Aggravated DocSurg

Out of the hospital...

2011-09-29T11:45:00.004-06:00

Beautiful fall days call for beautiful fall activities. This weekend, SWIMBO and I headed to Williams Canyon outside of Manitou Springs. Day one --- HIKE IT!

Looks like some bozo doesn't know how to read.

And for the next day's activities --- BIKE IT!

Sweet!

Gambling with Matches

2011-04-25T14:26:00.000-06:00

"Match Day" came and went this year on March 17th; I find it interesting to look at the raw data from the residency match, as it gives one an idea of what the next generation of physicians are thinking about the future, and my chosen specialty in particular. It is also instructive to see what is put out as PR for the match and compare it to the match results themselves:

For Second Year, More U.S. Medical School Seniors Match to Primary Care Residencies
For the second year in a row, more U.S. medical school seniors will train as family medicine residents, according to new data released today by the National Resident Matching Program (NRMP). The number of U.S. seniors matched to family medicine positions rose by 11 percent over 2010. In Match Day ceremonies across the country today, these individuals will be among more than 16,000 U.S. medical school seniors who will learn where they are going to spend the next three to seven years of residency training.

Well. Here is the raw data.

I'd like to focus on three residencies --- Family Medicine, Internal Medicine, and General Surgery. For Family Medicine, 48% of the 2,708 slots this year went to US medical school graduates, compared with 44.8%, 42.2%, 43.9%, and 42.1% in the previous four years. For Internal Medicine, the numbers were somewhat higher, with 57.4% of the 5,121 positions being filled by US graduates, in comparison to 54.5%, 53.5%, 54.8%, and 55.9%. Both are a bit of a bump up, but the 11% rise noted for Family Medicine in the press release is a bit misleading, as the number of slots increased by 100 over 2010 as well.

General surgery numbers were a bit mixed, as there were more slots available this year (1,108 versus 1,077 in 2010), 81% of which were filled by US graduates; in comparison, the percentages were 83.1%, 77.4%, 83.1%, and 78.1% going back to 2007. Pediatrics and OB-GYN numbers are hanging in the low-to-mid 70% range for the same time period.

What does all of this mean? I'm not really sure. Not being a statistician, I can't say for sure but none of these numbers suggest a statistically significant change in the percentage of US medical school graduates going into these residencies, all political and PR posturing aside. One thing that many tend to forget is that subspecialty care will draw off many of these primary care physicians with time --- into cardiology, GI, neonatology, high-risk OB, plastic surgery, cardiothoracic surgery, etc.

If I was a betting man, I would bet that the minor increase in FP and IM numbers this year will not be sustained; there are too many financial forces working against the physicians in those specialties. And general surgery is not terribly different in the long run.

The Aggravated DocSurg Field Guide to the American Surgeon

2011-04-15T08:59:00.002-06:00

I’m in Las Vegas. Actually, I was in Las Vegas, but because my swanky hotel didn't provide the basic internet service that your average Travelodge does, I didn't get to post this until now. Not my favorite place, to be honest --- I don’t gamble, smoke, or hang out with hookers. The ads for “Kourtney Kardashian’s birthday party” at Planet Hollywood don’t interest me in the least. I’m quite sure that that mobile billboard advertising for “girls that want to meet” me are a bit less than honest. And I think it is frankly immoral to charge a guy $22 for a martini that isn’t served in a quart-sized glass.

This trip was about business, not pleasure. I was at the Trauma, Critical Care, and Acute Care Surgery meeting held at Caesar’s Palace every spring. Basically, it’s a meeting that talks about all of the things that you don’t want to have happen to you. I have a general rule about medical meetings --- never stay at the hotel hosting the event. The room rates are high, despite the advertisements for “discounted” prices in the meeting brochure, and I like to stretch my legs a bit on the way to and from the lectures. This provides me plenty of time to practice my people watching skills.

This year, the trauma surgeon meeting was held one floor above a meeting for academic internists. Oil and water, so to speak. Being the slacker that I am, I didn’t bring along the meeting brochure with me to tell me where to go. And since Caesar’s wants people to wander and get mired in the casino, there were no signs directing me to the meeting this morning. So with a couple of thousand doctors streaming up the escalators to meeting rooms, how was I to tell where to go?

It’s simple. I know my peeps! I had no more trouble distinguishing the surgeons from the internists than a mother does her twins. And now, thanks to the Aggravated DocSurg Field Guide to the American Surgeon™, you too can know how to spot a surgeon in any environment.

The first clue to differentiating surgeons from internists at a meeting is a careful observation of how they walk --- surgeons are an impatient lot, and don’t tend to stand on escalators, wander, or stroll slowly. We tend to be on time, but just barely, and mostly arrive solo. Clothing is generally a bit rumpled, and at meetings older surgeons tend to adopt the same “uniform” --- khakis, a blue sport coat, and no tie. A quick glance at the wrist generally confirms a cheap watch --- Timex or Casio “nerd watch,” as SWIMBO calls them --- because we are always taking them off to scrub. Lost of loafers --- once again, because they have to be taken off frequently.

The internists were easy for me to pick out. They traveled in packs, ambled peripatetically, and were constantly fiddling with their smartphones. They tended to be rushing, audibly complaining of being late. All of them carried a meeting satchel every day, which the surgeons almost universally leave in their hotel rooms after the first day of the meeting (or never pick up). The shoes ranged from pumps to wingtips (really -- in 2011) to tennis shoes to sandals.

What about in the hospital? I know who everyone is at my place, but if somehow I was dropped into an ICU in Kalamazoo at midnight, and every doc in the place was wearing scrubs, it’s not really that hard. The surgeon in scrubs will unfailingly have messy hair from wearing a scrub cap all day, will be wearing some sort of OR-friendly shoes (Crocs, Danskos, etc.), more often than not is wearing a white coat, will roll his eyes a lot, and will have a feral look about him/her --- this is a deep-seated response to spending years in training where the hours were long and access to the next meal was suspect. If there’s a surgeon nearby, no doubt there’s a bit of food and coffee in the vicinity.

The internist in scrubs looks a bit different --- wearing the same shoes he came to the hospital in, almost never in a white coat, carrying an armful of stuff that generally consists of patient lists, scribbled notes, and a laptop. But the single most distinguishing characteristic that marks the internist who is wearing scrubs is the presence of a stethoscope slung around his neck. This is as pathognomonic as the blue light special at K-mart.

I hope this serves as a good introduction for those intrepid explorers who brave the halls of a hospital or who come across flocks of docs at a meeting place. The next edition of Aggravated DocSurg Field Guide to the American Surgeon™ will explore the finer points of surgeon identification, such as distinguishing residents from attendings, neurosurgeons from cardiothoracic surgeons, and the finer points of separating joint replacement orthopedists from hand surgeons based upon golf club brands.

If you are wondering if this guide is worthwhile, I can say I have already had one successful student -- Jimmy Buffett:

We're stayin' in a Holiday Inn full of surgeons

I guess they meet there once a year

They exchange physician's stories

And get drunk on Tuborg beer

Then they're off to catch a stripper

With their eyes glued to her G

But I don't think that I would ever let 'em cut on me

Waiting & watching for Jon

2011-03-25T13:20:00.003-06:00

We were invincible. Packed into Jon’s pale yellow Olds Cutlass, the car I’d always wanted, careening down the road between our high school and its “sister” all-girls school, we’d sing along with whatever was playing on the oversized speakers garishly mounted in the back. More exactly, we’d usually be screaming along with the music, which was loud enough to rouse more than a few nearby drivers from their afternoon daydreams.

We were on our way to......take a typing class. Twice a week, seniors who had asked for the class would get to spend a glorious hour pecking away at the Smith Corona keys. It was a treat, a privilege, something bestowed only on those who had grades that were up to par, and I’m sure some other selection process was at work as well. Even though there were no girls actually in the class at the time, we were surrounded by them.

And Jon was in his element.

I had never met anyone quite like Jon. He was smart, but didn’t take himself -- or anyone else -- seriously. We’d joke and laugh like other teenage boys, but I never laughed as hard or long as when I was with Jon. His humor was so much a part of his personality that he was able to disarm even the scowling older priests at our school who had quite literally “seen it all” before. A quick jest and a raised eyebrow was generally all it took for him to win someone over to his side. Even when he screwed up, it was hard to stay angry at him for long. Heck, he even started dating a girl I’d broken up with a week before, and I couldn’t hold it against him.

Jon had one other arrow in his quiver, a gift from God, really. His eyes were the color of a Colorado winter sky, and brighter than a neon night. I suppose I’ve only seen something similar in movies, watching Grace Kelly or Paul Newman. But to see them in real life, in “action” so to speak, was remarkable. Personality plus pulsating blue eyes left the girls at Ursuline red-faced and giggling, and left the rest of us laughing, shaking our heads at how easily he could charm the pants off a nun.

Some time, somewhere later, Jon fell off a cliff. Looking back, as it always is, it is easy to recognize the direction he was headed. But the speed with which his drug problem took him down, and the depths to which it drug him, remains breathtaking to me even today. College was never completed --- hell, probably in reality never attempted. Having not seen him in several years, he showed up at my wedding, and then disappeared again, only to arrive unceremoniously at my doorstep with a pregnant girlfriend in tow. It was 11 PM, and I was dog-tired from working as a resident. And there he was, bright eyed as usual, but dirty, disheveled, and totally unaware of how badly he smelled.

That was 1990. I haven’t laid eyes on Jon since.

I know about the successive stents in drug rehab. I have had the opportunity to spend time with his ex-wife and children, and to learn of the tremendous loving influence his parents have had on them. And I have seen the pain in all of their faces, the ache in their voices. They, like me, miss Jon. But they have had to live with the person he became, and certainly don’t miss that guy.

I have put at least twenty versions of this down in electronic ink (those typing classes came in handy), and deleted them all. I have tried to write it in my head about a hundred times more. I guess I can’t come up with a way to end it, because there is no ending that will make me feel any better. Perhaps that is why I catch myself watching for Jon in places that I hope I might find him --- ski resorts, airports, restaurants when I go back to Dallas --- and more often in a place I fear I will find him --- in my ED.

We weren’t invincible.

2011-02-19T15:28:00.003-07:00

It doesn't get any better than this -- America's mountain, a sunny day, and a mountain bike.

Thanks go to the surglings for my new Texas Tech mountain biking jersey!

Henny Penny in the Hospital

2011-02-14T10:04:00.010-07:00

As much as I am not a fan of many of the studies that clutter medical journals --- poorly designed studies or those that display extreme bias --- I am occasionally delighted to find an article that is a bit out of the ordinary. It helps when it confirms my own biases (I admit it, I like to say "toldya so"), and there's an extra bonus for teaching me a new word. Such is the case for an article from the January edition of the American Journal of Surgery --- Catastrophizing: a predictive factor for postoperative pain.

What the heck is catastrophizing? Well, it's listed in Dorland's medical dictionary (not in my prehistoric version, but in their online version), but I haven't been able to find it elsewhere. Put simply, catastrophizing is an irrational belief that something is far worse than it actually is. In the realm of pain research, pain catastrophizing is defined in the article as:

...an exaggerated negative mental set brought to bear during an actual or anticipated painful experience (defined in simple words as expectation or worry about major negative consequences, even one of minor importance).

OK, that means that some people worry excessively about pain associated with medical care, either during or before the actual care event. So? I worry about lots of things --- whether my kids will be alright when they are adults, whether or not I'll be able to bike to the top of the next hill without hacking up a lung, or whether SWIMBO will wake up one day and realize that she was duped into marrying me 23 years ago. I lay awake at night worrying about patients in the hospital, knowing that there is little I can do but wait. Well, in this situation, it's the degree of worry involved --- hence the provocative name for the problem. Once again from the article,

High levels of catastrophizing have been reported to be associated with a heightened pain experience and can result in the development of chronic pain.

The authors reviewed a large number of pain studies in surgical patients, and came up with a few general findings:

Pain catastrophizing is becoming recognized as a key predictor of the severity of acute post-surgical pain and its progression to chronic post-surgical pain. That's a big deal, because the severity of a patient's pain perception significantly alters their recovery and postoperative mobility, which can lead to other problems (DVT, atalectasis, etc.).
There are screening tools available (the Coping Strategies Questionnaire and the Pain Catastrophizing Scale) to identify patients with a tendency to catasrophize, which could potentially allow us to tailor postoperative pain management for them.

Hmm. I am a surgeon. Basically, that means that everything I do hurts. It's important for me to make sure patients know and fully understand that before we go to the OR, because otherwise I would be a lying SOB. But, it is also important for them to know that we try to mitigate their pain ---- but we are unable to take it completely away --- and that it will gradually improve with time and eventually pass. I am definitely not a fan of the current pain management fads such as identifying pain as a "5th vital sign," and really think this sort of pain scale is a poor substitute for patient assessment:

I suspect that those who have pain catastrophizing issues would routinely self-assess their pain levels as "above 10" on such a scale.

So what should we do? Should we try to identify patients who have a tendency to catastrophize their pain levels preoperatively? That would involve yet another set of screening questions that already take up way too much of the preop nurses' time, and would probably cast such a wide net that many patients would needlessly be labeled (as almost every patient entering the hospital is now labeled as having the potential sleep apnea; that's a rant for another day). Or should we add this as a diagnosis to those who exhibit these tendencies, which will hopefully allow a more aggressive approach at working with these patients during subsequent hospitalizations?

I'm not sure. I just know that we all see patients with this issue, and now at least I have a name with which to identify them.

Perhaps until some regulatory body passes a decree mandating some new pain management rule, passing out these bumper stickers might be of some benefit, especially in the ED:

I am not...

2011-01-12T18:33:00.004-07:00

am not

old enough

to have a

21 year old daughter today!

The OR Rorschach Test #8

2011-01-11T09:23:00.005-07:00

For today's quiz, you need to be old enough to have read classic children's books, and young enough (at heart) to recognize a character:

OK, after searching high and low, I now realize that Curious George was never drawn with a tail, but c'mon ---

--- if you are as old as I am, you gotta think Curious George when you see a monkey shape! Besides, Cheeta never played the piano, and though the Barenaked Ladies sing about chimpanzees, there's not actually one playing an instrument in their video.

Any other ideas?

Snow White, RN and the Seven Surgeons

2011-01-04T22:20:00.000-07:00

Once upon a time, there was a princess who lived on the hospital surgical ward named Snow White, RN. She was beautiful, cheerful, helpful, efficient, and a damn good nurse. She took great care of her patients, and expected the same level of care from her compatriots. Naturally, that meant that she ran afoul the wicked witch, AKA the Queen Nurse, RN, BSN, PhD, QRS, ABC, etc. Fearing her independence and strengths, the Queen refused to promote Snow White, RN, to management. Every day, she would peer into her Blackberry to ask "~~who is the ablest one of all~~ who has filled in the most EBN matrix forms, completed the most forms on the EMR system, answered every question on the staff survey correctly, and doesn't ask "Who is that" on my semi-annual trips to the ward." Never seeing Snow White's name on the Blackberry, she was pleased; she did not need Snow White's heart in a jeweled box, because she was boxed in. (image source)

Snow White, RN was not pleased, and sought another position. The HR department, despite being warned by the Queen Nurse, had a moment of weakness and directed her to flee to the ~~woods~~ Operating Room. Lost and frightened, Snow White, RN was befriended by creatures who rarely ventured beyond the OR -- scrub techs, CNAs, anesthesia techs, PACU nurses and operating room RNs. The friendly staff showed her around, and she soon discovered a room deep in the ~~woods~~ OR. Finding seven scruffy chairs, crumbs on the floor, spilled soda, half-eaten pizza, a table with coffee stains resembling an ancient mozaic, and a TV permanently tuned to ESPN, she assumed the room was an adjunct of the frat house at the local university.

But it soon became apparent to Snow White, RN that the room was the surgeons' lounge, occupied daily by seven surgeons --- Doc, Grumpy, Happy, Sleepy, Bashful, Sneezy, and Dopey? Er, not exactly:

Dick Doc is the, well, you know...

Grumpy old Bastard is the general surgeon in his late 50s who has never seen an OR run more inefficiently, has never seen a room turnover in less than an hour, and looks like the barnacle encrusted crab that he is.

Hippie is the laid back surgeon who listens to Tales From Topographic Oceans during surgery. Thought he'd look like The Dude when he got to be 50, but looks a bit more like this dude instead.

Sleepy is the trauma surgeon who lives by the motto "Don't walk when you can ride the elevator, don't stand when you can sit down, don't sit down when you can lay down, and don't lay down when you can sleep." He enjoys a cozy relationship with the recliner in the surgeon's lounge; the anesthesiologists can tell him from the OB sleeping next to him by counting snorts per minute.

Brashful is the young general surgeon just out of training, full of piss, vinegar, and opinions. Sometimes wrong, but never in doubt.

Sleazy is the surgeon who is working -- hard -- on his third divorce; also known to the staff as "Dr. Winky" or "Dr. Pinchmeister." Never got the memo about sexual harassment in the workplace; thinks gold chains aren't just a fashion accessory, they are a lifestyle.

Mopey is the general surgeon who (according to him) just can't seem to catch a break. His cases never start on time, always run late, are always harder than everybody else's cases, and never seem to be elective. He'd hire Eeyeore as a personal life coach if he just got enough time off call....(deep sigh).

As for Prince Charming, Snow White, RN never found him in the surgeons' lounge. She wised up and met a nice cardiologist who swept her off her feet and took her away to live happily ever after.....working in his office with no night call, no medication reconciliation forms, no admission and discharge matrix forms, and no weekends!

Billing Fraud or Documentation Errors?

2011-01-03T11:24:00.000-07:00

I'm not really sure where it came from. Perhaps it started during medical school, where I funded dates with SWIMBO by typing lecture notes ($30 a pop for the shared lecture note service). Maybe it came later, trying to understand a patient's prior hospitalization reading someone else's notes that were so cryptic Mr. Turing would have had difficulty sorting through them. Regardless, I am sort of compulsive about documentation of my interactions with patients --- histories are always dictated as soon as I see a patient, operative notes are dictated as soon as I have spoken with the patient's family, etc. Even if I check on a (sick) patient half a dozen times during the day, I always leave a brief note in the chart.

There are two reasons to be compulsive about medical record keeping: [1] to provide a clear trail of a patient's course of care, as well as the thought process that led to it; and [2] to protect myself in the possibility of a lawsuit --- the adage in medical malpractice cases is that "if it isn't documented, it didn't happen."

A third, and more troublesome to deal with, reason to be anal-compulsive about documentation is to be compliant with Medicare's billing regulations. The billing process involves a tangled mess of diagnostic (ICD9-CM) and treatment (CPT) codes that must align accurately to get the government (or insurance company) to cut you a check. Sounds simple --- you arrive in the office with uncomplicated gallstones (ICD code 574.10) and episodic right upper abdominal pain 789.01), I see you and schedule you for a laparoscopic cholecystectomy (CPT 47562). Assuming you are fairly healthy, most of the visit is taken up by discussing gallstone disease, treatment options, and the risks associated with surgery or observation. If you are not so healthy --- have heart disease, diabetes, a history of blood clots, etc. --- I gotta

think a bit more about how to care for you. Common sense would dictate that the healthier person with gallstones would be charged a lower level office visit than the sicker patient with the same problem, but getting paid for that service is not really common sense. In order to ensure that I get paid, I have to document a large amount of information; unfortunately, much of the documentation required is as useless to the patient's care as a wristwatch is to a pig.

Here is the 51 page document laying out the requirements for each "level" of evaluation and management charge. If it looks a bit silly and even contradictory in areas.....it is IMNSHO. It also forms the focus for a big chunk of electronic medical record systems, which can automate the process of documenting the large number of "negative" systems reviews and physical findings that patients have (which have nothing to do with their care or presenting problem), all required to make sure that your office note aligns with the bill for the patient's visit.

Because it is easier to measure, regulate, fold, spindle, and mutilate the documentation and billing part of medicine than actually measuring quality of care, there is a significant effort expended to prevent physicians from overbilling for patient care. From the OIG web site:

Because the Government invests so much trust in physicians on the front end, Congress provided powerful criminal, civil, and administrative enforcement tools for instances when unscrupulous providers abuse that trust. The Government has broad capabilities to audit claims and investigate providers when it has a reason to suspect fraud. Suspicion of fraud and abuse may be raised by irregular billing patterns or reports from others, including your staff, competitors, and patients. When you submit a claim for services performed for a Medicare or Medicaid beneficiary, you are filing a bill with the Federal Government and certifying that you have earned the payment requested and complied with the billing requirements. If you knew or should have known that the submitted claim was false, then the attempt to collect unearned money constitutes a violation. A common type of false claim is “upcoding,” which refers to using billing codes that reflect a more severe illness than actually existed or a more expensive treatment than was provided.

So, American physicians daily go through the exercise of trying to document properly --- not completely for patient care, but to make sure we can get paid for the care we deliver and to make sure that CMS can't come after us for improper billing. It's kind of like playing Jenga, but instead of pulling out blocks, each patient bill can be something that brings your whole practice down.

Of course, I have read about several instances where unscrupulous physicians have bilked the government out of substantial amounts of money; I like the idea that they are caught and prosecuted. But like most law abiding physicians, I am nervous about the idea that the government has created a system more Byzantine than the IRS with the potential to make any physician that is audited a criminal, because it is pretty dang difficult to document well enough to satisfy a government auditor who has never taken care of a patient.

