Sunday, April 30, 2017

Thank You

                             Thank You

“Thank you,” Bruce’s father said as he took my hand and shook it with great vigor. “Thank you for taking such good care of my son.”
He shook my had again.
I’m not sure I deserve this.
Not deserve thanks after toiling for hours in the operating room?
Bruce was a complicated case.
He was transferred to our hospital from a sister facility in anticipation of having surgery by one of our Cardiothoracic specialists. He had a large paraesophageal hiatal hernia. The General surgeon at the other facility thought the best approach to his problem would be a thoracic approach, rather than the usual abdominal approach.
Beyond the hiatal hernia Bruce had a few other issues. He was bipolar and possibly schizophrenic. He also tipped the scales at just under three hundred pounds which were packed into his five foot three frame.
I became involved on a Thursday afternoon.
“I know you’re not on call,” Dr. D, the hospitalist, apologized, but Dr. M., who is on call, is tied up at another hospital and says he doesn’t think he can do the necessary surgery anyway.”
“What’s the problem,” I asked, a bit of trepidation in my voice.
She told me the tale of Bruce’s hiatal hernia and transfer to our facility and then came to the point.
“Bruce became short of breath today. We were thinking Pulmonary Embolus and did a CT of the chest. He doesn’t have a PE, but he does have free intraperitoneal air.”
Free air. A surgical emergency. At least it’s two in the afternoon, rather than two am.
“What’s Bruce’s overall condition?” I queried.
“Septic shock, BP 80/50, heart rate 130, O2 saturation 91%, about to be intubated,” she answered.
“OK, I’ll be there shortly.”
I called the OR as I drove the short distance back to the hospital.
I didn’t have anything else to do today, anyway.
Bruce was intubated and unresponsive when I arrived. His BP was 105/60 on IV fluids and some Levophed, a pressor which helps maintain blood pressure by driving the heart to work harder.
“Open up his fluids,” I ordered. “We need to get him as good as we can to go to surgery.”
Sitting at Bruce’s bedside was his father, very concerned and worried.
“You’re going to help my boy?” he asked softly.
“I will do all I can,” I replied. “It looks like he has a hole in his stomach or intestines somewhere. Most likely it’s related to his hiatal hernia. His stomach probably twisted and then ruptured.”
“He is going to be alright?” his father asked again, hope in his voice.
“I hope so, but he’s very sick right now. He has a severe infection affecting his whole body and most of his organs. He may not survive. But, we will do all we can.”
The OR crew arrived and he was wheeled down to surgery.
“Thank you,” Bruce’s father said as I turned to follow the stretcher down to surgery.
I looked back at him.
“I haven’t done anything yet,” I responded.
“Yes, you have done a great deal.”
I didn’t answer, just turned and walked out of the ICU, following Bruce to the OR.
I hope he still wants to thank me after I’m done.
I was not too confident about Bruce’s chances.
Bruce managed to survive the induction of anesthesia, maintaining his blood pressure, although his oxygenation was borderline, hovering around 94%, even with 100% oxygen.
“OK, let’s go,” I exhorted the OR crew.
I made an upper midline incision and was in the belly in about a minute, greeted by a flood of turbid, green fluid.
“Suction and some laps and a culture tube,” I requested, all neatly passed to me and my assistant.
Not good, not good at all.
We managed to suck out and wash all the vile fluid which allowed me to track down its source. I put my money on the stomach. I put my hand up under the liver where I could feel the stomach herniated through the esophageal hiatus.
Looks like this is the problem. Why do you have such a big liver?
I mobilized the left lobe of the liver and moved it out of my way and then I began to gently tease and cajole the herniated stomach back into the abdomen.
Easy, gently, don’t make things worse.
“It feels like there is a little gremlin up in the chest holding onto the stomach,” I remarked to no one in particular.
Bit by bit the stomach started to move, first a few millimeters, then a couple of centimeters and, finally, almost with a “Whoosh” the stomach was out of the chest where I could see the damage.
“Quite a mess,” I commented out loud.
Looks like it’s been going on for two or three days.
The stomach had twisted around itself, a gastric volvulus, and had patches of frank necrosis along with extensive ischemic change. There was a large perforation along the necrotic fundus which was leaking the same foul green fluid which had filled Bruce’s belly.
Looks like a mixture of antifreeze and poop.
