back. So don't write about how the back up center for the Bulls came into the ER at 3AM with a sex toy stuck in his rectum, thinking that simply using pseudonyms gets you off the hook.

2) Strive to present cases for educational purposes. Ramona Bates is the exemplar for medical blogging when it comes to case presentation (how she has the patience to type out full bibliographies just kills me). I'm not so regimented but I try to at least provide a little pathophysiology and surgical dogma background. Compare a write up of cecal bascule in a peer reviewed journal here with my post on the same topic. My post was certaintly a little less dry and stuffy, perhaps a little too irreverent, but that's why you won't be reading much of my work in renowned journals. Conversely, my cecal bascule post was read by a lot more people that the one in Applied Radiology.

3) When you post images/scans, make sure you have removed all identifying data. Duh.

4) Let the case marinate in your mind a bit. Don't rush immediately from the OR/ER to the laptop. I usually give the cases several weeks/months to mature.

5) Review the literature to make sure your management correlates with standard of care protocols. You don't want to write about that APR you did on an early stage squamous cell anal cancer, and then have someone point out on a public blog that you ought to have sent the patient for an oncology consult to discuss the efficacy of the Nigro protocol (chemo/radiotherapy) as sole treatment.

6) Don't be a jackass. Don't brag or write things like "the patient was in good hands that night.."

7) Make sure your operative consents contain a section about "using images for educational purposes".

8) For cases that involve detailed, individualized descriptions of the operation, post op events, and eventual recovery phase---- discuss your plans to blog about it with the actual patient. Even let them read the post before you publish it.

Wednesday, May 18, 2011

Andrew Sullivan Continues his Anti-Physician Drumbeat

The Cause Of Death: Greed?
Earlier this week, Michelle Andrews reported that "hospitals perform autopsies on only about 5 percent of patients who die, down from roughly 50 percent in the 1960s." She also dug up a 1998 report that found "autopsy results showed that clinicians misdiagnosed the cause of death up to 40 percent of the time." Robin Hanson has a theory:

A pretty obvious explanation for fewer autopsies: docs don’t like being proven wrong. Such dislike can lead to lawsuits, and generally make docs look bad. ... Could there be any clearer evidence that docs care more about getting paid than about healing patients, yet the public can’t bring itself to imagine docs are that selfish?

That was from one of his blog-link posts this morning. Let me first deconstruct the incoherence of the assertion of the title---> "The Cause of Death: Greed?" I mean seriously. What is being scrutinized here is the decrease in autopsies that are performed in American hospitals over the past 50 years. What on earth does that issue (worthy of investigation, certainly) have to do with greedy physicians being the cause of those patients' deaths? If the patient is already dead, then what does the relative generosity of a physician have to do with what caused his death, in the context of whether or not an autopsy is done? Let's say an autopsy would reveal that the physician made an error and he wants to conceal that fact by quashing an autopsy, then one could make the assertion that the physician is acting greedily by seeking to reduce autopsies and enhance his reputation amongst peers/patients. But by no means can one use such behavior to infer that the physician also caused the patient's death through avaricious conduct. It's a malicious, misleading headline that attempts to re-assign after the fact vices as the precipitating factor that led to the event in question. In other words, if a kid knocks over his aunt's thousand dollar Chinese vase and attempts to cover it up by lying because he knows she will make him pay for it you could rightly infer that his greed led to his deceitful post-event behavior. But you wouldn't ever state that the kid's greed led to the vase getting knocked over in the first place would you?? It's absurd.

The piece furthermore leads the casual reader to infer that doctors are engaged in a nation-wide conspiracy to cover-up the causes of death in hospitals, like some cheesy Robin Cook novel. Do you think this is true? Are doctors actively trying to talk family members out of autopsies on their dead loved ones? I don't think so. I know for damn sure if I lost a loved one in the hospital and a bedraggled doctor immediately tried to talk me out of getting an autopsy, the first thing I would do would be to demand an autopsy STAT. I think the fact that fewer autopsies are performed has less to do with doctor practices/behaviors than with our preferences as a society. We aren't comfortable with actual death (unless it's the patriotic, hyper-violent, glorified kind you see in video games and American pop culture). It's a sociocultural issue. We can let Malcolm Gladwell figure that one out. The reality is, when someone dies in the hospital, a doctor has to fill out the death certificate. On that certificate, we have to indicate whether or not the incident qualifies as a coroner's case (mandatory autopsy) and whether or not the family decided to pursue an autopsy.

The article Sullivan links to contains this paragraph:
Autopsies play a critical role in helping to advance understanding of the progress of a disease and the effectiveness of various treatments. At the same time, they may identify medical conditions that clinicians and high-tech imaging miss or misdiagnose. For example, Elizabeth Burton, deputy director of the autopsy service at Johns Hopkins Hospital in Baltimore, recalls that when she autopsied a 50-year-old alcoholic patient, what appeared to be cirrhosis of the liver was actually cancer.