Oh. One more thing. This process just got worse:

It has created a new interagency task force called HEAT (Health Care Fraud Prevention and Enforcement Action Team) under which health-care officials will collaborate with the FBI to go after Medicare fraud. In addition, it has expanded to several cities the Medicaid Fraud Strike Force that authorizes FBI and Drug Enforcement Agency agents to jointly analyze Medicare claims data in real time to detect and investigate irregularities by area doctors. More chillingly, however, the administration is defining Medicare fraud down to include “unnecessary” and “ineffective” care. And to root this out, it plans to make expanded use of private mercenaries—officially called Recovery Audit Contracts—who will be authorized to go to doctors’ offices and rummage through patients’ records, matching them with billing claims to uncover illicit charges. What’s more, Obamacare increases the fine for billing errors from $11,000 per item to $50,000 without the government even having to prove intent to defraud.

That doesn't give me warm and fuzzies about "single payer" health care delivery in this country.

What a difference 1/6th of a day makes

2010-12-30T14:07:00.003-07:00

A spectacular day in Colorado today ---- more accurately, a spectacular morning. When the sun is shining, 30 degrees feels like 50, letting Fat Boy get out for a little ride. This photo was taken at 10:00 this morning:

This afternoon --- not so spectacular. The view from my window right now, 4 hours after my ride:

And the forecast for tonight....

Thu

36° | -4°

If I can ride my bike, walk my dog, and ski in the same week, I'll take it!

The OR Rorschach Test #7

2010-12-19T11:21:00.001-07:00

For your viewing pleasure, or puzzlement, today's OR Rorschach Test ---

I spy.....a rounded schnozz and a huge chin. This guy perhaps?

As for me, I think I'd go with Marv from Sin City:

Who's with me?

The OR Rorschach Test #6

2010-12-17T09:43:00.000-07:00

Today's pop quiz --- what can you make of this OR Rorschach?

Not much there, unless you have an active imagination (or unless you take these home from the operating room for study with a nicely chilled martini). I can see eyes -- slits with shadowed eyes really. And a face shrouded by something....gauze perhaps? Got it - Darkman!

Bad (über-bad, IMHO) movie, but a good image match. Any questions?

The OR Rorschach Test #5

2010-12-16T09:19:00.003-07:00

Quiz time! Here's the OR Rorschach Test for today --- what do you see?

Droopy nose? Check.

Big round eye(s)? Check

Indistinct features otherwise? Check.

Ladies and gentleman, looks like we've bagged a Snuffleupagus!

As always, your image interpretation mileage may vary.

Operating Better, With Electricity!

2010-09-09T16:02:00.000-06:00

Sharp knives. Sutures. Hot lights and warm blood. Great music. That's what most folks picture when thinking about operating rooms. It's easy to overlook that we make use of plain old electrical energy in the OR --- electrosurgery. Sounds like something from a '50s SciFi novel. Perhaps a gift from the Red Lectroids from the 8th dimension?

Actually, the modern era of electrosurgery started in 1926, courtesy of Dr. William Bovie, a physicist, and Dr. Harvey Cushing, the father of neurosurgery in the US. The term "Bovie" is still standard jargon for the electrosurgical generator used in surgery, though most surgeons are only casually aware of its origins (there is a fair amount of history here and here, for those interested; image from Medscape). Me? Back in the dark ages, when (general, non-GYN) laparoscopic surgery was undergoing rapid growth and research opportunities abounded, I spent a year doing research, teaching laparoscopic surgery courses, and writing papers & book chapters. There had been considerable debate about the relative merits of using laser energy versus electrosurgery in laparoscopic gallbladder removal, and I landed the plum job of writing one of the papers that helped relegate laser laparoscopic cholecystectomy to the dustbin. Of course, as these things go, I also had many more writing assignments, including a book chapter entitled "Endoscopic Technology" for a book about laparoscopic and endoscopic surgery.

Let's just say, for someone who struggled to remember everything his father taught him about wiring a house, I learned quite a bit about electricity to write that chapter. And I learned even more about the potential for patient safety problems when using electrosurgery. For simplicity, though, the best way to think about electrosurgery is to picture a complete electrical circuit (image source):

Any interruption in the circuit results in cessation of the flow of electrical energy (electrons). In the operating room, the "battery" is the electrosurgical generator, and rather than lighting a lamp, the energy is focused in the tip of an instrument, resulting in heat and tissue destruction, also called diathermy, where it is focused.

OK, wait a minute. The generator is connected to the instrument, which is supposed to deliver electrical energy. But that doesn't make a complete circuit --- where is the rest of the circuit connecting back to the generator?

Well, a big chunk of the circuit is made, just like Soylent Green, of people! More accurately, of one person -- the patient --, to whom is attached a grounding pad (the passive electrode) that then connects back to the generator. Voila! A complete circuit is made, allowing high current density produced at the tip of the instrument (the active electrode) to cut and cauterize tissue.

So what's different about using electrosurgery in laparoscopy? Well, a couple of things. First, we must use long instruments to reach the operative field, with an active electrode only at the tip of some of them. Second, those instruments must pass through trocars that maintain a seal to prevent the escape of CO2 from the inflated abdomen. And finally, we use a non-insulated telescope attached to a video camera to view what is happening in the operative field. As a result, there are many places where electricity may end up flowing other than where it is intended to be focused. If the active electrode/cautery tip is activated against an uninsulated portion of another instrument, tissue that is in contact with that instrument can be injured. If the cautery tip is activated out of view of the camera, it can result in unrecognized tissue injury. And there is a more complex problem called capacitive coupling, unique to laparoscopic surgery, that can result in tissue injury.

Perhaps the most pernicious risk, however, is insulation failure. Because we want action only at the tip of the active electrode, the remainder of the length of the instrument is insulated to prevent "leakage" of electricity ---- which can cause a tissue burn when the shaft of the instrument is laying against, for example, a piece of bowel, well out of view of the operative field. That risk, I have always felt, can be eliminated by using disposable rather than reusable cautery instruments. Additionally, the other instruments not actively delivering electrical injury may have insulation defects, and can similarly cause injury if they are used in contact with the active electrode/cautery.

Looks like I may be right for a change --- Insulation failure in laparoscopic instruments is a study published in Surgical Endoscopy earlier this year (unfortunately no unregistered access to article or abstract). Basically, the authors looked at reusable and disposable laparoscopic instruments used to deliver electrical energy and tested them for insulation defects. From the abstract:

Two hundred twenty-six laparoscopic instruments were tested (165 reusable). Insulation failure occurred more often in reusable (19%; 31/165) than in disposable instruments (3%; 2/61; p less than 0.01). When reusable sets were evaluated, 71% (12/17) were found to have at least one instrument with insulation failure. Insulation failure incidence in reusable instruments was similar between hospitals that routinely checked for insulation failure (19%; 25/130) and hospitals that do not routinely check for insulation failures (33%; 7/21; p = 0.16). Insulation failure was most common in the distal third of the instruments (54%; 25/46) compared to the middle or proximal third of the instruments (p less than 0.05).

Hmmm. One in five reusable instruments was found to have an insulation failure. Cue The Doors:

Five to one, baby
One in five
No one here gets out alive, now
You get yours, baby
I'll get mine
Gonna make it, baby
If we try

Hold on. If this was a humongous problem, wouldn't general surgeons be seeing electrosurgical injuries from laparoscopic surgery on a weekly basis? Yep. And we don't. Perversely, I would say that is a bit of an issue ---- because this is seen very rarely, it is something about which one may be less than vigilant.

From my standpoint, I have a few things I insist upon when doing laparoscopic surgery; most importantly, I will only use disposable cautery instruments, as they are heavily used and most prone to insulation failure. Secondly, I don't use any other instruments to help deliver electrical energy/cautery; in open surgery, we frequently pick up a small bleeding vessel with a pair of forceps and then deliver the cautery against the forceps, delivering the electricity through them to the tissue that they hold --- for me, an absolute never in laparoscopic surgery. Finally, when appropriate I use alternate methods of delivering energy to tissues --- bipolar electrosurgery (that's another post) or high frequency ultrasonic energy most commonly.

In the end, the problem associated with insulation failure is really no different than many other potential pitfalls in medicine --- being well aware of the potential problem is the best method of its prevention.

How to give your mother gray hair

2010-09-08T08:40:00.000-06:00

How I spent my Labor Day weekend:

No, that ain't me. Yep, I was waiting at the bottom of the hill for the youngest surgling to come hurtling down the mountain wearing enough gear to embarrass Mel Gibson in The Road Warrior with the speed of an out of control locomotive, hoping to get one good picture (pretty good if I say so myself).

Wish I was 16 again...

Red Neck Pick-up Pad

2010-09-07T20:17:00.003-06:00

Seen at a recent mountain biking race weekend. There's a cliché in here somewhere...

Necessity is the sincerest form of flattery?

Imitation is the mother of all invention?

I think both.

A Stroll Down Future Memories Lane

2010-08-24T20:14:00.000-06:00

You may not know this, but I have a hidden talent. I can predict the future. No, this doesn’t involve a crystal ball, Ouija board, or looking at the entrails of a freshly slaughtered surgical intern. I can see the future that is written out, plain as day, in medical journals. While this will not allow me to get rich in the stock market, predict the next presidential election result, or find out exactly when Monica Bellucci is planning to leave what’s-his-name and realize that she was meant for me, my limited skill gives me a little insight into how general surgeons will be treated --- and, more importantly, how they will respond to such treatment --- in the next few years.

A good example is the ongoing, relatively one-sided discussion regarding who should be doing certain procedures. Sounds relatively simple --- look at a variety of measurable outcomes for certain surgical procedures, and compare the results between “high volume” and “low volume” facilities and surgeons. This data is then often used to argue that across the board, we should as a matter of public policy push to shepherd certain types of patients to “high volume” facilities to achieve the best possible results. I have written about this a bit before, and certainly the freight train pushing certain types of procedures (pancreatectomy, esophagectomy, cardiac surgery, etc.) towards higher volume centers has been rolling down the track for so long that it is essentially unstoppable.

But what about procedures that are considered to be less complex? Should the same type of spotlight be placed upon cholecystectomy? Colectomy? Appendectomy? Hernia repair? And what if the data from such an evaluation reveals a contradictory result; should that instigate a reevaluation of prior “low versus high volume” studies? That’s good question, and one that is partially addressed by a study published in the July edition of the Journal of the American College of Surgeons --- Predictors of Major Complications after Laparoscopic Cholecystectomy: Surgeon, Hospital, or Patient?

From the abstract:

Using the Nationwide Inpatient Sample for patients undergoing laparoscopic cholecystectomy, major complications including acute myocardial infarction, pulmonary compromise, postoperative infection, deep vein thrombosis, pulmonary embolism, hemorrhage, and reoperation were assessed.
A total of 1,102,071 patients' records were available for this retrospective 1998-2006 study, with a complication rate of 6.8%.
Univariate analyses showed that advanced age, male gender, and higher Charlson Comorbidity Score were associated with higher complication rates
Higher surgeon volume and higher hospital volume were associated with fewer complications (6.7% versus 7.0%, 6.4% versus 7.0%, respectively)
Multivariable analysis showed that advanced age (65 years or older versus younger than 65 years), male gender, and comorbidities (Charlson Comorbidity Score 2 versus 0) were associated with complications
Neither surgeon nor hospital volume was independently associated with increased risk of complications.
Conclusions -- Major in-hospital complications after LC are associated with individual patient characteristics rather than surgeon or hospital operative volumes. These results suggest regionalization of general surgical procedures might be unnecessary. Rather, careful patient selection and preoperative preparation can diminish overall complication rates.

Uh, what did they just say? Let me repeat it --- “Major in-hospital complications after laparoscopic cholecystectomy are associated with individual patient characteristics rather than surgeon or hospital operative volumes.” In other words, we are not a bunch of rubes out here away from the miracle centers. On average, the general surgeons of this country are competent and well trained. “Rather, careful patient selection and preoperative preparation can diminish overall complication rates.”

Time for a little futurama. I have no doubt whatsoever that the push for regionalization of a whole swath of surgical procedures will continue unabated, especially in the current political environment. To an extent, I will benefit from such a push --- I am a high volume general surgeon working in a tertiary referral center, albeit not in the largest city in my state --- and would anticipate an increase in surgical volume over time if such proposals come to fruition. It would be very reasonable to also expect that the types of patients sent up the road will be sicker to a pretty substantial degree, with simpler, elective procedures being done on healthy patients being retained in lower volume facilities.

Look at it this way. Let’s say you are a well-trained and ~~salty~~ seasoned surgeon in a small-to-medium sized city. An hour away is a miracle center, and they have actively pushed to make sure that, for example, colon resections should only be done in high volume centers by high volume surgeons. And let’s say that at 1AM you get a call to the ED to see a 62 year old, 280# diabetic man with hypertension and coronary artery disease who has perforated diverticulitis. Peering into the future, I predict the response of most physicians put into that difficult position will be “Gee, if I am not considered good enough to do elective colon surgery during daylight hours, I certainly am not good enough to do something more complex and emergent on a someone who has had no careful patient selection and preoperative preparation in the middle of the night. Call the miracle center and arrange transport.”

Patient wants to stay in town? Too bad.
Patient is pretty darn sick? Give him antibiotics, load and go.
Patient has given googobs of cash to the hospital? Cue Lindsey Buckingham. Call the hospital CEO to hold his hand during transport.
ED really, really wants you to take care of the patient? Wouldn't be prudent. I can hear the attorney's question when I get sued for a complication: "Doctor, when was the last time you performed one of these operations electively?"

This sort of begs the question, is this a good thing for the patient, or a bad thing? I'm sure you can tell that I come down a bit on the side of "bad thing," but some might argue the opposite. The difficulty is that all hospitals cannot be staffed with high volume surgeons for every possible procedure. It's a Pollyannish idea, sort of like how the schoolkids in Lake Wobegon are all above average.

Please understand, I am not arguing that we should be avoiding progress; obviously, I don't think it's ethical to turn away a patient in need. But progress in medical care has generally come from striving for excellence in training and disseminating information about how to best care for patients. If there is a concern that surgeons performing a lower volume of certain common procedures need a little buffing up, first prove it.....and then I would humbly suggest that the way we have been going about steadily improving care in this country has worked extremely well over the past century. I have yet to see strong evidence that radically changing this system will be beneficial to patients in the long run.

My Recipe

2010-08-21T11:54:00.009-06:00

Take one part highly inflammable surgeon. Add a dash of chronic worry, a well-rounded tablespoon of sleep deprivation on call, and stir vigorously with an enormous slab of hospital inefficiency. The cherry on top? That would be ongoing concerns about government regulation compliance, increased taxes on my small business, Medicare payment games, and the Kabuki theater known as Obamacare. That would be my recipe for one, well, aggravated surgeon. To make this situation really cook, however, increase the on call load by having one physician leave the group (and act like a total rectal-discharge-head on the way out). Voila! Aggvavated DocSurg flambé ! C’est magnifique!

What was not so magnifique was my blood pressure, weight, and stress. Think of Ox in Stripes.

"Well, my name's Dewey Oxburger. My friends call me Ox. I dont know if you've noticed, but I got a slight weight problem.....When I was younger, I swallowed a lot of aggression...along with a lot of pizzas!!"

A few changes were in order if I was going to avoid sharing John Candy’s fate. Trying to put one’s time in order when working in a field where a predictable day is a false hope has always been one of my biggest challenges, but I was able to make a few adjustments over the past few months. Activities that helped decrease stress were put on the front burner, and those that simply added consternation with no discernible benefit were dropped faster than you can say “Frankly, my dear, I don’t give a damn.” Or something like that.

What went out with the screaming baby and the bath water?

Any hospital committee that I wasn’t absolutely required to be a member of.
Any meeting with hospital administrators that was unscheduled or open-ended. No agenda and no clear reason to be asking for my time? Then sayonara, baby.
Any time wasted in my office waiting for patients who cost me money, i.e. Medicaid patients, who fail to show up on time. I cannot afford the expense or aggravation involved in trying to work in someone who shows up a half hour late for a scheduled appointment, but whose insurance coverage pays so little that I lose money seeing them to begin with.
Any time sitting in the surgeon’s lounge bitching about Obumblecare, politics, hospital administration, and healthcare in general. Wasted words, as Mr. Allman would say.
Potato chips. Worse than crack cocaine for me.
Orchestrating OR schedule contortions worthy of a pretzel maker in order to accommodate every patient’s request. I try to make things work as well as possible, but it made no sense for me to go to three different places to operate in one day, doing a single case at each location, and racing across town to be on time.
Any time blogging. Not really a conscious choice, but I needed to quit bitching here too.

What went into the mixing bowl?

My mountain bike. Specifically, I have tried over the past 5 months to get outside and ride at least 4 times per week. This means lunchtime rides on office days whenever possible, and using any other available time on OR days. I had to carve an extra hour out at lunch and run my office later, but it has been worth it (especially when it was snowing).
Travel. SWIMBO and I took the Surglings on a long-awaited trip to Rome & Paris. Simply fabulous.
My books. I love to read, but have felt that the time I had available to dip into a good book had evaporated. Made time, read some good books, and then the Surglings bought me a Kindle --- I now have a new version of crack cocaine. I have enjoyed Vanished Smile, The Gardner Heist, The Man Who Loved Books Too Much, the "Dragon Tattoo" trilogy, and Fire among others this summer.
Music. My younger self spent waaaaay too much money on vinyl and concert tickets, but I enjoyed every bit of it. So I have spent time spinning old records and seeing a few concerts --- there is nothing that can compare to an evening at Red Rocks.

But.

But.

But....I haven’t received the miracle cure. I remain, after all, aggravated at my core. Which means that while I haven’t necessarily posted anything, I have been keeping notes. Taking down names. Reading BS journal articles that whose authors don't seem to understand the difference between good medical care and mumbo-jumbo. You know the drill. And while the exercise has been good, to the tune of ~30#, it has also provided me time to consider things I want to write about --- I gotta concentrate on something other than my heavy breathing while climbing a hill.

I guess that means that posting here will have to be added back into the mixing bowl. Sorry. And if I get too worked up --- too aggravated --- let me know.

Surprise, surprise....

2010-06-13T02:27:00.003-06:00

OK, I am on vacation, and while it was against my better judgment to look at a little news, SWIMBO and the surglings are sleeping, and I can't (big time difference here, plus I usually get up at 5:30). What do I find? Yet another example of how Obumbles spun lie after lie about Obumblecare:

According to the report, by 2013 51% of all employers — 66% of small employers (3-99 employees) and 45% of large employers — would have to relinquish current coverage. In a worst-case scenario, 69% of firms would lose their grandfathered status.

This could pose a serious threat to President Obama’s claim that if you like your coverage, you’d get to keep it.

Gomer Pyle could not be reached for comment.

Shocker

2010-05-18T09:13:00.000-06:00

Color me (not so) surprised.

The OR Rorschach Test, #4

2010-05-11T09:57:00.010-06:00

Working, biking, and not posting. Hardly a recipe for loads of hits, but I've been busy and the weather has been great.......so I've ridden instead of posting. But I have accumulated a few new OR Rorschachs for your viewing pleasure. First question for today's test:

Ahh, the belly button always leaves a nice divot in the Betadine and gives most OR Rorschachs a handy "eye" to anchor the picture. This one is almost too easy --- while one could say that Jim Carrey had lost The Mask in the OR

...I think this looks more like an Easter Island moai:

I guess it all depends on your cultural perspective.

Next up, another face....or is it?

I dunno ---- this one strikes me as if The Shadow is peering around the corner of a building

SWIMBO, however, who is used to feeding my teenage son massive quantities of food, immediately thought of this:

A nice, steaming slice of pepperoni pizza. Reminds me of college! (Pizza Express, 744-4444, sadly no longer in business)

Last question for today's test:

While this sort of puts in mid the Union Jack,

I'm more inclined to think of a famous guitar:

Never have much cared for Van Halen, but this is rather iconic.

Class, any questions? Remember, there are no wrong answers here.

Today's ride

2010-04-20T18:09:00.002-06:00

Dirt, sand, rocks, and trees. All mixed with a little bit of my blood after coming down this run --- I like to call it "Hell, no, I have a mortgage!"

If they could only all be taken to Rampart Hospital

2010-04-01T00:19:00.000-06:00

Trauma surgery for me is a whole lotta non-operative care interspersed with occasional surgery for things like a ruptured spleen. This is because I don't practice in a large urban center, and most of the trauma patients I care for have suffered blunt force injuries rather than penetrating ones. For most of the non-physician population, the idea of trauma surgery is heavily influenced by television --- shows like "E.R.," "Grey's Anatomy," and the like (I am asked at least weekly whether I enjoy these shows; I haven't seen a medical drama since "Emergency" ended its run in the 70's). Like other dramas, these shows try to maximize tension to keep the viewer interested; in trauma, there is nothing quite like a gunshot victim to achieve that goal. Lots of blood and screaming, along with an intense urgency to getting a patient off to the operating room.....where they are miraculously saved every time.

Every time. Except in real life, where some patients die of their gunshot wound (GSW). Sometimes, the reasons are obvious --- shot through the heart or the head with a fatal brain injury. Sometimes, the reasons are harder to understand ---- see a description of irreversible coagulopathy here. As for the rest, we don't have all of the answers, though not for a lack of searching.

Insurance Coverage Is Associated With Mortality After Gunshot Trauma is a recent retrospective study that is part of that searching. The trauma department at UCSF - East Bay Alameda County Medical Center in Oakland reviewed the records of 2,164 patients over a 10 year period who presented to their facility with a trauma activation for GSW. A few salient points from this report:

92% of GSW victims were male
Average age of 28 (+/-9), with no difference between insured and uninsured patients
Injury severity scores (a system to "score" how badly a patient is injured) were similar between groups
~25% were insured and less than 1% were on Medicare or Medicaid
Overall hospital mortality was 8%
There were no differences in mortality between Hispanic, Caucasian, and African-American patients
Uninsured patients had an odds ration for death of 2.2 in comparison to insured patients, despite access to the same level of care

This disparity is puzzling. From the authors' summary,

...despite similar injury severity, uninsured trauma patients were significantly more likely to die after admission for gunshot injury than insured patients. This difference could not be attributed to racial demographics or hospital resource use, and it held true even after adjusting for the effects of race, age, gender, and injury severity.