The area of necrosis started a couple of centimeters from the gastroesophageal junction and extended along the greater curvature to the proximal antrum.
Looks like he’ll be getting a sleeve gastrectomy. He certainly qualifies as overweight.
Sleeve gastrectomy is the preferred operation du jour for weight reduction.
The surgery was pretty simple at this point. Most of the vessels along the area of necrosis were already thrombosed. I divided them all with the Ligasure anyway, just in case. Then I stapled along the stomach where it looked to be healthy. I was a little concerned about the blood supply to the most proximal portion, so I added a layer of sutures to the staple line and then buttressed the entire closure with the omentum.
That should do the job.
Bruce’s belly was washed, rinsed and washed some more, until the fluid out was as clear as the fluid in. He was back in the ICU in short order, looking very stable. Oxygen saturation 100%, urine flowing in the bag, blood pressure holding at 115/70.
Should be a save for modern medicine.
I went to talk to Bruce’s father.
“We found the problem and fixed it. His stomach had gone up into his chest and twisted and ruptured. He’s still very sick, but he looks stable right now and the source of his problems is fixed. Now he just has to heal…”
I added a few words about sepsis and organ failure, but I could tell that he had heard only a few of the words I’d said.
“Do you have any questions?” I finished.
“Thank you, thank you for your efforts and taking the time to talk to me,” he replied and we shook hands.
He sat down, waiting for a signal that he could go to see his son.
‘Give the nurses a few minutes to get Bruce all settled and then they should let you come to see him,” I added.
“Thank you,” he said again.
I went back in to the ICU.
Bruce was kept intubated and on a ventilator. He was remarkably stable with normal blood pressure, heart rate around one hundred, urine filling the Foley bag. He was still under the effects of anesthesia which made any assessment of his mental status impossible. But, all things considered he was as good as he could be.
I checked on him later that evening and there was little change.
“Very stable,” the nurse reported, “but, he’s still not moving much. He does open his eyes and stares straight up, but that’s it. The hospitalist consulted Neuro, but they won’t be by until tomorrow. We are also taking him for a CT of his head.”
“Ok, sounds like everything is being done,” I commented.
The CT of his head was normal. He continued to stare at nothing and did not remove or respond. For five days he was in this catatonic state. That’s what our Psychiatrist consultant called it: “Catatonic State.”
Besides this psychiatric disorder, he was otherwise healing quite well. His vital signs and all his other organ functions normalized. He was extubated and breathing well on his own. Then, on post op day number five he decided it was time to wake up. He smiled and asked the nurse for some water and started talking and behaving as if the past five days never existed.
“Looks like he’s turned the corner,” I told his father.
“Thank you,” was the reply.
Except, it wasn’t all smooth sailing. Bruce complained of persistent nausea and vomiting.
X-rays of his abdomen reported: “Retained Barium in the gastric fundus, mild ileus.”
Something’s amiss. I took out his fundus.
Consultation was obtained with Gastroenterology and an EGD (endoscopy of the UGI tract) was scheduled. Normally I would merely read the report, but I was present for Bruce’s endoscopy.
“Looks like a fold or ridge leading to the fundus,” Dr. S commented.
“Except, I took out that part of his stomach. I think that’s a large contained perforation,” I observed.
“Should I biopsy it?”
“Maybe not. That could be the spleen. I don’t think such a large hole is going to heal. I think he’ll need surgery, again.”
It was Thursday and Bruce was very stable. Correlation with CT scan suggested that the cavity was contained in the left subphrenic space. The opening in the stomach was about five centimeters.
I met with Bruce and his father a few hours later and explained the situation.
“It looks like where I removed part of your stomach, where it was stapled closed, has not healed. Sometimes, a small hole can heal on its own, but in your case the area that is open is just too large. I need to do surgery to fix it.”
Bruce just nodded his head.
“Thank you for explaining it to us and for working so hard to take care of my son,” Bruce’s father replied.
“It’s my job,” I answered.
I wasn’t sure I deserved any thanks for what I viewed as a failure.
Maybe I should have removed more stomach. Maybe I should not have oversewed that part of the stomach. Maybe a bigger, thicker omental patch should have been used…
