More Things

A Parable for Our Times

George was a normal guy who set out to live a normal life after graduating from Mundane University. He moved to Regular City and went to work. He started with nothing, but he was very diligent and determined and gradually began to accumulate a few things.

At first it was only a few small things, but when he got these things he was very pleased and realized that if he worked harder he could get more things. So, he doubled his efforts and, in addition to the things that he already had, he started to get more and better things. Mary saw that George had some nice things, so she decided to take an interest in George and before long they were married.

They both worked even harder and really started to accumulate a lot of things. They decided that they needed more room to store all their things so they bought a house in Suburbs, kept working and soon had everything they needed and many extra things. Finally, George and Mary sat down together one day and looked at all their things and George said, “I’m so happy we have all these things; I don’t think there’s anything else that I could possibly want.”

Just as he said this he saw his neighbor, Mickey, go by with a new shiny thing and George realized that there were other things that he could get. The happiness he had felt a few minutes before disappeared when he realized his neighbor had more things than he had.

George and Mary worked even harder and soon he had more and better things than Mickey. Once again George was filled with contentment because of all the things that he had; until Andy walked by George’s house and stopped and said, “Look at the new thing that I just got.”

George was sad because Andy’s thing was truly special and George realized that he would probably never find any thing as nice as Andy’s. That night George couldn’t sleep, because he kept thinking about the thing that Andy had and that he wanted a thing just like it, only better. He resolved to ask Andy to share his thing with him. The next day, first thing in the morning, even before he’d had his morning coffee, George went to Andy’s house and asked him to share his wonderful thing. Andy refused. George became very angry and turned around and stormed home. Later that day, after Andy had left his home, George returned to Andy’s house, broke in through a window and stole Andy’s wonderful thing. That evening George showed Mary this wonderful thing, but he was careful not to take it out if other people could see, or else the foul truth would be discovered and he would lose this wonderful thing.

The people in the neighborhood soon became wary of each other and decided that they needed to be more careful or else someone would come and try to take their things. Everyone decided to protect themselves from having their things stolen; so each man went to work and built a strong, high wall around his house. This way they kept their things safe from their neighbors and from anyone else that might have wanted to take their things.

A short time later, Samuel moved into the neighborhood. Everyone watched from behind their walls as Samuel moved in to the small vacant house that was in the middle of the street. Everyone noticed that Samuel had only a few things, and they also noticed that he smiled all the time and seemed to whistle a lot as he walked up and down the street. He waved to all his neighbors as he passed by their houses where he could see them peering out at him from behind their walls. Every day Samuel walked down the street with his spry jaunty stride, always wearing the same white clothes, sandals on his feet and holding an elaborately carved walking stick.

One day as he walked by George’s house, George called out to him from behind his high wall. “Samuel, that’s a very fancy walking stick.”

Samuel stopped and smiled, looked down at his walking stick and said, “You have a very keen eye. This was carved by my father fifty years ago. It’s the only thing I have that was his.” Samuel saw the look of admiration on George’s face and went closer to the wall.

“I see that this walking stick impresses you. I’d like you to have it.” He held the ornately carved stick up high and George was just able to reach and pull it up and over the wall into his protected sanctuary. Samuel went on his way, smiling and whistling as he walked as George put the fancy object in a pile by the wall with some of his other things.

Everyday Samuel did the same thing, walked down the street smiling and whistling. All his neighbors began to feel uneasy and decide to get together and talk about Samuel; this troublemaker that had invaded their quiet neighborhood.

“He must have a truly great thing”, George said, “or else he wouldn’t be so happy.”

All the neighbors nodded in agreement. “We must have this great thing for ourselves” George said.

“Perhaps we should ask him to share this great thing”, Mickey said.

But George interrupted, “No, we must have this thing for ourselves.” Secretly, George decided that he would keep this great thing for only himself. All his neighbors had the exact same thought.

So they all went together, men and women and knocked on Samuel’s door. He answered it with a smile wearing the same clean white outfit he wore every day.

As soon as the door opened George said, “You seem to be happy all the time and we have all concluded that you must have a great thing that makes you feel that way.”

“Welcome to my home”, Samuel responded, “Please come inside. I have hoped for a long time that someone would come to visit. You are all correct; I do have a very great thing, perhaps the greatest thing anyone can imagine. I am happy to share it with you.”

They all went in, George in the lead with a big smile on his face. He and the others realized that they were finally going to get the thing they all had dreamed about. As soon as the door was closed and before Samuel could utter another sound the entire mob set upon Samuel and beat him mercilessly until he was dead, a bloody mass that was barely recognizable as human. Everyone went their own way, searching throughout the small home for the one great thing. All they found was a small mat and a thin blanket, one slice of bread and a bottle of wine with only a few drops left in the bottom. They searched high and low, but couldn’t find anything else.