You know what a risk factor for liver cancer is in this country? Cirrhosis, either from alcohol or viral hepatitis. So in the above example, the autopsy revealed something that, although undiagnosed at the time of death, didn't necessarily cause the patient's demise (almost certainly the cirrhosis did) and is a clinical finding most clinicians would find unsurprising.

In the 1960's we often had no idea why in the hell people died. We didn't have CT scans or coronary angiography or high tech hemodynamic monitoring devices like we do today. Nowadays we can explain to patients with a reasonable degree of certainty that patient X died "likely due to condition X, Y, and Z." Autopsies in the 60's gave families and doctors closure. A family member just wants to hear something other than "I don't know what happened".

I'm a Sullivan fan, generally (torture, Palin, etc). But he's out of his league on the health care issue.

Tuesday, May 17, 2011

Health Costs: Blame the Doctors?

I'd like Andrew Sullivan to square his stance that simply allowing the SGR-determined cuts on Medicare reimbursement to physicians to stand (due to be about 29% in 2012) with the below graphs. He seems to think that all we have to do is chop physician reimbursement and a big chunk of the spiralling health care deficit can be bridged. Well, you can't squeeze a gin martini from a cold stone, buddy. We surgeons get paid 3% less than what we were paid in the mid-nineties for a laparoscopic cholecystectomy. I have a feeling that your local plumbers or lawn mowing companies aren'tcharging 3% less than what they did ten years ago to plug a leak or mulch your lawn.

Laparoscopic Adrenalectomy

I love these cases. A patient was sent to me with an adrenal mass that had been increasing in size over the past 2 years. You can see it in the above image (hint: look above the right kidney). Adrenal masses over 6 cm (or even 5 cm in women) have a high likelihood of being malignant. But before you get them on the OR table you have to do some boring doctor-work first. Specifically, you have to make sure you aren't dealing with a functional adrenal adenoma. That means sending off a barage of blood/urine tests to rule out aldosteronoma, pheochromocytoma, or a cortisol-producing tumor.

The big one to worry about is a pheochromocytoma. Pheos produce catecholamines (adrenaline) and indentification of one prior to surgery is crucial. At least two weeks of pre-operative alpha blockade (a specific anti-hypertensive agent) is required to protect the patient from the surge of adrenalin release that can occur during the operative manipulation of the tumor, and also the sudden drop in systemic catecholamine levels once the tumor is removed.

This particular tumor ended up being a benign adenoma. The case hinges on identifying and controlling the adrenal vein. The little bastard is about two centimeters long and it enters directly into the cava. If it tears you end up with torrential bleeding. Which sucks. Until you get clips on the vein, snip it, and watch the bulging blue vena cava gently roll away from the gland it's a very high tension environment. I keep the music down and, believe it or not, I can get a little snippy and high maintenance. Sliding my Maryland dissector under the vein, then slowly spreading to break up the adventia, watching it flatten and whiten and elongate, stretching out away from Big Blue, nearing its maximal tensile strength.... shit, I'm getting beads of forehead sweat just thinking about it. But once it's controlled, it's time to blast the Playing in the Band and have a good time. All that's left is to hack the gland out of the retroperitoneal fat with my harmonic scalpel. For Academic Endocrine Surgeons, the hacking out part is probably a bothersome distraction, best left to the fourth year resident who, heretofore, had been assigned to camera-holding duty. But I like it.

Torture as Party Platform

Outrageously, we are now a country where potential candidates for President of the United States can raise their hands at primary debates and aver their unabashed support for torture without suffering any backlash. Listen to the audience roar their approval to see three of five hands held aloft. Waterboarding has always been considered a form of torture. The definition doesn't change just because America sanctioned it during the Bush regime. Torture is torture. It is illegal, a moral transgression of the highest order, and a permanent stain on the integrity of this country. And apparently it has now become a litmus test for Republican party purity.....Unbelievable.

Friday, April 29, 2011

Large Bowel Obstruction

It cannot be emphasized enough: suspicion of a large bowel obstruction mandates an early surgical evaluation---- even if you think it's just a little old lady with another episode of constipation. LBO represents a potential surgical emergency. These patients ought not to be sitting on regular nursing floors for days and days. Within hours of arrival, a surgeon needs to be on the case. The consequences of delay can be catastrophic. Patients who perforate and dump liters of feces into their own abdominal cavities don't do so well.

Here's what to look for:
1) Colonic dilatation, especially cecal, greater than 6-8 cm.
2) Severe distention with tympany
3) PAIN. This is a sign of impending vascular compromise.
4) Don't be fooled by a report of "patient had some diarrhea". In a high grade colonic obstruction, sometimes passage of liquid fecal matter is the only stuff that gets through. Never assume that this suggests complete resolution of the blockage.

