14-3

Go Bucks! Looks like the Rose Bowl awaits. Need West Virginia to lose to have a shot at the title game. God I hope Lloyd Carr doesn't retire. The legend of the red sweater vest continues.........

Too many doctors?

I read an interesting piece in the Atlantic Monthly last week questioning the almost dogmatic assumption that the United States is facing a physician shortage is the coming years. The link only gives you the first couple of paragraphs unless you're a subscriber, so either subscribe or buy the hard copy off the rack. We're always reading that we need to train more doctors, that with the aging population there won't be enough physicians to satisfy demand. But then I was waiting for the elevator the other day, reading the names of all the doctors on the peg board who practice at one of my hospitals. The board is 4x4 feet and just crammed with names, names, names. It's unbelievable how many doctors there are. There's two large GI groups. There's three general surgery groups. There's three separate pulmonary groups. The ID group has 7 doctors. (Don't get me started on ID again). And on and on. What we have isn't a physician shortage, but rather a physician overabundance. And I don't think it's too different at most suburban hospitals across the country. The scenario isn't one of overworked doctors struggling to keep up with the demands of patients waiting in line for care. Rather, it's a hyper-competitive world of doctors in the same specialty fighting over a limited supply of patients. Hence, all the ass-kissing and overwrought phony letters specialists have to send to primary care docs for "the privilege of assisting in the care of this highly interesting and fascinating patient." If I were to suddenly disappear from the face pf the earth like that Chris McCandless dude in "Into the Wild", the other surgeons here would be more than willing to swoop in and score my referral base. Patients would not be affected (other than in quality, of course). I mean, maybe if you live somewhere in the middle of nowhere in Nebraska or Wyoming, you worry about physician availability, but not in major metropolitan areas at private hospitals if you have insurance.

So here's a moral dilemma. As a physician in training, what obligations do you have to society in undertaking a career than is essentially one of service? Everyone wants to be a specialist. It pays more. It's more interesting. You get to do procedures. Maybe the lifestyle is better. These are important issues. You're just a human being with selfish desires like everyone else. Why should you go into primary care and work long hours at low pay, based in some practice in Coscocton, Ohio because there's a demographic need? Increasing medical school enrollments isn't going to solve the problem. You'll just end up with proportionally more cardiologists, more gastroenterologists, more cardiac surgeons to flood an already supesaturated metropolitan market. Until we compensate primary care/family practice in such a way wo make it financially appealing to medical students, there's still going to be physician shortages in South Dakota and Southern Ohio and Rural Kansas.

At Cook County hospital in Chicago where I trained, people wait 6-8 months to get their hernias repaired or gallbladders removed. Old guys show up lugging around these fifty pound scrotal hernias. At Northwestern or Rush, you wait a few days or weeks. If you're a VIP, you wait a few hours. Now, I'm not naive enough to be morally offended by this. That's the way the world works. Money talks. Nothing different than the way things have been for a thousand years of human interaction. But there are physician shortages. Right here in front of us. Right in the middle of cosmopolitan, wealthy, sophisticated Chicago. People go without access to health care. What is a physician's responsibility to help remedy this? We all go into six figures of debt to pay for med school. We defer gratification for material things until well into our thirties. And now we have to accept low paying jobs taking care of ungrateful patients in lousy isolated rural towns or inner city free clinics? I don't know. Maybe we should. It's something all docs need to explore, I think. I know I've been thinking about it. Doctors without borders, and other volunteer opportunites are an option. Maybe I'll have to show up one day in South Africa and see what I can do to help old Bongi.

Not just appendicitis

A 36 year old construction worker showed up one night in the ER with excrutiating right sided abdominal pain for three days. Of course, he'd been toughing it out, going to work anyway. But then he started to develop fevers and chills and rigors and finally his wife talked him into coming into the hospital. His temperature was 102.5F when I saw him and he certainly had tenderness and fullness on the right abdomen. The ER had already obtained the CT scan. The pertinent cuts are included above.
It looked like a perforated appendicitis with periappendiceal abscess. Generally, it's advisable to simply drain this abscesses percutaneously to clear the sepsis and consider bringing the patient back in 2 months or so for an interval appendectomy (although this strategy is debatable). The problem was that it was Friday night and getting radiology to come in for weekend procedures is like asking my wife to wear Ohio State Buckeye gear. I've handled this situation before simply by going to the OR and evacuating the abscess laparoscopically. He was young and anxious to have something done quickly so he could get back to work ASAP. So I took him that night and, interestingly, there was no pus. Nor did I ever identify an appendix. The cecum, however, was rock hard and indurated. So I did a laparoscopic ileocecectomy. The path is still pending; grossly it didn't seem like a cancer. In the one cut, you can see a suggestion of an appendicolith, so maybe this was complicated appendicitis with an intramural perforation. Weird.

