Never?

This study from Johns Hopkins surprised the hell out of me:

After a cautious and rigorous analysis of national malpractice claims, Johns Hopkins patient safety researchers estimate that a surgeon in the United States leaves a foreign object such as a sponge or a towel inside a patient’s body after an operation 39 times a week, performs the wrong procedure on a patient 20 times a week and operates on the wrong body site 20 times a week.
The researchers, reporting online in the journal Surgery, say they estimate that 80,000 of these so-called "never events" occurred in American hospitals between 1990 and 2010 - and believe their estimates are likely on the low side
 

The numbers seem quite high, but it's hard to argue with the methodology of using historical information from the National Practitioner Data Bank.  And one can assume that even these results underestimate the true problem; not all patients sue for retained sponges or wrong site surgeries.  It truly is mind boggling to me, a practicing general surgeon, that we are leaving foreign bodies inside patients to the extent of 39 times a week.

It's unacceptable, of course.  And in this era of the Timeout, pre-operative marking of the surgical site, and Checklists, hopefully future outcomes will not be so alarming.     

Hospital Scenes

The old man lie down sprawled in a contorted mechanical hospital bed, configured like a caterpillar scrunching its way across a sidewalk.  I had operated on him a few weeks ago; subtotal colectomy for patchy diffuse ischemia.  After an initial rocky course he stabilized, was extubated, and we were able to get him out of the ICU.  It was mid-morning on a weekend.  His head was kinked sideways into his shoulder as he dozed.  Spittle dried in the corners of his mouth. 
-Good morning Mr L, I said.  He stirred and opened his eyes.
-Morning, he murmured.  His eyes fluttered and then fell closed. 
-You've come a long way, I said, listening to his heart and lungs.
He opened his eyes again.  He looked at me like looking at someone standing too close to you on a bus or a subway. 
The TV blared from a wall mount.  There are few more depressing sounds in life than the dulled, hollowed-out sound of a telelvision playing too loud in a patient room.  It's hard to explain.  The only form of entertainment.  The recipient not even really watching it.  The way it echoes out into the main hallway. 
-What did you used to do in your younger days, sir?
-Drywall and....    He shifted to the side, stiffening in an attempt to lean forward.  His face showed gaunt and grayed under the halogen lights.  He hadn't been shaved in at least a week, sparse coarse thickets of gray splotched across face and neck. 
-Labor? Owned a business?
-Drywall...and....and....I....drywall.....I can't.....
-It's ok, I said.  It's Ok. 
-I can't talk anymore....
He relented to fatigue, let his body fall back stricken into bed.  He dozed again.  His stoma made a noise under the covers.
I stood there for a while, perhaps 3-4 minutes, not quite ready to just leave.  He was about set for transfer to a rehab facility.  I probably wouldn't see him again for weeks.  The TV was showing some old collge football game from years ago.  I turned to leave.
-Can you cover my feet? he said, suddenly reanimated.
-Of course. 
He had pulled the sheets and blankets up tight around his chest, leaving his long pale, skeletal feet bare.  The thickened toenails were yellowed and hooked around the confines of the nail beds.  I pulled one of the blankets over them, tucked it under his heels.
-Thank you. 
-No problem.
-You said your name was?
-Parks.  Dr. Parks.  I did your surgery a a couple weeks ago.
-Parks.  Parks, you say.  Ok...... 
And he drifted off again.  His chest rose and fell slowly, emphatically.    
 

Stool Sniffers

The British Journal of Medicine has published a paper about a beagle sniffing out cases of clostridium difficile (c diff) colitis in hospitals.  C diff is a certifiable plague in this era of antibiotic overuse.  I have taken out my fair share of colons in toxic patients.  Until recently, the diagnosis of c diff required a stool sample (sometimes multiple) that could sometimes take several days for results to post.  This dog, Cliff, in the paper was able to correctly identify the bug in 25/30 patients with confirmed infection.  Furthermore, he accurately indicated absence of infection in 265/270 stool samples. 

I suppose this is a nice little study.  It's the end of the year, the Holiday season.  We all like mood-elevating stories about cute animals doing amazing things.  Surprising that it would find its way into the esteemed BMJ, however. 

Anyway, the whole thing is sort of moot.  Newer PCR testing techniques for c diff have shortened diagnosis turnover time to around an hour.  It is lamentable that there is little likelihood that hospitals will commandeer packs of hounds to make olfactory rounds on inpatient toilets.  Alas. 

