Sunday, November 16, 2014
The title above is an old medical saying which means “the act of performing surgery often cures a patient from whatever condition is ailing him or her.” This contrasts with “medical” management which is the way of treatment for many chronic medical conditions such as Congestive Heart Failure, Diabetes, Hypertension and so many others. These conditions are treated primarily with pills and life style changes, surgery being reserved for complications of the underlying illness. Examples of such surgery are joint replacement in the severe arthritic or amputation of a limb as a complication of Diabetes. These operations relieve symptoms, can be life saving, but are not curative.
There are, however, many instances where surgery is truly curative. Appendicitis comes to mind. The inflamed appendix is removed and the patient is never troubled by appendicitis again.
Then there are instances where a patient has suffered for years, seen a multitude of doctors and been treated with pills, surgery and everything else but continues to suffer. It seems like nothing will provide relief. Even so, such patients grasp at the narrowest of straws, hoping against hope that surgery, ie “to cut” will lead to a cure. Patricia was such a patient.
She was 37 years old and I was asked to see her for small bowel obstruction. She had previously undergone twelve abdominal surgeries which included a subtotal gastrectomy for a “lazy stomach” (a condition called gastroparesis), cholecystectomy, hysterectomy, appendectomy, and multiple operations for small bowel obstruction. The records indicated that over the prior 18 months she had been operated five times for small bowel obstruction, four by the same surgeon. Each time the procedure was “lysis of adhesions” which means cutting away scar tissue. And, each time she would feel better for a short time, but her symptoms always returned.
She had become dependent on pain medication, taking narcotics on a daily basis. Her abdomen had scars running up and down and crossways. Her imaging studies looked like a classic small bowel obstruction, dilated small bowel transitioning to collapsed bowel. Her post gastrectomy reconstruction was with a Roux-en-Y gastrojejunostomy, which is common after most of the stomach has been removed.
She reported nausea and vomiting of bilious fluid which is very uncommon after Roux-en-Y reconstruction. She also reported passing flatus and having regular bowel movements which suggested she was not completely obstructed.
Gathering all the information together I elected not to operate on her initially. She was managed with a nasogastric tube and gradually improved so that she could eat and she was sent home. She returned three weeks later with the exact same symptoms and X-Ray findings.
She’ll probably need another surgery, I thought.
Before plunging back into what I was sure would be a very difficult surgical exploration more workup was called for. Upper GI endoscopy revealed a very small gastric pouch, some gastritis but nothing to explain her X-ray findings. UGI series was done and these X-Rays corroborated the CT Scan findings of incomplete small bowel obstruction. The ingested contrast did pass all the way through, the proximal bowel was dilated and there was no discernible stricture.
Maybe I should watch her a bit longer, maybe she’ll open up. Maybe it’s all related to her narcotic use.
So I watched and waited and she didn’t get better.
No choice. Operation number 13 coming up.
I did have a plan of sorts. As best as I could determine she always presented with a dilation of her Roux-en-Y limb which was connected to her stomach and then the bowel became normal a short distance beyond.
There must be an adhesion or stricture in that area.
The big day came. She looked up at me in the moments before she went to sleep with a look of hope in her eyes. I wondered if her previous surgeons had seen that same look.
I made a midline incision and gingerly worked my way into her abdomen. I managed to get into the peritoneal cavity without causing any serious damage. The adhesions were not nearly as nasty as I’d encountered in other patients, at least not yet. I cut my way through the web of scar tissue which was encrusting some normal caliber small bowel, suggesting that this bowel was downstream from the real problem area. As I made my way towards the small bowel’s beginnings the adhesions became denser and I soon encountered a very dilated loop of small intestine. This told me I was at least getting close to an area where her pathology might be found.
After a while I reached a point where the scar tissue was extremely dense. Usually when I encounter something like this I will change direction. Look for another angle or approach which might make the task simpler. I began my assault on the adhesions at a different point, an easier point and, at first I was rewarded.
I figured out that I was dissecting the Roux-en-Y limb and that this would lead to what was left of her stomach. This loop of bowel was very dilated suggesting that it was obstructed. After a bit more careful snipping I struck gold or was it oil. Anyway, I found where two segments of small bowel had been anastamosed (connected together) and a point where the dilated bowel collapsed to normal caliber. This was just beyond the point where the bowel coming from the stomach was reconnected to the rest of the small bowel. There were extensive adhesions here and my first thought was that cutting away this scar tissue would solve poor Patricia’s problem.
In the course of my dissection I reattacked the area of dense adhesions and was able to discern that this was a segment of bowel which originated at her duodenum and it was also very dilated. So, I had two limbs of small bowel which were both dilated. Where they met and were anastamosed was also dilated, but just beyond this the small bowel was normal. There had been extensive adhesions in this area which I had already removed.
Could it be that simple?
It was at this point I either was very smart or very lucky. In the course of my dissection I had inadvertently made a hole in the small bowel. (Nobody’s perfect). It was just beyond the point of obstruction. Palpation of the area did not suggest anything particularly unusual. The anastamosis from her previous surgery was wide open and the bowel itself felt soft, rather than fibrotic. But, I decided to put my finger inside the bowel. After all, I already had a hole in the bowel.
Much to my surprise and relief there was a definite stricture, a ring of hard, fibrotic tissue which narrowed the bowel to about 1/3 its normal caliber. This was at the point of obstruction, where the dilated bowel collapsed to normal.
This is her problem. But, how to fix it?
It really didn’t take much thought. I could have redone the entire Roux-en-Y limb, which would have involved taking all the previous connections apart and starting over. Or, I could do a stricturoplasty, which would means doing something at the point of the stricture to widen it. This probably would have worked, but I worried that it could restructure and then Patricia would be back where she started.
I decide to let physics rule and bypass around the stricture. Physics comes into play because fluid passing through a tube will tend to take the path of least resistance. In Patricia’s case the fluid which originated in the duodenum, which is composed of bile from the liver and pancreatic juices, was, for the most part taking the path of least resistance which was up the Roux-en-Y limb to her stomach instead of downstream through the rest of her small bowel. Creating a new outlet from the Roux-en-y limb should have provided relief.
Therefore, I took the simple, easy way out and connected the Roux-en-Y limb, which was attached to her stomach, to the small bowel which was beyond the stricture. This allowed food from the stomach to avoid the stricture and the duodenal fluid to go around the stricture also, passing briefly into the Roux-en-y limb, but then exiting via the newly created outlet.
