Monday, July 31, 2006

What Your Doctor Didn't Learn in School

Several years ago, my mother-in-law gave me a book called "What Your Doctor Didn't Learn in Medical School," which contained all of the usual arrows shot at doctors and hospitals with salvation offered in the form of nutrition (of course, what is not included in the book is how there seems to be an endless supply of these cure-everything diets; the author even has --- I know you'll be shocked -- published two different diet books; which one do we follow?). I'll leave it up to Orac to debunk all of that stuff.

It remains true, however, that there is a whole range of things your doctor didn't learn in medical school --- or residency, for that matter. That is why every physician must see himself/herself as a perpetual student. Many times, the education we get does not come in the form of Continuing Medical Education courses, lectures, or journals --- it's good old-fashioned learnin' on the job! Sort of makes one feel a bit like Jethro Bodine in his quest to be a brain surgeon.

The problem is that when a physician sees patients with a lot of chronic medical problems, sorting out the best way to care for them is not always straightforward, and there are no treatment algorithms available in textbooks for them. As an illustration, here are a few patient scenarios I have seen in the past week:

  • >> 65 year old man with a very symptomatic hernia. Pretty simple? Actually, he smokes 2 packs a day, has had 4 (yes, four) MIs, had a coronary bypass with porcine aortic valve replacement and is therefore chronically anticoagulated....Avoid him like the plague, you say? Operate on him on the day before Armageddon, so the postop complications can be avoided? Hey, the guy has symptoms with his hernia, and although he's not a great surgical risk, we can mitigate many of his risks with appropriate perioperative care (for which Medicare does not reimburse) and get him through this without too much difficulty.
  • >> Morbidly obese (>300 lbs) man with recurrent diverticulitis and a recurrent incisional hernia; somebody in some other state did his initial colon resection and initial (soon to fail) hernia repair. Add a dash of sleep apnea and a pinch of hypertension into the mixture. Hopefully he will not need emergent surgery, as bringing up a stoma in someone with his abdominal girth is an exercise in frustration, and repairing his hernia is an exercise in futility.
  • >> 60 year old lady from Mexico who gets some of her care there and some here; some from regular physicians, some from "alternative" therapy providers. Presents with profound anemia and a sigmoid colon tumor, and a prior history of a hysterectomy for "cancer" in Mexico --- despite the lack of HIPAA laws in Mexico, there are no available records. Undergoes surgery and then chemotherapy......and then disappears to pursue what I don't exactly know. Shows back up two years later with a tumor in the pelvis, seen on studies done in Mexico ---- is this recurrent colon cancer or recurrence of the still-unnamed GYN malignancy? Should it be surgically removed, radiated, or treated with chemotherapy? Going through the options is difficult when dealing with translators.
  • >> Healthy middle-aged man who undergoes a "shave" biopsy of a skin lesion by his primary care physician. It shows melanoma, but because the excision is incomplete, the margins of the lesion are positive for melanoma ---- what is the stage of this tumor? That is a question that will nag both the patient and I, as there is now no longer a way to determine the stage.
  • >> Middle-aged man with oh-my-God worsening pulmonary insufficiency and pretty severe gastroesophageal reflux. It's pretty clear that his reflux is contributing to his lung situation with silent aspiration, but how much improvement will he see if he undergoes an antireflux procedure? 10%? 50%? Zero, with only maintenance of his current level of disease and no improvement? Anybody's guess.
  • >> Older gentleman with such severe COPD that he was turned down for cataract surgery (that's pretty darn bad) who shows up in the ED with a perforated viscus. He needs emergency surgery, but he's not a good candidate for a haircut, much less a laparotomy.

And so it goes. These are the types of patients who continue to teach me, to push me to think long and hard about the best way to care for them. The lessons learned are not always easy for the student or teacher. While there are lots of patients who see me with straightforward problems who have an uncomplicated operation and move on, the other ones are the patients that give me plenty of fodder for thinkin' and learnin'.

Sunday, July 23, 2006

Aggravated DocSurg Public Service Announcement #1

For those of you who missed out on a few lessons in physics and biology, here is today's little tip to help you from ending up in my ICU:

............


Any questions?

Wednesday, July 19, 2006

Tick, tick, tick.....

Ticking away, the moments that make up a dull day...

Time.

