A spectacular day in Colorado today ---- more accurately, a spectacular morning. When the sun is shining, 30 degrees feels like 50, letting Fat Boy get out for a little ride. This photo was taken at 10:00 this morning:
This afternoon --- not so spectacular. The view from my window right now, 4 hours after my ride:
Thursday, December 30, 2010
A spectacular day in Colorado today ---- more accurately, a spectacular morning. When the sun is shining, 30 degrees feels like 50, letting Fat Boy get out for a little ride. This photo was taken at 10:00 this morning:
Posted by Aggravated DocSurg at 2:07 PM
Sunday, December 19, 2010
Friday, December 17, 2010
Today's pop quiz --- what can you make of this OR Rorschach?
Posted by Aggravated DocSurg at 9:43 AM
Thursday, December 16, 2010
Posted by Aggravated DocSurg at 9:19 AM
Thursday, September 09, 2010
Sharp knives. Sutures. Hot lights and warm blood. Great music. That's what most folks picture when thinking about operating rooms. It's easy to overlook that we make use of plain old electrical energy in the OR --- electrosurgery. Sounds like something from a '50s SciFi novel. Perhaps a gift from the Red Lectroids from the 8th dimension?
Actually, the modern era of electrosurgery started in 1926, courtesy of Dr. William Bovie, a physicist, and Dr. Harvey Cushing, the father of neurosurgery in the US. The term "Bovie" is still standard jargon for the electrosurgical generator used in surgery, though most surgeons are only casually aware of its origins (there is a fair amount of history here and here, for those interested; image from Medscape). Me? Back in the dark ages, when (general, non-GYN) laparoscopic surgery was undergoing rapid growth and research opportunities abounded, I spent a year doing research, teaching laparoscopic surgery courses, and writing papers & book chapters. There had been considerable debate about the relative merits of using laser energy versus electrosurgery in laparoscopic gallbladder removal, and I landed the plum job of writing one of the papers that helped relegate laser laparoscopic cholecystectomy to the dustbin. Of course, as these things go, I also had many more writing assignments, including a book chapter entitled "Endoscopic Technology" for a book about laparoscopic and endoscopic surgery.
Let's just say, for someone who struggled to remember everything his father taught him about wiring a house, I learned quite a bit about electricity to write that chapter. And I learned even more about the potential for patient safety problems when using electrosurgery. For simplicity, though, the best way to think about electrosurgery is to picture a complete electrical circuit (image source):
OK, wait a minute. The generator is connected to the instrument, which is supposed to deliver electrical energy. But that doesn't make a complete circuit --- where is the rest of the circuit connecting back to the generator?
Well, a big chunk of the circuit is made, just like Soylent Green, of people! More accurately, of one person -- the patient --, to whom is attached a grounding pad (the passive electrode) that then connects back to the generator. Voila! A complete circuit is made, allowing high current density produced at the tip of the instrument (the active electrode) to cut and cauterize tissue.
So what's different about using electrosurgery in laparoscopy? Well, a couple of things. First, we must use long instruments to reach the operative field, with an active electrode only at the tip of some of them. Second, those instruments must pass through trocars that maintain a seal to prevent the escape of CO2 from the inflated abdomen. And finally, we use a non-insulated telescope attached to a video camera to view what is happening in the operative field. As a result, there are many places where electricity may end up flowing other than where it is intended to be focused. If the active electrode/cautery tip is activated against an uninsulated portion of another instrument, tissue that is in contact with that instrument can be injured. If the cautery tip is activated out of view of the camera, it can result in unrecognized tissue injury. And there is a more complex problem called capacitive coupling, unique to laparoscopic surgery, that can result in tissue injury.
Perhaps the most pernicious risk, however, is insulation failure. Because we want action only at the tip of the active electrode, the remainder of the length of the instrument is insulated to prevent "leakage" of electricity ---- which can cause a tissue burn when the shaft of the instrument is laying against, for example, a piece of bowel, well out of view of the operative field. That risk, I have always felt, can be eliminated by using disposable rather than reusable cautery instruments. Additionally, the other instruments not actively delivering electrical injury may have insulation defects, and can similarly cause injury if they are used in contact with the active electrode/cautery.
