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" --

Rocco Oyster Bar

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?

Monday, April 13, 2009

96 Tears? No, 100 Lab Coats

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

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

"Good Lord, look at yourself! Get some new lab coats! NOW!!"
Indignant and hurt (how could she say that about my.....comfy, wrinkled and coffee-stained coat?), I pulled out the best retort in my quiver --- "Er, yes dear."

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

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

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

The first was thin, with buttons that had a tendency to fall off during the most embarrassing moments, such as when I had to present a patient's history and workup to the smartest man in my then known universe after a sleepless night of work. It had no embroidery or markings whatsoever, but had pockets that were ridiculously large enough to hold :
  • a stethescope
  • a pen light
  • a reflex hammer
  • a copy of the Sanford guide
  • a well-worn copy of the Washington manual
  • at least 3 pens
  • scrap paper; lots of scrap paper
  • most importantly, a copy of the Scutpuppy Guide to the Lands, an indispensable guide book to Parkland Hospital, its idiosyncrasies and Byzantine method of operation, and its navigable hallways, along with a few helpful Spanish phrases (download it here for fun and exciting reading!)
  • lunch
I am sort of a big guy, and was fortunate to go to not only to The Best Medical School in the Country®, but also one which did not require students and junior residents to wear short, short-sleeved lab coats. Those things have a tendency to make one look like Bozo the clown when he's trying to dress down to the level of a real doofus. And that, I believe, has always been the point in those institutions ---- to single out the junior level folks, sort of like fraternity hazing on a prolonged scale. Since I was a Γ Δ Ι in college, that sort of crap really pisses tees me off.

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

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

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

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

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