When a complication rears its ugly head there is a lot of second guessing. Sometimes it’s hard to accept “thank you” when things have gone awry.
Bruce went back to surgery and I managed to wade through a morass of fibrosis and adhesions to find the hole in his stomach, six centimeters long, but confined to the left subphrenic space.
I was able to close the hole in 2 layers, wash out the abscess cavity and leave a drain without causing any damage. The spleen was left intact and Bruce avoided the catatonic state which followed the first operation.
“Thank you,” his father said.
“Your welcome,” I replied. “I hope this is the last surgery Bruce needs.”
All was well for a week, The drain in the left subphrenic space collected only diminishing amounts of serous fluid, Bruce felt well and there were no signs of any new problems. Until day eight.
Why is Bruce’s heart rate 125? Nothing much in the drain. What was his temperature? A hundred point seven last night? Something is going on.
Something was going on. The requisite CT of the abdomen revealed a new fluid collection starting in the left subphrenic area extending down to the tail of the pancreas. My surgically placed drain was going right through the middle of it, obviously not doing its job
Maybe Interventional Radiology can help.
I reviewed the scan with the radiologist and determined a new could be safely placed. Bruce had the procedure the following day.
Two hundred milliliters of slightly greenish fluid was drained and Bruce was better,
But, he still had a fistula.
I guess he needs more time.
I met with Bruce and his father and explained the situation. Bruce just nodded his head, resigned to waiting.
“Thank you for taking the time to explain Bruce’s condition,” his father said.
I don’t deserve thanks. I should be apologizing.
Such are the thoughts I have when serious complications develop. If I had done things in a different way, managed things differently then the complication could have been avoided. Of course, I never know for sure. It’s true that Bruce had been very sick when I first met him, but now he had gone through two operations along with other procedures and he still wasn’t out of the woods.
Bruce just smoldered along, neither getting better nor worse. The drainage from the fistula decreased, but didn’t stop. He was very stable, however, and arrangements were made for continued care at home. He was being fed intravenously with TPN, had the drain in place and overall was fine, at least for someone with a hole in their stomach.
Bruce was home about four days when his father called.
“Bruce keeps vomiting and he had fever this morning,” he reported.
“Bring him back to the hospital,” I advised.
“Thank you for calling me back so quickly,” he replied.
Bruce was readmitted with pneumonia. He still had a fistula, but there was less output, less than one hundred cc’s per day. I ordered an UGI series to try to get a better picture of the fistula.
“No extravasation or fistula demonstrated on this exam” the X-Ray report stated.
I reviewed the images with the Radiologist.
“Everything went straight through and I don’t see anything outside the stomach,” Dr. H stated, a touch of excitement in his voice.
Looks good to me.
Bruce was started on a liquid diet. There was no change in the output from the drain. His pneumonia improved. He was started on solid food which he tolerated in small amounts. Finally, the day came for his discharge.
“See you in about a week or ten days, Bruce,” I said as Bruce moved into a wheelchair. He had been in the hospital off and on for three and a half months.
“Thank you for being so patient with my son and for taking care of him,” Bruce’s father remarked.
“You’ll be with him when he comes to the office?” I asked.
“Yes, I’ll be sure to get him there, Thank you again.”
“Your welcome,” I replied.
“Thank you.”
Every time Bruce suffered through one of his many complications and I tried to explain his condition to his father I heard those two words.
“Thank you.”
Each time he said them there was genuine, heart felt gratitude behind the words, gratitude I’m not sure I warranted. Whenever a patient of mine suffers a complication I wonder what I did wrong. Sometimes I can think of a particular step in the surgery or a suture that I placed that maybe wasn’t quite right, or I think maybe I should have left a drain or done a different procedure or taken a different approach. Sometimes … most of the time…I can’t think of any reason for the complication. But, it still happened and I was and am responsible.
“Thank you.”
I do appreciate these words even when I don’t merit them. And, after every operation I do I try to remember them. My parting words to my OR crew, as I walk out the door, are, almost always:
“Thank y’all.”
The only bit of Texas I’ve adopted after more than twenty five years.




