Bad News

I saw a 28 year old guy about a week and a half ago who presented septic with three to four weeks of crampy abdominal pain and malaise. Initial CT scan in the ER suggested an inflammatory phlegmon in the RLQ consistent with perforated appendicitis. I admitted him, started Zosyn and had interventional radiology place a pigtail catheter in the fluid collection. He quickly got better; pain resolved, WBC normalized, hemodynamic paramters back to baseline. The working diagnosis was appendicitis. The plan was to potentially bring him back for an elective interval appendectomy in 6-8 weeks. Well, he returned to the ER 3 days after his discharge with tachycardia, worsening pain and a leukocytosis. CT scan this time showed a peristent fluid collection in the RLQ and a distal small bowel obstruction. It was obvious he had failed conservative management and I prepared him for the OR. I anticipated finding a bunch of muck in the ileocecal area; ileocecectomy was the likely procedure. Upon entering the peritoneal cavity, everything was stuck in the RLQ. I gently teased the omentum and small bowel away, and immediately broke into a large cavity of pure stool. Further mobilization of the right colon revealed that the posterior (retroperitoneal) wall of the cecum was completely blown out. I'd never seen anything like it. I ended up doing a formal right hemicolectomy just to ensure that healthy bowel would be involved in the anastomosis. He did reasonably well post-operatively. After all, he is only 28 years old. Young healthy males can withstand just about anything. But then I received a phone call from the pathologist on Friday (day after Thanksgiving).
-Your patient appears to have a mucinous adenocarcinoma arising out of a villous adenoma. Eleven of twenty five lymph nodes are involved with the cancer.
-Excuse me? I asked. Are we talking about the right patient? You better double check that specimen. My guy is only 28 years old.
- Sorry... This is the real deal. Any family history?
-No. None...........

I told him the next day. His voice wavered as he struggled to ask questions, to process what he was hearing. Cancer. Chemotherapy. Prognosis. Words he was too young to have to comprehend. Hell, he didn't know what to ask. Why would he? No one prepares you for a moment like that. He has a fiancee'. He works in the health care business. He has a loving, dedicated immediate family. He woke that morning thinking about life as an open field extending as far as the eye could see, into the horizon, limitless. And now there are limits. Boundaries have been drawn. What do you say to him? What is there to say? What comfort can be elicited?

Sick

Physicians have a different conception of what the word "sick" means. It's different than the meaning an eight year old boy gives it when he tells his mommy he feels "sick". Different than what a college kid means when he relates how "sick" he got after shot-gunning six beers. For a physician, deeming someone "sick" is a declaration of war, of sorts. It means the patient isn't doing well. It means death lurks around the corner. Usually the patient is in an ICU, hooked up to a ventilator, on multiple antibiotics, vasopressors, swollen and distorted, fluids seeping out the vascular system. I was closing the fascia on a guy yesterday who had perforated his cecum. This guy's going to be sick, I kept thinking. Sick patients keep you on edge. There's no relaxing. You can't miss anything. The degree of vigilance has to be ramped up ten fold. They give me an ulcer sometimes. So how do you know if someone's really "sick"? What are the best indicators? How can you predict the ones who are likely to struggle? Here's a top five list of clinical indicators that a lot of docs use:

5. White blood cell count: I'm not a fan of this one. Sure, leukocytosis is usually associated with severe infection/inflammation but I've seen planty of patients on death's door with normal WBC counts.
4. Lactate levels: When tissues aren't being perfused, the cells undergo anaerobic metabolism. Thus, lactate will be elevated. I don't use this one very often. It always takes the lab too long to run it and lactatemia doesn't usually manifest until the patient is already starting to decompensate. So it just confirms what you already know.
3. Heartrate: An old school surgeon from my Chicago residency used to call us in the middle of the night for updates on his post op whipples. I'd ramble off streams of data; urine output, CVP, blood pressure, etc. Stop, he'd say. What's the pulse? That's all he wanted to know. Tachycardia is the first response mechanism to stress. All tachycardia ought to be investigated. Post op tachycardia should make you very very nervous. Find out why it's so fast.
2. Bandemia: I like this one. Bands are immature WBC. In the face of severe infection/iinflammation, the bone marrow will mount a massive leukocytosis. Initially, this won't show up on the CBC. Always look at the differential. Bandemia and left shifts are early indicators of something drasticly wrong.
1. Base Deficit: This is my favorite. Cells that aren't getting enough oxygen will undergo anaerobic metabolism. Lactic acid then builds up in the blood stream, lowering the pH. The body has an amazing buffering capacity, but when it gets overloaded, the pH will drop anyway. Base defict is a way of measuring one's relative buffering capacity. A high base deficit is suggestive of a body being overrun by a catastrophic event.
1a. Gestalt: How does the patient look? If they look like shit, trust your hunch. It's like that Malcolm Gladwell book Blink; sometimes your intial, subconscious perception is right on. Be very afraid of patients with a sense of impending doom, telling you they feel like they're about to die. They probably are.

On a brighter note, Happy Thanksgiving.

Chemotherapy = Poison

Unfortunate case yesterday. I was called emergently to see 50 year old lady in the ER who presented with 24 hours of severe unrelenting abdominal pain. When I arrived she was intubated and hypotensive. They had her in some crazy trendelenburg position (why do people still do this? arterial flow isn't facilitated by gravity. You just impede venous return to the heart.) Most of the history was obtained from terrified family members. My partner had operated on her a month ago for breast cancer. He'd done a lumpectomy and axillary dissection for a T2N0 poorly differentiated, Her2Neu positive, ER/PR positive ductal carcinoma. Nine days prior, she had received her first cycle of Taxane/Carboplatin based adjuvant chemotherapy. Over the past four days she'd suffered from horrible diarrhea, with abdominal pain coming on suddenly over the past 12 hours. Her skin was mottled and dusky and her heart rate was 140. Blood pressure was barely registering. Resuscitation with IV fluids was ongoing and the ER attending had already started multiple pressors. Her exam was unrewarding, as she was still completely zonked from the intubation meds. CT scan had been done prior to her crashing. (By the way, she'd been in the ER 8 hours prior to her decompensation.) The pictures were suggestive of diffuse enterocolitis. I was especially concerned about the cecum, which looked abnormally thickened with questionable pneumatosis. Her WBC count came back <1,000. Basically, I told the family that severe neutropenic enterocolitis carries a grim prognosis. Surgical intervention might potentially be life saving, but it could just as well hasten her demise. Without surgery she most certainly wasn't going to survive the night. She had three daughters, all in their twenties, and they wanted everything done. So I explored her; the cecum and part of the ascending colon were frankly gangrenous but the rest of the bowel looked pink and viable (although thickened and beefy red in some places.) So I did a right hemicolectomy, end ileostomy and transverse colon mucous fistula. She's still critically ill, as one would imagine. I'd give her about a 10-20% chance of meaningful recovery. Without white cells, the body just doesn't do well.

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.