Here's what you do:
1)Consult surgery
2)Bowel rest, possible NG tube
3)Do not give oral motility or bowel cleansing agents

Here's what we will do:
1)Review films and examine patient. Pain on exam sets off our alarm systems.
2) Obtain barium enema study vs flexible sigmoidoscopy (usually in concert with our GI colleagues)
3) Operate

The type of operation can vary from case to case. Left sided obstructions usually result in a colostomy (unless you have endoscopic stenting specialists in your hospital). Right sided blockages can be addressed in a single stage without diverting ostomies. Sometimes all you can do is decompress the patient with a loop colostomy or even a cecostomy. But you can't let these patients with 10 cm cecums linger on the floor. The Law of LaPlace is an immutable physical reality.

Taxanes and Neutropenic Colitis

One of the dreaded complications of taxane-based chemotherapy agents is severe neutropenic colitis. The images above are pretty classic. Mortality rates approach 50%. Surgical treatment is usually an ileocolectomy with an ileostomy. When I saw this particular patient, there wasn't much to be done. He had extensive mottling of his legs and abdominal wall and, hemodynamically, he was already starting to crash. (As an aside, mottling is one of the most ominous random clinical findings you can encounter. The bluish-black stippling of the skin is an imprint of death itself.

Friday, April 22, 2011

Greenfield Doubles Down

In response to stepping down as incoming Preseident of the American College of Surgeons, Lazar Greenfield MD fired off an unrepentant, angry-as-hell email to several national media organizations on Wednesday. Here's the full text (with my comments in italics):

"The reports surrounding my resignation as President-elect of the American College of Surgeons lead readers to conclude that I represent an old-guard generation that represses women in surgery. Since nothing could be further from the truth, I can no longer remain silent in an attempt to protect the organization.

"These are the facts:

"1. The editorial was an opinion-piece written for a monthly throw-away newspaper, not a scientific journal. It reaches supposedly mature readers interested in new discoveries. (All of a sudden Surgery News is just a "throwaway newspaper". I'm pretty sure Doc Greenfield doesn't describe his tenure as editor of Surgery News as "Editor of Throwaway Newspaper" on his CV. And anyway, what difference does it make where it was published? You click "publish" on your laptop, you have to deal with the consequences. Would it matter if he had slipped his Discourse on Semen into the Archives of Surgery? In Mad Magazine?)

"2. The biochemical properties of semen that were reviewed have been documented in peer-reviewed journals and represent the remarkable way that Nature promotes bonding between men and women, not something demeaning.
(The "science" on this is a little suspect, at best, as per Orac. And besides, I thought this was supposed to be a "joke". Is it a joke or was it science? Or humor lightly sauteed in scientific olive oil? I don't know whether to laugh or run a PubMed search.)

"3. My light-hearted comment related to Valentine's Day was intended to amuse readers, but some found it offensive, so I extended sincere apologies and resigned as Editor-in-Chief of the paper. No one questioned my intent, since I have a long record of recruiting and promoting women in surgery. (Ah, the old "well some of my best friends are black people" defense.)

"4. That was not sufficient for some women who convinced the leadership that I was unsuited for the Presidency to which I had been elected. Facing threats of demonstrations by women at any medical meetings I might attend, I resigned.
(Only women found the article stupid and puerile and genuinely unfunny? Sure about that Lazar? I don't have a vagina. And I thought you sounded ridiculous and would have laughed my ass off from the back row every time you got behind a podium to give a speech as President of the ACS).

"I had hoped to make my experience one that others could learn from by appearing at meetings of women surgeons to discuss forms of hidden or unconscious discrimination, but that did not fit their agenda. There should have been a way to reach a less destructive outcome. (WTF does this paragraph even mean? Is he admitting that he may have expressed "hidden" or "unconscious" discrimination with his op-ed? Or is he implying that he is the one being discriminated against? And I love the phrase "destructive outcome", turning the tables and presenting poor Doc Greenfield as the victim.)

"So lets reverse the situation, and say that a woman editor wrote something that some men found offensive. After they voiced their history of repression, she decided it would be best for the paper if she resigned as Editor. But that wasn't enough, and other men's organizations demanded that she resign as the incoming elected President. The conclusion is obvious: men are ruthless and vindictive.
(Oh my god. That might have been the most retarded concluding sentence to a written defense that I have ever read. The old role reversal argument! Which makes no sense! And allows him to passively assert that the women who bitched about his semen treatise are RUTHLESS and VINDICTIVE!)

"Lazar J. Greenfield, M.D."

