Under the Drapes

Why do you do it?

Do what? Get up in the middle of the night? Rush in to the hospital to patch mangled bodies, sew holes closed, stick my finger in a dike spewing blood and, hopefully, repair what’s broken and allow some unfortunate soul to live and love another day? A good question. I could have been a pediatrician, almost became one as a matter of fact, or a plastic surgeon, but I failed the ego test. No, I had to be a general surgeon… for glory? No… for personal satisfaction? Maybe… for intellectual stimulation, perhaps… for the money, definitely not. Then…Why?

Why did I go to school for all those years? Elementary school, junior high school, senior high school, four years of college, four years of medical school, five years of residency, working a hundred hours a week. All for what? To be able to wrestle with an intoxicated man at 3 am, trying to evaluate the stab wound to his buttock or fathom why a beautiful woman would decide, in a moment of severe, devastating depression, that she didn’t like her breasts and try to cut them off? Or why a distraught father failed to check behind his car as he pulled out of his driveway, just to pick up a container of milk, and inadvertently ran over his two year old daughter?

Why do bowels perforate, aneurysms burst, appendices rupture, arteries clog, gallstones form; why does anything bad have to happen? Why do the nicest people you could ever meet develop inoperable and incurable stomach cancer; why does anyone have to get cancer? Can’t we do something to prevent it?

You ask why I do it. Can anyone answer even one of these questions or a million other, similar ones?

But, every illness, all the injuries, all the misguided thoughts and actions, every trivial, little act that we wish we could take back, every moment that should never have happened, all these things that bring us to a doctor seeking a remedy, are they reason enough? The battle against disease rages onward, fought by doctors, nurses, technicians and therapists at all hours of the day and night; most of the time the battle is won, but the war always goes on, never ending. And if it never ends, if there can be no victory, what’s the point?

Is it enough to replace the look of overwhelming fear and distress, a look I routinely see on patient’s ( and their family’s) faces, with a smile? Is the look of relief on the faces of worried family members when they are told that everything went well, that the lump was benign, that the injuries are not severe, that their son will be back on the basketball court in just a few weeks, is this enough reward?

I’ve asked myself these questions over and over again. Sometimes I have the answer; sometimes I just shake my head in bewilderment, but all the time I answer the call, do my best, and hope that those I try to help, the sick and injured, return to a normal life.

So I come to the hospital at 3 am and probe and palpate and listen and probe some more. And then, I cut and dissect and clamp and tie and cauterize and sew and resect and reanastamose and bypass and sew some more. All of this so that, in the end, a person, broken by the struggles of life in this fallen world, can have a few more moments as a complete individual.

Why do I do it? Because of what’s waiting for me under those drapes. A patient, with a name and a family, who has entrusted me with their very being. But…do I deserve such trust?

This is the first chapter of "Under the Drapes: More Mystique of Surgery", a follow up to "Behind the Mask: The Mystique of Surgery and the Surgeons Who perform Them".

Thief

I have the misfortune of living in the same household as a diminutive, diabolical thief. She joined our family about four years ago, an innocent young thing, fresh off the plane from Hungary. She moved in and made herself at home right away. Of course, we cared for her, gave her food, a place to sleep, kept her sheltered from the wicked Houston heat and she flourished. It wasn’t until later that her true colors emerged.

The bandit I’m talking about is not a cat burglar or armed robber; she’s a cute, moderately (well more than moderately) overweight Norwich Terrier named Zoe. And, she doesn’t strive to steal just anything. She is only on the prowl for food, particularly dog treats. Her victims are, primarily) our three other dogs, Bonnie, Coconut and Leo (AKA Dumbo).

From the moment our little Zoe arrived she had a strong hankering for food. Despite our best efforts she grew; primarily sideways, to the robust weight of 19 pounds. The supposed ideal weight for a Norwich Terrier, the smallest of the true terriers, is 12 pounds. We have done our best to limit her eating, but, apart from her robust appetite, she also has a particular attitude towards exercise. Her motto is “No Pain, No Pain”. Her favorite activity, after eating, is curling up on the couch and snoozing. But, back to her light fingers, well jaws in this case.