It's a mercurial thing -- never seeming to go fast enough when you need it too, and all too short for the majority of folks on the planet. And yet it plods along, dragging us along for the ride. I often feel that time is less like the sand slowly falling in an hourglass than a whirlpool sucking me swiftly down while I'm desperately trying to grab hold of any piece of driftwood to let me catch my breath. I know I'm not alone -- all of my brothers (none of whom were silly enough to go into medicine) feel that they never have the time to finish the day's work and still spend a few quality hours with their kids either.

But for the surgeon, there exists a place where time seems to run as slowly as the words coming out of a Southerner's mouth. No, it's not in the OR, which is generally a pleasant place (for me) to be. It happens when you are not sure if a patient is going sour or will be OK. It happens when a complication occurs, and you are waiting to see if the remedy you provided is the right solution. It happens when you have done a major, complicated operation on a fragile patient. It happens, in most cases, in the dead of night.

This is the part of surgery that largely goes unspoken --- the worry that is involved with caring for sick patients. Most of the time, the operations I do are "routine," although nothing is ever routine about surgery for patients. But certain situations generate enough worry to make me feel as if the devil himself has taken up residence in my stomach, stoking the furnace of hell. The profound uneasiness that comes with taking care of the acutely ill is something that I have never been able to fully conquer. Maybe that's good --- I'd hate to think that I would ever not worry about a sick patient --- but it doesn't seem to be beneficial to my sleep deficit (nor to my graying scalp).

I'm sure I have kept SWIMBO up many a night, rolling around in bed in a fruitless search for a few moments of peaceful sleep. The clock silently progresses, but never with the speed needed to get me to morning with my sanity intact. The sleep I do get is fitful, and every time I rise to the surface of consciousness the apprehension starts in again, pounding its fist on my forehead to remind me that the time for fretting has not yet ended. There is little else to do; just as it takes time for water to boil, it takes time for patients to "declare" themselves, either improving or not.

In the vast majority of cases, all the anguish turns out to be a long night of self torment, and the patient does just fine. But the need to worry never changes, because not every patient sails through their hospitalization without a few squalls, and correcting their course early is critical to prevent catastrophe. And so I fret. I brood. I stew. I agonize. I worry. Because, as my old program director once told me, "...that's what a good surgeon does. Nobody knows what went on in that operating room except you and God, but only you can correct a problem."

Sunday, July 02, 2006

i-Trauma

As I have said before, I really prefer to have good music playing in the OR --- at least, what I would call good music. I have finally caught up with the rest of civilization and bought an i-Pod, one of those huge 60 gigabyte monsters that will play at random for days on end. So far, I have loaded about 8 days worth of music, which pretty much assures a wide range of songs to play as we while away our time in the room with no windows. Don't like the song that's playing? Just wait a few minutes.

I have to admit that much of my misspent youth was devoted to listening to music, something which has carried over to the present day. Records, cassette tapes, and concerts (including the requisite t-shirts) consumed a lot of the cash I generated in high school. I’m sure that engendered a severe character flaw, or at least a personality quirk the size of Gibraltar, that compels me to “connect” everyday things to song titles and lyrics (and also makes me quote movie lines, and obliges me to fill in any crossword puzzle in sight, etc…). If you want to know how my brain sometime’s ticks, I’d like to take you on a musical tour of a shift on trauma call, courtesy of some of the songs on my i-Pod (yes, all of these are on my "OR Music" playlist --bonus points for those who know the songs without hitting the links) ---without further ado, If You Want Blood (You've Got It):

Morning has broken, and the first page of the day leaves my pager all shook up. “I’ve still got the night in my veins,” I tell The Doctor in the ED. What's the matter here? It turns out it’s a typical situation; she was only sixteen, and decided to try drive the new roundabout at the speed of sound. Trouble is…. she had also been drinking a bit of some strange brew all through the long night. “A bit banged up, black and blue,” says the ED doc, “but watch out. She’s a piece of work. So’s her mother -- who wanted me to make sure you knew she’s waiting.” Hold on! I’m comin’!” I tell him, knowing I need to get some java in my system to stop the Shakin’ shakin’ shakes before heading to the ED.