On possibility is that patients who died had more medical problems....except that insured patients were found to have more comorbid conditions than uninsured patients (17% versus 12%). In fact, because this was felt to represent an increased exposure to medical care on the part of insured patients, comorbid conditions were specifically excluded from the data analysis in this study.

In the end, the authors concluded that

...insurance coverage most likely reflects social environment and the many social determinants of health. Social support networks, coping skills, and similar social factors likely affect outcomes after gunshot trauma..... The health burden of chronic social stress has been well studied and even physiologically quantified,and environmental stress is known to affect the health of young adults.

...Lack of insurance may be a reflection of the social environment and the many social determinants of health. Improving the social environment of patients affected by violent trauma is a potential intervention to improve mortality from gunshot trauma.

What do I think? Meh. Several things strike me at the same time.

It's hard to extrapolate the effect of varied social environments to medical outcomes. In fact, this is one of those areas where well-meaning researchers sometimes reach for non-quantifiable data to come up with answers that probably don't fully satisfy the questions they pose.
When such disparities in outcomes occur following full implementation of ~~Socialist~~ObamaCare, when "everyone will have coverage" --- and the disparities inevitably will occur --- how will we account for those differences?
Maybe the insured patients had caring family members praying for them, and more of the uninsured had support systems consisting of gang members who really didn't care if they made it out of the hospital walking or with a toe tag. This, I suppose, would play into the authors' feeling that social support networks are important; I just don't think we as a society do a good job of fostering this type of behavior.
Nothing good ever happens after midnight, like getting shot. In case you were wondering.

Just a little food for thought.

The OR Rorschach Test, #3

2010-03-31T12:00:00.009-06:00

You know, I get a lot of crazy stares as I walk out of the OR holding big, crinkled sheets of paper covered with brown stains. What, exactly, people ask me, is in the OR that will stain something brown......eewwww! Here's your test for today:

Lots of Betadine on a great big belly; the telltale sign is the "eye" somewhere on the imprint caused by the belly button. Given the amount of time I have spent in my life listening to music, and I pretty much don't regret one second (well, maybe some disco crap my high school girlfriend was into....but, one does what one must), you must forgive me for immediately thinking of Pink Floyd. No, not an acid trip --- the Division Bell album cover:

OK. I admit it. That was a bit obtuse, even for me. I'd be happy to hear other suggestions.

Although it's a bit fuzzy, I think anyone near my age who spent a little time in front of the boob tube on Saturday mornings should think of one and only one cartoon with this OR Rorschach:

Need a hint? Here's a little sound bite to jog your memory.

Woody laughing sound bite

OK. So now you know where my deep well of sarcasm and brooding springs from. In fact, I think Woody Woodpecker (ya think that name would get past the censors today?) is probably the best role model one could have in this Obmamanation --- impertinent, sarcastic, and with a healthy dose of disrespect for authority.

Uno mas for today ---

I'm of two minds here. Perhaps the Chatterer from Hellraiser?

Nah. I'm in a better mood than that today. I'm going with another cartoon character ---

Your answers on this test will be graded. But, with a curve!

"I'd Like To Go Home Today"

2010-02-25T12:27:00.000-07:00

He was a big, burly man with a gruff voice and a temperament to match. His abdomen was a sprawling landscape of scars. And he was sick --- seriously so --- and needed to spend a little time with me in a cold room with hot lights. As is often the case, his surgery and recovery were complicated by chronic anticoagulation, a history of thromboembolism, a little heart disease, and a few other things that in the end caused me more worry than actual problems. Him? He was never worried, never complained, and treated the whole episode as a mere annoyance.

When he was at the point where discharge from the hospital was little more than a mild consideration percolating around my frontal lobes, I talked with him about perhaps staying for one more day to be sure he was ready to go home. I laid out my reasons --- he had just started having good bowel function, his protime wasn't therapeutic, he had enough medical problems to make me a bit nervous, etc. He listened, patiently, and then simply stated "I would really like to go home today. Today is March 4th, and it's my anniversary."

What a cold-hearted bastard I would be if I didn't let him go home for his anniversary! Even so, he had really not fully recovered to the point where I was comfortable with the idea of his going home. Deploying a delaying tactic while I fumbled for a reasonable excuse to keep him hospitalized one more day, I asked "How long have you been married?"

"No," he said, "it's not that kind of anniversary. On March 4, 1973 I landed in the U.S. after 6 years and 6 weeks in a Vietnamese POW camp."

His prescriptions and discharge papers were filled out in record time.

As it turns out, I cared for this retired, decorated Air Force Colonel one more time, when he required abdominal surgery yet again. I did not quibble when he asked to go home a day earlier than my comfort level. He was kind enough to give me a copy of a movie that included his experiences, Return With Honor. Though certainly not forgotten, following his recovery I had not seen the Colonel for several years. His obituary was in the paper this week, and I learned much of what I knew without asking:

Shot down in 1967, suffering vertebral fractures, facial fractures, and blindness in his right eye. Spent 6 years and 6 weeks in the Hoa Lo prison, the "Hanoi Hilton." Flew F-89's, F-101-'s, and F4 Phantoms, but was grounded due to his injuries; he did not retire from the Air Force until 1981. Recipient of the Silver Star, Purple Heart, Legion of Merit, POW Medal, Distinguished Flying Cross, and the Air Medal with Cluster. In short, a hero.

The Colonel was rightfully proud of his service, and his anniversary was something he cherished in a way that I will never know. I hope he has landed safely.

The OR Rorschach Test, part 2

2010-02-22T21:08:00.004-07:00

Here's today's test --- what do you see?

Now, my problem is that just about any of these things tends to make me think of a semi-naked Monica Bellucci, but I'll just have to pony up for therapy to deal with it at some point (that's what the Google Ads are for). A close second? Scarecrow, from Batman Begins:

Any other ideas?

I've had a good life...

2010-02-22T19:33:00.003-07:00

...so, if the end is coming, so be it. John Paul Jones being featured on the front page of the Wall Street Journal is surely a sign the Apocalypse is nigh.

Nudge, nudge

2010-02-21T10:52:00.000-07:00

So...the three stooges are now planning once again to ram through government-run health care. Some are calling them tone deaf. Where I grew up, we'd just call them plain ignorant, completely unable to see that the US populace has not only flatly rejected their ideas, they are now making open sport of them.

Let's check the a few items from big government playbook narrative, and see how accurate it is:

Those evil insurance company profits are immoral....oh, wait, their margin is only about 3.3%, leaving them with a profit ranking of 88 out of 215 industries, well behind the "obscene" profits of cigarette companies, periodical publishers, long distance carriers, and brewers. Heck, your electrical utility has on average double the profit margin as the average health insurance company.
Canada has an exceptional government run health care system....except that Canadians are more than willing to spend their own cash and leave the Great White North to obtain health care. Sometimes, that's the only way they can get it.
But, but, the people really, really want it!.....except that they don't. In more than 30 states , legislators are proceeding to pass statutes or ballot initiatives that would guarantee the right to choose medical services and insurance.

At this point, the big government stooges have all the self absorption and total lack of awareness of others as Eric Idle:

Big Government Stooge : Is your country a....goer, eh? Know what I mean? Know what I mean? Nudge nudge. Nudge nudge. Know what I mean? Say no more...know what I mean?

Average US Joe: I, uh, I beg your pardon?

Big Government Stooge: Your, uh, your country, does she go, eh, does she go, eh?

Average US Joe: (flustered) Well, she sometimes 'goes', yes.

Big Government Stooge: Aaaaaaaah bet she does, I bet she does, say no more, say no more, know whatahmean, nudge nudge?

Average US Joe: (confused) I'm afraid I don't quite follow you.

Big Government Stooge: Follow me. Follow me. That's good, that's good! A nod's as good as a wink to a blind bat!

Average US Joe: Are you, uh,...are you selling something?

Big Government Stooge: SELLING! Very good, very good! Ay? Ay? Ay? (pause) Oooh! Ya wicked Ay! Wicked Ay! Oooh hooh! Say No MORE!

Average US Joe: Well, I, uh....

Big Government Stooge: Is, your uh, is your country a sport, ay?

Average US Joe: Um, she likes sport, yes!

Big Government Stooge: I bet she does, I bet she does!

Average US Joe: As a matter of fact she's very fond of baseball.

Big Government Stooge: 'Oo isn't? Likes games, eh? Knew she would. Likes games, eh? She's been around a bit, been around?

Average US Joe: She has traveled, yes. She's helped free untold millions in the world. (pause)

Big Government Stooge: SAY NO MORE!!

Big Government Stooge: Millions, saynomore, saynomore, saynomore, squire!

Average US Joe: I wasn't going to!

Big Government Stooge: Oh! Well, never mind. Dib dib? Is your uh, is your wife interested in....more bureaucracy, ay? 'Bureaucrats, ay', he asked him knowlingly?

Average US Joe: Bureaucracy?

Big Government Stooge: Snap snap, grin grin, wink wink, nudge nudge, say no more?

Average US Joe: Government expansion into private interactions between US citizens and their doctors, eh?

Big Government Stooge: That could be, that could be what we're talking about. Intrusive, you know, INTRUSIVE bureaucracy?

Average US Joe: No, no I'm afraid we are simply not interested.

Big Government Stooge: Oh. (leeringly) Still, mooooooh, ay? Mwoohohohohoo, ay? Hohohohohoho, ay?

Average US Joe: Look... are you insinuating something?

Big Government Stooge: Oh, no, no, no...yes.

Average US Joe: Well?

Big Government Stooge: Well, you're a man of the world, squire. I mean, you've been around a bit, you know, like, you've, uh.... You've 'done it'....

Average US Joe: What do you mean?

Big Government Stooge: Well, I mean like,....you've RUN, a business...you've MET a payroll...you've STAYED within a budget....

Average US Joe: Yes....

Big Government Stooge: What's it like?

*************************************

How about this, guys -- Nudge, nudge. Wink, wink. Just. Say. No. More!

The OR Rorschach Test, Part 1

2010-02-10T16:17:00.000-07:00

"The abdomen was prepped and draped in the usual sterile fashion." A standard operative note phrase, I've dictated this so often that it spills out of my mouth before I think twice about it. But what does this entail?

Well, it means that the abdomen, or other body part about to see the business end of a scalpel, is exposed and then cleansed with a topical antiseptic agent. The area is then surrounded by sterile towels, and the a large sterile field is created by placing a large drape that covers the patient; the drape contains an opening that frames the ~~playing~~ operative field.

Most of the drapes we use in the US are disposable, allowing us to cut the pre-set opening if needed, and they come with a white piece of paper in that opening that is removed once the drape is in place.

Bear with me. I'm getting to the point.

For years, we have used Betadine® to prep an operative field. Betadine is deep orange-brown in color, and dries slowly. When the white paper of the drape set is placed across the operative field, the wet paint of the Betadine leaves a painting upon it that is unique to each patient.

I like to look at these fresh impressions and try to draw out any image that may be there --- and I am not alone. Anyone that has ever worked in an operating room knows the expression "OR Roschach Test," and just like the real thing, what I see says volumes about the odd way my mind works.

I'd like to share --- what do you see?

Me? I'd say a Lon Chaney, Jr. as The Wolf Man....

...but, then, I spent far too many late nights watching bad movies as an impressionable youth.

How 'bout another?

I'm not much of one for modern art --- my feelings about it are not appropriate for a family discussion. My favorite museums are the Musee d'Orsay and the Kimbell, to give you an idea. However, this gives me an impression of Jackson Pollock working with a bad hangover.

I hate to say it, but the OR Rorschach is a dying art form --- there is reasonable evidence that an alternate prep solution (Chloraprep®) is modestly better than Betadine at decreasing skin bacterial load. Chloraprep is 70% isopropyl alcohol, and therefore very flammable, so it must be completely dry before drapes are placed.....leaving no artwork for us to enjoy. Betadine is still used quite a bit, and will be unless the CDC changes its recommendations. So, I'll have more images to interpret, and so will you when I find time to post.

Office Tours, 25 cents

2010-02-09T14:54:00.004-07:00

It's Tuesday. Which means that everybody in the medical blog world is, appropriately, over at Dr. Leap's place perusing Grand Rounds. I, on the other hand, am slogging away in the office. We surgeons like to call this "baiting the traps." You see, in order to have patients to operate upon, one must first persuade them into the idea that surgery would be good for them. Not quite "here little girl, want some candy?", but something of the sort.

I know some physicians who like to have their patients sit down in the comfy confines of their personal office. One of my closest friends, an oncologist, prefers this as a way to remove patients from the exam room environment to ensure a good discussion of treatment options with patients who are stressed by difficult problems. That has never been my practice, in part because I have a small office and in part because that's not my personality. There may be a third reason, however --- no matter how hard I try to keep up, my office can be a bit of a mess.

Want a tour?

Here it is: Aggravated DocSurg Central Command. I have a great view out my windows, but prefer it a bit darker.

Lest you think that for the past 5 years I have been deceiving you, I did actually graduate from to The Best Medical School in the Country®, but -- here's the diploma to prove it.

Yeah, I have a few other things on the wall --- pictures, certificates, etc. More importantly, I have a futon to crash on.

I try to vote in every election. In 2008, I voted for Pedro.

Words to live by --- Peter's Laws (The Creed of the Sociopathic Obsessive Compulsive).

And more words to live by -- Vocatus atque non vocatus deus aderit. Or, anything in Harold and the Purple Crayon.

There is always an extra pair of Crocs hanging around my office. These, according to SWIMBO, make me look like Barney. I kinda like them --- tacky, yet obnoxious.

One can never have too much Elvis.

Do you marvel at the wondrous future of the paperless medical office, made possible by the unicorn otherwise known as the "Electronic Medical Record?" I do too, but I also used to dream that Raquel Welch would waltz in the door of my 8th grade classroom to take me away to a life of debauchery. Paperless, in the case of our hospital's EMR, is a description for my children's future, as they are going through trees like a squadron of beavers on a bender. This is a one-day pile of output "pushed" to my fax machine, sitting on top of my HIPAA mandated shredder.

The object of my ~~desire~~ derision. And since it is now shrieking at me with the intensity of a Stuka in a steep dive, it's time to wrap up our little tour. Come again ---- and, if you happen to have any decorating suggestions, I would be eternally grateful.

I've been....everywhere

2010-02-03T13:51:00.000-07:00

Where have I been lately? With apologies to the man in black......I've been everywhere.

I was totin' my scalpel along the long hospital road,
When along came a patient with a heavy belly pain load,
"If you're goin' to the OR, Mack, with me you can ride."
And so I called in the crew and sat with time to bide.
He asked me if I'd seen a belly with so much malady.
And I said, "Listen, I've rooted around every part of a broken body!"

(chorus)
I've been everywhere, man.
I've been everywhere, man.
Crossed the liver's bare area, man.
I've breathed pus in the air, man.

I've been to:
Vena cava, pleural space, oral cavity,
Scarpa's fascia, linea alba, duct of Santorini,
Hesselbach's triangle, the point of McBurney,
Ampulla of Vater, Gerota's fascia, round the Vagus,
Right lobe, left lobe, along the esophagus.

(chorus)

I've been to:
Zuckerkandl's organ, Artery of Adamkiewicz,
Triangle of Calot, ligament of Trietz,
Caudate lobe, quadrate lobe, tunica vaginalis,
Denonvilliers' fascia, obturator foramen,
Rectum? Damn near killed 'em!

(chorus)

I've been to:
Drummond's marginal artery, pubic tubercle,
Cremaster, Billroth's cords, seminal vesicle,
Auerbach's plexus, terminal bronchiole,
Cooper's ligament, through the rings of the trachea,
Falciform ligament, See what I mean-a?

(chorus)

In other words, I've been busy.

Are You With Me, Dr. Woo?

2009-11-09T00:50:00.000-07:00

Are you with me Doctor Wu?
Are you really just a shadow of the man that I once knew?
Are you crazy? Are you high? Or just an ordinary guy?
Have you done all you can do?
Are you with me Doctor?
....
Are you with me Doctor Wu?
Are you really just a shadow of the man that I once knew?
She is lovely - yes she's sly - and you're an ordinary guy
Has she finally got to you?
Can you hear me Doctor?

Great song. Gotta love a band named for a huge metal, er, "marital aid." And, just because I can, I'll take some spelling liberties with Dr. Wu for this post.

*****************************

I missed out on the big medical blogger convocation in Las Vegas a few weeks ago. No disrespect, but.....I got a better offer. From SWIMBO. She offered to let me take her to Santa Fe for a few days, and well, a few days of relaxation, wine, and good food with my wife sounded better than casinos and meeting halls.

The weather was spectacular, the town (as always) charming and interesting, and the food was fabulous (especially the Coyote Cafe and The Compound). But in Santa Fe, there is always a side show --- a collection of woo providers that would make Orac's head spin. Acupuncture, iron cleanse detox footbaths, BodyTalk Systems, Myers cocktails, Prolotherapy, Raindrop Technique®, resonance repatterning, colon hydrotherapy, quantum stilus, Reiki, blood chemistry analysis, doctors of Oriental medicine, ....... all taking themselves with a degree of seriousness usually seen only in Wall Street bankers investing their own money. Forget Orac, my head was spinning.

Who are these ~~con-men~~ practitioners? They have such fabulous titles!

Reiki Master Practitioner & Teacher, Movement facilitator, Body worker, Visionary, Intuitive Spiritual Coach and Healer
Doctor of Oriental Medicine
Chiropractor, BodyTalk Practitioner, Yoga Therapist
Certified in Family Medicine and Integrative Holistic Medicine
Reflexologist
Yellow Moon Readings & Gentle Healing Bodywork
Energy Medicine
Brain Dynamics
Prosperity Coach, Resonance Repatterning, Deeply Nourishing Energy Healing
Ceremonial Song Circles
Sacred Shamanic Healing
Holistic Financial Planning "When more than money matters"
ThetaHealing Instructor and Practitioner
Biological Dentist

Driving around town, it struck me that at the time, the US Congress was considering a sweeping change in the way we provide medical care in this country. I think anyone that reads this blog knows where I stand on this, so I won't belabor the point. But it is interesting that the parking lots of these ~~shysters~~ practitioners were uniformly filled with cars festooned with Obama stickers. This begs a few questions:

Are these folks spending their hard-earned cash on quackery instead of health insurance or evidence-based medical care? Do they expect that hard working Americans elsewhere feel a strong desire to be taxed to help them continue this type of behavior? And are they hoping --- actually, expecting --- that these types of "therapies" will be covered by the train wreck known as Obamacare?

The answers, in order, would appear to be Yes, Yes, and, You Betcha! As far as the last question is concerned, this type of language is just the beginning of an blitzkrieg against a century of progressively improving medical care that would make Erwin Rommel proud ---

Section 125. PROHIBITION OF DISCRIMINATION IN HEALTH CARE SERVICES BASED ON RELIGIOUS OR SPIRITUAL CONTENT.
Neither the Commissioner nor any health insurance issuer offering health insurance coverage through the Exchange shall discriminate in approving or covering a health care service on the basis of its religious or spiritual content if expenditures for such a health care service are allowable as a deduction under 213(d) of the Internal Revenue Code of 1986, as in effect on January 1, 2009.

For those of you who were absolutely certain that the government would only be covering care that is "evidence-based," the joke's on you. The only thing that is certain is that the government is planning to decrease healthcare spending by rationing access to costly care. Seeing a ThetaHealing Instructor or Practitioner or Integrative Holistic Medicine Practitioner is cheap in comparison to an oncologist or cardiac surgeon!

You know how all of those helpful websites, books, and daytime TV talk show hosts recommend that you write down all of your questions before seeing a physician. With the help of Steely Dan, here are a few you may need to keep in mind in the future:

Are you with me Doctor Woo?
Are you really just a shadow of the doctor that I once ~~knew~~ used to see?
Are you crazy? Are you high? Or just an ordinary guy (with no medical degree except one that came from a online training course)?
Have you done all you can do? I mean, wouldn't it be a good idea for my "blood analysis" to be done by, oh, I don't know, a freaking pathologist?!!
Are you with me Doctor? Because it seems to me that the touch therapy, Reiki, and colon hydrotherapy you prescribed really have nothing to do with my fill in the blank diabetes/hypertension/melanoma/etc.

I choose to ignore the woo, and those that keep trying to ram it down our throats in the name of "inclusiveness" in health care -- and I'll stick with the words of an interesting man who wrote a few thought-provoking books a few decades ago.

"We have now sunk to a depth where the restatement of the obvious is the duty of intelligent men"
- George Orwell.

Bastards

2009-10-30T12:57:00.004-06:00

There can be no simpler example of why the new healthcare "reform" bill has nothing to do with reform whatsoever than this :

...Pelosi’s bill has an anti-tort-reform measure. On pages 1431-1433 of the 1990 spellbinder, there is a financial incentive for states to try “alternative medical liability laws.” But look — you don’t get the incentive if you have a law that would “limit attorneys’ fees or impose caps on damages.” That’s what the trial lawyers get for the millions spent in supporting the Democratic party, and that’s what tort “reform” in the Alice-in-Wonderland world of health-care legislation amounts to. States will be strong-armed into repealing existing caps in order to get the Fed’s money. Sweet, huh? Well, unless you thought the aim was to reduce medical costs. No, this will go a long way toward ensuring that tort lawyers remain rich, malpractice insurance remains high, and unnecessary defensive medicine remains a fixture of the health-care system.