Our dogs are all fed at the same time each morning, Zoe receiving about half a cup of food. In the evening, the dogs all expect a few treats. However, unlike little Zoe, who devours her few biscuits in a matter of seconds, the other dogs will often carry their stash of goodies around, sometimes “burying” them in one of the dog beds which are strategically positioned around the house. This is when Zoe goes into action. First she makes the rounds of each bed, searching for stray treats. None being found she will next try to sneak up on one of the other dogs, most often Bonnie, our Basset Hound, who is the largest dog, and gets the largest pile. Of course, Bonnie is well aware of Zoe’s tricks, but sometimes Zoe manages to sneak up and snatch a biscuit.

To accomplish her task Zoe will crouch down low and creep towards our unsuspecting Basset. Sometimes one of Bonnie’s treats is a few inches away from the rest. Often, while Bonnie is gathering her stash into her mouth, Zoe manages to slip in, grab a wayward morsel and spirit it away. The worst she has to suffer is a short sharp “Rowf” from Bonnie. And, that short bark will often cause Bonnie to drop her carefully gathered hoard and allow Zoe to grab even another treat.

Sometimes this surreptitious behavior is adequate. But sometimes Zoe is forced to be a bit more imaginative and resort to a diversion. This is where Zoe’s genius shines. A bit of background: at our house, whenever a stranger, particularly a strange dog, walks by, our dogs race out to the driveway and bark at them through the gate. Rather, three of our dogs. Zoe rarely joins the fray. However, she has learned to use such acts to her advantage. Should one of the other dogs have a particular treat that Zoe fancies, and attempts to sneak up and steal it have been unsuccessful, Zoe will head towards the back door and start to bark, thus signaling to the other three that a stranger is afoot. Defending the house trumps treats in canine minds, I guess, because those three dogs will race out to the driveway to investigate, barking and howling, leaving Zoe free to choose, at her leisure, from the treats that have been left behind. Brilliant, truly brilliant.

I’m not sure if sneakiness and dishonesty is an inbred characteristic of all Norwich Terriers, or if it is peculiar to Zoe. I do know that if we find any food missing in our house our first suspect is our short, stocky thief.

Treat the Patient

It happened again. A phone call from an Emergency Center at two am requesting that a patient be admitted to my service. The ER physician explained that the patient had a small bowel obstruction, a problem commonly managed by general surgeons. I pressed the ER doctor for more history.

The patient was thirty on years old, had been sick for about twelve hours with abdominal pain, nausea, vomiting and diarrhea. The obligatory abdominal and pelvic CT Scan had been performed and the reading was “small bowel obstruction”. I asked for more details, which was almost like pulling teeth. The patient had not had previous surgery, there were no apparent hernias on exam, but the CT report was unequivocal: “dilated proximal small bowel with collapsed ileum and normal appearing colon”, the classic radiologic appearance of a small bowel obstruction.

I explained to the calling physician that, almost certainly, this patient did not have a small bowel obstruction; most likely it was acute gastroenteritis and it would likely resolve spontaneously within twenty four hours. The ER doc persisted, however, stating that the patient had an elevated white blood cell count at 21,000, there were ketones in his urine and the BUN was elevated at 28. I did agree with his diagnosis of dehydration and that the patient would benefit from admission, so that IV fluids could be administered. I saw the patient in the morning. His pain was gone, his nausea and vomiting had resolved, he still had some diarrhea, the WBC had decreased to 12,000 and the BUN was normal. I started him on a liquid diet, which he tolerated without problem and he was discharged that day without any significant sequelae. In retrospect, the patient could just as easily have been managed in the ER with an infusion of IV fluids and discharged home with medication to address his symptoms; admission being reserved only if he did not improve with such measures.

The scenario above is played out on an almost daily basis around the country. A patient is admitted to the hospital because an X-Ray or lab test suggests a certain diagnosis, even if a patient’s clinical presentation suggests something completely different. The patient above gave a pretty good history for acute gastroenteritis. It is unusual for patients without hernias or previous surgery to develop small bowel obstruction, certainly not impossible, but definitely out of the ordinary. But, the hallmark of diagnosing intestinal obstruction is the X-Ray findings. The CT Scan clearly demonstrated the classic appearance of small bowel obstruction. Sometimes, I wonder.

