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.