Read it for yourself. As I have said before, Obamacare Delenda Est. These are unscrupulous, dishonorable people bent on controlling every aspect of your lives in order to maintain their power and positions. I am afraid I don't have enough control to add anything short of a very long stream of expletives. Disgusting.

The Sickth Sense

2009-10-30T11:54:00.001-06:00

Every once in a while, I run across an old friend or meet someone new, and after they compliment me on marrying well above my pay grade, the conversation turns to work. "What type of doctor are you" is a very frequent question, and I admit I don't have an answer that is terribly complete and accurate. "I'm a general surgeon," I usually say, adding "that is a very nonspecific name for what I do." Because I have much difficulty describing my profession, I usually throw out a laundry list of things that may cause a patient to come see me --- colon cancer, thyroid mass, gallstones, hernia, stabbing, car crash, etc. It is sometimes easier for me to describe one part of what I do, rather than the whole chalupa. So, here's a little bit of what I do for a living:

I see (near)dead people.

When on call, the types of not so sick, ill, very ill, or desperately sick patients I may be asked to see may include

a person having an acute myocardial infarction who has severe belly pain
a young lady 3 weeks postpartum with gallstone pancreatitis
a previously healthy lady 3 days postop from a difficult hysterectomy, tachycardic, tachypneic, with peritonitis and a plummeting white blood cell count
one of my own patients with severe shortness of breath a few days out from an uncomplicated colon resection
an elderly gentleman with a small bowel obstruction
an elderly lady 4 days out from a total hip replacement with Ogilvie's syndrome
a patient on a ventilator with sepsis from pneumonia who may or may not have an intraabdominal catastrophe
a patient pancytopenic from chemotherapy with a GI bleed
a middle aged person involved in a high speed MVA, white as a ghost and with a blood pressure approaching levels seen in invertebrates
the passenger in the same MVA who is hemodynamically stable but complaining of back pain and tingling in their toes
a patient on chronic narcotics complaining of abdominal pain well out of proportion to their examination
a patient with severe Clostridium difficile colitis and diarrhea with a WBC count in the 20s

Which of these patients needs surgery now? Later? At all? Who needs a CT, an angiogram, transfer to the ICU, an endoscopic evaluation? Who is at risk to die in the immediate future if surgery is delayed? Who has a high risk of death if taken to the operating room? And, who are you gonna call to make those decisions? Me, or somebody like me.

So, what do I do in these situations? Once again, there is not a simple explanation. Obviously, the patient has to be seen and all available information reviewed --- history, labs, imaging studies, etc. But I suppose that there is also a difficult to define aspect to evaluating these types of patients, which is not tangible or quantifiable. It is the need to see a patient and relatively quickly determine "how sick" they are.

Call it a 6th sense -- or Sickth Sense -- if you like.

Am I an expert at this, a true Clever Hans of the hospital? Oh, not in the least. But I am better at this now than I was, say, 15 years ago when I started practice. No doubt, this is a skill that hopefully I have honed a bit over the years. Medical problems in surgical patients such as a postoperative MI, pulmonary embolism, aspiration pneumonia, etc. require careful evaluation and care, but most of the time can be distinguished from acute surgical emergencies.

Am I always right? Not to sound Clintonesque, but that sort of depends on what your definition of "right" is. Let me give you an example. Let's say that the elderly gentleman with a bowel obstruction also has chronic lymphocytic leukemia, making his WBC count unreliable in determining acute illness. And let's say his abdominal exam is questionable, and he's a bit more tender than I'd like to see. And let's also say that he states he's miserable, hasn't felt this bad ever in his life, and can't get comfortable. With this scenario, a trip to the OR is very reasonable --- pain out of proportion to his exam can indicate that some of his small intestine may not be viable at this point. But let's say a simple bowel obstruction was found and corrected, and all of his bowel was healthy, and even that perhaps with time the obstruction would have resolved without surgery. Was his surgery necessary? Was it the "right" decision to go to the OR?

Yes! And, perhaps, no. If such a patient were to suffer a postoperative complication, such as a wound infection, pneumonia, or MI, then we tend to second guess ourselves. Our "sickth sense" is not infallible, and it is often much more difficult to not take someone to the OR than it is to go ahead. An old surgical aphorism that describes this impetus is

Never let the skin get between you and a diagnosis.

About as subtle as a rocket launcher, that one. I prefer to look upon these situations as comparative ones --- what is the worst thing that could happen if we take this patient to the OR versus what is the worst thing that could happen if we don't? Most of the time, we have to come down in favor of surgery, as patients with intraabdominal disasters don't tend to do well when watched.

In short, if I am going to be wrong, I'd rather it be a "sin of commission" rather than a "sin of omission."

I'll freely admit it, I have sinned plenty in this way. But have mercy and please cast no stones at this poor sinner. After all, I'm already spending plenty of time in atonement in the hospital's equivalent of purgatory ---- the Emergency Department.

How Doctors Think? Oh, my...

2009-10-07T21:45:00.005-06:00

Call me a nonconformist -- everybody else does. Yeah, I was the guy with long hair and a ZZ Top beard in college during the height of the "preppy" era. I even went so far as to sew an Izod alligator onto my flip flops just to be annoying. I suppose I haven't really changed. That's why I don't have a whole lotta use for books that paint physicians (or any group, for that matter) with a brush as wide as a '57 Caddy. How Doctors Think, for example, really is more a collection of one man's opinions (like this blog) than a complete investigation into what goes into everyday issues that make us doctors tick. Don't get me started on this guy, either, whose deeply flawed study on checklists in the OR has unfortunately been adopted as Gospel without being objectively repeated and verified.

So, how exactly do I think, you may ask. The stream of consciousness in my head that passes for rational thought is populated by all of those doctors that influenced me along the way --- their images and words just fly by so fast at times I have a hard time keeping up. Here's a little preview of a typical day for me.....

Me, pissed off that we are yet again not starting on time in the OR.

Ma'am, we are surgeons and we are here to operate. We're just waiting for a starting time. That's all.

Me, talking to an administrator.

You're hiding... hiding behind rules and regulations. ...Logic? My God, the man's talking about logic; we're talking about universal Armageddon! You green-blooded, inhuman...

Me, seeing someone who presents a difficult diagnostic dilemma.

I think we may go mad if we think about all that.

Me, irritated at one of my more senior partners showing up late.

Someone get that dirty old man out of this operating theater.

Me, when audible bleeding is found in a trauma patient.

Work faster, Doctor!

Me, irritated at the patient who assumes that I take every Wednesday afternoon off to golf.

Oooh, cutie pie, eh?

Me, at 2:12AM, explaining for the 4,693rd time to the same night shift RN that, yes, this truly is an emergency and I need to get this patient to the OR right now.

Look, mother, I want to go to work in one hour. We are the Pros from Dover and we figure to crack this kid's chest and get out to golf course before it gets dark. So you go find the gas-passer and you have him pre-medicate this patient. Then bring me the latest pictures on him. The ones we saw must be 48 hours old by now. Then call the kitchen and have them rustle us up some lunch.

Me, beating myself up while waiting on a CT to see if I may have missed a diagnosis, second guessing myself over a possible error in judgment, or while I'm just plain worried about a patient.

You bubble-headed booby! You realize what you've done?!

Me, finding an abdomen full of stool from perforated diverticulitis.

You put me right off my fresh fried lobster, do you realize that? I'm now going to go back to my bed, I'm going to put away the best part of a bottle of scotch...

Me, talking to myself when I'm getting ready to start a case.

With a knife in your hands?

Me, trying to be patient when I have a full day of complicated cases lined up and a new scrub tech student in the room.

And then give me at least ONE nurse who knows how
to work in close without getting her tits in my way.

Me, seeing a drunk and abusive idiot just brought to the ED after his third MVA in as many months.

Oh, a wise guy, eh, I gotta good mind to hand you a ticket. Where's your driver's license?

Me, cautiously entering a no mans land of inflammation and adhesions in a multiply operated upon belly.

Is it safe?... Is it safe?

Me, meeting with the hospital CFO.

Silence, you ninny.

Me, scalpel in hand, ready to get to work.

Nurse: Everything''s ready.
Moe: We''ll make an incision like this.
Curly: No, we''ll make an insertion like that.
Larry: No, we''ll make an excursion like this.
All Three: Tic-tac-toe!

Me, hoping for a break from taking trauma call.

There's a CATCH...Sure. Catch-22. Anyone who wants to get out of combat isn't really crazy, so I can't ground him.

Me, getting some insight on how best to proceed in a difficult case

Sir! I have a plan!

Me, exasperated with some supercilious JCAHO reviewer.

Laugh-a while you can, monkey-boy!

Me, to my partner, trying to break the tension in a difficult case.

If this guy knew the clowns who were operating on him, I think he'd faint.

Me, dragging my ass out of bed at 5AM to make rounds before the 7AM meeting that precedes the 8AM start of a full OR day.

Now come along with me, you ludicrous lump, there's much to be done!

Me, wondering yet again if I made the right career choice.

I been in the right place
But it must have been the wrong time
I'd of said the right thing
But I must have used the wrong line
I been in the right trip
But I must have used the wrong car
My head was in a bad place
And I'm wondering what it's good for

Me, with my end-of-the-day martini.

Wonderful stuff, that Romulan Ale...I only use it for medicinal purposes.

Me, when asked if I'd like a refill on said martini.

Soitenly!

For those of you too young to know, these are direct quotes from (in order) Hawkeye Pierce in M*A*S*H, Dr. McCoy in Star Trek, Dr. Zhivago, Hawkeye Pierce, Dr. Phibes, the Three Stooges, Trapper John in M*A*S*H, Dr. Smith in Lost in Space, Hawkeye Pierce, Dr. Phibes, Trapper John, the Three Stooges, Dr. Szell in Marathon Man, Dr. Smith, the Three Stooges, Dr. Daneeka in Catch 22, Dr. Strangelove, Dr. Emilio Lizardo in Buckaroo Banzai, Trapper John, Dr. Smith, Dr. John, Dr. McCoy, and the Stooges.

Calling for Reinforcements

2009-10-03T13:15:00.000-06:00

Bluebonnets, dogwoods, and azaleas are just about the only thing I miss about Texas. Good Tex-Mex too --- I do love good fajitas and a cold margarita or two. Now, where I come from there is only one way to make fajitas, and that involves using skirt steak. I don't want to make you cough up your milk, but that means properly prepared steak fajitas are made with grilled marinated strips of a cow's diaphragm.

The human diaphragm, if I may say so, are one of God's neat little tricks. It's a tough, broad sheet of muscle, modest in thickness, that acts both as a barrier between the abdominal and thoracic cavities, but also as a vacuum assist device for breathing. When you take a deep breath, the chest wall and abdominal muscles expand the chest cavity, and the diaphragm moves outward and downward, drawing air into the lungs. It's also a favorite subject for pimping medical students --- what water fowl cross the diaphragm?

The thoracic "duck" (duct)
The "azygoose" (azygous vein"
The "vagoose" (vagus nerve)
The "esophagoose" (esophagus)

Each of these structures, as well as the aorta and inferior vena cava, passes through an opening in the diaphragm; occasionally, one of those openings is larger than it should be. The opening through which the esophagus passes, called the esophageal hiatus, is sometimes large enough to cause a few problems, and when it is so it is termed a hiatal hernia. Without getting into too much detail, a hiatal hernia needs to be surgically addressed when we are performing antireflux surgery for GERD or when there is a large paraesophageal hernia.

OK, you say, no biggie. Just put a few stitches in it and close it up! Well, it can't be completely closed, or the esophagus gets tied off in the process. No Big Macs for you! But there is another problem. If you look at the image to the right displaying the undersurface of the diaphragm (from the online version of Gray's Anatomy), you will see a whole bunch of red, and not a lot of white. Compare that to the illustration on the left, which is an oblique view of the abdominal wall; in the mid-portion of the abdomen there is a sea of white.

The white areas represent muscle that is covered by a nice, tough layer of fascia --- that is the stuff we sew together when closing the abdomen, the good stuff that will hold sutures. The red areas represent muscle without much fascial covering, which hold sutures about as well as a cup of water. We have an expression for this --- "sewing flatus to a moonbeam" --- and an expectation that the closure won't hold up well. There is minimal fascia at the hiatus, so as a result, hiatal closures don't tend to hold up well in the long run.

Over the past few years, some enterprising souls have taken note of the good experience we have with augmenting hernia repairs with mesh (usually polypropylene) and have placed mesh overlying the hiatal closure. Initial results have been quite good, with a significant reduction in repair failures. However, I have always been reluctant to consider this option --- we have years of evidence that leaving mesh exposed to the GI tract is in general a bad thing, as it can densely adhere to bowel and even erode into it. And having chip-chip-chipped away at a few Angelchik devices that have eroded into the esophagus, I'm not eager to do the same with material that will create a significant inflammatory response.

Hah! I have been shown to be prescient once again. Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series is an article published in the June edition of Surgical Endoscopy. The authors cobbled together their collective experiences with mesh complications at the hiatus and published them:

Twenty-six patients underwent laparoscopic and two patients open surgery for large hiatal hernia (n = 28). Twenty-five patients had a concomitant Nissen fundoplication, two a Toupet fundoplication, and one a Watson fundoplication. Mesh types placed were polypropylene (n = 8), polytetrafluoroethylene (PTFE) (n = 12), biological mesh (n = 7), and dual mesh (n = 1). .... Main reoperative findings were intraluminal mesh erosion (n = 17), esophageal stenosis (n = 6), and dense fibrosis (n = 5). Six patients required esophagectomy, two patients had partial gastrectomy, and 1 patient had total gastrectomy. Five patients did not require surgery. In this group one patient had mesh removal by endoscopy. There was no immediate postoperative mortality, however one patient has severe gastroparesis and five patients are dependent on tube feeding. .... There is no apparent relationship between mesh type and configuration with the complications encountered.

Now, I'd like to say a few things about this study. First of all, thank you. Thank you to the authors who published results that call into question a practice that has gradually become a bit more common, calling for some caution and for a multicenter prospective study. Secondly, while the names on the list of authors may not mean much to you, they represent a large cross-section of the most respected surgeons in this field, including the "godfather" of gastroesophageal junction surgery. Two I know personally, and I know that they are extremely honest in their reporting. So this is not a collection of complications from a bunch of fly-by-night yahoos, but folks who do and study these operations extensively --- i.e., when they were doing this, they had good reason to expect it would work, and work well. Lastly, it was interesting to me that certain types of mesh that are specifically touted as being better to use in this area --- PTFE (Gortex) and biological mesh (denatured tissues of a variety of types, which allow ingrowth of natural collagen) were found to have the same risk of complications as old-fashioned polypropylene.

So, what to do? I agree with the authors when they call for a prospective multicenter trial, but it is important to recognize that when this type of complication occurs, it can be pretty devastating for the patient. And I suppose that more surgeons will be a bit reluctant to use mesh for hiatal closure unless there is no alternative, even though we use them extensively (safely) elsewhere.

Hic Sunt Dracones

2009-09-30T18:04:00.000-06:00

The New York Public Library houses a cool historical curiosity, the Hunt-Lenox Globe, which according to Wikipedia is the second or third oldest terrestrial globe still in existence. And, popular myth aside, it is also the only historical map that contains the phrase "Hic Sunt Dracones," or "here be dragons" (the Carta Marina to the left, while it contains dragons, doesn't identify them in the same way) That's a phrase I am drawn to frequently when delving into hostile abdominal territory --- patients who have an abdominal catastrophe, huge pancreatic phlegmons, or a dense thicket of adhesions from prior surgery. These are cases where we tread carefully, and quietly, trying to avoid awakening a slumbering beast.

Surgical dragons, however, aren't always found in dangerous or unfriendly regions. The "routine" operation is populated with enough fire breathing demons to make St. George wince. It is the surgeon's job to perform the "routine" operation with the same care and wariness as he would the more complicated one, or he risks falling into the dragon's lair and dragging his patient with him. Such is the case with laparoscopic cholecystectomy, which is bedeviled with a small but definable risk of bile duct injury, estimated at somewhere between 0.2 t0 0.5% (about one in 200 patients to one in 400), compared to a risk of about 0.1-0.2% for open cholecystectomy. Because cholecystectomy is such a common operation, while the risk for this complication are quite small, it is seen not infrequently. Hence quite a bit of research has gone into trying to figure out why it occurs and what we can do to minimize the incidence of common bile duct injury with laparoscopic cholecystectomy. The amount of ink poured out discussing this problem could easily fill a large reservoir.

The most recent interesting article I have read about this subject comes from the Surgical Outcomes Research Center at the University of Washington, published in the Journal of the American College of Surgeons -- "Risk Tolerance and Bile Duct Injury: Surgeon Characteristics, Risk-Taking Preference, and Common Bile Duct Injuries." The article reports on a survey sent to a random selection of 4,100 general surgeons in the ACS database. The authors received about 1,400 valid responses; in addition to what would be considered typical questions (Have you had a common bile duct injury in your practice? What do you think was the cause? How was it repaired? etc.), an interesting additional set of questions were asked:

I enjoy taking risks
I try to avoid situations with uncertain outcomes.
Taking risks does not bother me if the gains involved are high.
I consider security an important element in every aspect of my life.
People have told me that I seem to enjoy taking chances.
I rarely take risks when there is another alternative.

This method of assessing one's level of risk taking (or aversion) has been used in several studies; for example, one study demonstrated that the degree of an ED's risk-taking or risk-aversion correlated with admission rates for patients presenting with chest pain. So, the question is, does this study show a trend towards a higher rate of common bile duct injury with laparoscopic cholecystectomy depending on a surgeon's risk tolerance?

Er, well, not exactly. The authors concluded that "we did not find any substantial differences based on low-, moderate-, and high-risk categories." But, to justify the title of the article, they did feel that there was a trend in this direction...."Compared with surgeons in the lowest three deciles of risk score, relative risk for CBDI among surgeons in the upper three deciles was 17% greater (p = 0.07)."

Sorry. I'm not buying this or the Brooklyn Bridge. I think that this study is yet another example of authors trying to prop up an idea without solid data that proves their point. I have a few nits to pick with this one, such as:

When you mail out 4,100 surveys, and get back only 1,412 that are usable for your study, I'd say that you may have a bit of a selection bias.
Who is more likely to respond to this kind of survey? The surgeon who has had a CBD injury? Or the surgeon who has not? (I really don't know).
Who is more likely to respond to this kind of survey, the very busy surgeon who may have a boatload of experience but not a whole lotta time or patience for filling out surveys, or the less busy surgeon? (This one I know the answer to. You may guess if you like.)
Risk taking behavior may vary rather considerably from one's clinical practice to one's private life. I know more than a few unbelievably careful and conservative neurosurgeons who ride motorcycles. Without helmets. Fast.

Maybe I'm just not into that whole touchy-feely, psychobabble part of medicine. Blame it on a bad experience in college psychology (waste of time extraordinaire) and a worse experience in medical school psychiatry (AKA, my time in Purgatory). I prefer cold, hard facts and think that solutions to thorny medical problems lies in dealing with those facts directly. In the case of common bile duct injury with laparoscopic cholecystectomy the facts are that

It happens, once again somewhere between 0.2-0.7% of the time
The incidence has not dropped in the past decade, as many had predicted
There are a few techniques that when utilized routinely can help to minimize (N.B, not eliminate) this risk
The average general surgeon in this country will have this complication once in his or her career

When I was doing a little reading and thinking for this post, I thought it would be interesting to do a Google search on the incidence of CBD injury in laparoscopic cholecystectomy. Unlike the last time I performed this search, there were more medical journal articles than lawyer sites. That's a good thing, IMHO, and may reflect a gradual maturation in the way that this known, rare complication is seen --- not as always reflecting malpractice, but as something that can and will happen with a certain, small degree of frequency. Indeed, one legal site even describes the routine steps we use to minimize the risk of CBD injury. Now that we have had a two decade experience with laparoscopic cholecystectomy in this country, I agree with a recent editorial by Dr. Josef Fischer from Harvard -- injury to the common duct during laparoscopic cholecystectomy is not a result of practice below the standard, but an inherent risk of the operation. This injury needs to be emphasized by the surgical community as an inherent risk of the operation, and patients should be fully informed of this potential complication.

Hic sunt dracones --- here, I like to say when doing a cholecystectomy, be dragons. This part of the body is expensive real estate, the seat of the soul, a slippery precipice. But even the best sailors have been lost at sea, even Donald Trump has had a real estate venture go south, even Rob Hall fell to his death on Everest. And at some point, the dragon known as a common bile duct injury may breathe fire on even the best surgeon around.

New Neighbors!

2009-09-30T10:26:00.005-06:00

We had a few visitors the other day . With apologies to Mr. Fogerty,

Doo, doo, doo, lookin' out my front door

Needless to say, DogSurg was less than pleased, and he had to take an extra-long nap after 3 hours of solid barking.

The Not-So-Accidental Tourist

2009-09-22T15:30:00.000-06:00

Should surgeons treat the complications of medical tourism? Today, that's not purely a hypothetical question, as some patients seek out lower-cost alternatives for elective surgical care (something I wrote about a while back). It is also a question posed at last year's clinical congress of the American College of Surgeons in a "point/counterpoint" debate. The surgeons chosen to address the topic are well respected academicians -- Dr. Karen Deveny from the Oregon Health and Science University, and Dr. Ira Kodner from Washington University in St. Louis. The scenario presented was :

A 53 year old man visits an American orthopedic surgeon 10 weeks ago after undergoing a total knee replacement in Thailand. He's had pain and erythema for 1 week, and a physical exam indicates probable cellulitis. Is it the surgeon's responsibility to treat this patient?