                  







Sunday, March 5, 2017

My Surgery

                               

It started about three and a half years ago: an episode of pain in my abdomen. Not terrible pain, but a gnawing pain in my upper abdomen, coupled with a queasy feeling.
Probably just my GERD acting up.
I took my Prilosec and an antacid and went on my way. The pain, however, stayed with me.
All day.
And the next day.
And the next.
This is annoying. It must be more than reflux. Maybe it’s my gallbladder?
One would think that I would have thought of gallbladder disease first. I see patients with gallstones, dysfunctional gallbladders, biliary dyskinesia and every other manifestation of biliary tract disease almost every day.
“Do you think you can do a quick sono on my gallbladder?” I asked Dr. L., a Radiologist friend. “I’ve been having epigastric pain for four days and I think it might be my gallbladder. That is, if you’re not too busy and the ultrasound is available.”
“Sure,” he answered.
“No doubt about it,” he remarked a few minutes later. “Those are gallstones. You should get an official ultrasound if you are going to have anything done.”
“Agreed,” I answered as I went on my way, still with pain, but at least with the knowledge of what was causing the problem.
The next day the pain was gone. I thought about having surgery at that time, but the pain stayed away and I didn’t think about it again until about five months ago.
Pain came back, but different than before.
It’s just my reflux. I’ll go back on my Prilosec.
The pain was a little sharper than previous, but only lasted about twenty minutes, at first.
The days went by and the pain lasted longer, still not terribly severe. It was always in my epigastrium, now lasted about an hour, almost always in the morning. And, it got better if I ate, particularly a large meal.
Definitely atypical for gallbladder.
Pain from gallstones typically is worse after eating, often occurs at night. Pain the morning, relieved by food was more consistent with peptic ulcer disease. Except, I’d had an Upper GI endoscopy only about a month before which did not reveal any ulcer.
Still, it was just an annoyance. And, I did have gallstones.
There was a change for the worse about two months ago. The pain I had was sharper, just to the right of the midline in the epigastrium and it persisted for about three hours. Then, it moved to my back for an hour before vanishing completely.
RUQ abdominal pain, lasting for hours, radiating to the back? No question. This is my gallbladder.
Still, I considered it an annoyance rather than something dire, something mandating immediate intervention. I occasionally took two Tylenol which helped, but otherwise went about my daily buisiness.
Pain, however, can wear you down. Particularly when it occurs every day and lasts for hours.
A daily cycle began.
I awoke each morning feeling well. After about an hour the pain would start in my upper abdomen, always in the middle. It would intensify for about an hour. By the time lunch rolled around it would start to diminish and disappeared by early evening.
Every day.
You need to be a good patient.
I scheduled myself for an ultrasound of my gallbladder which confirmed a gallbladder packed full of stones. Then I went to see my partner, gave him the whole story and scheduled my surgery.
I guess there’s no way I can operate on myself? I’ll just have to trust my partner.
We scheduled the surgery for a Friday about ten days hence. The abdominal pain continued its daily pattern unabated. Some days the pain was sharper  and lasted for 4-5 hours. It eventually moved to my back and then dissipated. Unlike so many of my patients who say the pain occurs at night, mine almost always started in the morning and disappeared completely by dinner time.
Three days before surgery the pain was less, merely a mild gnawing ache which only lasted a couple of hours. Two days before surgery I only felt a slight queasiness without real pain.
Maybe I don’t really need this surgery.
But, the day before surgery the real pain returned.
I guess it’s time.
The morning of surgery I did my usual thing: got up a little after five, fed the bird, fed the dogs, fed everybody but myself.
My wife and I parked the car at six twenty five and went into Bayshore Hospital’s Day Surgery.
“This way Dr. Gelber, we’ve got the VIP suite ready,” one of the nurses chimed.
“Room fifteen?” I answered. “Nothing very VIP about it.”
Back in the old Day surgery unit there was Room Twenty Two. It was larger and had its own bathroom. Now the only difference between room fifteen and the other rooms is that is separated from the other rooms by a hallway. I suppose it does afford a little more privacy.