This task completed, I made a graceful exit form Patricia’s abdomen and then sat back and waited. The first morning after surgery I was greeted by a definite absence of bile draining from her NG tube. And, she noticed a difference immediately. She sailed through an uneventful post op course and was discharged home after about a week, eating a regular diet.
On her post op visit in the office she had gained four pounds and she made this comment:
“For the first time in seven years I don’t wake up with the taste of bile in my mouth.”
She has continued to heal uneventfully.
Truly, “To cut is to cure,” but sometimes it helps to be lucky.
Sunday, November 2, 2014
Years ago I read a book about former US Senator and basketball great Bill Bradley which was titled “A Sense of Where You Are.”
The title derived from a basketball move he could perform which had him drive along the baseline to blindly shoot a reverse layup. He described how he had developed a sort of sixth sense which allowed him to make this shot, even though he couldn’t see the basket. He had played so much basketball and knew the court so well that he had developed “a sense of where you are.”
This saying popped into my head the other day as I was doing a parathyroidectomy. Now don’t get the idea that I perform surgery blindly. But, parathyroid surgery sometimes requires this sixth sense to track down these pesky little glands. For those of you unfamiliar with the anatomy of the human neck, the parathyroids are four separate glands which hide behind the thyroid gland. A normal parathyroid is about 4-5 millimeters in diameter. Each gland is described relative to its position to the thyroid gland, which is a butterfly shaped organ sitting in the middle of the neck. Thus, there are right and left, upper and lower parathyroid glands, depending on their position behind or adjacent to the thyroid gland. Sometimes, (often) these parathyroids like to hide. They may be lower in the neck closer to the carotid artery or even lower, in the mediastinum (behind the breast bone). It’s sort of like they know someone is searching for them and they don’t want to be found, so, decide to take shelter away from their usual residence.
I’ve done a lot of parathyroid surgeries over the years. Most of the time preoperative testing provides some guidance as to where the abnormal gland is residing. But, these preop scans usually only tell me right or left, upper of lower. I still have to find the offending little beast. This is where it is helpful to have a good sense of where one is.
So, I start by getting the thyroid out of the way which requires dividing a few veins which are collectively called the middle thyroid vein. Then it’s time to look, first for “the nerve”, but also for bulges rising from beneath fat which don’t look like they belong or send a signal which says, “there’s something hiding under here.” The vast majority of the time it is this “something looks out of place” sense that leads me straight to the offending parathyroid gland. After that, it is relatively simple to remove the gland and have a friendly neighborhood Pathologist confirm it is abnormal.
Unfortunately, it’s not always easy.
Vince was in his sixties when he came to me with long standing hypercalcemia and very elevated parathyroid hormone levels, lab tests which led to the diagnosis of primary hyperparathyroidism. Surgery was recommended. His pre operative imaging studies were all normal. Despite this, he still needed surgery, only with him I had nothing to tell me where to look. So I started, first in the left lower position, which is the easiest area to explore. I was heartened as I saw a nodule that appeared to be separate from the thyroid gland. However, as my dissection continued it became clear that this nodule was part of the thyroid itself. Onward went the dissection. In the left upper thyroid I found a tiny, normal appearing parathyroid, about 2 mm in diameter. I looked at the right side and saw a tiny gland behind the lower pole of the thyroid. I didn’t find anything that looked like parathyroid on the upper end. I did identify the recurrent laryngeal nerves and both carotid arteries on both sides. I went back to searching. Perhaps behind the mound of fat next to the right carotid. There was something there. As I removed it my heart sank. It looked more like a lymph node. I sent it off anyway and was not surprised when the Pathologist confirmed that it was a lymph node and not parathyroid.
Where are you, you irritating, mischievous sprite?
Well, maybe down in the mediastinum, which is behind the sternum. So I start pulling tissue, mostly fat, out of the upper chest. Nothing, nothing and more nothing. I had been searching for more than two hours without success.
Maybe it’s time to give up, do more tests, perhaps?
I looked a bit more, farther down in the chest, more towards the middle. I found something. It looked like a parathyroid, kidney bean size, shape and color. Out it came and off it went to the lab.
Thank you, Pathologist.
Vince’s parathyroid hormone was checked before we woke him up. It fell from a preop level of 2200 down to 500 and then to 40 prior to discharge. His calcium levels dropped to normal. He was cured.
This “sense of where you are” is important in surgeries beside parathyroidectomy. Every operation requires knowledge of anatomy, with all its variants. Plus, normal anatomy is often distorted by cancer or inflammation or trauma.
Operations require dissection and cutting and more dissection, all the time knowing that an important structures may be lurking nearby. Colon surgery requires the surgeon to be aware that the ureter and iliac artery and vein are just behind the bowel; biliary tract surgery requires cognizance of the proximity of the common bile duct, hepatic artery, inferior vena cava, portal vein, duodenum and pancreas. The spleen is always hanging around gastric and pancreatic surgery. A sense of where you are becomes important in almost all operations.
All surgeons must be aware of the potential pitfalls of each operation they perform. Some surgeons have this “sixth sense” that tells them to be careful, to dissect gingerly as catastrophe and disaster may be only a small snip away.
This “sense of where you are” is honed by experience. It isn’t “evidence based,” but it is real and helps make surgery cleaner, quicker and safer.
Saturday, October 18, 2014
“There he is, Dr. Ryan Lockheart, casually resting in the lounge. He certainly looks like he is ready to tackle anything that comes along and run his winning streak to an unheard of three hundred fifteen,” the announcer shouted into his microphone. “ Hello, I’m Ted Blaylock coming to you live from Halsted Operating Theater in Atlanta where Ryan Lockheart, MD FACS is about to make his way to the operating arena. Joining me here in the booth is our color analyst, former superstar surgeon and renowned textbook author for the Johns Hopkins Jays, Dr. Seeee-Mooour Fielder.”
Applause off screen
“It’s Dr. Fielder.”
“OK, welcome Dr. Seymour. What can you tell us about this exciting young surgeon who seems to be indestructible and unbeatable. Is he worth the two million dollars he’s paid for each operation?”