Clearly, that email was just awful. Could he have come off any whinier and self-pitying? He seems convinced that a small cadre of feminazis colluded to deny him his long overdue anointment as the chief representative of American surgeons. The email makes him look even more sexist than how he appeared after the original op-ed. Not a lick of contrition to be found. The clueless lack of self-awareness is just stupefying. The dude honestly feels like he's been egregiously wronged. Anyway, that's about all the Lazar Greenfield I can take for a week. Happy Easter everyone.

VA MRSA reeduction

The New England Journal of Medicine recently published findings from a multi-institutional VA study that demonstrated drastic reductions in hospital-acquired MRSA infections when a "bundled approach" infection reduction was adopted. This MRSA "bundle" included universal screening of new patients for MRSA colonization, strict isolation and contact precautions of infected patients, and a strong emphasis on hand hygiene after patient contact. After three years, ICU-related MRSA infections had dropped by 62%.

Those are good results, of course. MRSA is depressingly common in the hospital, and even outpatient, setting. Simple maneuvers like washing your damn hands after examining a patient in the ICU have to be considered standard of care measures. I'm not convinced that it's cost effective to screen every single patient who walks in through the ER for MRSA (why not just adopt universal precautions?) but the results certainly speak to the beneficial effects of increased attention to hygiene and a checklist-oriented approach to medicine.

But it strikes me as a somewhat hollow victory. So we've learned how to reduce MRSA and other hospital-acquired infections. Terrific. We could also completely eliminate all hospital infections by forcing doctors and nurses to don HazMat suits when entering a patient room and quarantining every patient in sealed iso-chambers like it's some hackneyed, faux-thriller Ebola outbreak movie on Lifetime Channel starring Brian Austin Green and Valerie Bertinelli.

My question is, what are we doing to address the underlying source of rampant antibiotic-resistant bacterial infections? If MRSA and C. Diff are never events, then why isn't indiscriminate use of prescribed antibiotics also being monitored as strictly? Why don't we have databases documenting all the unwarranted orders for oral and Iv antibiotics? When a PCP calls in a script for a Z-pack on a patient who complains of a "head cold'", why isn't that considered a "never event??

Friday, April 15, 2011

Lazar Greenfield's Cure for Depression

Lazar Greenfield is one of the truly pre-eminent, almost legendary figures in modern general surgery. He has mentored countless academic surgeons over the years at the University of Michigan. He is the eponymous originator of the IVC filter used to protect high risk patients from potential pulmonary embolisms. He is the editor in chief of Surgery News, the official newspaper of the American College of Surgeons (ACS). And recently he won election as the new President of ACS. That's a hell of a resume'.

And then old Dr Greenfield had to cap off a sterling career by writing a bizarre op-ed piece in Surgery News this past February wherein he makes the argument that women would be a whole lot happier if they, um, absorbed a little more semen into their bloodstreams. Yeah, unfortunately, I'm dead serious. Semen. As in man sauce. Based on exhaustive research into fruit fly mating habits, apparently. Or something like that.
It’s been known since the 1990s that heterosexual women living together synchronize their menstrual cycles because of pheromones, but when a study of lesbians showed that they do not synchronize, the researchers suspected that semen played a role. In fact, they found ingredients in semen that include mood enhancers like estrone, cortisol, prolactin, oxytocin, and serotonin; a sleep enhancer, melatonin; and of course, sperm, which makes up only 1%-5%. Delivering these compounds into the richly vascularized vagina also turns out to have major salutary effects for the recipient. Female college students having unprotected sex were significantly less depressed than were those whose partners used condoms (Arch. Sex. Behav. 2002;31:289-93). Their better moods were not just a feature of promiscuity, because women using condoms were just as depressed as those practicing total abstinence. The benefits of semen contact also were seen in fewer suicide attempts and better performance on cognition tests.

So there’s a deeper bond between men and women than St. Valentine would have suspected, and now we know there’s a better gift for that day than chocolates.

I can only hope that Dr Greenfield just has an awful sense of humor and that he truly thought he was writing a witty, seasonally-appropriate op ed for the Valentine's Day holiday. It isn't far fetched--- academic surgeons aren't exactly known for being Louis CK clones in the doctor's lounge. (Although, precisely because they are academic hot shots, they invariably are feted with guaranteed, disingenuous forced laughter after every awful joke they make by obsequious residents and med students who seek glowing personalized recommendations from them when the rotation is over, and so they never pick up on the fact they what they are saying truly isn't funny, in the standard meaning of the term.)

Anyway, he stepped down as editor of the paper and his status as incoming President of ACS is still TBD. He's sort of a creepy looking chap in that picture isn't he?