Porcelain

Consult on a lady with "porcelain gallbladder" today. Traditional surgical dogma was that one should never attempt laparoscopic cholecystectomy in the presence of known porcelain gallbladder because of the high incidence of malignancy. (Concern about port site implants and adequacy of resection.) Recent literature however suggests that one oughn't to rush into open cholecystectomy. The incidence of invasive cancer in the setting of calcified gallbladder is actually much lower than originally thought. Therefore the morbidity of the open approach cannot be routinely justified. Everyone else practice similarly?

This is utterly astounding to me. $4.85 billion dollars? Amazing that the settlement can be considered a triumph for Merck. What does that say about their bottom line? Apparently, each individual will get a little less than $100,000 as a payout (BEFORE the lawyers get their cut.) Once again, the real winners seem to be the attorneys.

Favors

I can't believe I wrote an entire post on Plavix. I must have been bored as hell in clinic yesterday. Quite possibly one of the more tedious posts of all-time. Poor plavix. It was a venomous attack.

The issue today is gifts/favors from patients. I have a cool little Italian lady who is one year out from a mastectomy for multifocal/multicentric DCIS. Just a classy, composed lady throughout the whole ordeal. She returned the other day for a routine follow up. Surveillance mammogram was clean. She was on Arimidex. Basically, it was a social visit. I was asking what she thought the best Italian restaurants were in Cleveland and she named a few, with the caveat that none of them could make sauce the way she could. Then she asked if my wife and I wanted to come over for dinner some time. I took her number and said "we'll see". Is this illegal? Will the HIPAA police come after me? Is it inappropriate to eat delicious lasagna with a patient whom I operated on last year? I'm still hedging.

And then there's the demented old guy I operated on a few weeks ago for severe C diff colitis. Yesterday an aide from the nursing home wheeled him in with a bouquet of flowers on his lap. The card read something along the lines of, thank you so much for helping my husband and god bless. Nice gesture, I thought. And then when I tried to move the flowers to examine him, he shouted "don't you effing touch me!" I had no problem accepting his wife's gift.

Plavix

I felt like writing about my least favorite medicine today. It's called Plavix and it is probably the most dangerous med to have on board when dealing with surgical patients. Plavix (clopidogrel bisulfate) is an anti-platelet drug (like aspirin) that inhibits the binding of ADP to its platelet receptor, thus shutting down platelet aggegation. It's used a lot in patients who have had strokes or myocardial infarctions. After coronary angioplasty and stenting, plavix is used to prevent restenosis. Platelet aggregation leads to thrombosis; shut down platelet aggregation and, theoretically, long term patient outcomes will be better. Now the data to support Plavix, in my humble opinion, is a little suspect. The CAPRIE and CURE trials have established a "statistically significant" but atoundingly modest benefit of Plavix over aspirin. Combined Plavix/aspirin therapy seems to have a more substantial benefit. I'll leave the specifics to the professionals. All I know is that whenever someone shows up in the office for hernia/gallbladder/etc., one the first things I look for is whether the box for "Plavix use" is checked yes or no. I hate the stuff. Platelets are a surgeon's friend. During an operation, it doesn't take long to see the effects of Plavix use; skin edges that won't stop bleeding, the raw liver of the gallbladder fossa that persistently oozes like a skinned knee, taple lines that have to be oversewn. It's a royal pain in the ass. But it doesn't end there. The worst part is the long term effects. Platelets aren't just for clotting. They're actually the intial mediators of the entire inflammatory cascade. Dysfunctional platelets can impair wound healing and infection-fighting capabilities. I've had two seromas for inguinal hernias over the past 6 months. Both were in patients on Plavix. Now, I usually stop it 7 days in advance of an operation, but maybe that's not long enough; lately I keep them off it for 10 days. The other problem is when patients come in with acute surgical illnesses and are on Plavix. You can give platelet transfusions or just bite the bullet. Either way, your stress quotient gets amped up significantly. And non-surgeons won't touch these patients for any interventions. I have a lady in the hospital now with choledocholithiasis who needs an ERCP prior to her lap chole, but the GI guy wants to wait a week before doing a sphincterotomy (reasonable, as she isn't toxic). So I hope this magic pill is preventing thousands of strokes and heart attacks every year because it doesn't do me any favors.