“He has set the surgery world on fire, Ted, just like I did during the 1970-71 season. I remember that year. Liver resection after liver resection, Whipples, pancreatectomies, nothing could stop me…”
“Until you made that hole in the portal vein and the patient died. Now back to Dr. Lockheart…”
“That wasn’t my fault; it was the G-D resident. Mark my words I’ll be back on top before you know it. This Lockheart is just a flash in the pan. He hasn’t done anything really noteworthy.”
“Except date the hottest Hollywood starlets and cure people from cancer and save, let’s see, last count was over two thousand lives. Wait I see some stirring in the back of the theater. Could it be? Yes, it’s the patient. A Mr. George G.
“Diagnosis is…wait for it…there it is on the big scoreboard: Carcinoma of the Stomach. That should present quite a challenge, Don’t you agree Dr. S.”
“It’s Dr. Fielder, F-I-E-L-D-E-R. Stomach cancer? Minor league stuff. Why I used to do those cases blindfolded with just an intern.”
“The patient is walking through the crowd. It looks like high fives all around. He’s stepping behind the screen…the air is just electric with excitement, I can just feel the anticipation in this crowd, he’s emerging, yes… here he is in his gown. This looks like it’s going to be quite a challenge for Ryan. Just look at these numbers: five foot three, three hundred pounds, Hemoglobin of 8, BUN 40, Creatinine 2.1, Glucose 198.”
“Just your average patient in East Baltiomore. I’d be in and out in under an hour.”
A loud roar comes from the crowd.
“They’re on their feet. What’s that chanting?
IV, IV, IV…
“Well, Sy, the crowd is screaming ‘IV,’ do you believe it? I’ve never seen such wild enthusiasm and that’s just for the preop nurse. I think I’m going to need earplugs when the real operating starts.”
“I think this could be the highlight of the evening, Ted. Just look at that nurse. She’s going through at least an inch of blubber to find a vein.”
“He’s on the table now, IV is in place and antibiotics are going in. If Dr. Lockheart follows protocol the surgery should be starting very soon. The audience is quiet again and there’s some commotion at the North entrance, Yes, it’s the crew. On Surgical tech we have Candy Kane, displaying her usual healthy “attitude.”
“I’d like to lick that Candy, Ted.”
“I’m sure you would, Seymour.”
“And, now, hand in hand, Dr Ernest Pill and his lovely wife and circulating Nurse, Angie.”
“You know, Dr. Pill stole Angie from my OR in Baltimore. Let me tell you, that Angie, she brings new meaning to the term ‘head nurse’.”
“Well, Sy, I’m sure she got out of Baltimore as quickly as she could. The audience is on their feet now. Listen to the enthusiasm and, how can I describe it? It has to be love.”
Ryan (softly), Ryan, Ryan (louder), Ryan, Ryan (even louder), Ryan, Ryan (now at 110 decibels) RYAN, RYAN, RYAN.
“There it is, the fabled surgery pole. It shouldn’t be long now. Dr. Pill is pushing the propofol. Just look at that intubation, smooth as silk. Candy has the clippers, she’s going for a clean shave. Just look at all that hair. Either it’s a full moon or this patient is part wolf. Angie’s got the Foley. It looks like it’s going to be a slick catheterization. There it goes. Wait, something’s holding it up. It could be a stricture. This could be a kink in Dr. Lockheart’s performance. She’s still pushing. Just look at that technique.”
“One of her better skills, I must say.”
“Wait, there it goes. We’ve got urine, it’s a go…it’s a go.”
“I can hardly wait,” Dr. Fielder sighed while he tapped his pencil on the microphone.
“ TAP, TAP, TAP, TAP.”
“Everything’s ready and this crowd is really on edge. Listen, there it goes again.”
“Ryan, Ryan, Ryan, Ryan, Ryan, RYAN, RYAN, RYAN, RY-AAAAN.”
“Lights are on now, the famous surgery pole looks like a circus side show. It should be any moment now.”
“RYAN, RYAN, RYAN, RY—AN.” (louder cheers erupt)
“There they are, I can see them now, the famed surgery boots of Doctor Ryan Lockheart MD. He’s on his way down the pole and, just listen to this adoring throng of humanity. I don’t know how he’ll be able to perform surgery with such noise.”
“I’m sure he’ll muddle through. Now if it was me…”
“Just a moment, Dr. F. He’s …”
“It’s Dr. Fielder.”
“Oh yeah, did you see that, a topless woman just ran out of the crowd and kissed him. So much for sterile technique. This crowd is up on its feet now, cheering, stomping those collective feet in unison. Wait, wait, Ryan is motioning for them to sit. It’s amazing the power he has over them. It was like a huge vacuum descended and sucked up all the shouting and cheers.”
Blaylock whispering now.
“Ryan is stepping up to the scrub sink now. I’m not sure, but I think it may be a full ten minute scrub today, instead of his usual Avagard rub. Yes, he’s at the sink, he’s turning the water on, he’s reaching for the scrub brush…wait, I don’t believe it. His foot’s on the pump and he’s squeezing out the Avagard, one, two three pumps. And, listen to that roar.”
“RYAN, RYAN, RYAN…”
“He’s walking to the table now, Candy is gowning and gloving him. Is this it? Is he about to start? But, he’s stopping. He’s about to address his circulator. Let’s see if we can pick up his words.”
“You heard it. Can you believe it, what perfection. Tell me, Sy, did you ever initiate a timeout? I’ll bet back in your day, a time out was unheard of.”
“It’s Dr. Fielder. D-O-C-T-O-R Fielder and no, I never did such a demeaning thing. I knew what I was doing. Time outs are for wimps and mediocre surgeons, both of which describe Dr. Lockheart.”
“Of course, Doc-tor Fiel-der. Let’s listen to Angie.”
“This Mr. G. 63 years old, born 4/12/1951. He’s having a total or subtotal gastrectomy. Dr. Lockheart is our surgeon (loud roar). He’s had two grams of Ancef and no allergies. Are we in agreement?”
“Yes, I concur, I agree.”
“There you have it, a near perfect timeout. Now let’s wait for Ryan Lockheart’s trademark start. The crowd is silent (Blaylock whispering again).
RYAN, RYAN, RYAN, RYAN, YAY.
“There you have it. The famous ‘it’s showtime.’ Now the surgery should commence.”
“I’m all agog.”