Looks like I may be right for a change --- Insulation failure in laparoscopic instruments is a study published in Surgical Endoscopy earlier this year (unfortunately no unregistered access to article or abstract). Basically, the authors looked at reusable and disposable laparoscopic instruments used to deliver electrical energy and tested them for insulation defects. From the abstract:
Two hundred twenty-six laparoscopic instruments were tested (165 reusable). Insulation failure occurred more often in reusable (19%; 31/165) than in disposable instruments (3%; 2/61; p less than 0.01). When reusable sets were evaluated, 71% (12/17) were found to have at least one instrument with insulation failure. Insulation failure incidence in reusable instruments was similar between hospitals that routinely checked for insulation failure (19%; 25/130) and hospitals that do not routinely check for insulation failures (33%; 7/21; p = 0.16). Insulation failure was most common in the distal third of the instruments (54%; 25/46) compared to the middle or proximal third of the instruments (p less than 0.05).Hmmm. One in five reusable instruments was found to have an insulation failure. Cue The Doors:
One in five
No one here gets out alive, now
You get yours, baby
I'll get mine
Gonna make it, baby
If we try
Hold on. If this was a humongous problem, wouldn't general surgeons be seeing electrosurgical injuries from laparoscopic surgery on a weekly basis? Yep. And we don't. Perversely, I would say that is a bit of an issue ---- because this is seen very rarely, it is something about which one may be less than vigilant.
From my standpoint, I have a few things I insist upon when doing laparoscopic surgery; most importantly, I will only use disposable cautery instruments, as they are heavily used and most prone to insulation failure. Secondly, I don't use any other instruments to help deliver electrical energy/cautery; in open surgery, we frequently pick up a small bleeding vessel with a pair of forceps and then deliver the cautery against the forceps, delivering the electricity through them to the tissue that they hold --- for me, an absolute never in laparoscopic surgery. Finally, when appropriate I use alternate methods of delivering energy to tissues --- bipolar electrosurgery (that's another post) or high frequency ultrasonic energy most commonly.
In the end, the problem associated with insulation failure is really no different than many other potential pitfalls in medicine --- being well aware of the potential problem is the best method of its prevention.
Posted by Aggravated DocSurg at 4:02 PM
Wednesday, September 08, 2010
How I spent my Labor Day weekend:
No, that ain't me. Yep, I was waiting at the bottom of the hill for the youngest surgling to come hurtling down the mountain wearing enough gear to embarrass Mel Gibson in The Road Warrior with the speed of an out of control locomotive, hoping to get one good picture (pretty good if I say so myself).
Wish I was 16 again...
Posted by Aggravated DocSurg at 8:40 AM
Tuesday, September 07, 2010
Tuesday, August 24, 2010
You may not know this, but I have a hidden talent. I can predict the future. No, this doesn’t involve a crystal ball, Ouija board, or looking at the entrails of a freshly slaughtered surgical intern. I can see the future that is written out, plain as day, in medical journals. While this will not allow me to get rich in the stock market, predict the next presidential election result, or find out exactly when Monica Bellucci is planning to leave what’s-his-name and realize that she was meant for me, my limited skill gives me a little insight into how general surgeons will be treated --- and, more importantly, how they will respond to such treatment --- in the next few years.
A good example is the ongoing, relatively one-sided discussion regarding who should be doing certain procedures. Sounds relatively simple --- look at a variety of measurable outcomes for certain surgical procedures, and compare the results between “high volume” and “low volume” facilities and surgeons. This data is then often used to argue that across the board, we should as a matter of public policy push to shepherd certain types of patients to “high volume” facilities to achieve the best possible results. I have written about this a bit before, and certainly the freight train pushing certain types of procedures (pancreatectomy, esophagectomy, cardiac surgery, etc.) towards higher volume centers has been rolling down the track for so long that it is essentially unstoppable.
But what about procedures that are considered to be less complex? Should the same type of spotlight be placed upon cholecystectomy? Colectomy? Appendectomy? Hernia repair? And what if the data from such an evaluation reveals a contradictory result; should that instigate a reevaluation of prior “low versus high volume” studies? That’s good question, and one that is partially addressed by a study published in the July edition of the Journal of the American College of Surgeons --- Predictors of Major Complications after Laparoscopic Cholecystectomy: Surgeon, Hospital, or Patient?
