Yeats for March Madness: Who Goes With Fergus

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

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

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

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

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

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

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

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

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

Why did Manning do it? For money? Because he's a traitor to his country? In his own words:

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

Hospital Royalty

This article from the Times did not surprise me in the least. In this era of exponentially increasing health care costs, to an extent that the very solvency of our nation could hang in the balance, we have identified that one sacrosanct budget item that will not go under the knife--- hospital CEO salaries.

At Bronx-Lebanon, a hospital that exists only by the grace and taxed fortunes of the people of New York State, the chief executive was paid $4.8 million in 2007 and $3.6 million in 2008, records show. At NewYork-Presbyterian, a hospital system that receives nearly half a billion dollars annually in public money, the chief executive was paid $9.8 million in 2007 and $2.8 million in 2008.

Is anyone surprised? I know, it's so cliched to begrudge someone what the market will bear to pay them. I'm sure there are manifold reasons for a hospital CEO to pull down 7 figures, even at "non-profit" hospitals. But when you have states chopping Medicaid left and right, when Congress faces an imminent debate on the inevitability of entitlement cuts (i.e. Medicare) in order to achieve some semblance of fiscal sanity, is it altogether justifiable for appointed leaders of non-profits to be so generously compensated?

We live in an age that deifies the famous and powerful. No one blinks an eye when Kendrick Perkins signs a $36 million extension. Tom Cruise's $20 million/per picture demand is met with a collective yawn. Sarah Palin commands 100 grand speaking fees. And now celebrity culture has infected the business world. Wall St. collapses and yet, within a year, all time-high bonuses are handed out to the very same idiots who contributed to the financial catastrophe. We expect our leaders, our winners if you will, to be obscenely compensated. They deserve it. This is the American Dream. This kingly submission to the "winners" in the capitalist game is what ultimately holds the entire house of cards together.

Shifting Appendectomy Consensus

An interesting article from Archives on the optimal treatment of children who present with perforated appendicitis. Previous dogma dictated an initial non-operative approach---- dick around with IV antibiotics, CT guided drains, etc--- and then bring the child back in 6-8 weeks for an "interval appendectomy". This article demonstrates that getting the kid into the OR ASAP leads to better outcomes and a faster return to normal activities.

I've advocated for this approach before. Explore the kid laparoscopically, evacuate any abscess collections, leave a drain in certain cases, and take the damn appendix out. I would even extrapolate from the pediatric population and apply such management to all patients with complex appendicitis.

The Best

Now that ESPN has been showing more soccer, don't miss a chance to watch Leo Messi play when Barcelona is on during the final stages of Champions League play. He's the best I've ever seen.

Stomach Partitioning

There are two articles in the latest Archives of Surgery that compare different techniques of bariatric surgery in terms of long term efficacy. (If you're interested, the more complex gastric bypass seems to lead to better diabetes control and quality of life compared to other techniques.) One paper was from Taiwan, the other from Wisconsin. I didn't realize Taiwan had such a problem with Chalupas. But it's true, apparently Taiwan has seen an increasing rise in obesity over the past two decades (that's what you get for aligning with America over the Chinese mainland!). Wisconsin, well, that's where all the Cheeseheads are.

But it's amazing to me the number of bariatric papers that get churned out every year by major surgical journals. It's really difficult to read Archives or Annals or JACS on a month to month basis without seeing at least one paper devoted to bariatrics.

Is this a good thing? Is this science on the march? Are we monthly witnesses to the ineluctable forward thrust of the scientific method in human endeavor?

The bariatric lobby has won the war I suppose. You no longer read dissents that question the philosophical nature of the "disease" of obesity and the appropriate steps a society ought to take to remedy it. The more papers they can manufacture touting the efficacy of chopping your stomach up into various new shapes and forms, the more they can avoid the fundamental question of means and skip ahead to ends. Obesity surgery works. But we've stopped asking why obesity exists to such a grave extent. The ontological nature of obesity has been buried under an avalanche of teleology.

Are we so resigned to the epidemic of morbid obesity that we no longer hope to change human behavior or the way we provide food on a massive scale? Have we become passive reactants to a national health scourge, offering only the option of anatomic rearrangement?