A new Paradigm?

Surgical dogma has long dictated a Hartman's procedure (sigmoid colectomy, end colostomy) for complicated acute diverticulitis requiring surgical intervention. A one stage procedure was considered substandard care in the acute phase. Ideally, a patient responds to antibiotics, has an abscess percutaneously drained, and then, 8 weeks later or so, returns for an elective laparoscopic sigmoid colectomy with primary anastomosis. That's the playbook I studied when I was a resident while preparing for oral boards. Then I started hearing stories from community general surgeons about draining an abscess, cooling the patient down for a few days with antibiotics, and then doing a one stage procedure on the same admission. I reviewed the surgical literature. It was apparent that people are certainly challenging the so-called standard of care. So I had an unfortunate woman come in a couple weeks ago with diverticulitis and a peri-diverticular abscess. I had interventional radiology place a drain. She got better and went home. Four days later she returns with worsening pain, fevers and a WBC of 24,000. Repeat CT scan sugested another abscess, more lateral to the original one. She clearly wasn't doing well. She hadn't been eating, she simply looked miserable. IV antibiotics were reinstituted and I considered my options. Surgery was obviously going to be necessary; she had failed conservative therapy, but what was the right surgery? Options: 1) Open sigmoid colectomy, end colostomy 2) Laparoscopic colectomy, end colostomy 3) Laparoscopic one stage procedure 4) Laparoscopic colectomy, primary anastomosis and diverting temporary ileostomy. She wasn't too thrilled to hear the word colostomy but I prepared her for the possibility. 50/50 chance. I started with a scope and of course the sigmoid looked lousy, but there wasn't gross contamination of the peritoneal cavity. There was a well contained abscess on the lateral side wall where the sigmoid was stuck and that was about it. I went about the usual business of medial to lateral mobilization of the colon, found the ureter, took down the IMA, and prepared the rectum. The splenic flexure was a bitch, but it came down. Going into the case I had prepared myself for some sort of ostomy, but now...... as I washed out the left lower quadrant I started thinking, reconsidering. It didn't look so bad. The rectum was nice and clean and pink and healthy looking. Same with the descending colon. I made the colorectostomy with the EEA stapler and then stepped back and thought a good three minutes about doing a diverting ileostomy. She was septic. Hadn't been eating well for over a week. But she was young and otherwise healthy. You hate these moments in an operation. Self doubt. Wanting to do what's best for the patient. You're always taught in surgery to take the "safe" option over anything heroic. Guess what? I skipped the ileostomy. It just seemed right. I left a couple drains in and closed up shop. Post op day #3 I get called because her heart rate has spiked to 135. Ah hell, I'm thinking. She's leaking. I send her down for CT abdomen and chest and, miraculously, the pelvis looks fantastic. No air out of place. No free fluid. She did have a small pulmonary embolism (despite compression boots and lovenox) to explain the tachycardia. Currently she's doing great. Just waiting for INR to be therapeutic and she'll go home. Did I just get lucky? Was that truly the right operation? In this case maybe it was. Not always. There are no cook books in surgery. Patients are individuals, not automatons. They don't always behave and react the way they're supposed to. I suppose that's where the "art" comes into play.

Monday thoughts

1. Everything in surgery seems to come in threes. As a resident, you never just did one whipple while on the hepatobiliary rotation; a third one always seemed to show up on the schedule before you switched services. Same with Appendectomies. Sometimes I'll go a couple weeks without doing one and then I'll have a weekend where I just line 'em up. I had two back to back early Sunday morning, but then it was quiet the rest of the day. I couldn't relax though; you just know it's eventually going to come. Bedtime rolled around and still nothing. Maybe this would be an exception to the rule. And then the inevitable page at 4AM. Trifecta. Start some Zosyn and I'll be in after I shower. One of the cases was a classic argument for laparoscopic appendectomy. The kid was 17 and he'd been languishing for 4 days at home with abdominal pain. His parents were out of the country and his older brother was ostensibly "watching" him. He showed up tachycardic with a white count of 24,000. A CT scan suggested some fluid around the liver, in addition to peri-appendiceal inflammatory changes. The appendectomy went fine, but then with the scope I was able to look around. He had pure pus above and below his liver. I spent twice as much time irrigating and aspirating as I did taking out the appendix. I don't think the open approach affords you the ability to do that.

2. My liver transplant bowel obstruction guy is now on the regular floor. The Clinic had a bed available today but I cancelled the transfer. He's mine now. Hell, I operated on him; doesn't seem fair to dump a post-op on the BFH.