From the abstract:
Uh, what did they just say? Let me repeat it --- “Major in-hospital complications after laparoscopic cholecystectomy are associated with individual patient characteristics rather than surgeon or hospital operative volumes.” In other words, we are not a bunch of rubes out here away from the miracle centers. On average, the general surgeons of this country are competent and well trained. “Rather, careful patient selection and preoperative preparation can diminish overall complication rates.”
Conclusions -- Major in-hospital complications after LC are associated with individual patient characteristics rather than surgeon or hospital operative volumes. These results suggest regionalization of general surgical procedures might be unnecessary. Rather, careful patient selection and preoperative preparation can diminish overall complication rates.
- Using the Nationwide Inpatient Sample for patients undergoing laparoscopic cholecystectomy, major complications including acute myocardial infarction, pulmonary compromise, postoperative infection, deep vein thrombosis, pulmonary embolism, hemorrhage, and reoperation were assessed.
- A total of 1,102,071 patients' records were available for this retrospective 1998-2006 study, with a complication rate of 6.8%.
- Univariate analyses showed that advanced age, male gender, and higher Charlson Comorbidity Score were associated with higher complication rates
- Higher surgeon volume and higher hospital volume were associated with fewer complications (6.7% versus 7.0%, 6.4% versus 7.0%, respectively)
- Multivariable analysis showed that advanced age (65 years or older versus younger than 65 years), male gender, and comorbidities (Charlson Comorbidity Score 2 versus 0) were associated with complications
- Neither surgeon nor hospital volume was independently associated with increased risk of complications.
Time for a little futurama. I have no doubt whatsoever that the push for regionalization of a whole swath of surgical procedures will continue unabated, especially in the current political environment. To an extent, I will benefit from such a push --- I am a high volume general surgeon working in a tertiary referral center, albeit not in the largest city in my state --- and would anticipate an increase in surgical volume over time if such proposals come to fruition. It would be very reasonable to also expect that the types of patients sent up the road will be sicker to a pretty substantial degree, with simpler, elective procedures being done on healthy patients being retained in lower volume facilities.
Look at it this way. Let’s say you are a well-trained and
Patient wants to stay in town? Too bad.
Patient is pretty darn sick? Give him antibiotics, load and go.
Patient has given googobs of cash to the hospital? Cue Lindsey Buckingham. Call the hospital CEO to hold his hand during transport.
ED really, really wants you to take care of the patient? Wouldn't be prudent. I can hear the attorney's question when I get sued for a complication: "Doctor, when was the last time you performed one of these operations electively?"
This sort of begs the question, is this a good thing for the patient, or a bad thing? I'm sure you can tell that I come down a bit on the side of "bad thing," but some might argue the opposite. The difficulty is that all hospitals cannot be staffed with high volume surgeons for every possible procedure. It's a Pollyannish idea, sort of like how the schoolkids in Lake Wobegon are all above average.
Please understand, I am not arguing that we should be avoiding progress; obviously, I don't think it's ethical to turn away a patient in need. But progress in medical care has generally come from striving for excellence in training and disseminating information about how to best care for patients. If there is a concern that surgeons performing a lower volume of certain common procedures need a little buffing up, first prove it.....and then I would humbly suggest that the way we have been going about steadily improving care in this country has worked extremely well over the past century. I have yet to see strong evidence that radically changing this system will be beneficial to patients in the long run.
Posted by Aggravated DocSurg at 8:14 PM
Saturday, August 21, 2010
Take one part highly inflammable surgeon. Add a dash of chronic worry, a well-rounded tablespoon of sleep deprivation on call, and stir vigorously with an enormous slab of hospital inefficiency. The cherry on top? That would be ongoing concerns about government regulation compliance, increased taxes on my small business, Medicare payment games, and the Kabuki theater known as Obamacare. That would be my recipe for one, well, aggravated surgeon. To make this situation really cook, however, increase the on call load by having one physician leave the group (and act like a total rectal-discharge-head on the way out). Voila! Aggvavated DocSurg flambé ! C’est magnifique!
What was not so magnifique was my blood pressure, weight, and stress. Think of Ox in Stripes.