Dr Greenfield has officially resigned as incoming President of the American College of Surgeons. There will be plenty of people who denounce this controversy as an "overreaction". Certainly we all have the right to say whatever the hell we want. But the 1st Amendment doesn't protect any of us from the societal consequences of our speech. Dr Greenfield isn't going to jail here. He simply lost his elected position as the primary representative of American surgeons. That doesn't seem unreasonable to me. His op-ed could have focused on something benign and non-controversial, along the lines of "sex makes for happier surgeons". But no, he had to concentrate on semen. And how women need to augment their intake of the creamy white paste. I mean, this wasn't some off hand comment made at a Michigan Surgical Society banquet, after one too many martinis. This was an op ed in a monthly newspaper for God's sakes, which lends an air of premeditation to everything. One mistake doesn't negate an entire career, however. Dr Greenfield ought not to be judged solely on the basis of an asinine editorial but unfortunately, in the modern internet era, you can't hide from a single indiscretion. The internet will find you.

Bin Laden is Laughing at Us

This is the Police State that has wrapped its tentacles around us, so subtly, without a whimper of protest....

Thursday, April 14, 2011

Weekend Palin/Trig fun!

Here's an entertaining read by some history professor in Kentucky who went through the evidence and concludes that Trig is not Sarah P's son. Just remember---before all you Palinites start brandishing your pitchforks---- all Palin ever had to do was produce Trig's birth certificate and the relevant hospital records and this all goes away.....

More Bariatric Follies

There's a paper out in Archives from March that pretty much slams the door on the idea of laparoscopic adjustable gastric banding (LAGB) becoming a universally accepted treatment option for morbid obesity. 151 patients were contacted over ten years after having had LAGB for follow up. Only 60% were overall satisfied with the long term results. Alarmingly, nearly 50% required surgical removal of the bands due to erosion. Long term reoperation rates were over 60%. That's bad medicine, baby.

And then I read an article like this one in the Journal of Pediatric Surgery, that tries to defend/justify the practice of slapping a choker on a teenager's stomach. Here's from the abstract:
One hundred patients aged 14 to 19 years underwent LAGB. Preoperative average weight was 136.7 kg, and median body mass index was 48.7. Comorbid medical conditions were common. Five reoperations were performed for port site bleeding, hiatal hernia repair, possible intestinal obstruction, and port slippage. Eighty-seven patients were followed for a minimum of 6 months. Average weight loss at 6 months was 12.4 (range, 33.2 to 16.2) kg, and average change in body mass index was 4.4 (range, 11.8 to −5.6).
Beyond the fact that their results are mediocre (12 kg weight loss over 6 months), I'm more concerned about the moral implications of the report---that somewhere in this country there are pediatric surgeons at major academic centers sitting down with parents and their 14 year old child, trying to convince them that they ought to consent to implanting a device that has known poor results. I mean, 14 years old. It's ghastly, really.

Wednesday, April 13, 2011

Poem of the Week

The Best of It

However carved up
or pared down we get,
we keep on making
the best of it as though
it doesn't matter that
our acre's down to
a square foot. As
though our garden
could be one bean
and we'd rejoice if
it flourishes, as
though one bean
could nourish us.

-Kay Ryan

Sunday, April 10, 2011

Portal Venous Gas and Cecal Bascule

Most cases of cecal volvulus involve the twisting of a redundant, poorly fixated cecum around its ileocolic pedicle. Cecal bascule is a weird variant of cecal volvulus wherein its anterior wall folds over on itself oddly. I can't describe it in words very well. The first picture above may or may not be helpful.

Anyway, I operated on this lady recently who presented with portal venous gas and had peritoneal signs on exam. A deep fold in the anterior wall of the cecum delineated the extent of the gangrene present, isolated to the anterolateral aspect of the cecum. We did an ileocolectomy and she ended up doing well. Then I went home and looked up the word "bascule", because it sounded so stupid. Sure enough, I found it is a French word meaning "seesaw" or "balance". Drawbridges operate on a similar principle. My daughter loves seesaws. There's a park around the corner from where we live that has one. She makes me ride it with her for longer than I would normally enjoy.

Wednesday, April 6, 2011

It's Time

I was asked to see a 95 year old lady with severe abdominal pain a few weeks ago. She had been admitted to the hospital with complaints of fatigue and chest palpitations. Suddenly one morning she developed severe, sharp abdominal pain. Her heart was racing in the 130's. The Xray technicians were just leaving her room when I arrived. Now I know what you're thinking: 95 years old, what the hell is a surgeon doing on the case? But this was a sharp old broad, entirely in control of faculties. She grabbed my ID to make sure she heard my name correctly. "I'm in a hell of a lot of pain doctor", she said.

Her code status was DNR-CCA, meaning that, in the event of cardiac or pulmonary arrest no invasive life saving maneuvers were to be done. When I pushed on her belly the diagnosis was clear enough. She had peritonitis, likely from a perforated ulcer or perhaps diverticulitis. The x-ray eventually confirmed free air. I quietly informed the lady of her predicament. She told me to hold my horses, as her daughter (POA) was on her way in.

