Monday, February 25, 2008

Top 10 Doctor Movies

The lovely and talented SWIMBO convinced me to watch the Oscars last night. Sort of interesting, because the last time I watched, Daniel Day-Lewis won for Best Actor. Anyways, it got me to thinking --- with all of the "top ten" lists wandering around in cyberspace, there doesn't seem to be one for doctor movies. So, without further ado, here is The Aggravated DocSurg Top 10 list of movies about or otherwise concerning doctors:

10. Master and Commander -- Paul Bettany was cast well as the ship's physician in this well done movie which didn't get as much praise as I thought it deserved. There's a gruesome amputation scene and another where the surgeon must operate on himself --- that's enough to put it on the list in my book.

9. The Last King of Scotland -- This movie won Forest Whitaker an Oscar for Best Actor (deservedly), but James McAvoy's portrayal of a young, idealistic yet opportunistic personal physician to Idi Amin is superb.

8. The Hospital -- This movie does not hold up well, unless you are terminally trapped in an early '70s mindset, but George C. Scott's performance is magnificent. It's worth watching just to remember what a great actor he was.

7. The Andromeda Strain -- Written by a doctor (Michael Crichton), with a "medical" theme that is well done and certainly better than many of its imitators. While not as good, another sci-fi flick from the same era that merits mention is Fantastic Voyage --- if only for the fact that it has Raquel Welch prominently displayed in a wet suit.

6. Alien -- technically, since he's not human, I suppose Ian Holm's character "Ash" isn't a doctor, but he certainly is the ship's medical officer. Besides, it's a great depiction of parasitology -- so good, that one of my professors at the country's best medical school , an infectious disease specialist, used its now-familiar scene to introduce his lecture on parasites.

5. Malice -- This movie has over the top acting, a confusing plot at times, and one of my least favorite actors on the planet. It also contains the only scene in any movie that made SWIMBO almost cough up her popcorn --- when, in a ridiculously darkened OR, the nurses clap (CLAP!) after the surgeon finishes a difficult case. But it has a devilishly good streak of revenge, and one simply cannot go wrong spending two hours gazing at Nicole Kidman.

4. The Painted Veil -- I thoroughly enjoyed this movie; a bit of a tear jerker, to be sure, but a beautifully filmed story of love and loss, with the background of an English bacteriologist dealing with cholera in Shanghai. Great acting, beautiful scenery, and a good story.

3. M*A*S*H --- what, you think I'd leave off the list the most irreverent look at surgeons ever put on film? Great, if dated flick, with at times a pretty fair depiction of "surgical humor." And lines like these are classic:

Capt. Peterson: What are you two HOODLUMS doing in this hospital?
Hawkeye: Ma'am, we are surgeons and we are here to operate. We just waiting for a starting time. That's all.
Capt. Peterson: You can't even go near a patient until Col. Merrill says its ok and he's still out to lunch.
Trapper John: 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.
[turns to Hakweye]
Trapper John: Ham and eggs will all right.
[turns back to Capt. Peterson]
Trapper John: Steak would be even better. And then give me at least ONE nurse who knows how to work in close without getting her tits in my way.
Try saying that in a hospital today! Somehow, I suspect you'd be on your way faster than you could say "incoming!"

2. The Doctor -- this movie had me sold on it in the first few minutes, as William Hurt waltzed from OR to OR, being serenaded by Jimmy Buffett on the stereo. Been there, done that. And, unquestionably, there are times I have been just as self-assured and arrogant as he was at the start of the movie. This is a great movie, IMHO, for every physician to see.

Now, of course, comes the moment you have been waiting for..... the Aggravated DocSurg's number one doctor movie:

1. Doctor Zhivago -- what!? Look, it's one of the top 10 movies ever made, in my opinion, and, well, he is a doctor! Plus, it has that most important "Aggravated DocSurg ingredient" -- Julie Christie! I grew up watching this movie every year on TV, and never tired of looking at her eyes.