The clinical presentation of acute gastroenteritis is, typically, sudden onset of abdominal pain, often crampy, nausea, vomiting, malaise, fever and diarrhea. But, what happens to the bowel in such a situation. Does it become hyperactive, trying to expel some offending agent, does it stop altogether and dilate, as our body’s defenses are mobilized to attack the noxious invader causing the illness? Does the bowel contract, dilate, or does it do both; perhaps the stomach dilates, while the small bowel contracts or vice versa. I don’t know.

Common teaching about acute gastroenteritis is that it is an exclusionary diagnosis based on clinical presentation and the absence any other discernible underlying cause of the associated symptoms. General consensus is that viral infection is the etiology and it is a self limited disease, usually resolving in 2-3 days. There have not been any good studies, at least to my knowledge, that document the CT scan findings of a patient suffering from acute gastroenteritis.

These days it seems to be common practice, by some physicians at least, to treat patients solely on the X-Ray and lab findings, often ignoring the fact that there is a patient attached to those images and numbers. These doctors are guilty of ignoring clinical judgment, treating the X-Ray and not treating patients. In my mind, it is one of the cardinal sins of modern medicine.

Diagnosis and therapeutic management of a patient requires that every aspect of the patient be included in the evaluation; history, physical exam, laboratory data and imaging. Each factor is weighed against a variety of possibilities and a diagnosis is made. As I’ve written previously, (See Talking to Patients, July 10, 2010), the majority of patients will tell you what is wrong within the context of a 5-10 minute interview. All the testing that follows confirms or rules out the various conditions that appear within the differential diagnosis. The knowledge necessary to ask the proper, probing question is taught in medical school and the skill is refined during residency and post residency practice. In our modern, harried, defensive, get ‘em in and get ‘em out quick, medical world, taking the few minutes necessary to properly interview the patient may not be seen as cost effective as ordering a CT Scan.

And, if the patient winds up being treated for the wrong condition, well, the CT Scan said they had it and that’s documentation enough to provide proper coverage of one’s derriere.

The only problem with this approach is that the patient suffers. Far too often, patients are sent home because the White Blood Cell count or CT Scan is normal, or admitted to the hospital because one or another exam is abnormal. The history and physical exam may suggest a serious condition, but the imaging and lab were unremarkable. Would it be better to forego such testing and base everything on clinical impression? Certainly not. As I’ve stated previously, it is best to approach patient care utilizing all the tools available. CT scans provide a great deal of information; detailed images that help clarify a murky clinical situation and allow physicians to say it’s OK to defer surgery or, conversely, to say that surgery is absolutely necessary.

For example, a 20 year old male is minding his own business, sitting on his porch reading his Bible when “two dudes” come out of nowhere and shoot this poor unfortunate soul in the right flank. He walks into the ER complaining of pain at the site of the wounds. There are entry and exit wounds, one just medial to the right anterior axillary line and the other posterior and a bit more lateral. The physical exam is equivocal and the chest X-Ray is normal. What should be done? In this case the CT Scan provides a wealth of information. Very often the latest model scanners will provide images that demonstrate the path of the bullet and provide information regarding damage to organs in that path.

I cared for a patient with this exact scenario recently. The path of the bullet was obvious, there was an injury to the right lateral aspect of the liver and the bullet appeared to have nicked the right kidney. The only thing I couldn’t be sure about was the hepatic flexure of the colon, a devastating injury if left untreated. I decided it would be best to operate on this patient. At surgery, the findings correlated perfectly with the scan. The bullet had travelled through the liver, just missed the colon and nicked the upper pole of the right kidney. The injuries required no special repair, just leaving a drain in the area of injury, and the patient recovered uneventfully.