Enough

The events in Newtown, Connecticut yesterday will hopefully jump start a national conversation.  That's about the only solace I can take from the senseless murder of 20 schoolchildren in a classroom.  This conversation ought to transcend minutiae like the specifics of gun laws and gun show loopholes (although there will be a time for redressing these inanities).  I don't want to hear about how we "need more God in our schools", as if ol' Jesus would have sent down a thunderbolt, Zeus-like, to prevent Adam Lanza from firing wantonly at Kindergartners, if only we hadn't halted compulsory prayer in our schools.  That's all you will hear about over the coming weeks, in this highly charged partisan echo chamber of red state/blue state, FoxNews/MSNBC.  And it's all irrelevant.  The fundamental questions will get buried beneath an avalanche of op eds and monologues advocating for or against the highlighted "issue" of the moment.  The important questions will never get asked. 

What has become of our culture?  Who are we?  Why do we glorify violence and mayhem?  Why have we embraced pre-emptive war and torture and rendition and robotic drones raining down death and destruction in far away lands?  We do we countenance the non-prosecution of Wall St fraudsters?  Why have we waged an unsuccessful 30 year Drug War (with militarized local SWAT teams) that overwhelmingly targets the poor and forlorn?  Why are video games like Call of Duty and Assassins Creed ubiquitous in the rec rooms of 12 year old boys?  Why are we the only advanced western country without a national health care system for all?  Why is the national sport a modern day gladiatorial contest, leaving its combatants wracked with the cognitive and psychiatric consequences of long term brain injury?  Why would a rational American respond to the murder of children in a school by posting a picture of this on Facebook? 

Who are we?

What is this nation of Americans?

What have we become?

A culture in the throes of decadence, one that embraces hypocrisy and degeneracy ought not to be surprised when the more disturbed elements of society act out in ways that stretch the bounds of pure unfathomable evil.  We are now inured to mere everyday evil.  The deranged psychopaths in our midst must come up with ever more creative acts of intransigence to draw our gaze.   It requires the massacre of innocent children in classrooms to get our attention.  That which was once unimaginable is now the only option left for attention-seeking deviants. 

We are all responsible for this atrocity, to some degree.  Our civilization's survival depends on a thorough reckoning with our own sins.  We must look in the mirror and acknowledge reflections of horror.  Our rotten core cannot be hidden any longer.  There is still time to salvage our souls.  Together, as a nation, we must seek our collective penance and redemption.   The words of Dostoevsky are uncomfortably appropriate at a time like this: 
"There is only one salvation for you: take yourself up, and make yourself responsible for all the sins of men. For indeed it is so, my friend, and the moment you make yourself sincerely responsible for everything and everyone, you will see at once that it is really so, that it is you who are guilty on behalf of all and for all. Whereas by shifting your own laziness and powerlessness onto others, you will end by sharing in Satan's pride and murmuring against God."

Hug your sons and daughters tight this Christmas season....

More Student Loan Bondage

Wisconsin Republican Congressman Tom Petri has introduced legislation that would allow the federal government (via the Department of Education and the IRS) to automatically deduct student loan payments from borrower's paychecks (capped at 15% of one's income).  This is being touted as a good thing because it would then obviate the need for third party collection agencies, who previously had been subcontracted by the government to help collect the $1 trillion in outstanding student loans. 

Because, you see, borrowers would much rather have actual money deducted directly from their paychecks by some all-powerful federal agency than to have to simply ignore repeated phone calls from relentless collection agencies who have no legal power to make you pay anything at all. 

Laparoscopic vs Open Ventral Hernia Repair

Dr Heniford's group down in North Carolina had a nice little paper out in the Annals of Surgery last month which prospectively studied quality of life (QoL) outcomes and complications in patients who had ventral hernias repaired either laparoscopically or at open surgery.  Both repair techniques incorporated the use of synthetic mesh. 

The conclusions are as follows:

• Laparoscopic repairs are associated with lower short-term QoL scores and higher degrees of post operative pain
• Long term recurrence and overall complication rates about the same
• Fewer infections and shorter length of hospital stay with laparoscopic approach

Pressured Giving

In line at Dick's today I overheard the cash register clerk ask the customer in front of me if she wished to donate to "St Jude Children's Research Hospital" during the checkout process.  It was asked in a very loud, matter of fact voice.  The store was crowded and all the lines were stacked five deep.  The woman sort of paused, almost blushed,  mumbled something about "having donated last week" while shaking her head, and the clerk ran her card without missing a beat. 