“Perhaps he kept it with him”, somebody said and they all ran to the body and pulled off the bloody clothes. There were pockets in the thin, blood stained top which they turned inside out, but nothing was found. Same for the pants.

Truly perplexed they filed out of Samuel’s home shaking their heads. “He seemed so happy all the time”, Mickey said, “but, he didn’t have any things. I don’t think he ever had any truly great thing.”

“It was all an act”, George said. “He was trying to trick us. It’s a good thing we did this or else he would’ve come to steal our things. Yes, he definitely deserved all that he got.”

As they walked down the street, each man and woman went into their home, locking themselves behind their walls and felt the comfort that came with having so many things.

Afterwards

I really think the story ends at that point, but the idealist in me would like to believe that there is more. What follows is one scenario that I hope would be the final outcome of Samuel’s sacrifice and one that reveals the truly great thing he possessed.

Months passed after Samuel’s murder and George lived a happy, peaceful life; safe behind his wall, surrounded by his many things. One day, while admiring all his things he saw Samuel’s walking stick. He picked it up and studied the elaborate carvings; some sort of lettering that he didn’t understand. He wrote the symbols down and using his translator thing read the words:

“You will love the Lord your God with all your heart and with all your soul and with all your mind. And, love your neighbor as yourself.”

He decided to take a walk and carried the fancy walking stick with him. He passed from his protected fortress, down the street and walked past Andy’s house, the words that were carved into the sturdy stick resonated in his mind. As he went by, Andy called to him from behind his wall.

“Hello, George”, Andy called from the safety of his home. “It’s a lovely day for a stroll.”

George stopped, looked down at Samuel’s walking stick and remembered how Samuel used to walk down the street, past the many houses and smile and wave to all his neighbors. To honor his guilty memories of Samuel, George stopped, smiled and waved to Andy and walked up to Andy’s wall.

“It certainly is a lovely day, Andy; far too nice to stay hidden behind a wall”, George remarked. He looked again at the fancy walking stick and remembered how Samuel had treasured it, but also how he had freely given it away. He looked up at Andy and then said, “I’d like you to have this very elaborate walking stick. Perhaps it will give you some incentive to escape from behind your wall and take at least a short a walk.” He hoisted the stick up to Andy, who quickly grabbed it and put it with his other things.

Later that day, as George looked at all his things, he felt a warm feeling in his heart. He realized it wasn’t all his things that gave him this feeling, rather it was the act of giving, freely and without any expectation of something in return that gave him this feeling. He looked at all his things again and then he started to cry. He resolved at that time to give all that he possessed to Samuel’s family, to try to make some restitution for his terrible crime.

George soon learned that Samuel had no family. But, instead, he gave all that he had and more to any needy person he met. Very soon most of his things were gone, but he felt like he had more things than any person in the world and that he had found Samuel’s one great thing.

Surrogate Surgery

Surrogate Surgery

It was announced today that a pilot program is commencing in Baltimore under provisions covered on page 2438 of the new Health Care Reform Act. It is anticipated that there will be considerable shortage of general surgeons in the years to come. Incomplete filling of residency rosters coupled with the aging population will lead to a deficit of over ten thousand general surgeons over the next twenty years.

This deficit is expected to hit hardest in rural areas, but many urban areas are already experiencing many weeks without adequate emergency and, at times, even elective coverage for many specialties, but particularly in the very important area of general surgery.

This section of the Health Care Act provides for coverage by health care providers that act as surrogates for the traditional physician or surgeon. Nurse practitioners, physician assistants, nurse midwives and similar health care providers all are anticipated to play vital roles insuring that quality healthcare is delivered to many underserved areas.

The new program, called the Simian Surrogate Program or SSP, is undertaking the task of training apes to perform many of the operations now performed by general surgeons. Specifically, chimpanzees and orangutans are currently undergoing intense education in surgical technique and decision making at the Halsted Memorial Training Center at Johns Hopkins Hospital.

Program director Dr. William Roundtree’s comments, “The use of simian surrogates to perform many of the more common operations will fill a tremendous gap in the delivery of quality surgical care that was anticipated to arise over the next few years. The retirement of the huge baby boom generation threatens to put an untenable strain on the available resources. The use of chimpanzees and orangutans has, thus far, yielded outstanding results. The program is proving a point I’ve made for years. The many residents that have passed through these hallowed halls are no better than monkees.”

Dr. Roundtree went on to explain that originally the plan was to train baboons to provide surgical care, but it was soon discovered that all the available baboons were tied up in a sister pilot program where they were being trained to become Senators and Representatives.