"Well, my name's Dewey Oxburger. My friends call me Ox. I dont know if you've noticed, but I got a slight weight problem.....When I was younger, I swallowed a lot of aggression...along with a lot of pizzas!!"A few changes were in order if I was going to avoid sharing John Candy’s fate. Trying to put one’s time in order when working in a field where a predictable day is a false hope has always been one of my biggest challenges, but I was able to make a few adjustments over the past few months. Activities that helped decrease stress were put on the front burner, and those that simply added consternation with no discernible benefit were dropped faster than you can say “Frankly, my dear, I don’t give a damn.” Or something like that.
What went out with the screaming baby and the bath water?
- Any hospital committee that I wasn’t absolutely required to be a member of.
- Any meeting with hospital administrators that was unscheduled or open-ended. No agenda and no clear reason to be asking for my time? Then sayonara, baby.
- Any time wasted in my office waiting for patients who cost me money, i.e. Medicaid patients, who fail to show up on time. I cannot afford the expense or aggravation involved in trying to work in someone who shows up a half hour late for a scheduled appointment, but whose insurance coverage pays so little that I lose money seeing them to begin with.
- Any time sitting in the surgeon’s lounge bitching about Obumblecare, politics, hospital administration, and healthcare in general. Wasted words, as Mr. Allman would say.
- Potato chips. Worse than crack cocaine for me.
- Orchestrating OR schedule contortions worthy of a pretzel maker in order to accommodate every patient’s request. I try to make things work as well as possible, but it made no sense for me to go to three different places to operate in one day, doing a single case at each location, and racing across town to be on time.
- Any time blogging. Not really a conscious choice, but I needed to quit bitching here too.
What went into the mixing bowl?
- My mountain bike. Specifically, I have tried over the past 5 months to get outside and ride at least 4 times per week. This means lunchtime rides on office days whenever possible, and using any other available time on OR days. I had to carve an extra hour out at lunch and run my office later, but it has been worth it (especially when it was snowing).
- Travel. SWIMBO and I took the Surglings on a long-awaited trip to Rome & Paris. Simply fabulous.
- My books. I love to read, but have felt that the time I had available to dip into a good book had evaporated. Made time, read some good books, and then the Surglings bought me a Kindle --- I now have a new version of crack cocaine. I have enjoyed Vanished Smile, The Gardner Heist, The Man Who Loved Books Too Much, the "Dragon Tattoo" trilogy, and Fire among others this summer.
- Music. My younger self spent waaaaay too much money on vinyl and concert tickets, but I enjoyed every bit of it. So I have spent time spinning old records and seeing a few concerts --- there is nothing that can compare to an evening at Red Rocks.
But....I haven’t received the miracle cure. I remain, after all, aggravated at my core. Which means that while I haven’t necessarily posted anything, I have been keeping notes. Taking down names. Reading BS journal articles that whose authors don't seem to understand the difference between good medical care and mumbo-jumbo. You know the drill. And while the exercise has been good, to the tune of ~30#, it has also provided me time to consider things I want to write about --- I gotta concentrate on something other than my heavy breathing while climbing a hill.
I guess that means that posting here will have to be added back into the mixing bowl. Sorry. And if I get too worked up --- too aggravated --- let me know.
Posted by Aggravated DocSurg at 11:54 AM
Sunday, June 13, 2010
OK, I am on vacation, and while it was against my better judgment to look at a little news, SWIMBO and the surglings are sleeping, and I can't (big time difference here, plus I usually get up at 5:30). What do I find? Yet another example of how Obumbles spun lie after lie about Obumblecare:
According to the report, by 2013 51% of all employers — 66% of small employers (3-99 employees) and 45% of large employers — would have to relinquish current coverage. In a worst-case scenario, 69% of firms would lose their grandfathered status.
This could pose a serious threat to President Obama’s claim that if you like your coverage, you’d get to keep it.
Gomer Pyle could not be reached for comment.
Posted by Aggravated DocSurg at 2:27 AM
Tuesday, May 11, 2010
Working, biking, and not posting. Hardly a recipe for loads of hits, but I've been busy and the weather has been great.......so I've ridden instead of posting. But I have accumulated a few new OR Rorschachs for your viewing pleasure. First question for today's test:
Ahh, the belly button always leaves a nice divot in the Betadine and gives most OR Rorschachs a handy "eye" to anchor the picture. This one is almost too easy --- while one could say that Jim Carrey had lost The Mask in the OR
...I think this looks more like an Easter Island moai:
I guess it all depends on your cultural perspective.