“As we all are, Dr. Sy. Scalpel is in hand. Just look at that hand. I’ve never seen such steadiness, nerves of steel. I don’t know how anyone can watch this and not know that there is a god this world. Only a deity could create such perfection.”
“You’ll excuse me while I go into the hallway and vomit.”
“Suit yourself, Sy, but you’ll miss this extraordinary performance. And it begins. Just look at that perfect incision, the way it swerves around the xiphoid and then the gentle curl around the umbilicus, this is sheer genius. Look at the precision; the depth is just to the fascia but not through it. He’s taking up the cautery now, although it’s almost not necessary. There can’t be more than a few drops of blood.”
A door opens and Dr. Fielder returns.
“Have I missed anything exciting? If it were me down there you better believe there would be some real excitement.”
“Well, Dr. Feldstein, the operation has just started and so far it’s a masterpiece.” (Blaylock’s voice lowers). Let’s just watch in silence for a while…”
(Blaylock whispering) “He’s moving along the colon now, separating the transverse colon from the omentum, what style, he makes it look effortless and clean. What’s this? There seems to be a hangup, the tumor is growing in the transverse mesocolon. This could put a kink in the operation, no…just look at that. He’s taking the mesentery with the tumor and the colon is just fine.”
Applause rises from the crowd, growing louder and louder.
“Well, Sy, any comments?”
“An intern could do better. I’d rather talk about Angie. She’s a real hot one.”
“Well, I can’t argue with you there, Dr. Shithead, oh I meant Dr. Fielder. Now back to the operation. (Blaylock’s voice lowers) He’s up around the spleen. Look at that dexterity. Weren’t you well known for having to take the spleen out on most of your gastric cases, Dr. Fielder?”
“It was necessary.”
“Lockheart’s cruising along now. My god, that’s a big tumor and all that fat. But, he makes it look like child’s play. He’s up by the esophagus now. It could be; maybe, no it won’t be a total. The tumor stops well away from the G-E junction. What a break for our patient and our esteemed surgeon. Looks like there won’t be any chest crackin’ today.”
“As you should be Dr. F. We’re in the homestretch now. He’s down to the left gastric artery. He’s being very careful and I don’t blame him. Just look at the size of those lymph nodes. I don’t think Dr. Lockheart, wonderful as he is, will cure this patient. Hold on, what’s that…?”
‘Whoosh”, a stream of blood shoots out of the patient as Dr. Lockheart grabs the suction while thrusting his hand into the patient.
“Oh my God, how terrible, what a tragedy. Lockheart must have cut a pretty big artery to have so much blood.”
(Dr. Fielder smiles) “Well, it looks like wonder boy may be a mere mortal after all. Well, it happens to the best of us.”
“It looks like the left gastric artery has broken loose right at its origin. I’ve never seen so much blood. And, look at the blood pressure, (everyone stares at the huge scoreboard hanging overhead) seventy, sixty, fifty forty…”
(Fielder chuckles) “It looks like the mighty Dr. Lockheart is just another hack surgeon after all.”
“Well, you should know, Sy. But wait. He’s closed his eyes and now he’s looking up.”
“That’s right, only divine intervention will help him now.”
Blaylock scowls at Dr. Fielder.
“What’s he doing? Is that a…yes, it’s a 5-0 Prolene. How can he see to suture anything through that morass of blood? He looks determined, however. The stitch is in, he’s tying now. The blood is not welling up anymore. Pressure’s coming up, sixty-five…”
(Crowd chanting) Seventy, eighty, ninety…cheers and applause.
“Do you believe that, do you? Blaylock hugs Dr. Fielder around the neck, jumping up and down. Fielder pushes him away.
(Fielder scowls) “Some surgeons are just lucky. Even a blind squirrel finds a nut once in awhile.”
“You should know about that, Sy. Nuts seem to be your specialty.”
Fielder gets up and leaves the booth.
“And there it is, the specimen. Now all that’s left is putting it all back together. He’s reaching for the stapler, a GIA 75. He’s dividing the bowel. Pure genius is all I can say. He’s putting in a 3-0 silk. Just look at the way he flips that needle around. He’s cool. That’s the only way to describe Ryan, cool, supercool.”
Loud murmurs run through the crowd of spectators as the final anastamosis is finished.
“Now it’s just closing, dressings and off to the Recovery Room. What an amazing performance. What, what’s going on? Who’s that old man? He’s going to contaminate the entire operative field. Sy, do you see that? Sy? Wait, that’s Dr. Fielder down there and he’s got a gun.”
A roar from the crowd causes Dr. Lockheart to look up as he puts the last staple in the patient. Seymour Fielder aims a handgun at Lockheart and squeezes the trigger. Angie pushes him as the shot is discharged, harmlessly hitting the scoreboard as security arrives and takes Fielder away.
“I just don’t believe it. He had his day, he was the star once. It’s sad, but true, we all get older and lose that edge. Well, there’s never a dull moment around Ryan Lockheart MD. Stay tuned for our post surgery show. We’ll have an interview with Candy and also with our lucky patient. And, don’t miss Dr. Lockheart’s next performance at the Harvey Cushing Center in Philadelphia, PA. Dr Lockheart is scheduled to tackle a retained intrabdominal foreign body, no doubt a sponge left behind by our own Seymour Fielder. So it’s goodnight from Atlanta, but stay tuned for the post surgery show. Goodnight.”
Sunday, September 7, 2014
It started at 4:30 pm. Another night on call, only today I was covering two busy emergency rooms. It was like that, back in those days, years ago. Our group provided emergency care at four different hospitals and sometimes we covered all of them. Tonight it was two. I wasn’t really concerned. There was another surgeon on back-up call and in all the years I’d been in practice there had only been a single episode of simultaneous life threatening emergencies which would have required me to be in two different places at the same time. Luckily, the back-up surgeon came to the rescue in that instance.
But, back to today. This first call from hospital A was about Lester, 55 years old with abdominal pain for two days. The pain started in the mid abdomen and then moved to the right lower quadrant. His white blood cell count was sixteen thousand and CT Scan of the abdomen and pelvis revealed acute appendicitis.
A no brainer.
I called the OR and told them to crank up the laparoscope as I made my way to the ER to see Lester. He was the manager of a well known used car dealership. His story and exam were textbook, he had an IV, antibiotics were flowing and the OR crew was ready to take him away.