I donned my hospital gown and my red, no skid socks and lay down on the stretcher to wait.
It wasn’t very long.
Two pre op nurses descended. One asked the usual questions: medical history, allergies, previous surgery, was I wanted by the FBI; you know, routine. The other started my IV. I pointed out my prominent “intern vein” which is at my right wrist and she started the IV like the pro she was.
There was another short wait until the anesthesiologist made an appearance. Unlike some other VIP’s I did not choose any particular anesthesiologist.
They all strike me as having equivalent levels of skill and I trust my patients with all of them.
Dr. M arrived and had me sign his consent. He didn’t give me a lot of explanation, rightly assuming that I was well versed in the anesthesia routine.
Dinah and JR, who would be circulating and scrubbing the case stopped in to say hello, asked if I had any questions or concerns and then left to make sure the room was ready.
Finally, the star of this endeavor, the surgeon, Dr. L., arrived, ten minutes early, a record for him. He smiled, introduced himself to Laura and said the surgery would take about an hour.
Finally time to start.
Dr. M made another appearance. He plugged an infusion of morphine into my IV, watched as the steady drip…drip…drip began and left.
Dinah reappeared and we were off. I remember being wheeled down the hall and the doors to the OR room, #8, I believe, opening and that was it.
I can only imagine being asked to move from stretcher to table. I don’t remember any of it.  I suspect Dr. M said I might feel a little sting as the Propofol was injected, but I don’t know for sure. There certainly was a time out, maybe a joke or two at my expense and the ensuing surgery.
The next thing I do remember is being asked to breathe in the Recovery room. Laura was sitting at the bedside. The PACU nurse asked if I was having any pain.
A little, certainly not excruciating.
“Some,” I answered.
A half milligram of Dilaudid was pushed through the IV.
It worked.
The little pain I had went away. Once again I forgot to breathe, so that every so often I would hear “take a deep breath.”
As a matter of fact the accumulated Morphine and Dilaudid worked very well.
I couldn’t stand up, couldn’t pee, couldn’t do much of anything for  about four hours.
Finally, the narcotic effects started to wear off. With help, I made it to the bathroom, emptied my bladder and was deemed fit to go home, about six hours after the surgery had finished.
Of course, I still felt the effects of anesthesia and narcotics. I drank a little water and went to bed. Winston, one our dogs, a Miniature Schnauzer/Pomeranian mix made it his personal responsibility to oversee my recovery. He jumped on the bed, sniffed me all over, made sure I was breathing then lay down beside me.
No doubt he’s concerned about me, rather he’s concerned that if anything happens to me he won’t get fed.
After a couple of hours I took my first pain pill, an Ultracet which is relatively mild. After seeing how I reacted to Morphine and Dilaudid Dr. L rightly decided that 7.5 mg of hydrocodone might be too much for my delicate system and added the prescription for Ultracet.
The entire recovery was uneventful. I was able to eat without any problem. I took only two Ultracets. And I was back to work on Monday.
I looked at the photos from the surgery. The gallbladder didn’t look inflamed, my liver looked normal.
“You had a lot of little stones,” Dr. L. reported.
Makes sense, goes along with the pain I was having. Probably passed a little stone every day.
All in all it was, as best as I can tell, a boring operation. Perfectly mundane and boring. Which is the way surgery should be.
This cholecystectomy was my third experience with general anesthesia. First was a fractured fibula which required a closed reduction in seventh grade. Then shoulder surgery after my second year of medical school.
Undergoing surgery, besides the benefit of eliminating the annoying gallbladder pain, should help me empathize with my patients. I now can say to my patients that I know what you are experiencing, even if I never had to take anything stronger than Tylenol for my gallbladder pain. Same story after this surgery, except for two Ultracet.
And, it does underscore the truth that every patient, every illness is unique. We are all individuals and deserve to have our health care tailored to our personal needs. This fact is not evidence based and doesn’t fit into any standard protocol.
It does, however, lead to happy patients and good care.