Next up, another face....or is it?
I dunno ---- this one strikes me as if The Shadow is peering around the corner of a building
SWIMBO, however, who is used to feeding my teenage son massive quantities of food, immediately thought of this:
A nice, steaming slice of pepperoni pizza. Reminds me of college! (Pizza Express, 744-4444, sadly no longer in business)
Last question for today's test:
While this sort of puts in mid the Union Jack,
I'm more inclined to think of a famous guitar:
Never have much cared for Van Halen, but this is rather iconic.
Class, any questions? Remember, there are no wrong answers here.
Posted by Aggravated DocSurg at 9:57 AM
Tuesday, April 20, 2010
Thursday, April 01, 2010
Trauma surgery for me is a whole lotta non-operative care interspersed with occasional surgery for things like a ruptured spleen. This is because I don't practice in a large urban center, and most of the trauma patients I care for have suffered blunt force injuries rather than penetrating ones. For most of the non-physician population, the idea of trauma surgery is heavily influenced by television --- shows like "E.R.," "Grey's Anatomy," and the like (I am asked at least weekly whether I enjoy these shows; I haven't seen a medical drama since "Emergency" ended its run in the 70's). Like other dramas, these shows try to maximize tension to keep the viewer interested; in trauma, there is nothing quite like a gunshot victim to achieve that goal. Lots of blood and screaming, along with an intense urgency to getting a patient off to the operating room.....where they are miraculously saved every time.
Every time. Except in real life, where some patients die of their gunshot wound (GSW). Sometimes, the reasons are obvious --- shot through the heart or the head with a fatal brain injury. Sometimes, the reasons are harder to understand ---- see a description of irreversible coagulopathy here. As for the rest, we don't have all of the answers, though not for a lack of searching.
Insurance Coverage Is Associated With Mortality After Gunshot Trauma is a recent retrospective study that is part of that searching. The trauma department at UCSF - East Bay Alameda County Medical Center in Oakland reviewed the records of 2,164 patients over a 10 year period who presented to their facility with a trauma activation for GSW. A few salient points from this report:
- 92% of GSW victims were male
- Average age of 28 (+/-9), with no difference between insured and uninsured patients
- Injury severity scores (a system to "score" how badly a patient is injured) were similar between groups
- ~25% were insured and less than 1% were on Medicare or Medicaid
- Overall hospital mortality was 8%
- There were no differences in mortality between Hispanic, Caucasian, and African-American patients
- Uninsured patients had an odds ration for death of 2.2 in comparison to insured patients, despite access to the same level of care
...despite similar injury severity, uninsured trauma patients were significantly more likely to die after admission for gunshot injury than insured patients. This difference could not be attributed to racial demographics or hospital resource use, and it held true even after adjusting for the effects of race, age, gender, and injury severity.On possibility is that patients who died had more medical problems....except that insured patients were found to have more comorbid conditions than uninsured patients (17% versus 12%). In fact, because this was felt to represent an increased exposure to medical care on the part of insured patients, comorbid conditions were specifically excluded from the data analysis in this study.
In the end, the authors concluded that
...insurance coverage most likely reflects social environment and the many social determinants of health. Social support networks, coping skills, and similar social factors likely affect outcomes after gunshot trauma..... The health burden of chronic social stress has been well studied and even physiologically quantified,and environmental stress is known to affect the health of young adults.What do I think? Meh. Several things strike me at the same time.
...Lack of insurance may be a reflection of the social environment and the many social determinants of health. Improving the social environment of patients affected by violent trauma is a potential intervention to improve mortality from gunshot trauma.
- It's hard to extrapolate the effect of varied social environments to medical outcomes. In fact, this is one of those areas where well-meaning researchers sometimes reach for non-quantifiable data to come up with answers that probably don't fully satisfy the questions they pose.
- When such disparities in outcomes occur following full implementation of
SocialistObamaCare, when "everyone will have coverage" --- and the disparities inevitably will occur --- how will we account for those differences?