Their responses, the complete text of which are here, are thoughtful. Me? Meh, I'm not always so thoughtful, but I do (as always) have a few opinions of my own.

Dr. Deveney took the "absolutely, treat and ask no questions" approach. Her response can be boiled down to one sentence -- "Of course, it is the orthopedic surgeon's responsibility to provide medical care to the patient, as that is the ethical high ground." Hard to ague with that. This patient has at a minimum a mild infection, and possibly a more severe underlying infected hunk of hardware that may need to be removed, and this is not a simple matter.

Dr. Kodner's response, on the other hand, is one that is in tune with time-honored principles of interactions with patients -- "Treating this patient would corrupt the doctor-patient relationship. That relationship requires trust, which would be hard to achieve in this situation because the patient has already decided that the system in the United States couldn't meet his needs." Plus, this is a very complicated problem, one which may require multiple operations and may lead to an unsatisfactory outcome (here's a good description).

Who is right? In the end, they both are. There is no question in my mind that should a patient with a similar problem ended up in the ED when Dr. Kodner was on call, he would care for that patient. That is what we are supposed to do -- care for patients in need, even when the patient has made what appears to me to be a boneheaded decision. But in my business, I routinely care for folks who make boneheaded decisions --- driving drunk, getting into a brawl in a nightclub, having a smoke while working on a carburetor.

When a patient leaves the US, which has the highest standards of care in the world, and chooses to have an elective operation outside of the country, one presumes he is doing so with a great deal of forethought. I think that is why most surgeons would feel just like Dr. Kodner --- in choosing to go out of the country for care, the medical tourist patient is viewed as specifically rejecting the care and physicians available here. Hey, we're human; this feels like a bit of an insult. Gee, if I am not good enough to care for a patient in the most optimal, elective situation, why am I good enough when things are going downhill faster than Michael Moore riding a greased sled in the Himalayas?

Unfortunately, I have been put into this exact predicament on two occasions. I had absolutely no records available for review, no ability to speak with the original surgeon, and no clear idea of what was done to their innards until I was there trying to sort out their anatomy. It was painful and frustrating, and certainly my "pucker factor" in worrying about being sued was off the charts. My worry is one that is shared by Dr. Kodner, who noted that in the hypothetical situation,

...the foreign hospital and the foreign physician will probably be out of the picture if there is a lawsuit. The orthopedic surgeon will be taking the full risk.

Dr. Deveney references this concern curiously, stating that

...a successful lawsuit is not at all likely as long as the surgeon documents the facts in the case and treats the patients with respect.

Hmm. If I am understand her correctly, I shouldn't worry because though I may be sued, it is unlikely that I will be sued successfully in this situation. Wow! I'm reassured already! Put the Rolaids away!

Perhaps this is simply a situation in which I am hopelessly behind the times. If I am nothing else, I am very old-fashioned in my approach to the way physicians should interact with patients and each other. However, it is hard to go wrong with the premise that a surgeon assumes significant responsibility for a patient once an incision is made. Rather than discussing what we should do when a patient shows up with a complication of a medical tourism excursion, we should focus on educating patients what such a trip may lead to. As Dr. Kodner puts it,

Once you have seen a patient, you have assumed responsibility and have entered into a physician-patient relationship. This includes the responsibility of finding another surgeon if you eventually want out. Once you start, you can't abandon the patient. Don't start!

Medical tourism is a clever business model, but let's be honest --- it is a business model, not a complete patient care model. As the eloquent Sir Robert Hutchison stated,

It is unnecessary - perhaps dangerous - in medicine to be too clever.

The Gates of Fatherhood for a Surgeon

2009-08-06T16:17:00.001-06:00

It sits on the terasse Rodin in the magnificent Musee d'Orsay. Huge, imposing, eerie and beautiful. Not simply a single sculpture, Porte de l'Enfer is a collection of large and small pieces thrown together in a multi-car pileup of literature, art, vision, and passion. (A very thorough view is here --gigapan)

I saw it for the first time in 1984 at the Dallas Museum of Art, where a bronze casting was placed on the sidewalk as an imposing reminder of what Dante's Inferno has in store for us. It was visually arresting, but not something I really had a handle on.

By the time I was next up close and personal to the Gates of Hell, I had the advantage of having read a little bit, both about Rodin and Dante. Staring at the huge hunk of plaster in the Musee d'Orsay in 1992, it had more meaning to me, and there was a depth to the piece of work that I did not appreciate before. The Thinker, sitting atop the gates, which had previously been a stand-alone sculpture in my mind, could represent any number of people --- is it Adam? Rodin himself? Satan, patiently waiting like a summer camp counselor for a new crop of kids dropped off by their parents?

Older now, bearing the experiences that a graying man will inexorably collect like dust bunnies in an empty house, I think I appreciate the intricacies, the stories, the humanity and inhumanity on display in the Gates of Hell. In other words, the knowledge I sought out and the personal experiences I own have allowed me to gain a better understanding of a complex piece of artwork.

This is hardly a new revelation --- the process of education is essentially built upon it. We rely on older and more experienced folks to teach us what they have learned, and the best teachers are those who have gained a deeper understanding of their subject over time. Yes, Father Bayhi, thirty years on I finally get it, and all of that Roman history you threw in during Latin class did sink in.

In a few weeks, the second of my children will traipse off to college, joining her sister. I couldn't be more proud, more excited, or in some respects more depressed and afraid. I have spent the last 21 years working on one side or the other of the Gates of Hell, sometimes acting as Virgil giving a grand tour of Dante's Inferno to those who will make it back to the land of the living, sometimes relegated to the role of Charon providing a final ferryboat ride. While at times this is exhilarating, it is also exhausting and emotionally taxing, and I fear that my daughters will be entering their college years with a view of me that is, well, less than cheerful. Will they see me as The Thinker, silently contemplating the unthinkable that inhabits the Gates which I cross so frequently? I certainly pray that will not be the case.

I hope instead that they will see a little bit of me in another Rodin sculpture --- that of Orpheus, known to the Greeks as the inventor of medicine and writing, as well as chief among poets and musicians.....I hope that I have been able to pass along a love for music and reading, and that maybe I know a thing or two about taking care of folks. In short, I hope that they see me as someone who still has something to offer as they mature.

As for how they think of SWIMBO and I, well, I'll once again hope they refer to Mr. Rodin:

ὕβρις

2009-07-31T09:55:00.007-06:00

Buffoonery is generally easy to spot -- it's just that when it is the "emperor" making an ass of himself, few will call attention to the fact that he has no "clothes," or more specifically, no clue. I view buffoonery as a form of hubris (ὕβρις) begging for ridicule. From one of my favorite movies:

Emperor Joseph II: Your work is ingenious. It's quality work. And there are simply too many notes, that's all. Just cut a few and it will be perfect.

Mozart: Which few did you have in mind, Majesty?

Without a doubt, that is my favorite line of an outstanding film, and it makes me giggle even now. Present day buffoonery, however, gives me heartburn --- though "Gates-gate" has gotten more press attention, the following is no less egregious:

"Right now, doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there. ... The doctor may look at the reimbursement system and say to himself, 'You know what? I make a lot more money if I take this kid's tonsils out.'"

Like I said, buffoonery. Which few tonsils did you have in mind for us to leave in, ~~Majesty~~ Mr. Obama?

Because there is always a deep well from which to draw upon in le cinema,

"Fat, drunk and stupid is no way to go through life, son."

Perhaps it is time for the people of this country to borrow a line from Dean Wormer to say the "emperor has no clothes:"

Arrogant, ill-informed, and condescending is no way to lead the country, sir.

~~Carthago~~ Obamacare delenda est.

Rosetta Stone, Medical Edition

2009-07-22T19:22:00.007-06:00

It's summertime, summertime Sum-sum-summertime Summertime, summertime Sum-sum-summertime Summertime, summertime Sum-sum-summertime Summertime, summertime Sum-sum-summertime Summerti-i-me ......

(Feller and Jameson, The Jamies 1958)

Yeah. Summertime. I love it here in the Rockies. Unfortunately, so do a whole lotta folks who take summertime activities in directions God never intended. Which means sum-sum-summertime is a busy one for those of us who treat trauma victims --- motorcyclists riding without helmets, mountain bikers going "endo," and toxic mixtures of ethanol, testosterone, and high-horsepower vehicles keep us hopping. Our group has lost two members this year, meaning that this summer is busier than most for me. Which means, in the end, no sum-sum-summertime blogging lately.

Time to make amends. Let's chat a bit about electronic medical records. Really! It will be fun! Exciting! A real waste of your next 4 minutes!

A wide policy net was cast in January by the federal government regarding the potential for physicians and to get some of the "stimulus" money as (partial) reimbursement for purchasing EHR systems. The kicker came with the phrase "meaningful use" --- in other words, physicians would have to demonstrate that they were using their EHR to a meaningful extent in order to be eligible to receive funds. What, exactly, does "meaningful use" mean?

Some framework was put into place in mid-June when the meaningful use workgroup of the HIT Policy Committee released its initial recommendations for a definition of "meaningful use" of electronic health records. 22 specific objectives for EHRs to be qualified by 2011, including:

Allow patients to access clinical information;
Comply with state and federal privacy, security and data sharing regulations;
Document patient progress and provide clinical summaries;
Exchange critical information with other care providers;
Implement drug interaction safeguards;
Send patient reminders about follow-up and preventive care;
Submit immunization and laboratory data to relevant public health registries; and
Use computerized physician order entry systems to transmit prescriptions.

What is not included is the implicit understanding that all clinical information will eventually be part of a government database, as part of the Take Over The Universe Healthcare Act of 2009, but that's a discussion for another day. But I was drawn to the first item on this list:

Allow patients to access clinical information

On the face of it, this is a reasonable proposal. Patients should have access to their medical records. But how many of them will be able to interpret those records?

I'll give an example; this is not a real patient, but is similar to many folks that I see.

59 year old lady
History of stage I left breast cancer, treated with breast conservation therapy
HTN, on Altace
Mild glucose intolerance
Family history of breast cancer, hypertension, diabetes and diabetes-related renal failure
Status post cholecystectomy, TAH/BSO, and appendectomy
Normal screening colonoscopy 18 months ago
Referred to surgeon by nurse practitioner in gynecologist's office for evaluation of an abnormal mammogram. The mammogram reads "indeterminate cluster of microcalcifications in the 5 to 6 o'clock position of the left breast, seen only in MLO view; recommend 6 month interval diagnostic mammograms and ultrasound."

OK. Let's hand the patient this problem list, so that she is fully aware of what her current clinical information is. By the time she gets to the surgeon's office, there is a pretty good chance that she will be far more confused than informed, and there is an excellent chance that having this information ---- without the ability to review it with a physician at the same time ---- will generate several phone calls. I have seen this happen on numerous occasions, especially since the government mandated that all patients receive a letter regarding their mammogram results. Add to that the note that will be generated by the surgical consultation, and we could end up with one very confused patient.

My little brother got an electrical engineering degree and mechanical engineering degree in college. Smart as a whip, even if he is a bit of a doofus. And even though he works in software now, I suspect he could make his way around an electrical wiring diagram in his sleep. But does he know what "indeterminate cluster of microcalcifications in the 5 to 6 o'clock position of the left breast, seen only in MLO view" means? Just as I can't make heads or tails of a microchip diagram, I wouldn't expect him to understand what a mammogram result means. It's in a different language, for all intents and purposes. And I wouldn't expect that he would understand that an abnormal mammographic finding in a breast that has been treated with breast conservation therapy for carcinoma is something that probably deserves a little more investigation than awaiting a 6 month follow-up study.

So, I have decided to drop this whole surgery gig and open up a new business venture. I'm going to publish a series of helpful little books designed to let patients navigate arcane medical jargon.

Surgical Diagnoses and Treatments For Dummies
Cardiology For Dummies
Pediatric Terminology For Dummies

Maybe the folks at Rosetta Stone will let me in on some of their action, too. I wouldn't mind hawking "Rosetta Stone -- Medical" at airports around the country!

I see Jimi in the mirror!

2009-06-08T15:03:00.000-06:00

A sticky wicket has been picked up.

A thorny problem has popped up out of the weeds.

Pandora's box has been breached.

A sh*tstorm will fly.

Got the idea? Then you know how I felt when I read a recent study in the May edition of the Journal of the American College of Surgeons. Entitled Trauma Surgeon Mortality Rates Correlate with Surgeon Time at Institution, this is a retrospective review of outcomes in trauma patients with a comparison of seasoned versus less experienced trauma surgeons. This is a very provocative paper, and comes from the University of Miami Miller School of Medicine in Miami. In essence, the authors took a close look at their own data to see if trauma surgeon experience played a role in how major trauma victims fared in their institution. From the abstract:

Using our prospectively collected database, we compared our results with mean mortality for high-volume American College of Surgeon–certified trauma centers reporting to the National Trauma Data Bank. Mortality rates for our 11 trauma surgeons were correlated with years of experience as faculty surgeons at our institution during a 2-year period.

That's a pretty honest look in the mirror. What did they see? Overall, their trauma center mortality rates were excellent, and were significantly better than the mean rates of the National Trauma Data Bank for patients with all levels of injury. However, despite such good numbers,

...there was a significant correlation between years of experience as a surgeon at our institution and improved outcomes for patients with an Injury Severity Score ≥ 35 (weighted linear regression, p < style="font-weight: bold;">It took, on average, 7.9 years of experience at our trauma center to reach benchmark mortality rates.

Wait a minute. That means.....yes! Experience makes a difference! Us old guys do have something to offer after all. Of course, common sense would tell us this any way, but it is nice to be "validated" every once in a while.

Oh. Wait a minute. This means......experience makes a difference. In other words, despite the best instruction in residencies and fellowships, it takes a while before even the most well trained trauma surgeon has enough accumulated knowledge and experience to reach the level of his more seasoned colleagues. And that means, well, I'm not so sure --- but I'm pretty sure that some folks would demand to only be cared for by the most experienced trauma surgeons.

One of my favorite expressions comes courtesy of my program director:

Good judgment comes from bad experience.
Bad experience comes from bad judgment.

I know that today, after 15 years in practice, that I have better judgment and better experience than I did after 1 or 2 years in practice. That has come from a whole bunch of nights on call, time spent with patients, time spent with colleagues, time spent reading......and just a whole lot of time period. The same can be said for any occupation, it's just that physicians are held under the microscope a bit more closely than most.

I suspect that if this type of study were applied across all aspects of medical care, similar results would be found. Surgery just tends to lend itself to more spectacular problems when there are errors in judgment compared to, say, dermatology. But there simply are not ever going to be enough fully experienced surgeons on call at every institution in the country every single night. I think we have to expect that there will be an ongoing learning curve for new surgeons, but we need to encourage newly minted surgeons to put themselves into positions that allow close interaction with older colleagues who can provide much needed help as well as mentoring.

However, with the average age of practicing general surgeons in this country being ~ 56, I'm not sure the mentors will stick around to pass along the wisdom they have gathered if plans for major upheavals in health care in this country actually come to pass. And that would be a huge loss in institutional experience.

We'll see.

Trite but True

2009-06-03T10:46:00.008-06:00

I must admit that the idea of sifting through reams of data makes me slightly nauseated. And antsy. And irritated. Let's just say it ain't my thing. But, as they say, somebody has to do it, and I'm all for that. Because sometimes sifting yields a little golden nugget --- the trick is to figure out if it is real gold or only pyrite.

A lotta data has been generated by the American College of Surgeons' NSQIP program --- the National Surgical Quality Improvement Program. While I have quibbles with some aspects of NSQIP, particularly about patient risk stratification, it is a laudable attempt to gather enough clinical information to steer patient care in the right direction. With the data that has been rounded up to date, the data analyzers have been able to start identifying hospitals that are outliers in certain areas, basically those with higher than or lower than expected complication and mortality rates. Figuring out what makes those facilities tick in a positive or negative direction is the whole goal of the program, so that every facility gets information to improve patient care delivery.

At the most recent Academic Surgical Congress, NSQIP data analysis of Medicare patients undergoing colectomy from 2005-2006 was presented. A total of 12,688 patients in 123 hospitals undergoing colectomy were included (article in ACS Surgery News). The reviewers looked at not only specific complication rates and risk-adjusted mortality rates, but also at the mortality rates following those complications -- what they termed as "failure to rescue."

High-mortality hospitals were found to have a 1.5-fold greater risk of postsurgical complications --- that stands to reason. However, there was not a linear association with increasing rates of complications and increasing mortality ---- the higher mortality facilities had a rate of mortality associated with postsurgical complications that was more than twice that of low mortality facilities (26% versus 11%).

What, exactly, does that mean? It means that a certain percentage of patients are going to have complications, and that complications are more frequent in higher-mortality hospitals. But it also means that if a patient has a complication in a higher-mortality hospital, their likelihood of mortality is greater than if they had a complication at a lower-mortality hospital. An unwelcome double whammy, to say the least

Why might that be the case? Here is where the trite but true saying comes into play --- it takes teamwork to get patients successfully through a hospitalization. Avoidance of postoperative complications starts well before surgery, with appropriate preoperative evaluation and testing; this includes the assistance of other physicians (cardiologists, pulmonologists, etc.) and staff (following protocols for preop lab and EKGs, initiation of DVT prophylaxis, etc.). In the OR, having a team approach is critical to minimize the risks for excess blood loss, prolonged OR time, avoidance of temperature loss, etc., ad infinitum. Postoperative care is crucial, with nurses, physical and respiratory therapists, and physicians being attentive to mobilization, pulmonary toilet, glucose control.........you get the picture.

"Failure to rescue" then may occur with any person or department involved in a patient's care --- the nurse who doesn't recognize that a patient's low blood pressure may indicate bleeding; the respiratory therapist who thinks a patient with worsening respiratory function will do OK through the night; the physician who doesn't see a patient who is doing a bit more poorly than expected in a timely fashion; the blood bank that doesn't get needed products to the patient's bedside quickly enough; failure to implement protocols to deal with DVT prophylaxis, antibiotic prophylaxis, ventilator management, etc.

To draw on the current phraseology of hospital management-types, it boils down to culture. Hospitals with lower mortality rates, I suspect, aggressively engender a culture of high expectations, where everyone down the line understands how important of a role they play on the team. High expectations come with accountability, and the squishiness of some administrators when it comes to meting out that accountability can lead to poor outcomes. That accountability must also apply to the physicians, and a physician culture that demands the best for our patients in our hospitals --- from the physicians and staff alike --- pays big dividends.

CMS : Flying Against the Headwind of Reality

2009-06-02T08:47:00.006-06:00

When good science, good medical care, and common sense sit athwart government bureaucrats, who wins? I think all of you know the answer, but it bears repeating.

One of the hidden dangers that lurk for patients -- particularly those who have undergone surgery or who have had trauma -- is the risk for developing a venous thromboembilism. I have written about this in the past, so I won't bore you with the details. Simply put, we try to aggressively treat patients with prophylactic measures to try to avoid the development of VTE, using medications (Heparin or Lovenox), early ambulation, and sequential compression devices. There are a few problems with this, however:

Some patients cannot be mobilized, due to injury, ventilator-dependence, etc.
Some patients cannot be given chemoprophylaxis, with injuries to the central nervous system, spleen, or liver which could bleed when they are given medications that interfere with clotting.
Some patients will develop VTE, regardless of whether or not they are treated with appropriate prophylaxis.

That's right, Kemo Sabe, some patients will develop a deep vein thrombosis or pulmonary embolism no matter what we do. While we may have prior knowledge of a hypercoaguable state in some patients, more often than not it becomes apparent only after the fact. Sometimes the hypercoaguable state is temporary, associated only with the episode of trauma, and sometimes it is genetically predetermined. But a really smart trauma surgeon at the University of Colorado has developed a test that appears to be able to detect patients who are at a significantly higher risk for VTE.

In the May issue of Surgery News (link is to a pdf file), Dr. Jeffry Kashuk describes the test, known as rapid thromboelastography (r-TEG), using a device manufactured by Haemoscope. For those of you who are interested in the chemical processes involved, read the article for the details that were presented at the Central Surgical Association's annual meeting (which I suspect will be published formally in the not to distant future). The bottom line? -->

19% of the hypercoaguable patients experienced a thromboembolic event despite chemoprophylaxis, compared with none of the patients who had normal coaguability.
Evidence of a hypercoaguable state predicted thromboembolic events with a 100% sensitivity and 45% specificity in patients who received chemoprophylaxis.

Cool. If this pans out in larger studies, it will provide us with another tool to treat patients in a more tailored fashion. For example, we may be quicker to place a temporary vena cava filter in some patients, or give them greater than standard doses of Heparin until the r-TEG results normalize. Alternately, we may be able to avoid placement of some IVC filters in trauma patients who cannot be given chemoprophylaxis if their r-TEG tests do not demonstrate a hypercoaguable process. Once again, this has the potential to be a very useful tool if it pans out.

Whoa, Nellie. Stop right there. According to the ~~Baghdad Bob~~ the Centers for Medicare & Medicaid Services, venous thromboembolism should never happen! It is, in their parlance, a "never event." That's sort of like saying that flat tires, frozen pipes, or computer crashes should never happen. It flies in the face of reality, an intentional offense to those caring for patients in this country. I say intentional, because the goal is not improving care, but denial of payment. (More on "never events" can be found here and here.)

So, we know that some patients are at an increased risk for VTE, and some are going to get VTE even with currently appropriate prophylactic measures. This test may help us identify some of those patients, and start trials on treating them differently. CMS, ignoring the science and accumulated weight of decades of clinical evidence, by declaring this to be a "never event" has rendered this type of investigation moot, as they simply will not fund care for "never events."