I loathe this on so many levels.  I hate the enforced  public display of philanthropy.  I hate the commingling of pure profit-seeking commerce with generosity.  I hate the disengaged, rote way it is asked by minimum wage-earning employees.  I hate that reluctance to donate on the spot can be perceived by others as a sign of miserliness and general sociopathy.  Typically those who are asked respond in one of several ways:

EMR Adventures

The hospitals I cover have all made the transition to electronic medical record  (EMR) documentation.  This means all our daily progress notes and H&P's have to be done using the templates in the EMR.  I'm fairly computer literate so the transition hasn't been awful.  I actually like being able to read the thoughts and recommendations of other physicians following  my patients.

The problem is my unease with some of the drop-down options for "physical exam findings".  When you click on "Cardiac", for example, a list of objective findings appears that you can choose to include in your note.  These findings include things like "S1 S2 normal, no murmurs, no rubs, no gallops, PMI location," etc.  I'll be honest--- I don't think I could reliably tell you what a rub or a gallop is.  What I can do is listen to heartsounds and determine if there is an arrhythmia or a murmur (in vague, nonspecific terms).  Beyond that, I am sort of flailing to describe what the hell I hear.  So most of the time I just opt for the blank option and manually type in my PE findings.  It's disconcerting using terminology outside one's comfort level.  It's sort of like a neophyte awkwardly trying to describe a wine to a connoisseur---this Pinot has a bold mahogany uplift with a sweet hint of, um, rosemary lingering on the palate, like a faint evocation of a youth spent in Tuscany reading Cicero...blah blah blah...pretentious vomit...  

Video Gamers

An experiment from the University of Texas at Galveston compared robotic surgical skills of three groups: high school students who played two hours a day of video games, college students who played four hours a day, and, finally, actual surgical residents.  The results indicate that moderate video gaming is predictive of superior robotic surgical skills. 

Specifically, the UTMB study measured participants' competency on more than 20 different skill parameters and 32 different teaching steps on the robotic surgery simulator – a training tool that resembles a video game booth complete with dual-hand-operated controllers a video monitor that displays real-time surgical movements. As a whole, the nine tenth graders participating in the study performed the best, followed by nine students from Texas A&M University and lastly the 11 UTMB residents; the mean age of each group was 16, 21 and 31 respectively.

12-0

Once again the Team Up North can go to hell. 

Drive Safely

Be careful out there.  This patient was wearing a seatbelt when T-boned on the highway.  The injury was a complete avulsion of a major branch off the ileocolic pedicle, along with complete shredding of the rectosigmoid mesentery.  All ended up well with timely intervention. 

Happy Thanksgiving Holiday Weekend. 

Mammogram Overdrive

A recent paper from the New England Journal demonstrates that mammographic screening paradigms have had little effect on ultimate survival.  Over three decades, screening all women from the age of forty on has identified 1.1 million more early stage breast cancers but we have not seen a concommitant decrease in the number of women presenting with advanced breast cancer.  This indicates that we are identifying a lot of non-aggressive, relatively benign tumors with little potential for metastatic extension.  The implication is that we are overtreating millions of women with unnecessary surgery, radiation, and chemotherapy for relatively benign, clinically insignificant mammographic findings.

Of course there are those who certainly do benefit from earlier intervention, just not to the degree we previously thought (old standards proclaimed that screening mammograms reduced mortality in breast cancer by 25%).   It is impossible right now to determine which women with microscopic pre-cancerous (DCIS) lesions are at higher risk for eventual transformation into aggressive, lethally invasive variants.  The direction oncologic research needs to be focused on over the coming years is in the realm of genetics so, through the meticulous identification of certain proteins and genes, we can more fruitfully identify which tumors need the bazooka in the armamentarium and which can be safely observed without interventional therapy. 

Are Doctors Rich?

A buddy of mine sent along an interesting link by a physician named Ben Brown that makes an argument that doctors actually aren't all that well off.   Salaries are down.  Education costs can exceed $300,000 over the course of college, medical school, and residency.  By the time you take that first job, you're on the wrong side of 30 and Wells Fargo is demanding $1800 a month for all your student loans.  It's a topic I've covered many times before.  If you are looking to make a killing in the world, to retire to some beach in the Caribbean at age 55, then medicine is not the career path for you. 

It didn't always used to be this way.  Medicine once was a very lucrative career tract.  All preening mothers wanted their little boys to grow up to be a doctor.  It was a ticket to elite status, country clubs, and three week summer vacations in Italy.  Such ideas are laughable now.  Mothers prod their sons to go into investment banking or become professional athletes nowadays.  Why spend 30 years in school and training just so you can be an employee for a giant health care conglomerate that may or may not renew your contract on a year to year basis? 