- Maybe the insured patients had caring family members praying for them, and more of the uninsured had support systems consisting of gang members who really didn't care if they made it out of the hospital walking or with a toe tag. This, I suppose, would play into the authors' feeling that social support networks are important; I just don't think we as a society do a good job of fostering this type of behavior.
- Nothing good ever happens after midnight, like getting shot. In case you were wondering.
Posted by Aggravated DocSurg at 12:19 AM
Wednesday, March 31, 2010
You know, I get a lot of crazy stares as I walk out of the OR holding big, crinkled sheets of paper covered with brown stains. What, exactly, people ask me, is in the OR that will stain something brown......eewwww! Here's your test for today:
Lots of Betadine on a great big belly; the telltale sign is the "eye" somewhere on the imprint caused by the belly button. Given the amount of time I have spent in my life listening to music, and I pretty much don't regret one second (well, maybe some disco crap my high school girlfriend was into....but, one does what one must), you must forgive me for immediately thinking of Pink Floyd. No, not an acid trip --- the Division Bell album cover:
OK. I admit it. That was a bit obtuse, even for me. I'd be happy to hear other suggestions.
Although it's a bit fuzzy, I think anyone near my age who spent a little time in front of the boob tube on Saturday mornings should think of one and only one cartoon with this OR Rorschach:
Need a hint? Here's a little sound bite to jog your memory.
OK. So now you know where my deep well of sarcasm and brooding springs from. In fact, I think Woody Woodpecker (ya think that name would get past the censors today?) is probably the best role model one could have in this Obmamanation --- impertinent, sarcastic, and with a healthy dose of disrespect for authority.
Uno mas for today ---
I'm of two minds here. Perhaps the Chatterer from Hellraiser?
Nah. I'm in a better mood than that today. I'm going with another cartoon character ---
Your answers on this test will be graded. But, with a curve!
Posted by Aggravated DocSurg at 12:00 PM
Thursday, February 25, 2010
He was a big, burly man with a gruff voice and a temperament to match. His abdomen was a sprawling landscape of scars. And he was sick --- seriously so --- and needed to spend a little time with me in a cold room with hot lights. As is often the case, his surgery and recovery were complicated by chronic anticoagulation, a history of thromboembolism, a little heart disease, and a few other things that in the end caused me more worry than actual problems. Him? He was never worried, never complained, and treated the whole episode as a mere annoyance.
When he was at the point where discharge from the hospital was little more than a mild consideration percolating around my frontal lobes, I talked with him about perhaps staying for one more day to be sure he was ready to go home. I laid out my reasons --- he had just started having good bowel function, his protime wasn't therapeutic, he had enough medical problems to make me a bit nervous, etc. He listened, patiently, and then simply stated "I would really like to go home today. Today is March 4th, and it's my anniversary."
What a cold-hearted bastard I would be if I didn't let him go home for his anniversary! Even so, he had really not fully recovered to the point where I was comfortable with the idea of his going home. Deploying a delaying tactic while I fumbled for a reasonable excuse to keep him hospitalized one more day, I asked "How long have you been married?"
"No," he said, "it's not that kind of anniversary. On March 4, 1973 I landed in the U.S. after 6 years and 6 weeks in a Vietnamese POW camp."
His prescriptions and discharge papers were filled out in record time.
As it turns out, I cared for this retired, decorated Air Force Colonel one more time, when he required abdominal surgery yet again. I did not quibble when he asked to go home a day earlier than my comfort level. He was kind enough to give me a copy of a movie that included his experiences, Return With Honor. Though certainly not forgotten, following his recovery I had not seen the Colonel for several years. His obituary was in the paper this week, and I learned much of what I knew without asking:
Shot down in 1967, suffering vertebral fractures, facial fractures, and blindness in his right eye. Spent 6 years and 6 weeks in the Hoa Lo prison, the "Hanoi Hilton." Flew F-89's, F-101-'s, and F4 Phantoms, but was grounded due to his injuries; he did not retire from the Air Force until 1981. Recipient of the Silver Star, Purple Heart, Legion of Merit, POW Medal, Distinguished Flying Cross, and the Air Medal with Cluster. In short, a hero.The Colonel was rightfully proud of his service, and his anniversary was something he cherished in a way that I will never know. I hope he has landed safely.
Posted by Aggravated DocSurg at 12:27 PM