So, what have we learned here? Not much, except that I fully admit I can't take my eyes off Julie Christie or Nicole Kidman. There is a simple reason for that:


(And I am a lucky man)

Any movies I missed? And, please, do not add Patch Adams to the list!

Tuesday, February 19, 2008

The Michelin Man, The Balloon, and the Harpoon

You know how some folks get when they see a pile of bubble wrap? They are drawn to it like Odysseus was drawn to the Sirens, can't keep their hands off it....pop, pop, pop, pop, pop.....Such is the case with subcutaneous emphysema.

SQ emphysema is kinda cool, unless you are the one with the problem. Basically, it occurs when air escapes from some portion of the respiratory tract and instead of staying within the chest cavity, it works its way into the subcutaneous tissues. I see this most frequently with blunt trauma to the chest, which causes a tear in the lung or even part of the bronchial tree. The air can track along the chest wall, into the neck, and even down along the abdomen or up into the face. With each breath, more air can escape, and in some cases the patient starts to look like Bibendum.

So, what's the deal with bubble wrap? Well, pressing on the area of SQ emphysema yields a crunchy but soft sensation .... sort of like popping bubble wrap. It can be for some sort of irresistible; since we don't see it every day, all of the students or young staff in the area wants to see what it feels like. The technical name for this is popping sensation is crepitus, but that term covers a wide variety of other processes that generate a vibratory and auditory sensation under the skin. (Image from Learning Radiology)

As dramatic as SQ emphysema in a trauma patient sounds, in many cases it can be an indicator that the patient's respiratory status will be OK, at least for a short while, without an immediate chest tube insertion. This is because the air that is leaking is making it's way out of the chest cavity. When air leaks from the lung or bronchial tree into the chest, and the leak persists with each new breath, then we've got a problem. In that situation, the air that escapes has nowhere to go, and starts taking up so much space that the lung has no place to expand into.....more air leaks with each breath, taking up more space with more built-up pressure, making the lung collapse further, and so on, and so on, etc.

And so on, up to a point where the lung is completely collapsed, the pressure in that half of the chest cavity is pretty great, and it starts to push the heart aside. This then prevents the heart from filling with blood (remember, the return of blood to the heart occurs via a low pressure system). Voila! You now have a perfect recipe for a cause of rapid death in a trauma patient: a tension pneumothorax. It's sort of like an over-filled balloon that needs to be popped.

Treatment for a tension pneumothorax, or a patient with SQ emphysema who has an associated pneumothorax (most often the case) is pretty simple and one of the most gratifying procedures in a surgeon's toolbox: put in a chest tube. It can be done quickly, and can be a life-saving maneuver. In the case of a tension pneumothorax, the amount of pressure present can be surprising, and I have had my hair blown back on more than one occasion upon getting into the pleural cavity. You sort of feel like a whaler, throwing a harpoon to finally put down Moby Dick, with the exhilaration of the chase and the wind in your hair raising your heart rate more than a few beats per minute.

Now, I know that most of you will (fortunately) never get the opportunity to harpoon a tension pneumothorax or pop the bubble wrap of SQ emphysema. But, here's a little substitute if you'd like to live vicariously through the trauma team. Have fun!

Oh, cr*p

As the state of Colorado returned to single party rule -- the party in the pocket of the trial lawyers -- my first prediction was that the malpractice caps that have been in place for many years would soon be flushed like used toilet paper. I hate being right.

There's simply no reason to continue to rehash the arguments against such a boneheaded move --- those who believe that an unfettered right to sue anybody, at any time, for anything, with no repercussions rarely are willing to have any type of discussion on the matter. Given the tone of those pushing this legislation, however, it does appear that we're headed back to the 70's....higher taxes, a trial lawyer lobby in complete control of the statehouse, etc. To quote the that staple of '70s radio, the Carpenters, what they are telling the physicians (and taxpayers) of Colorado is that "we've only just begun."

Crap. Maybe I need to get a license application from a more physician friendly state. Or, I could just call it a day and become a Wal-Mart greeter.