DNR

It has come to my attention that patients showing up in Emergency Rooms with DNR (Do Not Resuscitate) papers in place are nevertheless being aggressively treated for their latest acute medical crisis.  Sometimes the patient ends up intubated and on a mechical ventilator despite explicit instructions not to do so under any circumstances.  Rationale for ignoring DNR documentation invariably circles around to the idea that DNR engenders too much of a "gray area" in terms of how medical professionals are to respect the individual's wishes.  For instance, if a demented patient has a hip fracture and is in extreme pain, a daughter may decide to temporarily revoke her DNR-CC status and have the painful condition fixed.  Or maybe the 94 year old guy in the passenger seat is rear ended by a pickup truck and slams into the windshield.  He sustains a wicked scalp laceration and loses half his blood on the floor mats.  The trauma staff in the ER wastes little time closing the wound and transfusing blood products.  The tranfusions put him into failure and he is intubated.  The next day he is weaned and extubated.  He thanks the doctors and nurses for saving him.  He goes home.

Clearly, DNR status is not always an inflexible, dogmatic guide to patient care.  One needs to account for specifics and contingencies when composing DNR paperwork.  Here is a sampling of my own attempt in a living will to outline a protocol for my care, accounting for circumstances.  I have been as precise as possible only for the sake of clarity. 

Most Dangerous Drug in America?

Our trauma service has been seeing more and more elderly patients admitted for closed head injuries who are taking the blood-thinning agent Pradaxa.  As this NY Times article indicates, this is not a positive development.  Pradaxa is a direct thrombin and factor Xa inhibitor used in patients at high risk for developing cerebrovascular or systemic embolic events (i.e. patients with atrial fibrillation).  It is a newer alternative to the old standby, coumadin (warfarin) therapy.

Post Trauma Redemption

In honor of Veteran's Day, I encourage everyone to read the story of Lu Lobello's atonement from the New Yorker a few weeks ago.  The consequences of War and the effects on both soldiers and civilians has rarely been written more poignantly. 

The Election

Barack Obama and Mitt Romney have been campaigning for our votes seemingly for the past two years.  I have been getting emails from Juliana Smoot and Jim Messina for well over a year.  A President gets about 2.5 years after being elected to accomplish something before he/she must inevitably start the process all over again of "reaching out to the base" and "appealing to independents" and "articulating a narrative" and all that other pundit-speak that crackles my ears. Democracy in America has become degenerate.  We are run by a plutocracy of wealthy oligarchs who choose behind closed doors the figure heads to personify and articulate the narrow band of policies that they have deemed worthy of national discourse.  The Citizens United decision has entrenched the concept that the "monied interests" are the drivers of the political discourse.  The reality of our two party system is that there are very few differences existing on pertinent issues such as social security and national defense and executive authority between Republicans and Democrats.  We are led to believe that this  choice of President is "historic" and "fundamentally altering".  We are fooled into thinking that each party offers fundamentally different visions for how the nation will deal with future troubles.   The legitimacy of democracy depends on this perception;  for if the general population realized that choice A differed from choice B only in ornamental, unimportant ways then the facade-----"of the people, for the people"---- is shattered.  I say this as a preamble to the Buckeye Surgeon endorsement for President.   Never have I felt so disillusioned with my voting responsibility.

How I Do It: Severe perforated diverticulitis

Diverticulitis has a range of presentations.  Most cases are amenable to outpatient antibiotic therapy.  A small, but not inconsequential, percentage of patients will present with free air and peritonitis.  These patients warrant immediate exploration in OR, generally.  Findings usually include extensive inflammatory changes involving the rectosigmoid colon, along with secondary serositis of loops of small bowel entrapped by the process.  Purulent ascites is the norm and sometimes frank stool will be present.  Classic teaching states that the surgeon should wash out the abdomen, perform rectosigmoid resection, and then temporarily divert the stream of stool with an end colostomy (i.e. the Hartmann's procedure).

Recently, there has been a transition toward trying to re-anastomose the descending colon to the rectum, even in contaminated cases.  The benefit of such an approach is that one avoids a colostomy bag.  Colostomy reversals are notoriously tough cases and statistically only 70% will ever be reversed.  The drawback is that you are connecting bowel in very sub optimal circumstances.  The patient is septic.  The blood pressure may be labile post operatively.  And the tissues during acute peritonitis can be very friable and inconducive to holding staple or suture lines.  No one likes a leak.