Sunday, January 29, 2017

Super Bowl Prediction 2017

                            

It’s that time of year again. The national day of beer, pizza, occasionally clever commercials and one over hyped game. The Super bowl is upon us again.
Super Bowl LI.
When I first read about it I wondered who or what LI was. I did know that the game will be played in Houston, which meant that LI did not stand for Long Island. Maybe LI was a new fashion designer about to make a bold statement with the Super Bowl as his or her backdrop. But, it finally dawned on me that the annual event was always couched in Roman numerals and LI stood for “51.”
Super Bowl LI: New England Patriots vs Atlanta Falcons.
On the surface it shouldn’t even be a close game. Tom Brady, Bill Belichik with all their Super Bowl experience against a team who don’t have one player I’ve ever heard of. The current line is Patriots minus 3 points. A no brainer, at first glance.
But, such an important event deserves far closer scrutiny and analysis. I will start with the Patriots.
What are Patriots, particularly those from New England?
A rag tag band of colonists trying to separate themselves from their mother country. Typically they are armed with muskets; firearms which fire large caliber “balls” with all the accuracy of Shaquille O’Neal shooting free throws. It is true that such muskets can inflict great damage should they hit their mark, a relatively rare event.
And, battling these Patriots? Falcons. Sleek birds with sharp claws and beaks, perfectly designed for hunting and killing mice, rats and other small animals. The Falcon is the fastest of all birds, able to soar at speeds of close to seventy miles per hour and dive at speeds over two hundred miles per hour.
Is this a fair matchup?
A motley crew of colonials armed with inaccurate firearms vs. a deadly, high speed hunter with claws and beaks which could peck out eyes while their hapless prey are trying to reload their worthless muskets.
Surely, dear reader, you have heard of Alfred Hitchcock’s “The Birds.”
There is no question about this year’s ritual game. The Patriots will be caught flat footed by the lightning Falcon attacks and all that will remain will be the bloodied bodies and tattered uniforms of New England’s storied team.