What about a much different, but very common presentation. A few weeks ago I was asked to admit a ten year old boy who presented with complaints of right lower quadrant abdominal pain, present for twelve hours. CT scan was done and reported as acute appendicitis. Specifically, the appendix was described as having enhancement of its wall, a sign of inflammation, and was minimally dilated to 7 mm with inflammatory changes surrounding it. The boy was admitted to the hospital and seen by me about four hours later. When I evaluated him he reported that the pain had disappeared. His exam was perfectly normal; by normal I mean I could push on his abdomen through to his back and all he did was smile at me. What to do? In this case, nothing. I observed the patient in the hospital for about 8 hours more and then sent him home with instructions to his mother to call if any symptoms recur. Most likely, he had a self limiting stomach bug that had caused the CT Scan changes.

I suppose there are some surgeons who would have operated on that patient and, perhaps the appendix even would have been abnormal when examined by the pathologist. I have to believe, however, that it is always best to remember that radiologic images are only shadows, lab results are mere numbers and there is a live patient that comes with both.

Medical Terms

Antiseptic: the woman married to Uncle Septic

X-Ray: pornographic picture

Cine X-Ray: pornographic movie

CAT Scan: Imaging a patient by running a feline over their body

PET Scan: Similar to CAT Scan, except a variety of animals may be used

Perirectal: in and around a lizard or snake

Clamp: a pain in your side that develops while exercising

Ultrasound: a noise that can only be heard by dogs

Operation: A children’s game that asks the contestant to remove the “wishbone”, “spare ribs”, etc.

ICU: looking at someone

Surgeon: a large fresh water fish

Tumor: one less than three more

Carcinoma: Short for leaving one’s automobile in Omaha

Cervical: a British nobleman named “Vic” for short

Thyroid: a hemorrhoid on the upper leg

Appendix: a program for I-Phone

Kidney: part of a child’s leg

Rectum: stopping short of killin’ em

Resect: have intercourse again

Anal: to dissolve a marriage

Duct: feathered, web footed water fowl

Spinal Cord: a collection of musical notes

Lung: reaching for an object

Lymphatic: physically dependent on tree branches

Hypoglossal: not very shiny

Vagus: not very definite

Peritoneal: Two Irish brothers

Gastric: a joke performed with flatus

Parathyroid: two hemorrhoids on an upper leg

Bile Duct: to purchase a feathered web footed water fowl

Bunion: an onion roll

Metacarpal: to encounter a scavenging fish while swimming

Humerus: funny

Feel free to add to the list

Celebrity, Inc.

I sat in the waiting room clutching my portfolio waiting for my name to be called. This is it, my big chance, I thought. All those years of hard work were about to pay off.

“Ethel McDuff”, cried the receptionist, her voice betraying just a hint of contempt. A tall, thin young woman, with a face like a turkey stood up and approached her desk.

“I’m Miss McDuff”, the woman exclaimed, a bit breathlessly.

“What is it you want to be famous for?” the receptionist queried, looking a bit bored.

“Supermodel”, Miss Mcduff answered. “Here’s my portfolio. Also, here’s my sex tape and police reports detailing the terrible abuse I suffered as a child. The sex tape appeared all over the Internet. Her are links to blogs expressing my outrage that something that should have remained private was so shamelessly spread over the web without my permission.”

“Uh huh”, the receptionist responded.

“And, you can see from these police reports what shameful abuse I suffered at the hands of my high school Physics teacher. Why, there’s no question I’m scarred for life. And, my parents divorced when I was seventeen. Surely, coming from a broken home, suffering such abuse and then the final humiliation of having my private moments smeared across the Internet qualify me for celebrity status.”

“Go right into Room 22, Miss Mcduff. Mr. Qwan, our modeling coach is waiting for you.”

I watched her walk out and down the hall; shoulders slouched, head bobbing up and down, her backside sticking out a bit too far. All she could model would be a Thanksgiving day turkey, went through my head. I pictured her covered in feathers, making turkey noises.

“Allen Brown” The sound of my name brought me back to reality.

I grabbed my recordings and sheets of music and approached the desk.

“What do you do?” The receptionist asked, still looking bored.