Let this be a little introduction to government-run health care.

Doctor Death

2009-05-19T09:00:00.001-06:00

I belong to this quirky group of docs that gets together once a month --- we have a few adult beverages followed by two of us giving a talk. The talks have to be 10 minutes long, with no notes or visual aids (I said it was quirky). My turn comes around every two years or so --- I have posted some of the talks I have given a while back here and here. The last few weeks were light on blogging because my turn was up again, so time not spent working was frequently spent trying to put together a talk that would be entertaining and pass along something that the docs in the room had never heard. This rather long post is that talk -- I did edit it a bit to get to around 10 minutes, but this is the whole enchilada. And I know that there may be a few incorrect dates or factual errors, but I was trying to "tell a story."

On the night of September 5th, 2004, Ukranian presidential candidate Victor Yushchenko sat down for a relaxing dinner. He was fully at ease, dining with the chairman of Ukraine’s security services, Igor Smeshko, at the home of Smeshko’s head deputy, and so had released his usual security detail. The purpose of the meeting was to try to persuade Smeshko to restrain his underlings from interfering in the rather contentious election that was underway. Unfortunately for Mr. Yuschenkko, his dinner companion had already chosen to become a particularly active supporter of Yushchenko’s opponent, the sitting Prime Minister Victor Yanukovich.

Within hours of the dinner meeting, he was violently ill, with abdominal pain, nausea, and profuse vomiting. The following day, his face and trunk erupted with a forest of painful skin lesions. By the time he had been flown to Vienna for medical care four days later, he was desperately sick, barely able to walk, with biochemical evidence of hepatitis and pancreatitis. There was little doubt that Mr. Yushchenko had been poisoned, and the painful skin eruptions known as chloracne provided an important clue as to the agent that was used. Chloracne is almost exclusively seen as a result of heavy dioxin exposure.

Colorless, odorless, and tasteless, Tetrachlorodibenzo-p-dioxin had not previously been seen as a possible method of assassination or intimidation by poisoning. In this instance, however, it had been bound to alpha-fetoprotein. This created a highly soluble and toxic little bio-bomblet, carrying a much more immediate and devastating impact. In effect, the addition of a simple delivery system allowed the dioxin ingested by Mr. Yushchenko to nearly take his life.

Somewhere, someone was ringing a bell. Sending a message.

On the evening of November 1st, 2006, ex-KGB agent Alexander Litvinenko dined with a pair men at a sushi bar in the heart of London. Litvinenko was living in political asylum in England, fearful of his life after publicly clashing with Russian authorities. He met with these gentlemen because they offered information for an expose on the murder of a Russian journalist Mr. Litvinenko was working on.

When he fell ill later that night, he had enough prior experience as a KGB officer to know that his severe abdominal pains and nausea were not due to a bad batch of raw fish. His hospitalization and rapid deterioration over the next two weeks provided anyone with a newspaper or an internet connection with a crash course in radiation poisoning. Color-less, odorless, and tasteless, the dose of Polonium-210 ingested by Mr. Litvinenko in a cup of tea has been estimated at greater than 100 times the lethal dose.

Somewhere, someone was ringing a bell. Loudly. But whose hand was on the bell rope?

To answer that question, we need to travel eastwards a few thousand miles, and back-wards several decades.

In 1888, an imposing Baroque building was erected in central Moscow as the headquarters of the All Russia Insurance Company. After the Bolsheviks took control of the country, this massive structure became the headquarters of a different kind of insurer --- the kind that ensures the absolute subjugation of a populace. The Lubyanka housed not only the Russian secret police, called the Cheka since before the revolution, but also the infamous Lubyanka prison. For decades, Muscovites dared not even utter the name of Cheka’s headquarters, calling it instead after a nearby toy store, “Detsky Mir.”

But just one block away from Lubyanka square sits a nondescript, squat square building that generated no concern even to the ever apprehensive citizens of Moscow. This building housed Laboratory Number One, where Vladimir Lenin established the Office of Poisons in 1921, a short four years after establishing total control over the Soviet Union. But the “cabinet,” as it was then known, was relatively inactive, as the head of the Cheka preferred more “traditional” methods of eliminating “enemies of the people.” It was only with the active involvement of Josef Stalin and Lavrentiy Beria, the head of the Cheka after 1938, that the lab’s productivity blossomed as part of the First Chief Directorate of the secret police. The First Chief Directorate was responsible for foreign intelligence and special operations --- basically, everything associated with spies, assassinations, double agents, and the like. They were also responsible for assassinations within the Soviet Union. The poison laboratory would be given a half-dozen names over the next 40 years, but to those few that knew of its existence it was simply the “Kamera,” which is Russian for “chamber.”

The secret police certainly had no compunction about using a billy club, a piano wire around the neck, or a bullet in the back of the head to achieve their results; one does what one can with the tools at hand, after all. But some situations called for an approach that would be seen as less obvious, except to those being assassinated and their associates. Poisoning gives just such an effect, leaving a very cold corpse that gives off the hint of assassins who can reach anyone, at any time. In short, sending a signal. Ringing a bell that certain people are sure to hear.

But the Cheka at the time had very little to work with, and complaints about ineffective poisons from Cheka officers prompted Beria to jump start research in the Kamera. He wasted no time in finding a man with just the right combination of intelligence and amorality, tapping the head of the secret labs in the Bach Institute of Biochemistry in Moscow to take over poison research for the Cheka. For now, let’s simply call him by the nickname given to him by Stalin: Doctor Death.

A physician, Doctor Death was a professor of pathophysiology, but he was an unsavory character even by the standards of the secret police. Eager to please his patrons, Doctor Death took to this new task like Rosie O’Donnell with a bad case of PMS tearing into a box of chocolates. But his initial efforts fell a bit short of the high expectations of Beria and Stalin. Called on the carpet, he apologized, stating that it was difficult to predict the effect of poisons that had only been tested upon animals. Beria would have none of these excuses, asking “Who’s stopping you from experimenting on humans?”

Now, remember that Beria was most certainly aware of the rather artless murder of Rasputin a year before the revolution, who was poisoned, beaten, shot, and finally thrown into a river before he died. Or perhaps it was the lack of murderous elegance demonstrated by First Directorate agents in the assassination of Leon Trotsky, who failed to die for two days after being impaled with an ice axe to the head, that provided additional urgency for Stalin, Beria, and their pet biochemist to develop a simpler and less obvious method of state sponsored murder.

Regardless of the reason, Doctor Death was happy to comply, and he was rather success-ful. In fact, Stalin himself awarded him with a PhD for the thesis entitled “Biological Activity of the Products of Interaction of Mustard Gas with Human Skin Tissues.” Given the subject matter, it is no surprise that this award was kept highly classified.

In the long run, the ultimate goal of Doctor Death and his colleagues in the Kamera was the development of poisons which could be used without arousing suspicion in the victim, and which could not be easily traced. In other words, colorless, odorless, tasteless agents with rapid and devastating results. While death was the goal, an autopsy result of “heart failure” was seen as the optimal outcome.

Doctor Death certainly did not lack for research subjects, as the cellars of the Lubyanka were continuously refreshed with an influx of newly condemned enemies of the state. Almost all of these victims had been convicted on Statute 58: engaging in anti-Soviet propaganda, or in other words, thought crimes. He nicknamed his subjects “ptichki,” or little birds, and he had a preference for foreigners, including at least one known American named Cy Oggins.

The prisoners were brought in groups to the small lab, tricked into thinking they were getting medical treatment. Isolated in separate dingy cells, they were given poison and then observed through small windows. Sometimes, poisons that had worked with cruel efficiency on animals would fail to kill a prisoner. If they didn’t die, a bullet to the back of the head would suffice, but occasionally the victims were nursed back to health for another go with this deadly version of Russian roulette.

There were no survivors.

Over the next few years, Doctor Death experimented with a variety of agents, including digitalis, colchicine, cyanide, thallium, ricin, and curare. Delivery systems were devised for each agent, such as a ricin pellet in a sharp-tipped umbrella, poison cyanide sprayed from a rolled up newspaper, a poison-carrying bullet, or a powder surreptitiously slipped into a cup of tea. Each fresh victim was carted off for autopsy at the Lubyanka, looking for any obvious trace of poisoning, with all involved hoping for a result of "heart failure.".

Now, keep in mind the time frame here. Doctor Death was active in the Kamera from 1938 through at least 1945, and probably for a few years after that. The end of World War II was quickly followed by the Nuremberg trials, which made the Soviet hierarchy a bit nervous about the Kamera being discovered. Beria decreed that no further experiments on humans would be officially permitted, as “crimes against humanity” would most certainly include the research activities of Doctor Death and the rest of the Kamera crew.

Whether human experimentation continued after that is up for speculation, but what is not is that Kamera continued its existence for many decades longer, changing names about as frequently as Elizabeth Taylor changed husbands. Regardless of its official name at any given time, Kamera's poisonous biological and chemical agents were constantly refined over the years. Highly specialized poisons were crafted cause death or incapacity, and one thing in their design was constant, making the victim's death or illness appear natural, or at least produce symptoms that would baffle doctors and forensic investigators. In the long run, the Kamera became singularly specialized in transforming known poisons into original and untraceable forms. And they were highly successful.

So, in the post-Soviet world, who is ringing the bells now? Who is sending these kinds of messages today? The past few years have seen a dramatic increase in the number of politicians and journalists being murdered in Russia itself, and the non-Russian cases of Yushchenko and Litvinenko certainly have many pointing fingers at Moscow. Why would that be? Well, it is instructive to look at the current occupants of the upper echelons of the Kremlin. Russian governmental structure has changed in the past fifteen years, but there is still a Soviet style “top-down” approach in place. It is estimated that 80% of top Russian government officials are former or active KGB officers. And the man at the top, Prime Minister and former president Vladimir Putin, cut his teeth in the KGB as an officer in the First Chief Directorate --- the very same part of the Cheka responsible for running the Kamera.

In the end, though, there is no denying the role played by Doctor Death, or ultimately, by Beria and Stalin as well, who famously stated that "The death of one man is a tragedy, the death of millions is a statistic." While those men may not have had an active hand in ringing these bells, their bony carcasses are certainly still clinging to the ropes.

What became of Doctor Death and his patrons? Stalin died in 1953 after a night of heavy drinking with his Politburo cronies. The official cause of death was an intracranial hemorrhage, but the presence of Beria that evening has always led to speculation that Stalin was poisoned. Adding fuel to that speculation is the fact that Beria himself later claimed to have had a hand in Stalin’s death, and that he quickly moved to try to position himself as Stalin’s successor. But Beria’s poker hand was a few cards short of a full house, and he was arrested within a few months, with a bullet to the head being his reward for his service to the party.

With the fall of Beria, a raft of his Lubyanka cronies were arrested, interrogated and tortured with their own methods. A large contingent called the Berievtsy, or the Beria men, were shipped off to the Vladimir prison. Eager to save his own skin from mustard gas, Doctor Death testified against Beria, using his own notes as evidence. But he was not spared arrest, and was sentenced to 10 years in the Vladimir. In a classic example of Soviet era judicial double speak, he was imprisoned not for murder, but for “illegally storing strong-acting chemicals outside the workplace.”

Not content with such a light sentence, Doctor Death peppered officials with letters, pleading with them that he had been a good scientist in service of the Communist Party. Eventually given early release in 1961, he was sent to internal exile in the Caucasus region, heading up a chemical institute in Dagestan. But he was Jewish, and has commonly been referred to as “Stalin’s Jewish Mengele” in Russia since his existence became more publicized. And this Jewish Mengele, who somehow escaped Stalin’s own periodic bloody purges of Soviet Jews, was to spend his remaining years exiled in a backwater Soviet republic on the Caspian coast that was more than 90% Muslim.

The story of Doctor Death would have ended there, never to see the light of day, if it were not for the Soviet bureaucracy’s obsession for detailed record keeping. Researchers dedicated to uncovering and documenting the Soviet regime’s crimes against its citizens were able to bring Doctor Death back to life, so to speak, and in doing so have given us the rather ironic story of his death.

Doctor Grigory Mairainovsky, also known as Doctor Death, pining away in a dirty port city on the Caspian Sea, made a final, fatal miscalculation. He wrote a letter appealing directly to the new master of the Kremlin, Nikita Kruschev, for official rehabilitation. In his letter, he reminded Kruschev that they had once met. Not one for subtlety, Mairanosvsky eagerly asked Kruschev to remember that they had shared a conversation on a train in the Ukraine, just before the assassination of a troublesome Archbishop; gee, what a happy coincidence! I helped kill meddlesome Russians too!

Mairanovsky received no “official” response to his letter. But this little “remember me” note may have struck a nerve in the Kremlin, as soon thereafter Mairanovsky died. The official cause of death? “Heart failure.”

I first heard of Grigory Mairanovsky in a book entitled The Lost Spy: An American in Stalin's Secret Service. Eventually, I cobbled together a bit more information from a variety of other sources to try to put a coherent story together.

Publish or ... get tattooed by your department

2009-04-24T10:41:00.006-06:00

In my never-ending quest to be the most evidence-based surgeon out there, just to keep you über-informed, I pore through a stack of surgical journals every month thick enough to choke Rosanne Barr.

Just wanted you to picture that for a sec before moving on.

While it comes as no surprise to my medical colleagues, I must state for everybody else's benefit that there is, well, quite a bit of "filler" in medical journals. Articles that are really not quite up to snuff, so to speak. Ones that impart about as much knowledge as Ward Churchill on a bender. The kind of articles that leave you wondering, "Why was this even submitted for publication? And why in God's name was it accepted?"

We all know "filler" when we see it, whether it is in the newspaper, a magazine, or TV Guide. But medical journals are supposed to be full of scholarly stuff, right? Well, these journals need to fill their pages in some manner, and sometimes there just aren't enough quality submissions. Besides, us docs are just as eager to see our names in print as everyone else.

"Avoidance of tattoo disruption: a further benefit of laparoscopic surgery" is a bit of filler. The title pulls you in, sort of like a train wreck, but you know that there will be nothing of significance in the meat of the text. From the abstract:

Introduction Tattoos are increasingly common in both male and female patients. Abdominal skin tattoos may be present at the site of proposed incisions for conventional surgery whereas laparoscopic port site placement can be adjusted to accommodate tattoo constraints.

Methods Patients with tattoos were questioned by face-to-face interview to determine how long ago they had their tattoo, financial cost of the tattoo, and potential degree of distress caused by disruption of their tattoo (on a scale of 1–10). Consultant and higher surgical trainee general surgeons were asked by e-mail survey whether they had encountered a patient with a tattoo at the site of a proposed incision, did they avoid incising the tattoo during surgical intervention, and had they received a complaint from a patient about tattoo distortion.

Results Ninety six patients (50 male, median age 29 years) were questioned. Median cost of the tattoos was £35 ($70). Female patients were more likely to be distressed and complain than men about tattoo disruption (p = 0.0003) and there was a significant inverse correlation between time from tattooing and distress (p = 0.02). Most (79%) of the general surgeons questioned (n = 107, response rate 82%) had encountered tattoos at proposed incision sites; 61% had avoided making an incision through it and 4% had received a complaint about tattoo disruption by a patient.

Conclusion Tattoo disruption by surgical incision may cause distress especially in female patients who had their tattoo recently. Tattoos should be avoided where possible by alternative port site placement.

Perhaps I am too crusty and old, but I had two immediate reactions to this article. First of all, is this a pressing medical issue? Are we being deluged by patients irreparably harmed by having their tattoos altered as a result of surgery? Does this rank up there with, say, techniques to avoid bowel injury during laparoscopy in importance? Why, in fact, is this even something to write up, other than the fact that nobody else had done so yet? And secondly, if you are going to go to the trouble of asking the patients and doctors these questions, there are three that were conspicuously absent ---

(for the patient) On a scale of 1-10, what would have been more distressing, having the operation or not having the operation and leaving your tattoo intact? This is not a trick question, especially if the operation you had was an urgent one.
(for the patient) On a scale of 1-10, what would have been more distressing, having the surgeon struggle because he was trying to avoid your tattoo, or having him disrupt the tattoo to do the operation with as little trouble as possible?
(for the surgeon) What, exactly, takes precedence? Concerns about cosmesis, or concerns about doing the right operation the right way?

I'm not so crusty and cold-hearted that I won't work around a tattoo.....if it is the right thing to do .... but I hardly think that this rises to the level of a publishable activity. In academic medicine, there has long been an imperative to "publish or perish," so perhaps the authors wanted to be sure that theirs was the definitive article for "evidence-based medicine" in the realm of tattoo avoidance.

How Low Can You Go?

2009-04-23T22:02:00.000-06:00

Dallas in the early 80s was nightclub heaven, a city where there was always a "hot new trendy" place to go. "Trendy" as in "spendy." "Trendy" was not a good way to describe yours truly, so the amount of time I spent in hot new clubs was similar to the amount of time Nanc Pelosi has spent educating herself about basic economics. You could not, however, be young in that city and not hear something about a string of restaurants & clubs operated by a guy named Shannon Wynne. He had a thing for the letter "o" for some reason, and all of his clubs and restaurants ended with "o" --

8.0
Rocco Oyster Bar
Nostromo
Mexico
Tang-o

Everything he opened turned to gold, at least initially, with great crowds and publicity. But it was the Tang-o nightclub that was the place for an all-too-brief period of time in the early 80s. It was festooned with a gaudy cluster of six dancing frogs that were sculpted by Bob "Daddy-o" Wade specifically for the roof of the building, making it an instant landmark for the young and cool.

I gotta admit, I never went in. The lines were too long, and I wasn't really part of that crowd. But I absolutely loved their ads, and think about them every time I'm doing a particular operation. You see, Tang-o was located at the very southern end of Greenville Avenue in Dallas, a long stretch of road that at the time contained a treasure trove of restaurants and clubs. There was really nothing that far down Greenville, so the ads intoned with a deep, gravelly voice:

How low can you go?
Tang-o, on lowest Greenville.

How low can you go? That, in fact, is a question a surgeon must ask himself when evaluating and operating on a patient with a low rectal cancer.

Basically, a lot of what I do is plumbing --- the GI tract is one long tube, with twists, turns, special functions, different anatomic characteristics, etc. Each part of that tube has specific blood supply and lymphatic drainage, and anatomic positions and attachments that influence the ease, or lack thereof, with which we can operate upon it. The esophagus, for example, lies within the neck, the chest, and the abdomen, and depending upon what needs to be done to a patient it may be approached through any (or all) of those areas.

The rectum poses a few thorny problems for us. It's function is simply as a reservoir, albeit a rather important one for obvious reasons. Almost always, removal of a portion of the rectum is done for malignancy (or polyps that cannot otherwise be removed), but the location of the tumor dictates what must be done surgically. A tumor that is "too low," or too close to the anus, cannot be removed without leaving the patient with a permanent colostomy. But how low is "too low?"

The best way to describe this anatomic issue is to think of two bowls nestled one within another, with the inner bowl being more pliable but pretty thick, and the outer bowl as firm as stone. A garden hose runs from inside the inner bowl, down through its thick wall, and then out the outer bowl. From a simplistic standpoint:

Removing a segment of the hose and putting the two ends together above the inner bowl is pretty straightforward. This is the situation for the colon and the uppermost part of the rectum, which lies within the free peritoneal cavity.
Removing a segment of the hose that abuts, or lies within the wall of the inner bowl and connecting the two ends is more challenging. This is in general the case for the mid portion of the rectum, straddling the intra- and extraperitoneal areas as the bowel passes out of the abdomen on its way to the anus.
Removing a segment of the hose near its final exit pretty much can't be done if the goal is to have two functional ends to connect together. This is the issue for distal rectal cancers, i.e., how low can one go without crossing the Rubicon and committing a patient to a permanent colostomy?

There is much more involved, obviously --- blood supply and lymphatic drainage, for example --- and we need to make sure that our surgical margins are quite clear of tumor (at least a 2cm margin distally is a minimum requirement) for the best outcome. We help no patient if we leave tumor behind, or leave their sphincter mechanisms no longer functional.

This is, however, the kind of operation where there is just as much artistry as there is science, as well as a whole lotta patient-specific factors in play. There are a few tricks in a surgeon's bag that help us get way, way down in the pelvis, and a few things that make it impossible to do so. This is a physically demanding operation as well, and there are portions of the procedure where there is as much "feeling" as "seeing"...... the surgeon must free the rectum from the tissues in front of the sacrum, from the bladder and uterus & vagina or prostate anteriorly, and from dense fibrous and vascular tissues (the lateral rectal stalks) on either side, and tactile feedback is very important. Freeing the rectum in the deep pelvis becomes a process of working in each of these regions circumferentially, not in any single organized fashion but rather "taking what's easy" in one area and then doing the same in another.

Gradually, we reach the muscular floor of the pelvis, the levators (levator ani). Actually getting this far is very dependent upon the patient's anatomy --- it is easier to work in a wider space, i.e., in a women's pelvis in comarison to a man's. An obese patient poses big challenges (pun intended), as does a patient who has had a lot of prior surgery.

Remember the movie with Catherine Zeta-Jones slinking under, over, and around the laser beams of an alarm system to steal a rare piece of art? It sure left an impression on me, and I'm sure it was absolutely crucial to the plot. Well, in some respects, when we are working on "stealing" a part of the rectum, we must work carefully to avoid a few danger zones of our own. Potential problems include big-time bleeding from a nest of snakes along the anterior aspect of the sacrum known as the presacral plexus, injury to the ureter (which drains urine from the kidney to the bladder), injury to the bladder, and injury to the prostate or vagina (especially with bulky tumors).

