Friday, September 26, 2008

Unwelcome "Tiny Bubbles"

So, the big debate is on right now, and as I would rather not start blasting my TV with an over/under 12 gauge, I thought I would do a little random typing. About poop. And urine. Sort of what has been being flung around with glee during this political season.


As I may have stated before, I don't really go in for much of the esoteric when reading surgical journals --- just give me a straightforward presentation, preferably of a condition I am likely to encounter, and add something to the available data at my disposal. Here is a nice example -- Management of the Bladder During Surgical Treatment of Enterovesical Fistulas From Benign Disease. I know, the title alone is enough to drive the average person --- let alone an internist --- to sleep without a hot toddy, but indulge me.

An enterovesical fistula is basically an unnatural communication between a piece of the intestine and the bladder. EEEEWW! That's right, it allows poop and gas to pass from the inside of the bowel to the bladder. Its presence is heralded by recurring Oh-My-God urinary tract infections and somehing we physicians euphemistically refer to as "pneumaturia." Yeah. Google that one and then squirm a little bit, why dontcha. Let's just say that while urinating it makes one sound like a little kid blowing bubbles in the bathtub. "Tiny Bubbles" they may be, but certainly not the kind Don Ho sang about.

Why on God's Al Gore's green earth would somebody develop an enterovesical fistula? Three main reasons: cancer, inflammatory bowel disease, and diverticular disease. Since this article is about non-malignant causes, let's deal with cancer first and then ignore it from here on out --- basically, a tumor (usually colon) can erode from one hollow body part into another, setting up an abnormal communication.

Inflammatory bowel disease is another matter altogether. This name encompasses two conditions, Crohn's disease and ulcerative colitis, only one of which is associated with enterovesical fistulas ---- Crohn's, which is described in great detail here. Suffice it to say that the intense inflammation in Crohn's can result in abnormal communication between a loop of bowel and another loop of bowel, the ureter, the skin, the bladder....... Not pleasant, and in some patients it is a true scourge.

Diverticular disease of the colon is quite common, and can result in enterovesical fistula development due to episodes of diverticulitis (Lord help me, but I cannot type that word without thinking of Joe Piscopo and Robin Duke - "But we've got di-ver-tic-u-LI-tis!"). This is the most common cause of an enterovesical fistula in my practice, and I see about 1-2 cases a year where there is bladder involvement with diverticular disease.

The mainstay of treatment for an enterovesical fistula, everyone agrees, is to "remove the offending organ." Simply put, take out the piece of intestine causing all of the aggravation. The bladder is an innocent bystander here.....but, you know, when you take out the loop of bad bowel, there is a hole left there in the bladder. What is the upstanding surgeon to do with it?

Well, the bladder is part of a fairly low pressure system --- unless you really, really have to go. Drink a little coffee, and soon urine trickles from the kidneys down a pair of thin tubes called ureters into a reservoir that will expand (up to a point, depending on one's tolerance) to accomodate it. This is not like the arterial system, where blood is forcibly pumped through muscular arteries. So, some would say just leave a catheter in the bladder to keep it decompressed for a while and let things scar down. We do this in trauma settings when patients have a ruptured bladder..... but not when the bladder has ruptured into the free abdominal cavity. Others, including me, don't really like to see a hole, well, just left there for everybody to see! And so, my habit has been to close it with a few absorbable sutures, and leave a catheter in for about a week. It's an approach that has always worked, so why mess with it, right?

Well, these nice folks noticed that there was this minor discrepancy in practice patterns, and decided to retrospectively look at the outcomes of 74 patients over an eight year span. Basically, they found that regardless of the approach, as long as there is no huge defect in the bladder that mandated closure, simply leaving a Foley catheter in place for a week is all that is required. Simple, no muss, no fuss.
Oh well, I've wasted enough time, and hopefully have saved my TV from destruction again tonight. But there are two more of these debates, so SWIMBO will have to hide the shells.

Saturday, September 20, 2008

A Cultural Chasm

Kevin, M.D. recently highlighted an article in the Washington Post by a physician which outlines the difficulties faced when physicians and hospital administrations collide. It is an interesting take on things, and is, on balance, rather balanced. While pointing out the problems administrators face from a financial standpoint, it also describes the vexing issue of striking the right balance with a hospital's physician workforce. Appropriately, the author draws out some key distinctions between the physicians and administrators involved:

It's a basic cultural divide, says David Nash, a physician who is chairman of the department of health policy at Thomas Jefferson University Hospital in Philadelphia. Doctors, he told me, have a "single-patient worldview with a focus on clinical culture which emphasizes autonomy," while administrators have a "management-culture focus that emphasizes teamwork and integrated worldview."
OK. I can buy that. There is no question that physicians are taught from an early stage to emphasize that the care of their patient(s) is paramount. And when push comes to shove, that is where my allegiances always will stay. I think patients probably want us to act that way, but I also understand that sometimes this can be taken to extremes --- fighting to keep outdated medications or equipment when other, more cost-effective alternatives are available, because "I have always had success with this" is an anachronistic attitude in today's cost efficient hospital. However, I would argue that many times administrative decisions adversely impact patient care, and it is my responsibility as a physician to fight against those decisions.