Here's my management strategy for different scenarios:

Missing the Mark

A recent study from England has demonstrated an unexpectedly high re-operation rate in women who undergo breast conservation treatment (BCT) for breast cancer.  One in five women (out of 55,000) who were treated with lumpectomy required another surgery to ensure clear margins in a retrospective study of the years 2005-2008.  Re-excision rates were noted to be associated with the presence of ductal carcinoma in situ (DCIS) in the specimens, an entity that can often be multifocal on presentation. 

Foreign

What we watched last night in the foreign policy-themed Presidential debate was a travesty.  On the one hand we have a candidate from the Republican Party who was applauded by partisan supporters for adopting the "strategic" approach (i.e. don't rock the boat, just get a draw or something close) of running and hiding  (i.e. lie and distort) from the bellicosity and war mongering rhetoric he has repeatedly put on the record  over the past 12 months and simply averred that we ought to be doing exactly what Obama is doing, only more "severely". 

On the other hand, we have a President, a supposed lefty, commie, peacenik, Age of Aquarius, progressive liberal bragging about how many Muslims he has killed and how many Iranians he has starved over the past 4 years.  The bravado was nauseating.  The Commandeer in Chief as designated National Hitman.  Someone mentioned this already--- the true winner of last night's debate was George W. Bush.  Shoot first and ask questions later.  America is Good and Noble and the rest of the world can Suck on This.   The President is our fearless, Morally Pure Leader. 

There was one question about drones:  something to the extent of whether Romney would embrace them.  Of course, he says.  Romney at the controls of drones.  Hell yes.  Just give me that chance, his maniacal wide eyed grin seemed to say.

Here are some things that are happening in American foreign policy right now that were indisputably not addressed at the "foreign policy" debate last night.  It is up to all Americans to decide whether or not this even matters.

Of Human Bondage

My step-daughter is starting the process of searching for a college to attend next year.  More importantly, she has begun to look into her financial aid options.  The average cost of a four year undergraduate degree has gone up over 1000%  since 1978 .  Think about that.  Everyone is aware of skyrocketing health care costs and the difficulty of controlling their inexorable rise.  But the college and graduate school tuition explosion is far worse.  The average cost to attend a four year public university runs around $20 grand.  For a private school, the costs average close to $40 grand.  Certainly, these totals are attenuated somewhat by grant/scholarship outlays but, in general, the bulk of the costs are covered by obtaining federal subsidized and unsubsidized loans.  So even with a $5,500 grant/scholarship (the max allowable by current Pell grant rules), one is looking at graduating from say Ohio State or Kent St with a balance of somewhere between 50-75 grand.  Of course, one could always be born to rich parents and simply, as per Mittens, "borrow some money from them".  As for my step daughter, she unfortunately won't even qualify for a Pell grant because her mom married a physician and step parent income is inexplicably included in the application process.     

Further, imagine one decides to pursue a post grad degree in like law or medicine.  Tuition to medical/law schools runs from $25-45 grand.  Moreover, many if not all professional school students have to borrow additional unsubsidized or private loans in order to cover living expenses.  Many medical students are married, have young kids.  How does one pay the rent and put food on the table when one has no income.  Medical school is a fulltime job.  One can't  work part time at Wallmart three nights week while spending nights in the gross anatomy lab.

We are gutting our younger generations with onerous education debt loads.  If you don't get the degree, you're cooked.  If you graduate, then statistically you'll be better off but you'll spend the next 15-20 years forking over substantial chunks of take home pay to loan servicers.  And there is no recourse for those who find they cannot meet payments.  Revision of bankruptcy laws has made it nearly impossible to  evade responsibilities.  Enormous powers have been vested in the federal government to collect outstanding balances over the course of your life.   

Scenes from Hospitals

The Surgeon strides down the hall to his office, passing a series of patient rooms.  The last one on the right has the door wide open.   
-Mom, can you hear me?  It's me, Franky.  Mom?   I'm here.  Do you recognize me? ............. Ma?

The Surgeon pauses in the hall just outside the door.  He knows the woman in the room.  She had fallen the prior week and sustained a severe, inoperable cerebral hemorrhage.  She can only vacantly stare off into space.  The Surgeon had signed off the case after a few days.  He stands in the hallway and listens.  Nothing more is said.  He moves on.  There are patients waiting in the office.

Later that day he passes the room again.  The middle aged, balding man is still sitting in a chair bedside.  He's looking at his mother, a baseball cap balled up in his hands.  The TV is off and no one tries to speak anymore.  Silence.     