At some point, though, a point is reached where the surgeon must decide if a complete and safe resection with an anastomosis (putting the bowel back together in continuity) is possible. We try. We sweat it out. We really work at it to try to avoid a permanent colostomy. But each patient is different, so it is not always possible to be 100% sure before we are in the OR whether or not we will be able to put Humpty Dumpty back together again.

So, in the end, the question in each case remains the same --- how low can you go?

96 Tears? No, 100 Lab Coats

2009-04-13T10:24:00.014-06:00

When it comes to counting, ? & The Mysterians have nothing on me.

I entered medical school in the late summer of 1984. Almost 25 years later, I have much to look back upon, and as a result of a headlong rush through those years, many holes in my memory. Unlike a hunk of Swiss cheese, however, sometimes little things will jarringly cause me to fill in a few black holes in my cerebral RAM. SWIMBO sent me hurtling backwards in time with a simple little recent comment ---

"Good Lord, look at yourself! Get some new lab coats! NOW!!"

Indignant and hurt (how could she say that about my.....comfy, wrinkled and coffee-stained coat?), I pulled out the best retort in my quiver --- "Er, yes dear."

But it got me thinking. I am very old fashioned, and as a surgeon have always worn a lab coat in the hospital, either over scrubs or over my regular clothes. In some ways it may seem a silly convention, but I feel as naked without my lab coat in the hospital as I do without my helmet on my mountain bike. And I have been wearing one since the beginning of my third year in medical school.

Please, don't get me wrong. My inner fashion barometer tells me every morning that blue jeans and a very obnoxious Hawaiian shirt is just the thing to wear to work. However, SWIMBO has kindly arranged my clothes in such a manner that I can almost never fail to find some combination that has a greater than 50% chance of matching. Sort of like Garanimals for the fashion-challenged adult. But once I get to my office, the need to put on that white coat is as basic to my nature as is the urge to finish rounds before going to the OR in the morning.

So, SWIMBO's comment got me thinking. How many lab coats have I worn over the past 23 years? Perhaps the more salient question would be, how many lab coats have I ruined over the past 23 years, with coffee spills, rips when the pocket holes were caught on doorknobs, volcanic eruptions of pus while opening wound infections, ink stains, and the like? I'm putting the number at somewhere between 70 and 100, and given my severe coffee enslavement, 100 may be the more accurate estimate.

The first was thin, with buttons that had a tendency to fall off during the most embarrassing moments, such as when I had to present a patient's history and workup to the smartest man in my then known universe after a sleepless night of work. It had no embroidery or markings whatsoever, but had pockets that were ridiculously large enough to hold :

a stethescope
a pen light
a reflex hammer
a copy of the Sanford guide
a well-worn copy of the Washington manual
at least 3 pens
scrap paper; lots of scrap paper
most importantly, a copy of the Scutpuppy Guide to the Lands, an indispensable guide book to Parkland Hospital, its idiosyncrasies and Byzantine method of operation, and its navigable hallways, along with a few helpful Spanish phrases (download it here for fun and exciting reading!)
lunch

I am sort of a big guy, and was fortunate to go to not only to The Best Medical School in the Country®, but also one which did not require students and junior residents to wear short, short-sleeved lab coats. Those things have a tendency to make one look like Bozo the clown when he's trying to dress down to the level of a real doofus. And that, I believe, has always been the point in those institutions ---- to single out the junior level folks, sort of like fraternity hazing on a prolonged scale. Since I was a Γ Δ Ι in college, that sort of crap really ~~pisses~~ tees me off.

So, my big white lab coat with oversized pockets did me well for about 8 weeks, which was the length of my first rotation as a 3rd year medical student --- internal medicine at Parkland Hospital. This was followed by 8 more weeks in internal medicine at the Dallas VA Hospital, and by the time 16 weeks was up, "white" was a term that could only be used in the past tense when referring to that rag.

During the remainder of my time in medical school, I variously soiled and destroyed more than a few other coats, but arrived in Salt Lake City in the summer of 1988 freshly married to a woman doggedly determined to ensure I would show up for work cleaned and pressed (even if I didn't end the day that way). Somewhere along the way, she was kind enough to order me a plush, thick, 100% cotton lab coat embroidered with "Aggravated DocSurg, M.D." in dark red. It was great. Sort of made me feel like Navin Johnson ("The new phone book's here! The new phone book's here!"). Just like Navin having his name in the phone book, however, having my name on my coat made me a target for potshots for attending surgeons who needed to pimp someone, but who weren't always sure what everybody's name was.....except for that guy with his name out there for God and everybody else to see!

Fast forwarding through the 6 years of residency, each pristine and embroidered lab coat was donned with the hopefulness of Pig-Pen as he steps out of a bathtub. The results of a week's worth of work ended up generating the same level of disarray as Pig-Pen's entry onto the playground. Somehow, my attendings managed to maintain a razor-sharp crease and a zero "smudge quotient" on their lab coats. Surely, once I was out in practice, I could do the same!

Well, the "dirty" little secret I discovered was that the attending surgeons had the luxury of having residents do most of the scut work, and they could hang their bracingly white coats in their office after rounds (and no, I'm not complaining, only making an observation). In practice, well, I have no residents! So, while I may be able to afford a few more coats than I used to, they still get just as coffee-stained and worn out as ever.

Trashing at least 5 coats per year since starting practice in 1994, I suspect I have crested the century mark for lab coats through my career. It ain't over yet, so I suppose I need to start buying in bulk.

Just Do It

2009-03-30T12:31:00.008-06:00

My son and I just returned from a 4 day mountain biking trip in Canyonlands National Park, just outside of Moab. This was our fourth trip with Western Spirit Cycling, and I have to say once again that this is the best experience I have ever had with my son. The guides are fun, funny, great cooks, unbelievable riders, helpful, and genuinely great people; in four trips, I have ridden and camped with 12 different Western Spirit guides, and they have all been gems. Our trip this year was a bit windy and chilly (in the teens one night), but the scenery was beautiful.

We rode the White Rim Trail, which initially runs along the Colorado River, and then winds along the Green River. My son is now 15, and can absolutely kick my rear on a bike. Here is one of the few times he was within my sights during the day.

We did get caught in a spot of nasty weather -- cold winds, a touch of snow, and a few pretty chilly nights. But it was never bad enough to make this anything less than a great time.

I cannot recommend this company highly enough. While I think it's great to do with my son, by no means are all of their trips designed to be for families only.

So, if you are willing to sweat a bit on vacation, give 'em a call.

Canary, Meet a Possible Coal Mine Air Shaft

2009-03-24T08:56:00.001-06:00

GruntDoc recently posted about how he feels the EDs in this country are similar to lobsters, slowly cooking while to death while they think they are doing reasonably OK. The same could be said for a variety of specialties in medicine, where the poisonous trifecta of poor insight of our governing bodies, the insidious nature of reimbursement decreases brought on by the RBRVS system (thanks, AMA!), and government intervention has generated unintended outcomes in patient care and physician behavior. Add to that the cost of "CYA medicine" (yes, Matt, it does happen) generated by the fear of being sued, and you've got a swell recipe for boiled lobster.

But I've posted about this before, and certainly anyone connected with medical care can see that there are big challenges ahead for us. Peruse the most recent National Medical Resident Match Program Data, and compare it with historical data, and you'll get a sense of how few front line physicians there will be available in the future. There are not, however, a whole lotta big solutions on the horizon. Some folks are starting to get innovative in their thinking, however, and are starting to look beyond the knee-jerk response of "hire more physician extenders."

I spend a considerable amount of time in the hospital providing trauma coverage for our ED. This requires me to be physically here for a 24 hour stretch, in addition to my regular work as a general surgeon. It gets, to be honest, old. And I suspect that there will come a time when I will no longer provide trauma care, particularly if my income gets slashed by the socialists in Washington. There are many institutions in larger cities where there are trauma services that provide essentially nothing other than trauma care, because the volume of injured patients requires this. That, for me, would get really old.....and there really isn't an abundance of general surgeons who feel differently. As a result, there is already a shortage of dedicated trauma surgeons, and there will be a gradually growing deficit in the future.

Cue one innovative and interesting solution -- "Emergency Traumatologists as Partners in Trauma Care: The Future is Now." Brought to you courtesy of one of my old senior residents, now part of the Penn system. Here's the abstract:

Background Decreasing manpower available to care for trauma patients both in and out of the ICU has led to a number of proposed solutions, including increasing involvement of emergency medicine-trained physicians in the care of these patients. We performed a descriptive comparative study in an effort to define the role of fellowship-trained emergency medicine physicians as full-time traumatologists.

Study Design We performed a retrospective review of concurrent and prospectively collected data comparing process of care and outcomes for the resuscitative phase of trauma patients cared for by full-time fellowship-trained trauma surgeons (TS), a fellowship-trained emergency medicine physician (ET), and a first-year fellowship-trained trauma surgeon (TS1).

Results Patient age, Revised Trauma Score, and Injury Severity Score were similar between groups. Process of care, defined by transfusion of uncrossmatched blood, prevalence of hypotension in patients receiving uncrossmatched blood, time spent in the emergency department, frequency of ICU admission, severity of injury for ICU admission, and time between emergency department and operating room for patients requiring surgery, was equivalent between groups. Outcomes evaluated by mortality and length of stay in the hospital and ICU did not differ between groups, and provider group was not predictive of mortality in stepwise logistic regression.

Conclusions These data suggest that emergency traumatologists can provide trauma care effectively within a defined scope of practice and may provide an effective solution to manpower issues confronting trauma centers.

Interesting. Innovative. But workable?

Let's look at the positives first. Evaluating all the data, the patients cared primarily for by the fellowship trained trauma surgeons and the fellowship trained emergency medicine physician were similar in characteristics, and had similar outcomes. In other words, the patients did as well regardless of which of the three physicians were caring for them.

However, we are talking primarily about patients with blunt trauma --- auto accidents, primarily. Those with penetrating injuries, while they can initially be assessed by a non-surgeon, will require surgical intervention. And the occasional blunt trauma patient also needs a laparotomy. From the article --

Clinical coverage grids were designed using the ET in appropriate areas and in compliance with PTSF/ACS (American College of Surgeons) guidelines for trauma center accreditation. So the ET could not provide independent in-house coverage for trauma unless supported by a surgeon.

Additionally, this retrospective study looked at the involvement of a single fellowship trained emergency medicine physician. It would be very unwise to therefore extrapolate this data to suggest that it is a workable model for most institutions. But it may be an alternative to the approach that has been suggested by the AAST and ABS:

...the American Board of Surgery has supported efforts on behalf of the American Association for the Surgery of Trauma to establish a curriculum in acute care surgery in the hope that redefining the content and spectrum of care provided by trauma surgeons might attract more residents to the specialty. It is too early to judge the effectiveness of these efforts, but as yet only two institutions have applied for accreditation for this fellowship. In addition, it is unclear how much this curriculum differs from the current practice of many trauma surgeons, because the requirement and opportunity to learn and apply operative skill sets derived from orthopaedics and neurosurgery are very limited.

Is the Penn approach a good solution? Perhaps, rather than being a solution for all, it is an indication that there is no single solution that will work for every institution. As the system as a whole struggles in the future with fewer physicians, each hospital is going to have to find a workable solution to fill their needs, whether in trauma surgery, OB, thoracic surgery, or medicine. As I have often said, the future of medicine is paved not with concrete, but quicksand, and knowing how quickly to keep moving in any particular direction is difficult. Finding the missing piece of each puzzle will require innovative thinking. Nice work, Dr. Grossman.

Where are they?

2009-03-22T11:26:00.000-06:00

My brother was recently in Houston, and decided to do what all old farts do when they are in places they used to live ---- look up old girlfriends!!! Actually, he drove by the house we last lived in there, and sent along a photo or two:

Though I last was inside the house in 6th grade, I'm pretty sure I could walk in the front door, take an immediate right, head up the stairs, and find 6 miles of Hot Wheels track in a large room on the second floor. My little brothers and I would set the track up to start on top of a bed, snake through the room, run down the stairs, and end on a jump.....so the cars left a series of dents in the wall at the bottom of the stairs (Sorry, Mom. I hope the current owners have better luck with their kids).

My father planted the pine trees in the yard, and they have grown just as he had hoped. The weeping willow that was in the front yard was taken down some time ago, and the buckling sidewalks where we used to ride bikes looks to have been replaced. It seems as if I spent my entire childhood destroying decks of my parents' playing cards, clothespinning them so they would make noise while I cruised the neighborhood (Sorry, Mom).

At night, though, I got to see my future, or at least I thought I could. I'd read books like "20,000 Leagues Under the Sea" and "The Wind in the Willows," and think I could have great adventures. I'd watch SciFi shows like The Outer Limits, The Twilight Zone, and Night Gallery and think about all the cool things that would scare the willies out of me in the years ahead. But most of all, I'd watch Dino and the Golddiggers ---- that was going to be my real future!

Dean would swagger out from behind a curtain every Thursday night, carrying a martini, and spend an hour yukking it up with John Wayne, Frank Sinatra, Don Rickles, Lucille Ball, and whoever else was part of the Hollywood crowd at the time. I frankly don't remember much of that, other than the fact that he rarely got through a skit without barely contained laughter himself. What I do remember, however, are the Golddiggers surrounding him like a cloud of hot-looking angels. I remain convinced that before the show, they would check his tuxedo to make sure it looked sharp, and stirred the perfect martini just for him. It was the perfect image to send a 6th grade boy off to sleep.

My 6th grade mind became wholeheartedly set on the idea that I would grow up to be Dean Martin, and that every night I'd come home to a cold adult beverage and a harem of scantily clad women waiting for me. Really. Forget Cary Grant, Sinatra, or any of the current crop of stars --- Dino was the epitome of cool.

So, I've been wondering. The Outer limits has been recycled and repackaged. 20,000 Leagues Under the Sea has been made into yet another movie. Though not in name, Night Gallery themes can be found in myriad of TV shows and movies. The Twilight Zone has been revived more times than Resusci Annie. So, I've been wondering....I've got my martini glasses, olives, and gin, so...

when do I get my Golddiggers?

SWIMBO, I suppose, would not approve. But maybe she's waiting for Dino, martini in hand.

5 Steps to a Happier Healthcare System

2009-03-17T09:35:00.007-06:00

Too many nights on call, too many weekends on call, too little sleep lately to blog coherently. Oh, I've tried, but get 2/3 of the way through a post and realize that what I have written makes about as much sense as a Jackson Pollack painting --- colorful, but impenetrable and eventually utterly meaningless to someone who spends any time looking at it. So, I'll try again.

Much ink has been spilled recently in the newspapers regarding "health care reform," and many more pixels have burned brightly on news sites and blogs about the same. Since nobody in Washington gives a rat's rear end about what I have to say about the subject, I'll offer my prescription for health care reform right here. It's a 5 step program, easy to implement, but impossible for the politicians and lobbyists to swallow.

Step 1. Uncouple health insurance from employment. Basically, allow folks the same degree of freedom in selecting a health insurance product that they enjoy in selecting life, disability, and auto insurance. Ever notice how all of those GEICO and Progressive auto insurance ads tout not only better pricing, but better service as well? That's the cool thing about a competitive marketplace --- it tends to keep prices reasonable and allows an even playing field.

How to do this? Actually, despite the protestations from the Obamanistas, Sen. McCain's idea of allowing a tax credit for individuals purchasing their own insurance, while taxing the benefits of employer-provided health insurance was a reasonable step in this direction. I would prefer to simply not tax income used to purchase health insurance, regardless of who is footing the bill.

Why won't this be allowed by the folks in Washington? As is pretty obvious, the folks currently running the world's biggest money wasting entity simply want to find ways to get more of your hard-earned money, including taxing your health care benefits (but without the tax credit). Gotta pay for that "stimulus," you know.

Step 2. Eliminate state-specific health care requirements, and allow folks the freedom to choose health insurance from providers across the country. What many consumers don't know is that each state sets the requirements for what a health insurance plan must cover. For example, in my state, chiropractic care is mandated to be covered. That's sort of like requiring coverage for readings by Miss Cleo, in my opinion, but that's beside the point --- I, along with every other Colorado resident must pay for chiropractic care when paying for health insurance. And I am not allowed to call ~~bullshit~~ "Pelosi" on that and purchase coverage from an insurer in a neighboring state that doesn't have this requirement.

How to accomplish this? I think that most Americans can agree on a basic set of requirements of a health insurance plan, which could serve as a basic starting point for consumers to compare plans and coverage options that could be done more in an a la carte fashion. You want chiropractic coverage, aromatherapy, and massage therapy? Great, here's the pricing schedule. To my mind, this would be the only place where the feds would set policy, and eliminate the ability of lobbyists to get state regulators to insert a host of costly add-ons to plans that consumers don't want.

Why won't this be allowed by the folks in Washington? If those self-serving idjuts won't even allow a la carte pricing for cable TV, do you think they would do it for health care? Besides, the lobbyists for folks wanting their bailiwick to be fully covered would be out in force, so achieving a consensus on a basic level of coverage would be damn near impossible. Given the stinking pile of Pelosi that passed as a "stimulus package," we would probably end up with "basic" coverage that would be far more expensive than what we have now. Even so, I can dream, can't I?

Step 3. Tort Reform. This is a concept near and dear to my heart....and should be to anyone who runs a business. Tort reform would positively impact every single industry in the country, not just health care, with significant savings. Loads and loads of information here.

How to accomplish this? Take Shakespeare's suggestion (Henry VI -- Act IV, Scene II).

Why won't this be allowed by the folks in Washington? They are all lawyers, and most importantly the party currently in power owes a tremendous debt to the trial lawyer lobby. This will never, ever happen in our current political climate.

Step 4. Establish a system of health courts. Just because I think tort reform is desperately necessary for the U.S., I do not think that folks should be unable to access the legal system if they have been truly wronged, whether in the health care system or due to gross negligence in another field. But in the current medical malpractice environment, the only winners are the attorneys.

How to accomplish this? Once again, this would require the full participation and engagement of legislators willing to ignore the trial lawyer lobby.

Why won't this be allowed by the folks in Washington? See the answer in question 3. Ain't gonna happen, no matter how many good folks support the idea.

Step 5. Make me king. "Aggravated DocSurg, Lord of all that is Good and Reasonable, Emperor for Life." Has a nice ring to it, don't you think? That way, I can make sure that this is all accomplished with a minimal amount of ~~bloodshed~~ fuss.

OK, that's not realistic, at least not until I become better armed (time to visit Dragon Man). Actually, step 5 is to tackle the many headed hydra known as Medicare. There is simply not enough money lying around in the pockets of "the rich" to satisfy this cash sucking beast, but there are some concrete steps that could be used to rein it in a bit:

Eliminate coverage for chiropractic care. I mean, really, what a waste of cash. We'd be as justified as having Medicare cover astrology as chiropractic care.
Allow physicians and hospitals to write off the difference between what Medicare pays and what they would otherwise expect to get paid for the same care. Everybody knows that there is cost shifting going on, and Medicare simply does not cover the costs of providing care to most patients. Why shouldn't I be able to write that off as bad debt or charity on my income taxes? This would immediately solve access problems for patients, particularly in primary care; it has gotten so bad that in my community I cannot find physicians willing to see Medicare patients in many instances.
Put the institution of ICD-10-CM on the back burner. Permanently. Coding for care is expensive and time consuming, and the next version of the international classification of diseases is an exponential increase in complexity for coding, with no benefit to payors, consumers, hospitals, or physicians.
Eliminate the "3 day" rule to get patients from the hospital into a nursing facility. This is frankly a silly rule that increases costs for all hospitals and for Medicare.
Eliminate the rule that prevents Medicare patient from being held overnight at an outpatient surgical facility. This, too, is a silly rule that increases the costs that Medicare and patients must expend to have procedures done.
Eliminate the bastard stepchild of Teddy Kennedy and the Balrog known as GPCI. There is no difference in a laparoscopic cholecystectomy done in Colorado as compared to New York, but the pay from Medicare is different based upon Geographic Practice Cost Indices, which are determined by a formula so poorly designed that it would make Einstein blush. It's a ridiculous abuse of the physicans participating in Medicare.
Allow seniors with enough of their own money to fully opt out of Medicare. While this is currently technically possible, it is pretty damn difficult to achieve, and because of the issues above is pretty damn expensive.
Last, but not least, mandate that all Congressmen and their families be placed into the Medicare system during their time in office and for five years after they leave office. That will eliminate a whole lotta political poppycock.

Pipe dreams? Sure. But heck, if I can dream of being emperor for life, at least I can dream of doing something good with the title.

I Agree, But Can't Comply

2009-02-21T08:56:00.006-07:00

I received a thoughtful response to my recent over-the-top post about the difference between "consumers" and "patients" from a gentleman at HealthLeadersMedia.com. He raised some good points, but I am afraid that neither he nor I will get to see our ultimate vision of consumer- or patient-centered health care in the future. Here are a few snippets of what he had to say:

This is becoming one of those "get over it" moments for healthcare professionals. You can resist the notion all you want; the fact is patients more and more see themselves as consumers, and that's not necessarily a bad thing.

.....When it comes to my health, I have to do my own homework and make my own decisions. When it comes to my kids, I end up getting the best help and useful information from teachers and non-physician providers. The tired notion that as a patient I have some special connection with a physician who partners in my health is an alien concept. I don't blame physicians for this; it's just the way the system has evolved. As a result, I have no choice but to be a conscientious healthcare consumer.

I agree wholeheartedly --- it is important to be a conscientious healthcare consumer, and it is not necessarily a bad thing for patients to see themselves as consumers. But let's look at what a true provider of services-consumer interaction entails. Right now, my son is at swimming practice, and after spending the last hour catching up on paperwork, I am doing a little blogging. Where did I go for a cup of java and wifi access? I could have gone to Corporate Coffee Central; I like their coffee. I could have gone to my favorite coffee shop; it's pretty long drive, however. I chose instead to go to another locally-owned franchise, because it was convenient, has wifi, and serves a pretty good cup of joe.