I commented on the steady beeping of the OR monitors as he drifted off to sleep. The surgery went off without a hitch as I encountered a straightforward inflamed appendix which I deftly liberated with my trusty Endo GIA stapler, popped into an endopouch and pulled it out in all of twelve minutes.
As I placed the last stitch my phone went off again. The ER from hospital B was calling. Dr. P was on the other end of the call.
“I’ve got a nine year old girl with belly pain for four days, temp is 102 and CT shows appendicitis, possibly with an abscess. Do you do kids?”
I answered in the affirmative.
“Does she look very sick?”
“A little flushed, but her heart rate is around a hundred, BP is OK.”
“Does she have diffuse tenderness or is it localized?”
“Seems to only in the right lower quadrant.”
“I think we can do her surgery there. I’ll call the OR and I’ll be there in a little bit,” I informed Dr. P.
I tucked Lester away in the Hospital A PACU and made the fifteen minute drive to Hospital B. It was now 6:15 pm.
Luisa was a skinny nine year old. She smiled at me when I walked in the ER room and winced when I lightly tapped on her RLQ. Her pain had started four days previously, she’d had nausea and vomited about ten times and also had diarrhea. Her primary care doctor had diagnosed her with gastroenteritis and prescribed Pedialyte and Bactrim. It’s pretty common for appendicitis to be misdiagnosed and present late in its clinical course. Conditions such as gastroenteritis are very common and, as we are taught, common things occur commonly and gastroenteritis is more common than appendicitis.
She was wheeled off to surgery at 7:12.
She was asleep by 7:35. I put the scope in through her belly button and was greeted by a mass of inflamed bowel and omentum which was oozing pus. It wasn’t very attractive and it presented a bit of a challenge. Luisa was not going to be a twelve minute appendectomy.
I started to gingerly dissect. First the omentum. I could see the plane and gently pulled on the tissue. The “watchdog” peeled away so that I could now see a fat, grayish black appendix nesting against the small bowel, which was my next target. Carefully, carefully I separated the appendix from the small bowel. A well of brownish pus poured out and a large brown “fecalith” rolled down.
“Pac Man,” I requested.
The surgical tech rummaged around on her back table and produced the desired instrument, a device which opens and closes its jaws just like the creatures which race around the maze in the Pac Man video game. I’m not sure what this instrument’s proper name is.
I scooped up the fecalith and whisked it away, deposited it in the basin which was awaiting the offending (and offensive) appendix. Back to the task at hand, I finally had all the bowel and omentum away from the appendix and was able to proceed with what was now a “routine” appendectomy. Once the appendix gone, the final task was irrigating, washing, irrigating and more washing until the peritoneum was clean.
With the final steri placed my phone chimed again. Hospital A ER was calling.
“This is Dr. T. I’ve got a 22 year old male with two days of right lower quadrant abdominal pain, White blood count 22,000, CT shows appendicitis.”
Back I went to hospital A. It was now 8:52.
When I arrived in the ER at Hospital A I met Esteban. He had been having pain for about a day and half. He was lying motionless on the stretcher, his face was slightly flushed. He was thin with a black moustache and he only spoke Spanish.
“Tiene dolor en el estomago?” I asked reaching the limits of my Spanish.
“Cuando empezado el dolor?”
And so it went. I can take a reasonable history in Spanish as long as the patient’s symptoms are limited to the abdomen and their answers are limited to yes or no. Esteban reminded me of one of the rules I learned during residency:
If a young Latino male comes to the ER complaining of right lower quadrant abdominal pain you can schedule him for appendectomy without seeing him. You will make the proper diagnosis almost one hundred per cent of the time.
This was true because it was not considered “macho” to go to the doctor. In my experience, in the 1980’s, this rule held true. Esteban fell into this category, but he still had been evaluated with the requisite CT Scan which confirmed the obvious diagnosis of acute appendicitis.
He was in the OR by 9:45 and underwent a straightforward “lap appy,” which I finished just in time to get paged to the ER at hospital B.
“Mary Rogers, 59 years old, right lower abdominal pain for two days, White count is 12,000, CT shows a retrocecal appendicitis,” reported the familiar voice of Dr. M.
“Isn’t it early for you to call?” I asked Dr. M. “It’s usually two am when I get to hear your voice.”
“Be thankful you get an early start tonight,” she advised. “Oh and there may be another appendix brewing.”
“I’ll be there shortly,” I answered.
Luckily, the OR crew had not gone home yet. Mary was waiting in the OR holding area when I arrived. I did a quick history and physical and explained the surgery and they whisked her away to OR five. It was now 11:10.
The CT scan was one hundred per cent accurate in this case. Mary’s appendix was very retrocecal, which means it was hiding behind the Cecum (the first part of the colon which is where the appendix is attached to the colon), and behind the ascending colon, which is the next part of the colon.
I started by picking up the cecum and identifying the tenia coli, which are bands of muscular tissue in the wall of the colon. There are three tenia on the colon and they meet at the base of the appendix. Following these tenia coli allows the surgeon to find the appendix, which occasionally can be a difficult task. Using this technique I found the base of the appendix, but that was the only portion I could identify. The rest disappeared behind the colon, heading north towards the liver. In order to see what I needed to see I had to mobilize the right colon, which means divide the peritoneal attachments which keep the colon from flopping around.
This done I now could see the appendix, at least see where it was going. And so I began the tedious task of step by step clipping of the “mesoappendix” which contains the blood vessels going into the appendix. Normally I would take a stapling device and simply divide and staple this mesoappendix with one squeeze, but there was nothing easy about Mary.
Finally, the end was in sight as the inferior edge of the liver came into view. The appendix was inflamed over the distal half, not ruptured and it was finally completely free. Once it was out of the abdomen I measure it at eight inches in length, probably more than twice the norm.
No such luck. The phone went off again.
At least it was Hospital B again. Dr. M greeted me.
“Megan Bartlett is sixteen years old, right lower quadrant abdominal pain for eight hours, White Blood cell count is ten and her CT is normal. She is pretty tender, however.”
“OK, I’m still here. I’ll come take a look at her,” I replied.