In the trauma room, I find a blubbering teenager who has just enough of a concussion to perseverate like an alcoholic on a three day bender. O my God,” she says, over and over. Mercy mercy me,” says her mother, “does she have brain damage?” I assure her that her daughter has a minimal concussion, and needs to be with us for just another day. For now, it’s all over but the crying, and after looking her over I leave the two of them, her mother searching for divine intervention.

Seeing my half-empty cup, the ED doc asks “How bad’s the coffee? “Oh, man, bottom of the barrel mud here – it’s powerful stuff. Drink it too fast and you’ll get a rush of blood to the head.” Truth be told, I had lost my appetite for the coffee; this scenario always carries a sickening sense of déjà vu for me, and I fear this girl may be stupid enough to do it again. Love is the drug” I want to tell her mother, but am never too sure that is the right thing to do. Perhaps what they need now is A little less conversation, and a little Time in front of the deep dark truthful mirror. “Admitting orders are written,” I tell the clerk. I think I’ll disappear now.”

So off I go, thinking I can finish morning rounds. What a brilliant mistake! I guess I couldn’t call it unexpected, as the day was shaping up to be black friday. Tell the truth” says the ED doc, “you didn’t think you’d get one clear moment today, did you?” “I’m tired of the waiting,” I tell him, “just give me the Lowdown.” Turns out we have our second MVA of the day, but this one’s a bit worse. Two passengers rockin’ down the highway after a large time in the wild west end. “The driver is All F**ked Up, and we’re walking a tight rope with his respiratory status. His spooky girlfriend is more stable, and is on the road to find out what’s wrong with her over in CT.”

Sigh. Inside I let out a silent scream. Sure enough, the driver is a whiter shade of pale when I arrive, not moving much air, looking like he’s knockin’ on heaven’s door. One thing leads to another, and soon he’s intubated and lined, and we are the proud recipients of a chest X-Ray demonstrating a hemopneumothorax. Feeling like the king of pain, I put in a big chest tube. BP is better, but not great, and we’re doing the trauma room Lido shuffle, pushing fluids and then blood. By this time, we have a great ultrasound image of a bucket of blood in his belly. “It’s the end of the line down here,” I tell the ED crew. “Let’s head to the OR or we’ll be dead in the water.”

I decide to take a shortcut through the CT scanner to take a quick look at the girlfriend‘s wonderful, a repeat customer! Hello old friend,” I say upon recognizing her – this would be the third time I would admit her after a DUI incident. What’s wrong with this picture?” “Oh, doc, I’m crapped out again!” Typical Junkie’s Lament. “Look,” I say, “I just need to know what you, your Little Toy Brain, and your boyfriend were drinking or taking last night.” “Honest, doc, all he had was one bourbon, one scotch, one beer!”

Upstairs in the OR the room is hot, the lights are bright, and the scrub is ready with the Freezing Steel. Young Mr. Spaceman has a nice collection of trauma Souvenirs – a shattered spleen, a perinephric hematoma, and a segment of devascularized small bowel. The spleen hits the bucket, the kidney looks OK, and the anesthesiologists asks “What’cha gonna do about the small bowel?” “I’m going to do what is the least complicated – take out the bad piece and then staple it together. Then it will be time for this case to be over.”

By now I’m (un)comfortably numb. One of these days, I’m going to have to find some other career opportunities, as I’m not sure I’m tuff enuff to keep doing this for much longer. Fortunately, after tucking the two lovebirds into bed the trauma gods let me catch up for the rest of the day, even catch a few Zs in my sleeping bag. When I roll over and catch a glimpse of the clock at 5AM, I think it’s all over now, baby blue. No Such Thing, says my pager. Why get up, I wonder; getting up at this hour is always the hardest part of trauma call for me.

After a wild night of drinking, my newest customer is a middle aged guy who just found out what it feels like when the bullet hits the bone. But he’s the lucky man, because although the bullet busted up his femur, all of the nerves and vessels are intact. By the time I have arranged for the orthopod to see him, it’s time to start making morning rounds again! “Try to get the bullet,” I tell the pod. “The cops would like the evidence.”

And so it goes. The rest of the morning is spent playing catch-up, checking on all of the patients in the hospital, and then a day in the office. By the time 5PM rolls around Swimbo pages me to give me one last message for the day: "You better be home soon." I guess I'd better -- or I get to be the next patient in the trauma room.