I spoke with the daughter on the phone to prepare her. I told her that her mother had sustained a catastrophic intra-abdominal event. I further told her that time was of the utmost importance; we had to determine how aggressive we were going to be, ASAP.

We met at the bedside. The daughter looked understandably strung out and stressed. Her eyes were raw red open wounds. She had seized her mother's pale hand with two of her own, as if she was fervently praying. "I think she wants you to do the operation", was the first thing the daughter said to me. Her voice trembled. She wouldn't let go of her mother's hand. She looked like she had run up the four flights of stairs to get here.

This is where the art of medicine comes into play. I have made the mistake of operating in this situation before, when I was a less experienced surgeon. I used to think it was enough to objectively present patients/families with the options, like a mechanic at a oil change shop. Option A, operate with certain complication rates, including the possibility of death. Option B, palliative care with death to ensue sometime soon. It's your decision. I will support whatever it is you decide. And then to step back, put the onus of responsibility on their shoulders. Sometimes the choice is too overwhelming. The patient is suffering. Please just do whatever will make the pain stop, she pleads to her daughter. What if the pain medications dont work they wonder. Maybe she will be one of those rare patients who survive the surgery and get better. After all, Mom just had lunch with me yesterday at Olive Garden. And so doubt begins to creep in. Doubt about advanced directives and code status orders. It's one thing to fill out end of life documents in an abstract, detached manner years beforehand. It's quite another when actual life rears its unyielding head and strikes at you with its ferocious inexorability. And so adult children of these dying elderly patients will ask----can you save my mom?

I have saved a few. I remember one 89 year old guy I operated on for toxic megacolon. He miraculously survived the subtotal colectomy and was sent to a nursing home. I remembered him as a personal triumph, a transient victory over the brute relentlessness of death. I may have even blogged about it, I can't remember. The story didn't have a happy ending though. I got consulted to see him 8 months after that miracle surgery. He was in the ICU with sepsis from a decubitus ulcer. His granddaughter told me he never really regained his mental or full physical faculties after the surgery, despite the intense rehab. The ileostomy was a constant source of stress and irritation. He had slowly withdrawn into himself and rarely left his bed. He had become a living ghost of the man she had grown up with. He died shortly thereafter.

Sometimes you have an obligation to present a patient's options in such a way that sort of pushes them in one direction over the other. Call it paternalistic if you will. I call it humane.

I told her that an operation would be very difficult (she had had numerous previous surgeries over the years and had an obvious large ventral hernia). I told her that it's certain she would leave the operating room intubated and highly likely that she might never get off the ventilator safely. I told her that many of her organ systems were already starting to fail and that often that process was irreversible, especially in someone her age. I told her that aggressive pain control was an intervention in itself, that she ought not to consider simple pain alleviation as "doing nothing". I told her I would support their ultimate decision....but a surgery would be very tough for her to tolerate.

Well, I've never been one to drag things out, she said. Get me some pain medicine. I don't want any surgery. What are you crying for, she said softly to her daughter. When it's time, it's time.

I sometimes forget how courageous human beings can be if you give them the chance.

Thursday, March 31, 2011

Over Treatment

With utter dismay I've been following President Obama's unconscionable usurpation of limitless executive power with regards to the War in Libya. And let us clear: The bombing of Libyan ground targets, the arming of rebels, and CIA presence on Libyan soil (in an advisory capacity, so they say) all represent aggressive acts of war. This is a third war we have now embarked upon in a Muslim country. Absurdly, once again, American missiles are being fired at a country that poses absolutely zero threat to our national security. And this time our Commander in Chief has committed us to war by executive fiat. No congressional approval. No meaningful debate. Not even a symbolic vote by the legislature to at least give the pretense of abiding by the dictates of Article I of the US Constitution. Everything this man campaigned on---- hope and change, the dawn of a post-partisan era, the end of the Imperial Presidency-----all a complete fraud.

I'm no foreign policy guru. I'm not there in the Situation Room. I don't presume to think that my feelings wouldn't be different if I had access to all the relevant information that the national security council has. But such a monumental decision cannot be contingent on personal feelings. It's one thing to help avert a potential slaughter, such as at Benghazi (although such rationale appears to be somewhat arbitrary; otherwise why aren't there bombs raining down in the Ivory Coast, Yemen and Bahrain?) It's quite another to unilaterally assert the right to bomb the bejeesus out of a foreign land. We are not a nation of Great Benevolent Men. We are rather a nation of laws. Believe it or not, even the President of the United States must abide.