I've always felt that bariatric surgery ought to be an esoteric, poorly understood specialty, where patients were only rarely referred due to underlying metabolic or genetic abnormalities. I never thought it would flourish, sustainably, like the way it has. Surgery departments at major tertiary centers all have their own bariatric programs. The casual prevalence of such a development ought to astound us all.

Serena Williams and Anticoagulation Complications

Serena Williams was in the news recently. Apparently she was diagnosed with a pulmonary embolism last week. These typically arise from blood clots in the leg or pelvic veins that break off and propagate into the pulmonary arteries. Patients present with shortness of breath, chest pain, blah blah blah. You can also die from them. I'm not going to spend all morning writing about why you get them; the thought of doing that is excrutiating to me. Google it if you like.

I bring the story up because it sounds like Ms Williams had to undergo an emergency operation this week, several days after the original diagnosis of PE. All the news organizations are writing headlines like "Serena has emergency operation for Pulmonary Embolism". That strikes me as odd. Treatment of PE is typically not a surgical problem. Treatment involves placing one on the blood thinner coumadin for 6-12 months. Because coumadin takes several days to "kick in", a lot of docs will bridge the anti-coagulation therapy with either a heparin drip (inpatient) or subcutaneous high dose Lovenox (can be administered as an outpatient). In rare cases, such as when the patient presents in extremis, an emergency embolectomy is performed via a sternotomy while the patient is on cardiopulmonary bypass. Catheter directed fibrinolysis has also been described as an option for these very sick patients.

So in general, surgical intervention for a PE is a sign of impending doom--- it's unlikely Serena Williams had her chest cracked open. More plausibly, she required invasive intervention for a complication of the anti-coagulation therapy that all patients with PE's are administered. Spontaneous bleeding from the retroperitoneum spaces is a known, not uncommon, complication of lovenox or heparin induced anti-coagulation.

The pictures above demonstrate the extensive retroperitoneal hematoma of a lady I took care of several months ago who had been started on high dose lovenox and coumadin for a heart arrythmia. Initially you try to correct their coagulopathy and transfuse packed red cells because most of these spontaneous bleeds will eventually tamponade. This lady kept bleeding. I think she received something like 12 units of packed red cells, 10 units of plasma, and several transfusions of platelets and cryoprecipitate. Furthermore, the massive hematoma was starting to compress the right kidney, leading the renal consultant to believe that its very viability was compromised.

Reluctantly I took her for surgery. These aren't fun surgeries. Outcomes are generally pretty poor. Often, you never pinpoint the source of bleeding. You just scoops giant handfuls of gelatinous purplish-black clot into shiny metal bowels, coat the raw surfaces with thrombin/topical clotting agent and hope things don't get out of control. For some reason, just evacuating the hematoma can help halt the death spiral of sustained fibrinolysis that evolves in the setting of large in-situ clots. Anyway, she did allright and went to a nursing home.

The "Tyranny" of the Open Breast Biopsy

I found this article via the NY Times. A Florida study assessed the rate of needle versus surgical breast biopsies over a period of five years. What we're talking about here are non-palpable abnormalities that are identified on screening mammography. A mammogram report will come back that assesses the relative risk of an abnormal collection of calcifications harboring an invasive or pre-invasive cancer (staged on a scale from I-V). With such data, one is obligated, as the patient's advocate, to prove whether or not the mammogram represents true or false positive findings. This means doing a biopsy.

Two ways to go about clarifying the cancer/no cancer conundrum: A needle biopsy is scheduled in the department of radiology. The interventional radiologist uses the stereotactic images to advance a specialized needle into the midst of the concerning area and subsequently vacuum aspirate several "cores" of tissue. The technique is not without complications, but is generally very well tolerated without the complications seen from surgical biopsies (bleeding, infection, unsightly scars, etc). The sensitivity approaches 97-99%. A negative needle biopsy, although reassuring, still demands that close follow up is necessary, i.e. re-imaging of the breast within 3-6 months.