Megan was there with two very worried parents, but it soon became obvious that the parents were no longer together and didn’t agree on much. Daddy wanted to take his little girl downtown to “World Famous Medical Center.” Mommy thought she could stay at Hospital B. I did my usual history and physical exam, reviewed the CT Scan and then sat down to talk to all the partied involved.
“Megan’s history and exam are strongly suggestive of appendicitis,” I began, “but the CT looks normal. She’s only been sick for eight hours and sometimes the CT won’t show any of the usual changes we see with appendicitis if her pain hasn’t been going on very long.”
I recommended she stay in the hospital to be examined later and if her pain and tenderness persisted then operate at that time. Mommy was in agreement, but Daddy was still skeptical. I left them alone for a few minutes to hash it out and, in the end, Mommy won out. Daddy was not there when I returned.
Megan was admitted to the Pediatric floor and I went home. It was two am.
I reevaluated Megan in the morning. She was still tender and subsequently underwent an uncomplicated appendectomy.
This night confirmed the old medical adage: “Common things occur commonly.”
Appendicitis is one of the most common maladies General Surgeons are called upon to treat. Most of the time this means surgery, although there have been recent efforts made to treat appendicitis nonoperatively with antibiotics. In the end, removal of this offending organ seems to be the best approach. Most patients with uncomplicated appendicitis are discharged within twenty four hours and are back to normal activity in a few days.
The advent of CT Scanning to evaluate possible appendicitis has made my life much easier. When I started in the surgery business (too many years ago) the diagnosis and treatment of appendicitis usually took three hours. Appendicitis was diagnosed based on history, physical exam and labs. I would drive to the hospital, do my H&P, then call the OR crew, wait for them to arrive and set up, do the surgery and then go home. Total time: three hours. Now, the ER physician presents the patient, tells me the CT Scan result, I call the OR crew from home, arrive just before the surgery, perform the operation and go home. Total time: one hour.
But, I still have to come and evaluate the patient in cases like Megan. Watchful waiting sometimes prevents unnecessary surgery. It is not unusual for the pain to fade away and the patient discharged without any surgical intervention. Often we never find out what caused the pain. Presumably it is a virus or some other self limiting condition.
Five appendectomies in twenty four hours is a bit unusual. Recently, I broke this record by doing seven laparoscopic appendectomies in a twenty four hour period. Maybe this disease is becoming more common. When I was in medical school Denis Burkitt, a durgeon who lived in Africa, famous for describing Burkitt’s Lymphoma, spoke at one of my classes. He said that appendicitis, among several other diseases like hemorrhoids and colon cancer, was almost never seen in Africa. He chalked it up to Americans being “constipated society,” one where the highly processed, low fiber diet caused these colonic maladies. I don’t know if he is correct. I do know that that appendicitis is very common and seems to becoming even more prevalent.
Patients will sometimes ask: “What is the purpose of the appendix?”
I answer: “It gives General Surgeons something to do when we are bored or need to make a car payment.”
Friday, August 22, 2014
The latest and greatest thing in personal companions. The I Dog, along with the built in I Dog app, allows the user to select all the characteristics wanted in a canine pet. Size, personality, shedding, long hair or short hair, are only a few of the attributes available with the latest I Dog. Long for the complete Puppy experience? Turn off the built in house broken feature and your I Dog will Pee and Poop inside, just like a real puppy. And, don’t worry about astronomical food and vet bills; the I Dog is one hundred per cent digital fun. Just plug in and charge overnight and you are ready for hours of playful frolicking. Finally, scare off those unwanted guests and would be attackers with the I Dog guard dog app.
The I Dog is coming in time for Christmas.
Tired of the same old mattress, sheets and blankets? This April, the I Bed arrives. Completely integrated mattress, box spring, sheets and blankets conform to every sleep habit. Bad Back? The I Bed senses tight, wound up muscles and arthritic joints, automatically adjusting to provide just the right amount of support and cushion to eliminate lower back muscle pain. Husband snores? The I Bed keeps him turned and even gives him a short jolt to startle him awake and stifle the annoying noise. And, for those intimate moments the Romance App (available separately) fills your boudoir with sensuous perfume, automatically sets just the right mood lighting and senses every thrust and roll to provide maximum stimulation.
The I Bed, available this spring wherever fine bedroom furniture is sold.
The flush toilet has been around for years with very little innovation. Effective, but boring. Now, American Standard presents the I Toilet. Who says the bathroom can’t be fun? From the perfectly warmed seat to the amazing Elimination App, the I Toilet makes your bodily functions not only necessary but fun!! Even while it spares the environment, the I Toilet enhances the bathroom experience. The seat automatically conforms to even the largest buttocks for maximum comfort. Built in sensors monitor the acts of elimination and micturition and immediately calculate optimum sanitation and cleansing. The optional Bidet App cleanses your bottom with just the right amount of force at just the right temperature. The included toilet paper app allows the pooper to choose strong or soft with infinite choices, including color. The flush sensors detect liquid or solid waste and adjust the amount of water per flush accordingly. No more annoying multiple flushes; studies have shown that this app actually saves water, thus preserving our limited resources. And, for those days when things just aren’t coming out right, there is a built in catalog of books, movies and music to keep you entertained. Look to the future, Look to the I toilet.
I Back Scratcher
Itches on your back can be sooo annoying. And, if you find yourself alone with an itch what can you do? Rub against a tree? Roll around on the ground? Not very effective or efficient. NO!! You need the I Back Scratcher, the latest in body comfort solutions. Adjust the I Back Scratcher to light scratch for that superficial, but annoying itch or program it for deep and long scratching to feel the comforting scratch deep into those tiring muscles. And, don’t worry if it’s a large area or a tiny spot. The I Back Scratcher automatically senses the itch and provides a timely and soothing scratch either with its five finger mode or, for smaller more localized irritation, the single finger nail probing scratcher. The I Back Scratcher, the latest in personal comfort devices.
Don’t have a green thumb? Not even a yellow one? Don’t fret, the I Garden will turn the most incompetent farmer into Johnny Appleseed and fill your home with beautiful flowers and fresh fruit and vegetables all without any fuss or effort. Merely set the I Garden post into the middle of your garden and watch it flourish, all from the comfort of your personal I Garden lawn chair (sunblocking umbrella included only with I Garden Premium Edition).