I see parallels in this current military overreach with what is happening in healthcare. We spend 30% of a person's lifetime Medicare outlays on care provided during the last year of his or her life. We spent $50 billion of Medicare dollars last year on dying patients' last two months of life. Why are we doing this? Why has that 30% number remained unchanged for almost 30 years? Why do I continue to see consults on demented 89 year olds in the ICU who are intubated and unresponsive and suffering from multiple organ failure? And they linger for days and days. And the chart contains consults from numerous highly trained specialists, all dutifully offering the best that American health care can provide.

Is it greed? In our procedure-oriented, profit-driven health care culture, you eat what you kill. Why spend an hour doing a thorough history and physical examination, talking with family members and concluding that no further treatment is warranted when you can send your PA to do a quick consult, sign her note, and schedule the patient for a lucrative procedure the next day. Are we in Libyan merely to protect Italian oil interests? Are we there just to safeguard British Petroleum investments? Or is it truly a "humanitarian" venture?

Do we do it just because we can? Hey, we have a pulmonologist on staff. That 94 year old is dying of congestive heart failure. Send him down to the ICU, consult the pulmonologist who then orders the patient intubated based on an ABG that the nurse gives him over the phone. Then get the interventional cardiologist involved. And did you know, the hospital just recruited a new endocrinologist. The patient has a blood sugar of 356. Consult the new guy so we can tweak his insulin dosage. And on and on. Similarly, here we are sitting on the greatest military arsenal the world has ever seen. American military spending in 2010 was over $650 billion. That's 7 times more than the second highest national military budget (China). All this ordnance and materiel that, which each passing year, becomes more and more obsolete, necessitating even more spending in the future---might as well use it whenever a vaguely justifiable reason develops somewhere in the world, right?

Is it our arrogance? As doctors, do we presume to be the arbiters of life and death? Has our power to save and extend life been corrupted by an overweening sense of infallibility and righteousness? Has the American Hegemon unequivocally declared itself the Exceptional, Indispensable Nation? Do we truly believe we know what is "best" for every other group of human beings scattered across the expanse of the globe? Has the condescension of the White Man's Burden been passed on to 21st century America?

It's probably a combination of all those reasons, to some extent. Fundamentally something is rotten at the core of our nation. We define things in superficial terms. We demonize with catch phrases and sound bytes--- i.e. "death panels" and "they hate us for our freedom". We dare not look under the surface into the complexity and confusion and unpredictability of reality. We close our eyes to the discomfort of uncertainty and nuance. We would rather wear flag pins and dress up like 18th century New Englanders and sing God Bless America and publish papers on the effectiveness of colon surgery on nonagenarians. Death and decline prey upon us all---individual and nation as a whole. Nothing lasts forever. Clinging to a platitudinous nationalism, a jingoistic pride, a sense of professional omnipotence---these are all forms of an incipient dishonesty that threatens our collective soul. Death and decline are not to be feared. We can't save all patients. We can't rule the world forever. There are limits to human achievement. There is nothing shameful about recognizing futility. It's time we summoned the courage to look a little deeper, to find a sliver of humility through self analysis, and to reconcile ourselves to our ineluctable imperfection in this fallen world.

Tuesday, March 29, 2011

Dentists: Patient Advocates

From the New Haven Independent 3/24:

State dentists could get a monopoly on the lucrative business of teeth whitening pending action by a commission they control.

The State Dental Commission held a hearing in December to review whether teeth whitening should be classified as "dentistry" - a move that would result in the procedure being done only under a dentist's supervision. The commission is set to vote on the issue at its May 11 meeting. If the panel rules that it is dentistry, others who provide the service in shopping malls, salons and spas could be put out of business.

You think this is unreasonable? You think this is just a craven power play by a State Commission to monopolize a lucrative side business flimsily related to dental health? You see a conflict of interest in that the Dental Commission is comprised almost entirely of...dentists? Are you crazy? Just wait till you see what is coming down the pike in other fields:

The American Hand Surgery Commission is considering a resolution that defines all finger nail clipping as "digital-related surgery". Early drafts of the bill would require Americans to obtain finger nail clipper licenses from a Hand Surgeon-approved weekend instructional class. (To be renewed every three years.)

Rumors have it that the American College of Dermatologists are hoping to define the application of any SPF lotion above 30 as "practical dermatology" thereby mandating a visit with your local dermatologist and a prescription prior to that summer trip to the Outer Banks.

Working its way through subcommittees is a resolution from the State Board of Pediatrics that would try to re-classify classic remedies for your kids' colds as "rudimentary pediatric medicine". So no more over the counter Vicks to your kids' scrawny chests. No more TLC. No more ginger ale without a prescription. And the only chicken soup you can administer your kid is the the leftover slop that your pediatrician fed her family the previous night.

