Monday, November 09, 2009

Are You With Me, Dr. Woo?


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:
  1. Are you with me Doctor Woo?
  2. Are you really just a shadow of the doctor that I once knew used to see?
  3. Are you crazy? Are you high? Or just an ordinary guy (with no medical degree except one that came from a online training course)?
  4. 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?!!
  5. 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.

Friday, October 30, 2009

Bastards

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

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.

Wednesday, October 07, 2009

How Doctors Think? Oh, my...

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.

Saturday, October 03, 2009

Calling for Reinforcements

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.

Wednesday, September 30, 2009

Hic Sunt Dracones

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:
  1. 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.
  2. 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).
  3. 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.)
  4. 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!

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.

Tuesday, September 22, 2009

The Not-So-Accidental Tourist

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.

Thursday, August 06, 2009

The Gates of Fatherhood for a Surgeon


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:

Friday, July 31, 2009

ὕβρις

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.

Wednesday, July 22, 2009

Rosetta Stone, Medical Edition


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!

Monday, June 08, 2009

I see Jimi in the mirror!

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.

Wednesday, June 03, 2009

Trite but True


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.

Tuesday, June 02, 2009

CMS : Flying Against the Headwind of Reality

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.

Tuesday, May 19, 2009

Doctor Death

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.

Friday, April 24, 2009

Publish or ... get tattooed by your department


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.

Thursday, April 23, 2009

How Low Can You Go?

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?