“But I want to get down on my hands and knees and be part of my garden.” Don’t worry. The Green Thumb app allows you to do as much or as little gardening as you wish. Set it to the lowest level and the I Garden only provides fertilizer and pest control. Turn it up a notch and it will water your sprouting seeds to exact specification. Ramp it all the way up and watch the seeds get planted, watered, fertilized, cultivated, and harvested. Add the I Processor and your fresh fruits and veggies are scrubbed and stored to be enjoyed days, weeks, months or even years later. Worried about pesky crows absconding with the fruits of your labor? Have no fear as the I Scarecrow app zaps these pests and keeps your garden pristine. The I Garden, a must have for every outdoor hobbyist.
You go to the zoo, it’s July and it’s ninety five degrees. Your kids pester you to see the lions, which forces you to make the long trek from the cool confines of the snake house to the Lion’s Den. What do you find? A pride of lions sleeping in their caves, doing the smart thing and avoiding the midday heat. You think: I wish I was a lion, instead of a father having to explain to disappointed children why the lions are hiding.
Sound familiar? Well, you can avoid all these troubles with the incredible, intuitive and customizable I Zoo. Want to see lions. The I Zoo puts you right in the middle of the hunt with crystal clear, life size digital lions projected utilizing the latest in holographic imagery. The picture is so clear and lifelike that you’ll swear you can taste the blood of the wildebeest after the kill. And it’s not just images. The sounds, smells and feel of the African veldt are all available with the patented Sensarround app. Now, suppose penguins are your fancy. I Zoo allows you and your kids to slide down the ice flow, battle vicious seals and consume raw fish. You’ll swear you are right there in the Antarctic.
I Zoo let’s you choose the environment, animal and activity that interests you and it’s more alive and life like than the real thing.
The I Zoo, yours for only $599.95. Senssaround app sold separately.
Feet. We’re born with them, we take them for granted forcing them into any old shoe while all the time they take the abuse until…they rebel. Arches fall, bunions form, nails ingrow and then it’s too late. Chronic pain, crippling inflammation rule our lives because, no matter how hard we try, we can’t ignore our feet. What can one do? Like a noble white night the I Shoe comes into your life freeing you and your feet from endless days and nights of podiatric misery. One hundred per cent intuitive and sensitive to individual needs the I Shoe is practical, elegant, sturdy and comfortable. Built in apps include the arch app, nail maintenance app, odor sensing and elimination app and our very popular massage app. The I Shoe can be worn to a night at the opera or climbing Mount Everest. The sole is completely equipped with the latest 3D technology which allows it to go from a pump with 5 inch stilleto heels to a rugged work boot, all controlled from your smart phone or computer.
Live the life of comfort with the I Shoe, now available at Better Buy and Shoes Are Us and other fine clothing and electronics stores.
You’ve heard of Buck Naked underwear, boxers, briefs and boxer briefs, but we now present the revolutionary new I Underwear. I Underwear is guaranteed to be the most comfortable, versatile, durable and stylish underwear ever. Slip a pair on and the first thing you’ll feel is nothing. That’s right. I Underwear feels like your running free and easy. How can that be? Well, starting at the top, this amazing underwear has no elastic, no waist band, no tags, only the softest, smoothest cotton/nylon/linen blend which conforms to your personal body habitus. Built in sensors allow the I Underwear to anticipate every movement so that the fabric moves in perfect concert with all the body parts it is protecting. And what protection!! Not only are your movements anticipated, but every body fold, every nook and cranny is mapped and catalogued so that the I Underwear provides maximum support. Torn between boxers and briefs, but not sold on boxer briefs? No worries. I Underwear will scan for body shape, perspiration index, odor and nineteen other parameters and adjust to provide maximum support, comfort, hygiene and fertility.
I Underwear, slip into a pair today.
Work, work, work. At least that’s what many fish owners say about maintaining a home aquarium. Clean the filter, clean the water, feed the fish, change the water, check the pH, stop, repeat. Over and over and over. Is there an easier way? Of course, let technology do the work. The amazing I Aquarium will maintain your fresh or salt water aquarium just like the professionals. Water composition, pH level, alkalinity and acidity, copper levels, aluminum levels, arsenic levels and every other level is continuously monitored and adjusted to provide the perfect, optimum environment for your fine, finned friends.
But, the I Aquarium can do even more!! Tired of the same old boring cichlids? The Piscean App can alter the optics of the tank and water so that even the most boring Black Molly can become a bright, colorful virtual Clown Trigger fish or lovely orange and white Clown Fish.
And, if you want to go a step farther activate the virtual fish tank app. This remarkable and free app will simulate an underwater paradise without the need for live fish or water or any cumbersome equipment. But, you’ll swear it’s all real or we will completely refund your money.
The I Aquarium, a must have for every fresh water and salt water aficionado.
Start with the first time you set your tush down on the seat and begin the amazing journey. The I Car scanners relay data on every nook and fold of your derriere and adjust the seat to maximum comfort. It’s at that point that you realize you’ve embarked on a special voyage in a special and extraordinary vehicle. But, the I Car is not just any vehicle. It’s a fully automated, customized driving experience which will take you to your destination with a mere push of a button and a few softly spoken words. Settle down into your seat, push START, murmur “supermarket” and lay back as the I Car expertly carries you to the market, all the time gently massaging those tired muscles, playing soft, soothing music while doing all the mundane tasks you dread.
Too tired to get up and push a shopping cart? No problem. Merely upload your shopping list and relax. The I Car delivers your list and arranges to have it brought to your car loaded and brought home. It even tips the grocery boy.
The amazing affordable I Car coming in 2015 from Apple Motors.
Sunday, August 3, 2014
I’ve been practicing surgery for more than twenty five years. Over these many years I’ve had innumerable interactions and encounters with patients, nurses, doctors and other health care professionals. Sometimes I’m left scratching my head in wonder and amazement. This is not always a good thing.
A few years ago Martha, a patient of one of my partners, called on a Sunday morning, which also happened to be July 4th. She had a colostomy created along with what’s called a mucus fistula following surgery for a colon perforation a few years before. A colostomy means that the colon (large intestine) was brought out to the skin level so that stool passes into a bag instead of taking its normal course to the rectum and out through the anus, a common practice when patients require emergency colon surgery. A mucus fistula means the other end of the intestinal tube is also brought out to the skin where a small amount of mucus will drain intermittently. Such mucus fistulas usually only require a light gauze dressing, not a complete stoma appliance.
