Thursday, February 25, 2010

"I'd Like To Go Home Today"

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.

Monday, February 22, 2010

The OR Rorschach Test, part 2

Here's today's test --- what do you see?

Now, my problem is that just about any of these things tends to make me think of a semi-naked Monica Bellucci, but I'll just have to pony up for therapy to deal with it at some point (that's what the Google Ads are for). A close second? Scarecrow, from Batman Begins:

Any other ideas?

I've had a good life..., if the end is coming, so be it. John Paul Jones being featured on the front page of the Wall Street Journal is surely a sign the Apocalypse is nigh.

Sunday, February 21, 2010

Nudge, nudge

So...the three stooges are now planning once again to ram through government-run health care. Some are calling them tone deaf. Where I grew up, we'd just call them plain ignorant, completely unable to see that the US populace has not only flatly rejected their ideas, they are now making open sport of them.

Let's check the a few items from big government playbook narrative, and see how accurate it is:

At this point, the big government stooges have all the self absorption and total lack of awareness of others as Eric Idle:

Big Government Stooge : Is your country a....goer, eh? Know what I mean? Know what I mean? Nudge nudge. Nudge nudge. Know what I mean? Say no more...know what I mean?

Average US Joe: I, uh, I beg your pardon?

Big Government Stooge: Your, uh, your country, does she go, eh, does she go, eh?

Average US Joe: (flustered) Well, she sometimes 'goes', yes.

Big Government Stooge: Aaaaaaaah bet she does, I bet she does, say no more, say no more, know whatahmean, nudge nudge?

Average US Joe: (confused) I'm afraid I don't quite follow you.

Big Government Stooge: Follow me. Follow me. That's good, that's good! A nod's as good as a wink to a blind bat!

Average US Joe: Are you, uh,...are you selling something?

Big Government Stooge: SELLING! Very good, very good! Ay? Ay? Ay? (pause) Oooh! Ya wicked Ay! Wicked Ay! Oooh hooh! Say No MORE!

Average US Joe: Well, I, uh....

Big Government Stooge: Is, your uh, is your country a sport, ay?

Average US Joe: Um, she likes sport, yes!

Big Government Stooge: I bet she does, I bet she does!

Average US Joe: As a matter of fact she's very fond of baseball.

Big Government Stooge: 'Oo isn't? Likes games, eh? Knew she would. Likes games, eh? She's been around a bit, been around?

Average US Joe: She has traveled, yes. She's helped free untold millions in the world. (pause)

Big Government Stooge: SAY NO MORE!!

Big Government Stooge: Millions, saynomore, saynomore, saynomore, squire!

Average US Joe: I wasn't going to!

Big Government Stooge: Oh! Well, never mind. Dib dib? Is your uh, is your wife interested in....more bureaucracy, ay? 'Bureaucrats, ay', he asked him knowlingly?

Average US Joe: Bureaucracy?

Big Government Stooge: Snap snap, grin grin, wink wink, nudge nudge, say no more?

Average US Joe: Government expansion into private interactions between US citizens and their doctors, eh?

Big Government Stooge: That could be, that could be what we're talking about. Intrusive, you know, INTRUSIVE bureaucracy?

Average US Joe: No, no I'm afraid we are simply not interested.

Big Government Stooge: Oh. (leeringly) Still, mooooooh, ay? Mwoohohohohoo, ay? Hohohohohoho, ay?

Average US Joe: Look... are you insinuating something?

Big Government Stooge: Oh, no, no, no...yes.

Average US Joe: Well?

Big Government Stooge: Well, you're a man of the world, squire. I mean, you've been around a bit, you know, like, you've, uh.... You've 'done it'....

Average US Joe: What do you mean?

Big Government Stooge: Well, I mean like,'ve RUN, a've MET a've STAYED within a budget....

Average US Joe: Yes....

Big Government Stooge: What's it like?

How about this, guys -- Nudge, nudge. Wink, wink. Just. Say. No. More!

Wednesday, February 10, 2010

The OR Rorschach Test, Part 1

"The abdomen was prepped and draped in the usual sterile fashion." A standard operative note phrase, I've dictated this so often that it spills out of my mouth before I think twice about it. But what does this entail?

Well, it means that the abdomen, or other body part about to see the business end of a scalpel, is exposed and then cleansed with a topical antiseptic agent. The area is then surrounded by sterile towels, and the a large sterile field is created by placing a large drape that covers the patient; the drape contains an opening that frames the playing operative field.

Most of the drapes we use in the US are disposable, allowing us to cut the pre-set opening if needed, and they come with a white piece of paper in that opening that is removed once the drape is in place.

Bear with me. I'm getting to the point.

For years, we have used Betadine® to prep an operative field. Betadine is deep orange-brown in color, and dries slowly. When the white paper of the drape set is placed across the operative field, the wet paint of the Betadine leaves a painting upon it that is unique to each patient.