“I write music, all types of music and I play the violin. I have discs with all thirty of the symphonies I’ve written, each performed by a major symphony orchestra. The last, Symphony Number 30 was performed by the Philadelphia Orchestra last year. And here is the Met’s presentation of my opera, “The Minotaur Revisited”. It played to sold out houses for its entire run. Oh, and I have over fifty concertos and I’ve scored three Broadway musicals and Eight movies.”

“How old are you, Mr. Black?”

“Twenty two, and the name is Brown.”

“Any scandal in your life? Were you abused as a child, come from a broken home, suffer a life threatening illness as a teenager from which you miraculously recovered? Have you ever sailed around the world solo in only a dinghy or climbed Mt. Everest without an oxygen tank? Were you a sports star, perhaps you broke your neck playing football and were paralyzed from the neck down and learned to play your violin with only your lips?”

“I’m sorry Ma’am, I haven’t done any of those things. All I’ve done is write and play music, since I was two. See this Concerto, I wrote it when I was three. I did get straight A’s in school and I was the youngest winner of the Vienna Violin Competition.”

“Boring…nothing of any notoriety.”

“Should I make a sex tape?”

“Sex tapes only work for girls unless you make one with another guy and appear victimized, or if you’ve changed your gender. Even then, it’s a hard sell. I’m sorry Mr. Blue, I don’t see anything here that qualifies you to be a celebrity. Have a nice day.”

A bit of an exaggeration; you decide.

Haunted Houses

It’s that time of the year again; the time for witches and ghosts and other creepy things that come out top frighten us at night. In recent years, Haunted Houses have become big attractions. Scarier and scarier effects, live actors and actresses made up in ghastly displays, multiple themes are all created to make us scream, cringe and soil our underwear.

I have to admit that I’ve only been to a few haunted houses over the years and these have been at commercial theme parks. The Haunted House at Disney World is a tame, whimsical ride that barely calls for a peep of fear; the one at Universal Studios is a bit more frightening, but still pretty innocuous. One thing that almost all commercial haunted houses share is the certainty that, no matter what may seem to be happening, the visitor will, physically at least, be left unharmed.

But, suppose this wasn’t the case? Suppose the evil characters were allowed to touch their hapless prey. I believe there is one haunted house in New York that requires its patrons to sign a release which specifically allows physical contact. Certainly, such contact, even if relatively benign, considerably heighten the scare factor. But, suppose it is taken a step beyond mere incidental touching. Suppose, the character was allowed to accost his “guest” and cart him or her away. Allow Vampires to grab the unsuspecting soul about the neck and pretend to drink his blood; faux mass murderers could throw their victims onto a table while a buzz saw hovering overhead descends ever so close to their uncontrollably quivering torso. Scenarios like these and others would be overnight smashes. People looking for the extreme fright would line up days in advance for such an opportunity.

What about taking it all a step farther? Introduce the real possibility of physical harm. Not for customer; perhaps one out of every thousand or so visitors would actually be attacked and have to to fight off Leatherface’s chainsaw or battle ghoulish Zombies or face the consequences. Let’s have a random client be locked in a room overrun with live rats and scorpions and snakes and then have the room gradually shrink in size until our poor visitor is buried beneath a mountain of deadly vermin and reduced to shaking bowl of jello. That would be a real scare and well worth the price of admission. I’m sure there would be endless self described macho men who would go through the house over and over, just to have the opportunity to show their stuff.

What about going even beyond? Instead of bored, out of work actors pretending to be monsters, psychopaths and villains, employ the real thing. When I was in medical school I spent at day at the state psychiatric hospital and I can attest that the patients there were beyond bizarre and I wasn’t even allowed to venture near the high security ward for the criminally insane. Let’s give those inmates a meaningful job, doing what they do best. Instead of a fake ax murderer chained to a wall brandishing a rubber ax, bring in the real thing and, just for screams, let him loose every thirty minutes or so. The pyromaniac behind bars? Give him or her some real fire to play with. Hannibal the Cannibal? Keep him locked away, but every so often give him a knife and fork, open the bars to his cell and let him provide the smug visitor with a truly worthwhile and cleansing scare.