Back to Martha. She was concerned because she was out of bags for her colostomy and she needed to change it and the medical equipment stores were closed. She gave me a brief rundown on her history and assured me that besides needing a new a new bag everything else was OK.
I gave some thought about what she should do. We don’t keep such appliances at our office, so I couldn’t help her directly and it was true that the medical supply shops were closed. All I could think to do was to send her to the hospital where one of the nurses could fix her up. I advised her to go to the ER and then I called and spoke with the head nurse in the ER, explaining the situation and asking if she could do the patient a favor and find her a colostomy bag to get her through the holiday weekend.
I didn’t give the matter a second thought, assuming the nurses would be able to accommodate the desperate patient without any fuss. But, I was wrong. Three hours later I get a call from the ER doctor informing me that Martha was there and he had just eyeballed her. Now he was asking me about my concerns. At first I didn’t remember her, but the lightbulb went off in my head and I told him:
“Oh, she just needs a new colostomy bag. She called me a few hours ago and I spoke to your head nurse about her.”
There was a long pause and then the ER doctor replied, “She has two colostomies and nothing is coming out of one.”
“Oh, that’s just a mucus fistula. I wouldn’t expect her to have much drainage from it. Just get her a bag and she’ll be fine,” I reassured him.
“Do you think I can talk to your partner who did her surgery? Because if she has a colostomy something should be coming out,” he deduced, again.
“Well, he’s usually not available on the weekends when he’s off, but Martha will be fine if you just fix her up with a colostomy bag.”
“Unless, I can speak with your partner I feel I’m obligated to do a CAT Scan,” he reiterated more forcefully. “Colostomies should have some drainage and I don’t see anything coming out.”
I was beginning to get a little annoyed.
“Did you actually talk to the patient?” I asked. “Did she tell you what the problem is?”
“I did talk to her,” he replied, his frustration also beginning to surface, “and she told me just what you said. But, she could be confused and a colostomy should have something coming out. I really think I should do a CAT Scan.”
I realized I was going nowhere fast.
“OK, OK, do what you have to do. I haven’t seen her and you have. I’ll see if I can get a hold of my partner.”
I realize that once the ER doctor saw poor Martha he was responsible for her care and he was only trying to practice good medicine, at least from his perspective, but he really broke a few rules. He didn’t listen to the patient, he assumed an elderly patient must be confused if she didn’t tell him what he expected to hear, he ignored his consultant and refused to consider anything but his own inaccurate diagnosis. This also is an example of relying too heavily on CAT Scans for diagnosis, while refusing to utilize any clinical judgment.
In the end, Martha got her bags and a completely unnecessary CAT Scan of her abdomen and pelvis. That particular ER physician was fired about a month later, my encounter being only one of many similar episodes. It made me wonder how some people make it through medical school and residency.
I had another incident today that made me stop and think. I was called to consult on a patient at one of the Long Term Acute Care (LTAC) facilities. LTAC’s are hospitals for patients who are not sick enough to be in a regular acute care hospital, but are too sick for a nursing home. I consult at these facilities when necessary to evaluate surgical problems.
Mitch was a complicated patient who had undergone major intra-abdominal surgery and had numerous drains which had been placed to treat abscesses which had developed after his surgery. I had not done any of the surgery and I had never seen him before, but I was called because the patient’s actual surgeons did not go to LTAC’s.
“Dr. P wants you to see Mitch because his drain broke,” the nurse reported.
I did my best to extract as much information as I could from the nurse. Mitch was stable, the drain hadn’t been collecting much fluid and it sounded like a closed suction drain’s tubing had broken off near where it attached to the suction bulb.
“Sounds like you can just cut the tube a little shorter and reconnect it to the bulb,” I deduced.
“It’s broke, I can’t do that.”
“OK, I’ll see him tomorrow.”
“But doctor. The tube isn’t draining into anything; it’s open to air.”
This was not much of a problem to me, the tube would behave like a different type of drain, called a Penrose, but I could tell the nurse was very worried.
“Just wrap it with some sterile gauze and tape it and he should be fine,” I suggested.
I went to see Mitch and found just what I expected. He had an intraperitoneal closed suction drain with plenty of tubing outside his abdomen.
“Where’s the bulb?” I asked the nurse, who was not the same nurse I had spoken with yesterday.
“I told them to save it, but they didn’t listen,” Mitch said. “They threw it away yesterday.”
The nurse was able to scrounge up another bulb, the tube was cut a little shorter and the crisis was averted, but only after I made a special trip to the LTAC to take care of a problem that should not have been a problem.
Then there are the techniques I have observed in other surgeons. I hear stories of surgeons taking two or three hours to do very simple procedures and I wonder what they are doing for so long a time. Sometimes I will ask that very question of the OR staff. The answers are scary:
“He wasn’t sure about the anatomy. He asked me my opinion, but I couldn’t help him,” reported by a surgical technician.
“He made a hole in the bladder and we had to wait for the Urologist.” I know things like this can happen, but not on a cholecystectomy.
“She just dissects very slowly, like she’s not sure what’s what.”
It’s always best to be as sure as you can be during surgery, and never cut anything unless you know what it is, but there is also some truth to the saying that “a good fast operation is always better than a bad slow operation.”
On occasion I assist younger surgeons in the OR. Most are careful and meticulous as they should be, but I have also helped some who can best be described as cavalier and sometimes dangerous.
I was assisting another surgeon on a colon resection for diverticulitis, an inflammatory condition of the colon. The segment of colon which was diseased was adherent to structures posterior to it. These structures are the ureter, iliac artery and iliac vein. Rather than carefully dissect the colon away, this surgeon took a pair of scissors and just cut away blindly, injuring the iliac vein in the process. I had to fix the vein as this surgeon did not do any vascular surgery. The patient lost about a liter of blood, because of this surgeon’s carelessness and inattention to the most basic rules of proper operative technique.
Incidents such as these make me wonder and worry a bit. If a nurse is not familiar with a particular drain, that’s OK. But, it would have been prudent to ask her head nurse what to do, rather than call in a consultant to address what was really a very simple nursing problem. I worry about the judgment, training and basic knowledge of personnel who are in positions where decision making and responsibility are of central importance. I see more and more incidents like these and I worry what will happen as I get older and face the infirmities that always come with age.