What to do? The article proposes that physicians bear the brunt of the responsibility here.
The solutions to these kind of problems are not taught in medical school. Physicians have little training in management and teamwork skills, says Kenneth H. Cohn, a practicing surgeon and an author of "Better Communication for Better Care: Mastering Physician-Administration Collaboration." He says that strategies such as structured dialogue and inquiry that avoids finger-pointing can help.
In a word, bullshit. I am sorry, but I do not think that "structured dialogue and inquiry" means anything other than sitting in meetings with administrators on my time while they decide whether or not my opinion is worth listening to. Sorry, been there, done that, have the bald spots and gray hair to prove it. Going to meetings is what they do, it's what they get paid for --- it's all a donation of a (large chunk of) my time without reimbursement, and in my experience my input gets relegated to the circular file. And why is this only our responsibility; don't administrators need to move a bit as well to achieve harmony? We don't have a cultural divide, we have a chasm the size of the Mariana trench.

IMHO, one of the most important differences between the physician and administration cultures is one of commitment. I tend to view top level hospital and hospital system administrators as a series of revolving temps; at times it seems that our top management is nothing other than a bunch of Kelly girls. It is hard to have a "structured dialogue" about plans for a big institution with people who have been here a short time, and who will be looking to leave before the next new moon. One hospital nearby me is getting its fifth CEO in 14 years. That's not the type of long-term commitment that is exhibited by the physicians and staff at that facility, those that have a stake in its long-term viability and quality of care delivery.

Here is my terribly biased and profoundly unfair portrait of this type of hospital system administration:

OK, I know, that's simply ridiculous. But I use it to make a point. If administrators are interested in having a "structured dialogue," and want physicians to undergo "training in teamwork," perhaps it would behoove them to take some of their unpaid time to do a few things that would open their eyes a bit:
  • Spend every Friday night with the 11PM-7AM shift in the ED for a month
  • Follow a patient from the ED waiting room, to the ED, to the CT scanner, to the OR, and then to the ICU
  • Show up at the scheduled "start time" in the OR, and then spend a few days sorting out why "start time" is always in quotes
  • Stay up most of the night with a physician on call, receiving all of the same pages, getting out of bed to go see patients, and then go to that "dialogue" meeting at 7AM.....and then to the office to see a full day's load of patients
  • Go to one of the wards at 2AM to find out where the nurses get something to eat on a dinner break when the cafeteria was closed at night due to budget cuts
  • Make rounds in the ICU, and find out how many nurses don't always get a meal break, as they must cover more than their own patients as other nurses cart the critically ill down to radiology
The administrator who does some of these things gains a perspective that cannot be gleaned from reading or listening to reports in the comfort of a boardroom. He also gains something far more important, I would hope --- the respect of the staff working at the hospital, and an understanding that a long-term commitment to success is a better approach to make a hospital (or system) successful for the long haul. That guy I would "dialogue" with.

Black Holes, Alternate Universes, and My Belly Button

Even though I have not followed the news closely, I can personally attest to the fact that the Large Hadron Collider has been completed and turned on. Finely tuned into the universe as I am, I have been able to feel its effects......rather keenly. This behemoth of scientific wonder is thought to be capable of, among other things, creating little black holes and finding alternate universes. It seems that in recent weeks I have toured those alternate universes: I have taken one Surgling daughter to college, and then another to my alma mater for a college visit.

There was no single emotion felt when my oldest child -- a daughter, no less -- was left behind as SWIMBO and I drove away. Love, fear, depression, joy, pride, and an overwhelming sadness that defies description. My little girl isn't, well, my little girl any more. As I drove away, the sensation in my gut was one of having my intestines wound up by a windlass, like St. Erasmus. The feeling passed, but recurs in small spasms at completely unexpected times. Hopefully, with time, it will settle into a pattern more akin to Ignatius J. Reilly's problem with his "pyloric valve" than the torture of Erasmus.

Taking Surgling #2 to Lubbock would be, I thought, a bit more fun. And it was, with a long drive giving us time together to talk about all manner of interesting and mundane topics. Rather than a painful experience, however, walking around my old campus haunts on a tour was rather surreal. I felt as if the inside of my umbilicus had been firmly grasped and I was pulled simultaneously into a past universe and pushed beyod the present one --- sort of like being pulled inside out from the bellybutton. I did not understand how I could be both young enough to still feel like I had "just" graduated from college and old enough to be the father of a high school senior on a college tour! It has to be a result of one of those black holes escaping from the LHC.

Without a doubt, the most difficult thing in both of these situations for me were the memories.....the false ones, from alternate universes. Walking with my oldest daughter to her dorm, I heard the false echoes of things I wish I had said at one time or another as she grew up. On the college tour, I experienced vivid memories of things I wish I had done when I was in college, but failed to do. Things left unsaid, deeds left undone, rattling around my empty head as seemingly real as the keyboard at my fingertips. And accompanying them are enough regrets to fill an ocean.

All is slowly reverting to normalcy, and I no longer feel as if I am being folded, spindled, and mutilated from the inside. And as for regrets, I certainly have none about asking SWIMBO to marry me and having such wonderful children.