You, dear reader, may think all this far too extreme, but in this day and age, where we read about murders and arson and violent assault on a regular basis, where such evil is all around us, on television, our computers, in our schools and workplaces, it is necessary to push the envelope if one wants to be a success in the fright business. And if someone ends up injured or worse, there are always a gaggle of lawyers ready and waiting to step in.

Now that’s really scary.

Looking Cool

When I was in medical school, during my surgical clerkship, I was introduced to a large number of surgeons from a variety of different specialties. I always found the actual surgery to be fascinating, which is one reason I decided to specialize in this area. But, I also was fascinated by the surgeons. They all seemed so confident and comfortable in the operating room, like they were born to be there. In those early years, I also noticed that there were certain things that the surgeons did that looked “cool”. I distinctly remember being impressed by one surgeon’s ability to orient a needle exactly how he wanted it by manipulating it with only the needle holder. To my neophyte eyes this was the ultimate cool; recently I started thinking, again, about what it takes to look “cool” in the OR.

The cool OR façade begins with appearance; properly styled, slightly form fitting scrubs, preferably monogrammed or inscribed with the individual’s logo, are a must. Designer scrubs are most cool for women. Scrubs that are too tight or too loose are a no-no. Scrub bottoms that are pulled too high or hang too low are definitely uncool. Even slightly different colored tops and bottoms disqualify the wearer from membership in the cool surgeon fraternity. Men should sport surgical caps jauntily worn slightly to the side. Bouffant style head covering is not acceptable for male surgeons, which leaves me among the uncool. Women may wear the bouffant style, but custom designed ones are required. There are no requisite shoes to be amongst the cool, although clogs tend towards being cool.

The real test of coolness comes during the operation. The aforementioned ability to manipulate a needle without holding it is still way cool. Holding multiple instruments on one hand is also considered essential cool. This skill involves putting your ring finger through ringed handle of scissors and/or clamps and flipping them back out of the way while operating with a different instrument. One instrument on the ring ringer qualifies for mild coolness, two brings the surgeon to the intermediate level, three raises him or her to expert and four means membership in the exclusive “superstar” club. Of course, any fumbling at any time, no matter how many instruments are involved, demotes the surgeon to complete uncool status. Similarly, attempting to manipulate the needle sans hands, being unsuccessful and then having to use fingers to adjust it also is very uncool. As a resident, one particular attending repeatedly tried to teach me to hold instruments on my ring finger instead of putting them down, which was my preference. He wasn’t really trying to teach me to be cool, he ws trying to teach me to avoid wasted motion. I never really mastered this skill; I still put the instruments down when I’m not using them and exchange them as necessary. I guess I’m still making unnecessary wasted movements. I don’t think my patients have suffered because of this deficiency.

Music played in the OR also can be a major contributor to achieving the proper state of coolness. Heavy Metal Rock and Roll played at over 100 decibels is supposed to be cool, while country western is not far behind. Listening to Swiss yodeling, classical music (my preference) or no music is not cool and also relegates me to the uncool category.

Being cool in the OR has the potential for all sorts of benefits. Having one’s choice of surgical techs and nurses is one perk. Being forgiven rude or ill tempered behavior also seems to be the province of the “cool” surgeon. Charming the OR scheduler to get a favorable start time for surgery also comes much easier to the coolest surgeons.

After thinking about all this coolness I realize that nothing I do fits into the aforementioned cool category. But, there are some things that surgeons do that are really, really, really cool. Treating the surgical staff with the greatest respect, being attentive to the worries and needs of the patient before, during and after surgery and making their families fully aware of what has or may transpire throughout the course of surgery; all these are the true epitome of coolness.

Throwing instruments, belittling and berating staff, ignoring patients and their family’s questions and concerns are definitely uncool. The coolest surgeons put patient first, do what’s right whether it’s the middle of the day or 2:00 am. Doing the right operation, at the right time and staying on top of any bumps in the surgical journey is what’s truly cool. All the rest is empty window dressing.

However, being able to flip the needle around with just the needle holder still looks pretty cool.