3. There's a professional tennis player named Nikolay Davydenko. Apparently, he's pretty good, the top ranked Russian male player and ranked fourth in the world overall. A couple of months ago he was involved in a peculiar situation at a tournament in Poland. Somebody named Martin Vassallo Arguello defeated him when Davydenko "retired" due to injury in the third set. I guess that kind of thing occasionally happens. The peculiar aspect was that a British online bookkeeper suspended payouts on the match because of "betting irregularities". Ten times the average amount had been placed on the match, most of it for Arguello. Suspicious, no? And now last week, at a tournament in St Petersburg, Davydenko was fined $2000 for "lack of effort" during the third set of a match against another nobody that he ultimately ended up losing. Lack of effort? Are you kidding me? Please let this be the final dagger that kills off tennis as a major sport. I hate tennis. Especially this post-modern mash and maul variety with the titanium oversized rackets and the three hit rallies and the women with their orgasmic grunts after every shot and Roger Federer winning everything and Rafael Nadal wearing clamdiggers for some godawful reason. What if Dwyane Wade had been fined for "not trying"? Could you take basketball seriously as a sport? Please go away tennis.

Bed Shortages

Doc Schwab had a post recently about whether to get your surgery at the community hospital or to go downtown to the "big freaking hospital". I posted a comment describing certain scenarios where I would recommend that the patient go to the tertiary referral center. Examples included major liver resections, cholangiocarcinomas, complicated entercutaneous fistulas, severe necrotizing pancreatitis, and liver transplant patients with any of their attendant complications. If I had to pick one case most appropriate for transfer, however, it would be the liver transplant patients. You just don't want to deal with the immunosuppression dosing, the complicated anatomy, and all the infectious issues that inevitably arise. I would assert that you ought to refer even something as seemingly benign as an inguinal hernia repair to the transplant surgeon. So what happens this week? My partner gets called at 3am one night on a patient with a bowel obstruction. He drowsily agrees to admit. The next day we find out the patient had a liver transplant in 2003. His films look terrible and he has some tenderness in the epigastrium. I called the Clinic downtown and they agree to have him transferred. A couple of hours later I get called by the floor because there's a bed shortage at the Clinic. Transfer delayed until the next day. So I have them get a CT scan, to be better delineate the obstruction, since it seems we're stuck with him at least over night. I'm raking my leaves at home and the radiologist calls. "I see a high grade SBO and, more ominously, a suggestion of portal venous gas", he says. There's also a couple of air bubbles that may or may not be outside the bowel lumen. Fantastic. I call the floor. The nurses say he's been asking for morphine every hour. I rush in to see him and he's stable, but certainly more tender. You can't mess around with a patient who's on cellcept and cyclosporine. The natural inflammatory response to stress is altered. You can't trust vitals, white count, xrays. It's all unreliable. He could be sitting there with dead bowel and you wouldn't know. You have to be aggressive. I explored him that evening. Luckily, no ischemic bowel. The "portal venous gas" was actually just pneumobilia from a choledochojejunostomy. His midjejunum was the size of a South American Anaconda, status post ingestion of a wild boar. The scrub nurse kept asking me why his "colon" was so big. She wouldn't believe me it was small bowel. I lysed everything (easily because the adhesions were flimsy and soft secondary to the chronic immunosuppression) and decompressed his bowel. He's actually extubated and progressing fairly well. We're not out of the woods yet, but so far so good. Hopefully that bed at the Clinic becomes available again on Monday.

On the Brink

One more win, and it's on to the World Series. I can taste it. It'd be nice to close it out tonight; you don't want to go back to Fenway where anything can happen. Just finish the job. Time for CC Sabathia to step up and stop the gagfest he's been enduring so far this post season. It's a good time to be from Northeast Ohio. Cavs in the Finals last spring. Indians on the cusp of the Series. Browns actually showing some signs of life. And of course the Buckeyes currently ranked #1 in the country. Couple of things have to happen tonight:
1. Sabathia, crooked cap, beer gut and all, keeps his cool and acts like the ace he was all season.
2. Something, anything out of Hafner. He's coming off a desultory 0-4, four strikeout performance. You can't have your #3 hitter posting a line that your wife could duplicate if she had to grab a piece of lumber.
3. Unexpected source of offense. Trot Nixon tonight? Blake?
4. Get an early lead. Put the pressure on. Keep the crowd in the game.
5. Borowski to keep inexplicably mystifying the Red Sox with that lame 88MPH cheese he tosses up when the game is on the line.
Go Tribe.