I chose. Pretty simple concept in a capitalist society.

We had a simple cash exchange, a couple of bucks for a big, black cup of mud, and then a couple more for another cup. I had a menu of options to choose from, knew the price, and had the option of getting extras, such as a pastry that would make even Fat Bastard add a few inches to his waistline. Before I ever got here, I had seen advertisements for this and other places I could choose for coffee, all of which proclaim that they have the best tasting stuff. Some of them are running special discounts, which is really cool if you are a caffeine fiend like myself. If I became unruly, or refused to pay for my coffee, the shop owner can run me right on out the door, with no repercusions. If I ran a coffee shop, I would do all of these things --- advertise, make sure I offered the best product at a reasonable price, try to meet the desires of my customers, etc.

However, as a physician, I am not allowed to do these things. I cannot set my own price for providing care to patients ---- the government mandates what I can and cannot charge, with a list of rules that is so long it mirrors the tax code. I think that there are things that I do pretty well, and that I am caring and compassionate and very competent. However, I cannot advertise that I provide better care than my competitor across town ---- this is partly due to ethical standards, and partly due to the issues surrounding patient privacy. I cannot run a "special," giving patients a Mardis Gras discount for laparoscopic cholecystectomy ---- if I did so, Medicare or their insurer would demand repayment for the difference in price for all of the other cholecystectomies I did in the last three years. And if I have a patient who is rude to my staff, refuses to follow instructions, and doesn't pay his bill..... I still have to take care of him.

Realistically, Mr. Johnson and I are talking about two sides of the same coin --- or, more accurately, about two individual squares of a Rubik's cube, as there are many dimensions to this issue. Physicians are not allowed on the same playing field as other small businessmen. As a result, patients are not given all of the potential information that they may desire to be conscientious healthcare consumers. This problem will only worsen if we head to a single payer or totally government run healtcare system.

If Mr. Johnson and those at HealthLeadersMedia.com really believe in the consumer model of healthcare, then they must be at the forefront of the effort to prevent our headlong dash towards socialized/government run healthcare. How responsive are the folks at the DMV? The post office? How much help or information do you get from the DMV, and how much time does it take you to get it? Do you really think that the system that runs government offices will generate a more consumer-friendly, transparent healthcare system --- when they will have absolutely no competition? The answer is less government involvement in healthcare, with a decrease in the Byzantine set of regulations we deal with. This would allow physicians to negotiate with hospitals, labs, insurers, employers, etc., to form more efficient and integrated models of healthcare delivery. Then both Mr. Johnson and I would be happy, because he would be better able to get the data needed to make informed healthcare decisions, and I would have more time to devote to patient-centered care.

I do have one other question, though. At 2AM, when you are sick as a dog and need an emergency laparotomy, how are you supposed to be a conscientious healthcare consumer unless you have spent a considerable amount of time in preparation, studying all of the available surgeons in town?

Brush up on your German

2009-02-17T10:31:00.008-07:00

I am not a "movie snob." I have a little talking statue on of Napoleon Dynamite on my desk, m'kay? But I must say that I enjoy a well made foreign movie now and again. No, I don't mind reading subtitles one bit, and kind of like hearing the actors speak in their native tongue rather than having some hack job overdub in English. Over the past several months I have had the great fortune of discovering four movies in German, and although they have literally nothing to do with medicine, I'd like to recommend them to anyone who is interested in movies that concern conscience and morality, and who understands the destructive power of government. All of these are available at Netflix, and all but "After the Truth" are available at Blockbuster.

Sophie Scholl (Die Letzen Tage) is a depiction of anti-Nazi resistance movement members in their last days in 1943. While their story may be well known in Germany, certainly it is worth telling to an American audience as a reminder of the true bravery of those souls who stand against the evil that men do to others, and of the price they pay. Well acted and well worth the time to watch.

The Counterfeiters (Die Fälcher) is another true story from Nazi-era Germany, this one told from inside a concentration camp where a hand-picked group of prisoners were forced to participate in the largest counterfeiting operation in history. This excellent film is based upon a book by one of the survivors, The Devil's Workshop: A Memoir of the Nazi Counterfeiting Operation, and won the 2008 Oscar as the best foreign language film. What struck me the most about this film is how well it portrayed a rather unsympathetic character who is able to eventually recognize the inhumanity around him and do the right thing when needed.

The Lives of Others (Das Leben der Andersen) is also an Oscar winner for best foreign language film, and probably one of the best movies I have ever seen. Set in the period before the fall of the Berlin wall and the collapse of the Soviet Union, this film explores the insidious way in which the continuous intrusion into the privacy of the populace -- an absolute necessity to maintain a socialist state -- destroys the souls of the spy and those spied upon. This is truly a great film; obviously, I'm in good company.

After the Truth (Nichts als die Wahrheit) is the most esoteric film on this list, and the one which has the least grounding in actual events. Imagine that the Nazi "angel of death" didn't eventually die in Brazil in 1979, but bided his time for a last chance at public redemption. I won't spoil it for anyone who wishes to watch this fascinating movie, but to have an elderly Mengele recount his deeds as "merciful," and accurately compare them to embryo experimentation, euthanasia, and the like is chilling. This is the kind of movie that should have gotten much wider distribution.

So, brush up on your German, or get comfy with subtitles. I promise you won't be disappointed.

The Hard Sell

2009-02-12T11:21:00.000-07:00

Amy Tenderich (@ Diabetes Mine) recently wrote a thoughtful post about the difference between referring to people as "consumers" or "patients" when they interact with the health care system. After I threw in my ill-conceived two red pennies, I started thinking about what the logical extension of the trend to label our patients as "consumers" would be. And, of course given the way my mind tends to work, what the far-fetched, illogical extension would be. This being America, I think we need look no farther than day-time teevee for the answers. After all, we approach consumers ........ with advertising!

Yep, I'm talking infomercials and TV pitchmen. I can see in the not too distant future these type of pitches.

"HI! BILLY MAYS HERE! IF YOU'RE HAVING PROBLEMS WITH HARD STOOL BUILDUP CAUSING DIVERTICULITIS, NOT TO MENTION HEMORRHOIDS, THEN YOU NEED THE AMAZING NEW BOHINEY BLASTER^® COLON CLEANSE KIT! USE THIS STUFF ON FILTHY BOWELS AND IT GETS OUT CRAP THAT'S BEEN IN THERE SINCE THE NIXON ADMINISTRATION! IF YOU'VE GOT THAT HARD-TO-GET-RID-OF ROCK HARD STOOL, THEN BOHINEY BLAST^® IT RIGHT ON OUT OF THERE! IT'S GOT THE POWER TO BREAK DOWN AND DISSOLVE: POOP, UNDIGESTED POPCORN, AND THE COIN YOU SWALLOWED PLAYING QUARTERS IN COLLEGE!

OTHER CLEANSERS HAVE TERRIBLE ODORS --- NOT BOHINEY BLASTER^®! IT HAS A FRESH BUBBLEGUM SCENT WITH A HINT OF MERLOT! USE IT IN THE COMFORT OF YOUR OWN HOME, OR CARRY SOME TO WORK FOR THOSE TOUGH DAYS! YOU KNOW HOW HARD IT CAN BE WHEN YOU'RE CARRYING A LOAD AND YOU HAVE A MEETING WITH THE CFO TO GO OVER NEXT YEAR'S BUDGET!

THIS STUFF HAS THE POWER OF A SMALL THERMONUCLEAR WEAPON, BUT IT CAN BE SENT TO YOUR HOME TODAY FOR ONLY $19.99 A BOTTLE. BUT IF YOU ACT NOW, WE'LL SEND YOU TWO BOHINEY BLASTERS^® AND THROW IN NOT ONE, BUT TWO OF OUR SPECIALLY PREPARED GRAB, YANK AND GO^® HOME HEMORRHOIDECTOMY KITS!

Hi! It's Vince from ShamSurgery^©! This is the self-surgery kit for the hernia. The perirectal abscess. The skin cancer. A regular surgery kit doesn't work wet. Not the new ShamSurgery^©! It works wet or dry, whether you're performing self-surgery in the shower or on your kitchen table! Doesn't drip! Doesn't make a mess! When you're done, you wash it in the washing machine!

Here's a big perirectal abscess. That is going to be a real problem for the average surgery kit. Look at this --- with the adjustable set of mirrors, you can get back there in no time and get to work. You following me, camera guy? No other surgery kit is going to do that!

You're going to spend $20 every month on doctor copays anyway. To me, the ShamSurgery^© kit is for everyday use! You get four ShamSurgery^© kits for $19.95. If you call now, you get a second set, absolutely free. That's eight ShamSurgery^© kits for just $19.95! It comes with a 10 minute warranty --- here's how to order!

Have you ever wanted to get that great, stretched-as-tight-as-Spandex-on-Roseanne Barr face lift? Well, I'm Ron Pepool, and I'm here to tell you today that your prayers have been answered! Today, we'd like to introduce you to the Robco Facial Carver and Dehydration System^®.

This is truly revolutionary --- a device that allows even the most casually interested homemaker to become a surgeon par excellence. Let's look at the inner workings of this fabulous product. The knives are stainless steel, and sharp! (Crowd goes Whoo!) Why, without this you'd have to get pure obsidian to slice your skin that swiftly. You can carve off 4 and 1/2 pounds of fat from your face, or two 2 pound neck rolls! When you're done, the patented Facial Dehyrator will let all that left over juice and blood from surgery drip into the special collecting pan (whoo!), all while causing your skin to contract like Shrinky Dinks in a blast furnace!

Now, a system such as this is worth at least $500, but how much do you think you'd have to pay for such fabulous technology, and where can you get the set? First, let's review what you get -- Robco Facial Carver and Dehydration System^® comes complete with a dozen stainless steel scalpels, a pair of sterile gloves, a dozen packs of suture, a Jackson-Pratt drain, and a one-size-fits-all facial burn dressing. Remember that the patented Facial Dehyrator is made of stainless steel-lined plastic, and comes with 3 reusable drip trays. So, how much is all of this worth? (A shout for $400). You know you're not going to have to spend $400! Not $375. Not $300. This revolutionary system can be yours today for just 4 easy payments of $39.95.

But wait! There's more! If you call today, we'll throw in the new Pepool Pocket Appendectomizer absolutely free. You know you'd rather be able to take care of a pesky case of appendicitis in the comfort of your own home than to head to an emergency room. This nifty device includes a veritable Swiss Army knife collection of tools, such as a corkscrew to stick into and lift the abdominal wall while you root around your belly trying to grab that little guy with the Robco Appendix Clamp. But you have to call now, because you know that this deal just can't last! (thunderous applause from the crowd)

Do you need surgery? Does the idea of forking over cash just to get that pesky coronary bypass out of the way irritate you? Well, for the last 30 years I have been working on ways to get YOU free operating room equipment! That's right! I went through all of the IRS documents, all of the Facebook pages of hospital CEOs, and every tax return filed in the past 75 years to make sure YOU get FREE SURGERY EQUIPMENT! How do you qualify? All you need is a Social Security number, $3,000 in annual income, and more gullibility than an Obama voter expecting a tax cut!

Tired of those other kitchen table surgery sets that get dull with use? Have a family member who is a little on the overweight side, and you just can't get down to the abdomen with your worn out, dull scalpels that constantly need sharpening? Well, YOU need the Ginsu Home Surgical Knife Set^™! It's the Sharpest Scalpel Set on the Market^™! Skin? Fat? Muscle? Bone? No problem! The Ginsu Home Surgical Knife Set^™ will cut through it faster than Plaxico Burress goes through an ammo clip with his 9mm pistol.

How many times has this happened to you? Your kids all need their tonsils out! You are trying to come up with an exciting new way to get them to let you operate on them! You could go the standard route, tie them down, give them a slug of Everclear, and get to work. But why bother, now that you can use Rodco's amazing new home surgical tool, the Super Tonsill-o-matic 76! Yes, home surgeons, the days of roping your family members to the kitchen table are over because the Super Tonsill-o-matic 76 is so fast and easy to use you just need to give them a sniff of glue to briefly stun them, and away you go! The Super Tonsill-o-matic 76 will grab and blend those puppies into mush in no time!

Consumers. Merchants. Customers. Providers. Bullshit.

I dusted off my diploma, and put on my reading glasses (getting old, dammit), and looked hard. It says that I graduated from The University of Texas Southwestern Medical School (AKA The Best Medical School in the Country®). I checked their web site, and no, it still does not call itself a Provider School, churning out "providers" who deal with "consumers."

Although I am a small businessman, and have the tax headaches to prove it, my business is different than, say, selling shoes. It is my privilege and duty to care for people who come to see me ---- as patients. There is a respect involved with that term which is absent from the term consumer, and which is important in maintaining the dignity of the individual as he or she interacts with physicians, hospitals, and other places where medical care is delivered. When we lose that perspective ---- when physicians are seen only as "providers," or interchangeable widgets, and when patients are seen only as "consumers" ---- we will have totally lost any semblance of dignity as a profession, and by extension as a people.

Shakin', Shakin', Shakes

2009-02-07T19:23:00.000-07:00

The shakes. The shivers. The heebie jeebies. The jitterbugs. The jimjams. The horrors. The screaming meemies. The blue devils. Snakes in the boot. The DTs. All are expressions that refer to a clinical phenomenon known as delerium tremens ---- delerium associated with alcohol (or benzodiazepine) withdrawal. Why, pray tell, does a surgeon care about alcohol withdrawal? Because I see it, and not infrequently.

I like a good martini now and then. I've even enjoyed a glass of Delerium Tremens beer recently (oh, it was good). But I am not in the category of an Olympic caliber drinker, one who consumes a fair amount of alcohol on a daily basis. The dedicated drinker is the kind of patient who causes all kinds of havoc for us, and not just in the realm of trauma.

Alcohol can be a wonderful thing. A social lubricant, a relaxing tonic, a stress reliever, an enjoyable companion with a good meal, and in some forms possibly a good thing for your heart. It can also be destructive, a massive earthquake that destroys lives and tears apart families. I'll leave the social issues about alcoholism aside for this post, but I'd like to let you in on a little secret --- alcohol withdrawal is not a glamorous downward spiral or a simple hangover. It is an ugly, depressing, and potential deadly process. Unfortunately, we often see this when we least expect it.

Not surprisingly, many folks are a tad less than honest with their physicians. Alcohol dependence isn't as readily detected as, say, hypertension, a heart murmur, gallstones or appendicitis. We don't have a screening test available, and we thus must rely on a patient to be as forthright as possible when we ask the question "how much do you drink?" For obvious reasons, most answer with a miniscule fraction of what their real booze allotment really is --- I trained in Salt Lake City, where this question was frequently seen as an insult, but alcoholism knows no religious boundaries and I was given false information just as frequently there as here in Colorado.

For surgeons, especially those who work on the GI tract, an alcoholic can pose a vexing challenge. Basically, when a patient that overindulges regularly is hospitalized, the pint of vodka he usually downs on a daily basis is not readily available. For short hospitalizations of a day or so, this will generate irritability, nervousness, and shakiness ---- all relieved with a stop at the package store on the way home. For longer hospitalizations, it gets progressively worse, with nausea, headache, insomnia, excessive sweating, tachycardia, tremors and a variety of involuntary movements (such as constant picking at clothes, skin, and sheets) joining the display. This is the point where we generally pick up on the diagnosis --- basically the patient has the shakes.

A fault runs through the valley
It's long as it is mean
It starts to tear into the earth
And gets all in between
It shakes up through the mountains
It shakes down to the sea
It shakes up to the volcano
And then it starts to scream
And then it starts to shine
And Lord, it makes me tremble
And Lord, it makes me tremble
It's shakin' and shakin' and shakes

By this time, without a quick infusion of a couple of stiff drinks, the patient is well on his way to full blown withdrawal, marked by profound agitation, hallucinations, fever, convulsions, severe autonomic nervous system overactivity, and possibly death --> delerium tremens. We treat this by making a bargain with the patient's body --- if we give enough sedation, generally in the form of Ativan or another benzodiazepine, hopefully we can stave off the severe physiologic effects of alcohol withdrawal until the process passes. The tradeoff is that the patient must be pretty snockered, meaning ICU care, careful monitoring, a need for restraints, nutritional support, and a risk for aspiration. More severe cases may involve mechanical ventilation, particularly in the patient who has undergone major surgery or suffered severe trauma. Beta blockers and Clonidine also help mitigate the systemic effects of alcohol withdrawal, and though it seems a little bizarre, IV ethanol infusion has been used as an alternative to benzos.

Needless to say, it is often the case that alcohol withdrawal is often far worse than the other underlying reason a patient is hospitalized. It is also a big expense, one that is rarely reimbursed.

And Lord, it makes me tremble
And Lord, it makes me tremble
She's shakin' and shakin' and shakes

Throwing the Challenge Flag

2009-01-25T13:26:00.001-07:00

This is the worst sports weekend of the year --- everybody is waiting for the Super Bowl, and it ain't happening. Sure, I'll catch some of the NHL All Star game (full disclosure, my brother works for an NHL team), but I'm really jonesing for the big game. No party for me; I'll be serving the community on Drama Call.

Football has changed a lot in the past few years, and one wrinkle I'm not sure I like is the ability to challenge a call. Seeing a grown man throw out a little red hankie on the field is, well, unmanly. It sort of reminds me of old westerns with the town harlot sitting on a piano, dressed in red and black lace, twirling a red boa.

Maybe I'm not a fan because I have to deal with a couple of similar "challenge flags" in my line of work. Once or twice per month, I have a conversation with a new patient that includes some version or another of this phrase:

I have already talked to another surgeon, but I wanted to hear what you have to say.

Really what this means is:

I just want a second opinion.

In other words, the patient is throwing a challenge flag. He doesn't like, doesn't trust, or simply is preconditioned to want more than one physician's input into his problem. This, to me, is generally no big deal.....as long as I know that this is the case. It is disconcerting to hear this well into the visit, rather than at the beginning. (image source)

Honesty is truly the best policy when speaking with a physician. You see, we can cover a lot of ground in a conversation that is needless if a patient has seen three other physicians for the same problem, and already has a grasp of the situation. It is difficult for me to carefully go through a disease process, its ramifications, its treatment options, and potential complications of surgical options in detail when the patient across from me acts impatient because, well, it's all old hat to him. If we can establish up front that the patient already has heard, and understands, the basics, we can focus more closely upon options and answer questions that have prompted the idea of getting another opinion.

What motivates patients to seek alternate opinions? There are a couple of broad categories.

The patient truly has an unusual or complex problem, and the surgeon he sees freely admits that while he can deal with it, the issue at hand is not one he sees commonly. Cool, most docs have no issue with this.
The patient is uneasy with, or doesn't care for the surgeon he is sent to see. I'll be honest -- I would much rather that a patient is comfortable with his surgeon than take offense that he or she doesn't like me. Patients should feel comfortable with the guy that has to open them up and rearrange their insides --- if they are not comfortable with me, they will be best served by seeing someone else.
The patient has been told, through family, friends, the media, etc., that "you must always get a second opinion before having surgery." Realistically, for most things, this is unnecessary, but I understand the way that some folks have been conditioned.
The patient has "issues." This is a patient that is fairly difficult to deal with, as they trust no one in a lab coat, feel that physicians are simply out to make a pile of cash hurting people, and tend to believe in conspiracy theories. To say the least, they don't tend to have good outcomes (from their standpoint), regardless of whether their surgeon is Michael DeBakey or Jack the Ripper.
The patient was caught like a deer in the headlights at their first appointment. Sometimes, processing information, particularly difficult to understand or potentially devastating information, is a real challenge (for everybody). I don't mind a bit being the physician that needs to simply reiterate what the first surgeon told the patient, and hopefully reassure them that they are getting the best and most up-to-date advice possible.

My rule of thumb in all of these situations is to offer an opinion. Not a second opinion. Just my opinion, unedited and, as much as possible, unswayed by the information they have gleaned from a prior surgeon. If my opinion jives with what their first surgeon told them, I let them know that they have received good advice, and that I certainly have no magical store of knowledge not available to other surgeons. If they like me better, great. If not, great.

We get into trouble with asking for second opinions in urgent or emergent settings. GruntDoc and the docs at EP Monthly can probably tell a few tales about this. If you are in an ED, and you don't have an established relationship with a surgeon, and you need an operation, it's pretty dang hard to get another surgeon who is not on call to come in and see you if you don't like the recommendations given by the surgeon who is on call. I cannot recall in 15 years of practice an instance when this was requested by anyone other than a patient with "issues." Most folks in an ED who need urgent surgery are well aware that they are sick, and are happy to have a general surgeon available to care for them ---- any port in a storm, so to speak.

On the other hand, the patients with "issues" tend to have well-established track records of firing a number of doctors. In smaller communities, that means that they run out of surgeons that are able to care for them on an emergency basis, and occasionally have to be transferred. Just as Al Davis has a difficult time now finding top tier coaches to hire, these patients have fired so many physicians that they have no other alternatives. This is less than ideal for all concerned.

What about when doctors throw the challenge flag --- at each other? We all hope that when we disagree with the diagnosis or treatment of a patient, it can be handled professionally. Realistically, there are few instances when we have substantive disagreements; generally we will only quietly argue over a fine point or two. The arena of peer review, which is well beyond the scope of this post (and could take up an entire book), is where we go through the painful process of retrospectively evaluating the merits of a particular surgeon's decision-making and care when there are substantive disagreements.