When all the world is shining

The Surgeon has experienced three legitimate "religious experiences" in his life.  The first was one day in the summer in the mid nineties while living at his aunt and uncle's house in Akron.   He was studying half heartedly for the MCAT while working as a backroom kitchen grunt at a local restaurant/cabaret joint.  He didn't have a girlfriend.  His friends were all down in Columbus having an amazing time, apparently, and he spent his days nannying for his two younger cousins.  He was uncertain of the path his life should take.  He felt time was crunched, that he was running out of time to make a decision.  He had been reading too much Hemingway and Fitzgerald and not enough Biochemisty, not enough Biology.  He felt lost.  He wished he were marooned in some Left Bank flophouse from the 20's.  One day he broke down and prayed fervently, unlike anyway he had ever prayed before.  He asked for guidance and forgiveness.  He specifically invoked Jesus and God and asked for supplication.  What followed was a short period of warmth and clarity.  An indescribable joy bloomed within his breast and the future seemed limitless and wide open, and at the same time, irrelevant.  Whatever was to come, was irrelevant.  There was a deeper optimism that suffused his heart that day independent of medical school or musings on Lost Generation literature.  He had never before felt this premonition of impending joy.  Unfortunately, the episode and the feelings it had engendered faded with the end of summer and a return to college.  He went to services at a local campus Presbyterean church once or twice but he lost connection with any feelings of an enduring spirituality.  In retrospect, he feels that perhaps he was not ready to "settle" into a life of dogmatic religion.  He was repelled by the idea of choking off his intellectual curiosity at such an early stage of life and referring all probing questions about the nature of Man and ultimate ends to some 2000 year old book written by men just as confused and misinformed as the ones stomping the globe currently.

Self-Surgery

The Surgeon had been handicapped by a burr in the plantar aspect of his left foot.  All summer it had been causing discomfort on jogs, during soccer games, and,eventually, even just walking barefoot across the hardwood floors in the morning.  There was something lodged in the thick skin of the strikeplate of his foot--- a splinter, a piece of glass, whatever the hell--- and it was really starting to cramp his style. 

His wife tired of his frequent moaning and groaning and dutifully instructed him to "see a podiatrist".  The Surgeon considered this.  Why would I do that, he thought.  I'm a surgeon.  I can take the damn thing out myself.

So one Friday evening after finishing up the weekly charting/computer work, he gathered some lidocaine, a hemostat, a scalpel, gauze, and betadine swabs.  He situated himself on one of the exam tables and directed the light on his foot.  He prepped it sterilely like he had done a thousand other times for other people.  He drew up the local anesthetic.  And then he paused, staring at the needle.  Five minutes of silence elapsed.  There was a disconnect between what he was about to do and the consequences of said actions.  Normally, he jabs these needles into people all the time without hesitation.  Every time he moved to inject, however, the realization that the target was his own foot made him draw back.  He felt foolish and cowardly.  For chrissakes it's just a 25 gauge needle, he thought. 

Contempt

 

 

 

 

This man is not fit to serve all Americans as President.  For the first time during the long election season, Romney actually presents his authentic, real self.  He is a crass elitist who sneers contempt for anyone not earning at least a quarter million a year.  Even Americans who fall into the 53% category, the majority of them at least know someone in the no net federal tax paying fold--- a parent who lost a job during the recession, a grandma on social security, a cousin in grad school, an old college friend with three kids who works as a school teacher and gets a small check from the IRS every year due to child credits and his mortgage deduction.  This is the Ayn Randian worldview on full display, without ornamentation. 

 

"It's not my job to worry about those people".   One won't find the source for this quote in the red verses of the King James New Testament.   

 

The Surgeon finds himself resigned to voting for a man who keeps Gitmo open, who assassinates American citizens on a "kill list", who has opened the Pandora's box of secret, unregulated drone warfare without any congressional oversight, who launched a war in Libya without authorization, who refuses to hold the torturers in the previous administration accountable for war crimes.  It is difficult to stave off a sense of cynicism when it comes to the increasingly corrupt American political stage.  

Last Rites

At age 39, Michel de Montaigne retired fom public life to his estate in France to write and think.  His collection of essays, on everything from virtue to vanity to cannibalism to masturbation, became a timeless classic.  Arguably, Montaigne was the world's first blogger.  The Surgeon turned 39 this year but his two children are 15 and 17 years, respectively, from attending college.  The Surgeon will not be retiring to the countryside anytime soon in order to contemplate the state of human affairs.  He will content himself with slowly plowing though Montaigne's 800 plus pages of diverse riffs over the next several years.