The open biopsy is a surgical procedure. And it involves two phases. One, a woman has to go to the radiology suite for directed placement of a wire such that the tip resides in the hot zone of concern. She then is wheeled to the surgical area where she is sedated and anesthetized. The surgeon then makes a 2-5 cm incision in the skin and excises a lump of breast tissue containing the area of concern, using the pre-placed wire as a guide. She goes home the same day. Bleeding and infection complicate 1-3% of these procedures. Sensitivity is 100% and, if a cancer is confirmed, phase one of treatment has already been accomplished (excision of tumor).

This is the conversation, along with the options presented, that surgeons across the country have with patients who are referred to us with an abnormal mammogram. According to the paper cited above, 70% of women opt for the needle biopsy approach, while 30% are undergoing open surgical excision. My personal feeling is that it's always better to start small/less invasive and expand the armamentarium as needed. Acording to the authors of the paper, and other leading light Breast Surgeons, the idea that 30% of breast biopsies in this country are being done via the open approach is a miscarriage of justice akin to the 30 year torture/dictatorial regime of Mubarak in Egypt. (Seriously, some eminent scholar of supreme reknown named Melvin Silverstein, breast surgeon extraordinaire in California, actually compared lowering the 30% open biopsy rate to the recent uprising in Egypt to overthrow Mubarak. I'm not kidding.)

The study found that the open biopsy rate of Academic Breast Surgeons was about 10%. Private practice general surgeons conversely performed open biopsies 37% of the time. The discrepancy was attributed to several factors--- lack of knowledge by podunk non-academic surgeons, and pure greed being the main ones. Because, you know, if a surgeon refers a woman to a radiologist for biopsy of a suspicious lesion, then s/he loses the cost opportunity for an open excision. Only the holy white tower of academia prepares one for a surgical career free from financial incentive, didn't you know?

I love this passage from the NY Times article, again from the esteemed Dr Silverstein:

One way for hospitals to stop excess open biopsies is to ban them, Dr. Silverstein said, unless they are truly necessary, as in uncommon cases in which a needle cannot reach the spot.

“We made a rule,” he said. “If it can be done with a needle, it has to be. We embarrass you if you do an open biopsy. We bring you before a tumor board to explain.”

What a tool. Hey Dr Silverstein guess what? Not every freaking surgeon who takes care of patients with abnormal mammograms lives within two seconds of a giant tertiary care center with experienced, reliable interventional radiologists and pathologists available at all times. We don't all spend our Tues and Thurs morning sipping coffee for three hours in multidisciplinarian breast oncology conferences. Some Americans actually live in the rural midwest and sparsely populated western plains. Furthermore, surgeons who do fewer breast biopsies per year than a dedicated breast oncologist will have inflated stats if a few patients opt for the open approach. Also, some women actually prefer the option of surgical removal. Even if the needle biopsy is negative, the lesion may still show up on a subsequent follow-up mammogram. The report may call it "suspicious" or maybe it will be down- graded to "close follow up recommended". Either way, she must continue to live with it, knowing she harbors something "not quite right", albeit almost assuredly benign, in one of her breasts. Some women, believe it or not, just don't like to have to carry around that secret knowledge. Some women stop you short when you get to discussing the minimally invasive options: "just take it out", they say.

Again, I am a strong proponent of stereotactic needle biopsies for the initial assessment of a concerning mammographic lesion. But this pompous posturing by some in the field of academic breast surgery is simply intolerable. Non fellowship trained surgeons who perform lumpectomies and mastectomies are fully capable of staying up on the medical literature. We are adept at following best treatment guidelines. You don't need a special little framed fellowship certificate on your wall to have an informed, back and forth conversation with with a patient in a very vulnerable position.

Time to Leave

Enough is enough? Remember, this adventure in Afghanistan has gone on longer than the Vietnam War.

Colon Cancer Presenting as Intussusception

This patient presented with several weeks of crampy abdominal pain and blood-tinged stools. The images above show intussusception of terminal ileum into the cecum. Intussusception (perennial spelling bee candidate, incidentally) occurs when the proximal bowel telescopes into the lumen of the more distal bowel, causing bowel congestion, obstruction, even ischemia. In adults, it's a red flag for cancer. In this case, it was a giant fungating goomba at the ileocecal valve acting as the lead point. Laparoscopic right colectomy = cure (stage II disease).