Falcons 27    Patriots 17

Saturday, December 3, 2016

Memo

                             Memo to the Medical Staff

From the CEO,

A discussion at the recent meeting of the Hospital Employee Safety and Serenity (HESS) Committee brought to light work conditions which have caused some of our employees to experience feelings of uneasiness and agitation in the hospital work environment.
Specifically, the term “Physician’s Orders” inherently creates an intimidating work atmosphere. The idea that one individual may order another individual to perform any task, even a necessary one, strikes the HESS Committee as potentially threatening and harkens back to days of master and slave; of one individual lording over another for personal gain, thus introducing charges of racism, misogyny and xenophobia into our workplace.
Several members of the nursing staff have expressed feelings of fear, anxiety and apprehension when having to carry out “orders.”
To remedy this situation and fend off possible litigation, the term “Physician’s Orders” will be modified to reflect these more enlightened and progressive times.
Several alternative phrases were proposed, including Physician’s Directions, Physician’s Mandates, Physician’s Instructions, Physician’s Advice, Physician’s Commands (immediately rejected) and Physician’s Guidelines. After much discussion and debate, however, the HESS Committee has reached a consensus. The new terminology will be “Physician’s Suggestions.”
The Committee feels, very strongly, that this phraseology will promote the greatest sense of collegiality, warmth and acceptance in the hospital workplace.
I hope this change will not cause any undue stress and the that the medical staff will agree to this adjustment and see things in the proper light of twenty first century reality.
Thank you


Saturday, October 29, 2016

Walking Miss Daisy

             

About four years ago Miss Daisy wandered or was abandoned into our life. It was a typical Sunday. I was at the hospital making patient rounds when a call from my wife.
“I found two dogs in the circle,” she reported. “I’m texting you their picture.”
“OK,” I answered, “I’m still making rounds, but should be done home in an about an hour.”
“I think someone dropped them off in the neighborhood,” she concluded. “One is a Basset Hound.”
The picture arrived. There was a rather frazzled looking tan and white lady, fairly tall and thin. And there was her companion, a mostly black, fine looking Basset Hound. The phone rang again.
“I put the dogs in the driveway and gave them some food,” Laura reported. “Of course, no collars or tags.”
“Maybe they’re microchipped?” I wondered, full well knowing that the odds finding their true owners was around a thousand to one.
Needless to say, the owners remained a mystery and Freckles, a Weimariner mix, and Daisy, the Basset Hound were adopted into our family, joining our other four dogs.
Daisy, or Daisy Mae, as I call her, paying homage to Lil’ Abner, had glaucoma and was already blind in her left eye. Freckles had very early heartworms which were successfully eradicated with antibiotics.
Daisy Mae started on a regimen of eye drops, the blue bottle twice a day, the beige one three times and the pink and green ones once at night.
But, this article isn’t about the life story of Daisy Mae and Freckles. No, it’s about walking poor Daisy. I wonder if poor is the proper term? Daisy Mae has since gone on to lose the vision in the right eye which required surgical enucleation, that is, it was removed.
Now she is Daisy Mae, the blind Basset hound.
“Poor Daisy,” one might say.
But is she poor?
If you are familiar with the Basset Hound,
(see “Man’s Best Friend, The Noble Basset Hound http://heardintheor.blogspot.com/2010_04_01_archive.html)
then you know that this breed of dog lives its life on its own terms. They are not mean or unruly, just independent and stubborn. Their keen sense of smell is second only to the Bloodhound among dogs, following their nose to the finest discarded garbage in the neighborhood. They instinctively find the most comfortable spot in the house to sleep, happily usurping your favorite overstuffed chair.
Should you feel the urge to relax in this chair they will give you a look of shock that you would even consider taking their spot. That is if you are able to wake them.
Now consider Miss Daisy Mae. All she has is her amazing nose.
The chore, or is it joy, of walking her often falls on me.
Call her name and she rises from her bed, sensing that it is either time for treats or a walk. She trots through the kitchen, deftly avoiding cabinets, garbage cans, chairs and other dogs, barking in her deep, loud Basset voice until she is hooked to the leash and heads to the door. Sometimes in her excitement she bumps into a couch or table leg, but she manages, always leading me to the door. Somehow her nose can smell the step off the front stoop as she jumps down and is on her way.
First order of business is emptying her bladder. With nose millimeters from the ground and ears flapping she finds the perfect spot, squats and nature’s call is answered. Now she is free to follow her nose. Literally.
And what a nose. Sniffing subtle aromas may be almost as good as, or even better, than sights. Daisy Mae walks along, gingerly sniffing, always along the edge of the sidewalk close to the grass. Her nose can “see” where the sidewalk ends as she only veers off to pursue a new and, I assume, wonderful, interesting, enticing scent. Once an odor is discovered she will stop and sniff and snuffle until she’s had her fill of whatever she has unearthed. Then, she will raise her head, give a snort, cleansing her nostrils of the scent and go on her way.
Methodical, slow and steady, and relentless she goes her way, oblivious to me, her leash and any other impediments. And, if her chosen path varies from mine we are left with a classic battle of wills. Me, pulling the leash, against Daisy’s 65 low slung, dense pounds.
“There’s an interesting scent this way,” her face says. “I’m not budging until I investigate.
Most of the time she wins.
Then there are those moments of joy, for Daisy, at least. She will come across a trail that excites her. A howl escapes from her throat, followed by three loud barks and another howl. She forgets her blindness, she forgets me, she forgets everything but this unseen, odiferous trail. Off she goes at a fast trot, nose to the ground, determined and resolute as she tracks down a particularly pungent, perhaps dangerous and nefarious quarry. The chase lasts for thirty or even sixty seconds until she stops and raises her head pretending to look into the distance before she turns back to me and we begin the trek home.
But, in that moment she could “see.”