The Bariatric Surgery Commission is close to an agreement that would deem any form of exercise as a "bariatric intervention", to be monitored by highly trained obesity specialists. GPS monitors would be placed on anyone with a BMI of over 30 to ensure that nobody obese is moving faster than a crustacean without first seeking advice from a friendly local bariatric surgeon and informed of the harmless, easily tolerated surgical options in the War on Obesity.

Finally, the American Society of Pulmonologists and Critical Care Intensivists is lobbying to regulate the way Americans breathe. It isn't just a gasp or a sigh or a mere inhale. No sirree. Just because you breathe involuntarily doesn't mean that a highly trained sub specialist shouldn't be lucratively involved in your own personal world of O2/CO2 exchange. A mechanism that complex requires close surveillance. If enough votes are garnered, citizens will be forced to see a pulmonologist every 6 months for a full assessment of his or her "respiratory mechanics".

Chart of the Day

Thursday, March 24, 2011

Hedge Funds for Lawsuits

This is awesome. As if there aren't enough shady financial instruments out there for nefarious money making purposes. We now enter the era of the hedge fund- financed medical malpractice lawsuit.

I get it. Mounting a malpractice trial is expensive. You have to spend hours upon hours (at $500-800 per) taking depositions. You have to pay off, er, compensate whores, er, I mean, expert witnesses for their time. For a garden variety med mal case, trial attorneys can expect to spend upwards of 100 grand of their own stash. Given that physicians end up winning 70-80% of med mal cases that go to trial, this anticipated outlay of personal funds prior to a verdict can be somewhat discouraging to the less testicularly fortified litigation firms.

And this is part of the reason why malpractice lawsuits have declined over the past ten years. It doesn't have anything to do with the merits of cases; it's just simply too damn expensive to take a complaint to trial. This is the moral hazard that dissuades too many "frivolous" lawsuits. But it also hurts patients. Patients who have been injured through possible negligence may find that there are fewer firms willing to acept the case.

So what to do if you're a med mal lawyer without a fat bankroll? Contact one of these rapacious "lending firms" to front the costs of the litigation. You then pass the burden of the exorbitant interest payments on to your client. Awesome! So if you win the case, the first chunk goes towards your fee (did you think otherwise?). The second chunk pays off the interest on the loan. And whatever is left goes to the patient/client. And you aren't required by law to inform your client that you have leveraged the costs of the litigation. What a country!

Saturday, March 19, 2011

Yeats for March Madness: Who Goes With Fergus

I forgot to post this on St Paddy's Day. Go Bucks. (And yes, Drackman--- Jim Tressel is an embarassing phony).

Who will go drive with Fergus now,
And pierce the deep wood's woven shade,
And dance upon the level shore?
Young man, lift up your russet brow,
And lift your tender eyelids, maid,
And brood on hopes and fear no more.

And no more turn aside and brood
Upon love's bitter mystery;
For Fergus rules the brazen cars,
And rules the shadows of the wood,
And the white breast of the dim sea
And all dishevelled wandering stars.

Thursday, March 17, 2011

Mr. Obama, What Are You Doing About the Torture of Bradley Manning?

Bradley Manning may have broken the law. He allegedly is the source of the "Collateral Murder" videotape wherein an American Apache helicopter was filmed gunning down innocent Iraqi journalists. But he certainly may have violated military codes by leaking classified information. These allegations warrant an investigation. But Bradley Manning has been held in solitary confinement for 23/24 hours a day for ten months. He is now being forced to sleep nude. He is watched by military personnel throughout the night and is awakened roughly if his face is not visible to the surveillance cameras. Most concerningly, he has yet to be convicted of a crime.

Glenn Greenwald has been an invaluable thorn in the side of the US government's apparent mission to bring down Wikileaks and intimidate whistleblowers who dare to question military/executive branch authority.

His article on what exactly Wikileaks revealed to the world in 2010 is here.

Posts on the inhumane treatment suffered by PfC Manning can be found here and here.

Further embarassing are the brig psychiatrists who are signing off on the forms that deem Manning a "suicide risk", thereby providing the US government with the legal cover to continue its torture of a lowly private. Maybe one day the kid will simply break down and implicate Julian Assange and Wikileaks as co-conspirators. Surely, that's not what our noble, godly military/executive leaders had in mind all along is it??

Why did Manning do it? For money? Because he's a traitor to his country? In his own words:
well, it was forwarded to [WikiLeaks] - and god knows what happens now - hopefully worldwide discussion, debates, and reforms - if not, than [sic] we're doomed - as a species - i will officially give up on the society we have if nothing happens - the reaction to the [Baghdad Apache attack] video gave me immense hope; CNN's iReport was overwhelmed; Twitter exploded - people who saw, knew there was something wrong . . . Washington Post sat on the video… David Finkel acquired a copy while embedded out here. . . . - i want people to see the truth . . . regardless of who they are . . . because without information, you cannot make informed decisions as a public.