I like to look at these fresh impressions and try to draw out any image that may be there --- and I am not alone. Anyone that has ever worked in an operating room knows the expression "OR Roschach Test," and just like the real thing, what I see says volumes about the odd way my mind works.

I'd like to share --- what do you see?

Me? I'd say a Lon Chaney, Jr. as The Wolf Man....

...but, then, I spent far too many late nights watching bad movies as an impressionable youth.

How 'bout another?

I'm not much of one for modern art --- my feelings about it are not appropriate for a family discussion. My favorite museums are the Musee d'Orsay and the Kimbell, to give you an idea. However, this gives me an impression of Jackson Pollock working with a bad hangover.

I hate to say it, but the OR Rorschach is a dying art form --- there is reasonable evidence that an alternate prep solution (Chloraprep®) is modestly better than Betadine at decreasing skin bacterial load. Chloraprep is 70% isopropyl alcohol, and therefore very flammable, so it must be completely dry before drapes are placed.....leaving no artwork for us to enjoy. Betadine is still used quite a bit, and will be unless the CDC changes its recommendations. So, I'll have more images to interpret, and so will you when I find time to post.

Tuesday, February 09, 2010

Office Tours, 25 cents

It's Tuesday. Which means that everybody in the medical blog world is, appropriately, over at Dr. Leap's place perusing Grand Rounds. I, on the other hand, am slogging away in the office. We surgeons like to call this "baiting the traps." You see, in order to have patients to operate upon, one must first persuade them into the idea that surgery would be good for them. Not quite "here little girl, want some candy?", but something of the sort.

I know some physicians who like to have their patients sit down in the comfy confines of their personal office. One of my closest friends, an oncologist, prefers this as a way to remove patients from the exam room environment to ensure a good discussion of treatment options with patients who are stressed by difficult problems. That has never been my practice, in part because I have a small office and in part because that's not my personality. There may be a third reason, however --- no matter how hard I try to keep up, my office can be a bit of a mess.

Want a tour?

Here it is: Aggravated DocSurg Central Command. I have a great view out my windows, but prefer it a bit darker.

Lest you think that for the past 5 years I have been deceiving you, I did actually graduate from to The Best Medical School in the Country®, but -- here's the diploma to prove it.

Yeah, I have a few other things on the wall --- pictures, certificates, etc. More importantly, I have a futon to crash on.

I try to vote in every election. In 2008, I voted for Pedro.

Words to live by --- Peter's Laws (The Creed of the Sociopathic Obsessive Compulsive).

And more words to live by -- Vocatus atque non vocatus deus aderit. Or, anything in Harold and the Purple Crayon.

There is always an extra pair of Crocs hanging around my office. These, according to SWIMBO, make me look like Barney. I kinda like them --- tacky, yet obnoxious.

One can never have too much Elvis.

Do you marvel at the wondrous future of the paperless medical office, made possible by the unicorn otherwise known as the "Electronic Medical Record?" I do too, but I also used to dream that Raquel Welch would waltz in the door of my 8th grade classroom to take me away to a life of debauchery. Paperless, in the case of our hospital's EMR, is a description for my children's future, as they are going through trees like a squadron of beavers on a bender. This is a one-day pile of output "pushed" to my fax machine, sitting on top of my HIPAA mandated shredder.

The object of my desire derision. And since it is now shrieking at me with the intensity of a Stuka in a steep dive, it's time to wrap up our little tour. Come again ---- and, if you happen to have any decorating suggestions, I would be eternally grateful.

Wednesday, February 03, 2010

I've been....everywhere

Where have I been lately? With apologies to the man in black......I've been everywhere.

I was totin' my scalpel along the long hospital road,
When along came a patient with a heavy belly pain load,
"If you're goin' to the OR, Mack, with me you can ride."
And so I called in the crew and sat with time to bide.
He asked me if I'd seen a belly with so much malady.
And I said, "Listen, I've rooted around every part of a broken body!"

I've been everywhere, man.
I've been everywhere, man.
Crossed the liver's bare area, man.
I've breathed pus in the air, man.

I've been to:
Vena cava, pleural space, oral cavity,
Scarpa's fascia, linea alba, duct of Santorini,
Hesselbach's triangle, the point of McBurney,
Ampulla of Vater, Gerota's fascia, round the Vagus,
Right lobe, left lobe, along the esophagus.


I've been to:
Zuckerkandl's organ, Artery of Adamkiewicz,
Triangle of Calot, ligament of Trietz,
Caudate lobe, quadrate lobe, tunica vaginalis,
Denonvilliers' fascia, obturator foramen,
Rectum? Damn near killed 'em!


I've been to:
Drummond's marginal artery, pubic tubercle,
Cremaster, Billroth's cords, seminal vesicle,
Auerbach's plexus, terminal bronchiole,
Cooper's ligament, through the rings of the trachea,
Falciform ligament, See what I mean-a?


In other words, I've been busy.