Sunday, August 7, 2016

The Joy of Surgery

                                    

It was a bit exhilarating. By all accounts it should have been a mundane simple case. Tom was the patient. He had suffered with tuberculosis thirty years ago, but was pronounced cured after his treatment. Now he had a new problem, or was it a new manifestation of his old Tb?
He came to me with a mass in his neck, not really painful or tender, but draining through the skin for about a month. He was a smoker and drank a bit, but otherwise was healthy. His passion was fixing cars, a job which he began every morning at about 4:30.
The mass was a nuisance to him and his coworkers.
“Can you do it soon? Maybe tomorrow?” Tom asked.
He came with the report of a CT Scan of the neck which revealed the large mass with a low density center. Pulmonary doctor was hoping it was tuberculosis and not cancer.
The mass was three centimeters. It was inferior to the angle of the jaw, which suggested it was not from the parotid gland, and there was a sinus tract opening draining some cloudy, particulate fluid. There was no erythema and it was not tender.
What’s best? This looks more like cancer than Tb, a large node with necrotic tumor. Maybe a needle biopsy first? Still, it has ruptured through the skin which makes it unlikely to heal. It needs to be removed. Maybe I can do it this week. The schedule isn’t terribly busy.
“OK, Tom. Surgery in two days,” I answered.
I went on to explain the procedure in detail, did the necessary paperwork and sent him on his way.
The night before Tom’s operation I considered what his surgery might entail as I perused my schedule for the following day.
Inguinal hernia, venous access port, gallbladder, another inguinal hernia and Tom.
Everything straightforward and uncomplicated. What about Tom? Just a neck mass. But what if it’s more than that? Just do what you have to do.
I went to sleep.
The next morning I breezed through Mike’s inguinal hernia, Mary’s VAP, Lupe’s gallbladder and Oscar’s hernia.
Tom smiled at me as I greeted him in the pre-op area.
“Do a good job, doc. I’ve got a souped up Mustang waiting for me,” he conveyed.
“Don’t worry. We’ll take good care of you,” I gave my standard answer, the perfect words for a patient awaiting an operation, understated enough to provide a sense of calm and confidence, to the point, yet clearly stating that we will take care of everything.
Tom went to sleep and the dressing on his neck was removed, revealing the mass which was bulging against the skin. He was prepped and draped and the surgery began.
I started with an elliptical excision intended to remove the skin overlying the mass with the draining sinus. Skin flaps were raised lifting the skin and platysma off the underlying mass and the tissue surrounding it.
Find the sternomastoid muscle.
This muscle, the sternocleidomastoid is always a safe landmark when working around the neck. Important structures like the jugular vein and carotid artery run beneath it, other structures, like the parotid gland usually come down to it, but are easily separated. So the first task was accomplished quickly. The anterior border of this muscle a couple of centimeters away from the mass was exposed.
All the tissue superficial to this muscle was dissected away, the plan being to remove this normal tissue with the mass to ensure complete removal if it turned out to be cancer.
But things began to get complicated.
This mass is growing into the muscle. Where’s the jugular vein?
I identified this vein, once again, inferior to the point where the mass began, I began dissecting along the vein, isolating and ligating some side branches.
Uh-oh. This is not going to be simple.
The mass was abutting the vein.
It’s probably stuck.
Indeed, it was. As I pushed and teased the fat away from the vein, all of a sudden I was inundated with dark blood.
“5-0 Prolene, por favor,” I asked.
There was a hole in the jugular vein, but it wasn’t bleeding as much as I would expect. The blood was only coming from the thoracic side of the vein, none from the intracranial portion.
The tumor must be growing into and occluding the vein above where I’m working.
The hole was quickly repaired.
Time to reassess the situation.
It was clear that this was going to be a malignant process, but at this point I sent a piece of the mass to the pathologist to be sure.
“Squamous Cell Carcinoma,” she reported.
No surprise..
The mass was sitting squarely between the sternomastoid muscle and the jugular vein. It was now clear that it was going to take a neck dissection of some sort to remove it. The muscle and the vein would have to go.
I went to work above the mass.
“What’s that structure?” I pimped my assistant.
“Uh…”
“It’s the tendon of the digastric muscle. And this nerve?”
“Duh…”
“The hypoglossal. And that artery is the carotid.”
I don’t get to see these structures very often, although they are landmarks a surgeon always looks for in the course of any neck dissection. The digastric muscle is another safe place to dissect. I also spied the inferior edge of the parotid gland, the jugular vein above the tumor and the spinal accessory nerve and trapezius muscle soon came into view.
It was time to commit. I dissected and encircled the jugular vein inferior to the mass, ligated and divided it. I divided the sternocleidomastoid muscle with cautery.
These two structures were dissected off the underlying tissue together, once again removing the fatty lymphatic tissue with the specimen. The carotid artery and vagus nerve were preserve as they were not involved with the tumor. I reached the digastric muscle and dissected from the central tendon posteriorly, lifting the jugular vein off the muscle, followed by the sternomastoid muscle and the tumor.
A branch of the spinal accessory nerve, the one going into the sternocleidomastoid was divided while the main trunk of this nerve was preserved. Finally I was left with muscle and vein above the tumor. The vein was transected and sutured closed and the muscle was divided and the specimen was free, passed into the hands of the tech.
I took a moment to admire my handiwork. It looked like a page from Netter.
There were two ligated ends of the jugular vein. The carotid artery from the inferior neck to above the bifurcation was clearly seen as was the hypoglassal nerve crossing it. The vagus nerve ran alongside the carotid, perfectly intact. The lower end of the parotid gland stood out as did the digastric muscle. The most anterior portion of the trapezius muscle was also clearly exposed with its spinal accessory nerve. All in all it was a very neat and clean modified neck dissection.
A surgical Rembrandt? Or Picasso?
Tom’s case was a demonstration in how surgery can be so appealing to the inquisitive young mind. Tom’s was not a perfect operation and he was almost certainly not cured,  but this operation demonstrated the joy of surgery.
Joy of Cooking? Of course. Joy of Sex? Certainly.
But, the Joy of Surgery?
What is this joy that can come from cooking? Or sex? Or surgery? What is joy?
It is defined as the emotion evoked by well-being, success, or good fortune or by the prospect of possessing what one desires.
Such joy is the certainty that if you follow all the proper steps, do things in a certain way you will be rewarded with a contented or blissful or exhilarating outcome. It could be a delightful meal, or a wonderful sexual encounter, or a surgery which has a perfectly successful outcome for the patient and surgeon.
This does not mean that one needs to smoke a cigarette after the operation. But, an operation which provides complete relief for a sick patient while providing a gratifying challenge, sans frustration, worry or doubt would be considered joyful. Tom’s was such a case.
I think the closest thing would be collecting the fruits of a large wager on a perfectly handicapped horse race combined with the feeling one gets when looking at a beautiful painting.
Dissecting out all those named structures, knowing that it’s safe to cut along this muscle, that an important nerve is lurking nearby or that the jugular vein may be removed or that the external carotid may be ligated, but not the internal, or that this gland is the parotid, but if the dissection is more anterior then the submaxillary (or is it submandibular?) gland will be encountered are some of the important little facts surgeons must learn if any time is spent lurking around the neck. Every operation is filled with such little facts. Be aware of the common bile duct, or recurrent laryngeal nerve, or ureter or this artery or that.
All those little things start with basic anatomy, initially taught in the first year of medical school. But, beyond Anatomy 101, and far more important, are the knowledge and wisdom to properly assess a situation and make the appropriate decisions. What operation to do, when to do it, when to alter the plan to accommodate unforeseen pathology are skills which are difficult to teach. Book knowledge certainly helps, but there is no substitute for gray hair.