His essay "That to Philosophize is to Learn to Die" recently struck a chord.  Death, being ineluctably the ultimate end of all men, is strangely absent fom the modern dialogue.  It is something to flee from, a unpleasant flaw to lock up in a chest in a cobwebbed, dusty attic.  Especially here in 21st century America where we almost beatify accomplishment and material achievement, Death has become an embarassing scandal, an unmentionable.  The cycle of life has been overrun by the concept of unending progress and self-improvement.  There is always another day.  Anyone can become or achieve whatever she wants, if she puts her mind to it and works hard enough.  This is the orthodoxy of an America that has found a way to fuse Christian elitism (we are the exceptional, chosen nation) with a crass free market materialism that rewards the strong and purposeful.  Willful neglect of the final leveling force, the geat socialist, Death, is the only way to maintain the illusion of interminable vigor and prosperity.  Early death is now always a "tragedy".  The death of the old and decrepit is shunted off stage, to poorly lit vigils in stale smelling nursing homes or worse. 

The goal of our career is death. It is the necessary object of our aim. If it frightens us, how is it possible to go a step foward without feverishness? The remedy of the common herd is not to think about it. 

Cheesy

The Surgeon recently read another New Yorker piece (Big Med)  from the renowned surgeon/writer Atul Gawande.  This particular piece makes the startling claim that medicine would be better off (more efficient, cheaper) if it started to emulate the kitschy, impersonal chain restaurant Cheesecake Factory.  Yes, the same mega-chain notorious for the massive portions and enough calories per meal to fuel a man for three days.  Again, Cheesecake Factory.  The premise being that American medicine could stand to take a few pointers from one of the leading contributors to the national obesity epidemic. 

Initially the Surgeon suspected the piece was meant as satire, some sort of ironic parody of Gladwellian cross-analogizing of disparate disciplines.  But Dr Gawande is a serious man.  He has always written with a naif-like earnestness that makes him especially compelling.  So the Surgeon read the damn thing again.  And again, it is clear that the way of the future (per Gawande) lies via the corporate business model of the Cheesecake Factory.  The Surgeon is stupified.

Inevitable

With the coming advent of Accountable Care Organizations and the re-branding of capitation under the banner of "cost containment", the Surgeon realizes his days as an independently practicing general/trauma surgeon are probably limited.  He understands that the only way to make the coming paradigm work (where health care spending is capped for specific inpatient admissions) is if all the doctors are employees.  The idea is to eliminate the stake for physicians.  If you are employed, then it doesn't matter to you if the employer stops getting reimbursed after a set spending limit during a long, complex admission.  You get paid the same no matter what.  A non-employed surgeon who gets asked to see a decrepit old ICU patient with free air at two in the morning when said patient has already gone past the reimbursement cap will be none too happy when he finds out he will get paid zilch for his troubles.  The employed surgeon couldn't give less of a shit. 

The Surgeon understands this "solution" as a quintessential deferral of responsibility.  The main issue (performing unnecessary surgeries, providing futile care, ordering unnecessary tests) is kicked down the road.  All that is addressed is the cost issue; to the extent that, mathematically, final hospital tallies will end up being reliably less than before.  It is so much easier to declare, by fiat, that all this unnecessary medical care that occurs in the USA, especially in the last 6 months of life, will henceforth be written off, a victim of capitation, rather than to delve into the dark quagmires of rationed medicine and recognizing the limits of modern science.  Much more difficult to catechize a generation of physicians who are not afraid of limits, of death, of the futility of efforts--- once a certain line has been crossed---- who are willing to see this calling as something far nobler than an income stream worked in shifts.  And even more difficult to inculcate such complexity of thought in the mind of the general American populace.       

It's pure cowardice.

Grind

The call comes in at 9pm or so.  The patient sounds sick as all hell.  The Surgeon listens to the random assortment of numbers and vitals the nurse provides and clicks off his cell.  He finishes reading a boring Berenstain Bear story to his daughter (horrible children's lit, btw---- unfunny, droning, almost anachronistic are the travails of those generic asshole bears) and tucks her into bed.  He looks at the clock and runs some mental numbers.  By the time he arrives at Hospital, close to ten.  See the patient, talk to family, dictate notes, write all the orders and it's getting close to 11.  Then the wait for the call team to arrive, the inevitable dicking around of anesthesia.  The family questions.  The delay in transport getting patient from ICU to OR and now we're talking well after midnight.  Before he even cuts. 

The lady is in extremis.  Family is pacing in the hallway.  The Surgeon places hands on belly and the diagnosis is clear.  She is on pressors already and her lower legs seem mottled.  Fluids are running wide open.  The urine in the foley bag looks like bourbon.  After the usual back and forth with family--- surgery or no surgery, high risk, but what else can you do, she may make it /she may not, the only hope is to operate, but it could be futile and thus an operation would cause her unnecessary pain and suffering, etc etc---the decision is made to proceed to OR.  The abdomen is exposed, prepped, ready for scalpel five after one.  The arithmetic is just a little off.

Boys and Girls

The Surgeon likes the morning.  He likes them especially when he is off call and has no obligations to drive in to the hospital.  On these mornings he enjoys being in the presence of his two children.  There is a girl and a boy.  The girl is older.  Of course there is an element of sibling jealousy/rivalry but nothing pathologic.  The Surgeon has always worried about his little girl.  He wants to protect her and shield her from harm.  He worries that she doesn't eat enough.  He worries that living in two separate households will affect her negatively.  He worries about her development.  When she runs on the driveway, he catches his breath, terrified she will fall.  When she scrapes her knees he feels the pain as his own.   He wants her to be happy, always.  As for the boy, the Surgeon finds that he wants to tackle him and wrestle him and toss him laughing into the air.  When he bumps his little head, the Surgeon is not wracked with terror.  He'll shake it off, he thinks.  The boy is a litttle rough neck and eats like a starving wild boar and the Surgeon wants him to be strong and resilient, for the world is a harsh and unforgiving place. 

The Surgeon is troubled by these two attitudes.  He feels sexist, or at least somewhat unequal, in his perceptions/behaviors toward the boy and the girl.  One must treat one's children all equally.  This is such an obvious, fundamental principle that to state it out loud is ludicrous.  The surgeon has two children.  The boy has turned one and is not so much a novelty, a lump of carbon, anymore.  The boy has a distinctive personality now.  He burrows his head into the carpet and wails when he is mad.  He smiles and reaches for the Surgeon when he comes home.  The girl is in preschool.  She can spell her own name.  Sometimes she doesn't want Dada (the Surgeon) to take her to the potty because "he is a boy and she is a girl".  She is unaware of the distinction between men and boys.  He has two children.  He loves them both, equally, but in different ways.  He loves them terribly.     

It is 11pm and the Surgeon sits down to write at his laptop.  His children are asleep.  He checks the baseball scores on Yahoo (incompehensible, since he now hates baseball and is starting to hate all professional sports, the American ones anyway, the way they have been so commercialized and monetized and the way our culture elevates these games of marginal skill to levels of absurd importance, and he checks them self-loathingly, the way an addict feels while falling off the wagon, cracking open that first beer, sliding another needle into a sluggish, anguished vein, doing it once again, irrevocably, for old times sake, a pastime he used to do eagerly, almost joyfully as a boy, hoping the Indians may have won the night before, now rote and mechanical, mindlessly clicking though well-lit, laptop-halogenated boxscores).  The very definition of a desultory existence.   His fantasy football draft is the next day.  Another season awaits where the Surgeon knows he will waste entire Sundays fretting about YAC and 2 yard TD plunges and whether strangers in other cities will accumulate 100 yards of receiving or just 97, about torn ACL's and waiver wires and back up tight ends and sleepers and busts and pick sixes and garbage time scores.  He will concede that he is powerless to resist this allure.  Oh it's so stupid, he will lament.  Another Sunday on edge, worried about his starting RB1's matchup.  Why do you expend so much mental energy concerning yourself with such drivel?  Now, before it has begun, it is easy to wax poetic over the things he "ought" to be doing instead.  The rich vastness of knowledge and art that still eludes him  Go learn the fucking piano.  Memorize those stanzas you love, not to quote them pretentiously at dinner gatherings, but because you want to be able to whisper them to yourself when troubled, when alone, when sad.  Teach your kid.  Be a better Dad.  Call your Mom more often.  Send a hand written note to your cousin or uncle.  But then it will start, another season, another pretend "team", and all noble intentions careen off into the void.    The Surgeon realizes this.  He foresees another fall/winter of self-fulfilled failure.  He will fail himself.  Of course he understands that if it isn't fantasy football, it will be something else.  He'll want his lawn to look a little too immaculate and go to great lengths and costs to ensure an Augusta National-esque appearance.  He will buy amazing mowers and gas powered trimmers and powerful industrial strength fertilizers.  He will read about the difference between crabgrass and foxtail and be able to spot them in his lawn.  When the summer drought takes hold, he will be seized by a throat clutching panic.  He will find himself unable to simply sit in a chair and watch the wind soughing the piercing green leaves of the trees in the sun.  He will want to trim some goddam branch instead.