The first simian surgeons are expected to complete their training in 2013, coinciding with the introduction of the first health care reforms. When asked if there was to be any role for gorillas, Dr. Roundtree remarked, “Gorillas haven’t shown much aptitude for general surgery, but we are looking into training them to do orthopedics.”

News of this new pilot program sent the value of Chiquita stock soaring in after hours trading today.

Barriers

In the practice of surgery it is necessary to create barriers; obstacles that separate the surgeon from his patient. During any operation the surgeon and his assistants wear gowns, caps, masks and gloves which act as a barrier between the patient and the OR crew. These protective items help prevent contamination of the surgical field; keeping the bacteria that reside on our skin and in our mouths and noses from infecting the surgical wound. Indeed, certain orthopedic procedures, those in which any introduction of bacteria can be a life threatening disaster, take this barrier precaution to the extreme. The orthopedist has adopted an elaborate system of helmets and filters, strictly limits access to the room during the procedure and does everything humanly possible to banish the potentially deadly microorganism from the OR suite.

There is, however, much more to the barrier concept than protection of the patient. Unfortunately, it is a necessity of modern times that the OR crew also be protected; protected from contamination by the patient. It is one of the sad facts of our modern world that chronic infectious diseases exist. It is an almost daily occurrence that medical personnel will be called upon to care for patients with HIV, hepatitis B or C, MRSA and a host of other infectious agents that have the potential to be transmissible from the patient to OR personnel during the course of an operation. Proper barriers, proper technique and appropriate choice of operation protect us from our own patients and allow us the opportunity to live and serve another day.

At the end of most operations the final mechanical barrier is left with the patient, the surgical dressing. I have seen such dressings raised to the level of ritual, the surgeon mandating that only certain materials placed in a certain way be used, instructing the patient to leave the dressing in place for exactly 76 hours and 12 minutes and then remove it at precisely the proper time, unless there is a full moon, in which case it needs to be left until dawn the following day. A bit of an exaggeration, surely, but not as much as you might think. Personally, I think that a simple dressing is best; something that can be removed easily and painlessly in 48 hours.

The surgical dressing certainly is important, particularly for the first few hours. Most wounds, however are probably sealed from the outside world within twenty four hours. As a matter of fact, I instruct my hemorrhoidectomy patients to remove their dressings after only about six hours; for comfort and to begin proper care of the area. It is an extremely rare event for these patients to develop an infection, surprising really, given the location and environment of such surgery. There are reasons why infections in this area are rare which involve an entirely different sort of biological barrier, but that is a subject for another article.

There is another type of barrier that is necessarily built up between patient and physician. This is the psychological barrier; an invisible wall that prevents excessive bonding between a doctor and his patient, thus preserving an appropriate doctor-patient relationship, one that is intimate on a medically therapeutic level only. Medical School, at least my medical school, taught us to maintain an aloof concern for our patients, supposedly for the patient’s well being and to maintain our objectivity.

An excessively close relationship can make the patient too reliant on their doctor, while at the same time potentially cloud the physician’s judgment, leading to decisions based upon feelings, rather than proper objective findings. I carry this concept to its extreme in my upcoming novel Joshua and Aaron, as the doctors are prohibited from actually examining the patients in person. Such a scenario is unlikely, you are thinking, but the trend is already present.

Today, a patient visiting an emergency room is initially seen by a triage nurse, who makes the initial assessment of the severity of the condition and very often orders the indicated tests to help establish a diagnosis. After such tests are completed the emergency room physician will finally see the patient and confirm a diagnosis that has already been established. It won’t be long until the doctor becomes a superfluous intermediary and is completely eliminated from the equation, (Obamacare here we come).

It’s not just in emergency rooms such a scene plays out. The pressures of modern medicine force doctors to spend less and less time with the patient as regulations, paperwork and diminishing reimbursement force the doctor to do more and more in a limited period of time. However, don’t think that the quality of care suffers in such a system, because this definitely is not true. The amazing array of imaging systems and lab tests has made medical diagnosis far more accurate now than it was thirty years ago. What is lost is the personal aspect, the unique doctor-patient relationship.

In my surgical practice we have a physician’s assistant, whose job is to assist us in the operating room. When she first started with us our office manager asked me if I wanted her to help in the office. My answer was no. Surgery today requires much shorter hospital stays and the contact between surgeon and patient is greatly limited. Generally, I will see my patient once in the office; surgery will be scheduled, they’ll be seen again immediately before the operation and then once or twice more in the office afterwards. This is a far cry from years ago when the patient, for a similar operation, would go into the hospital the day before surgery and then stay for one or two weeks afterwards; certainly all this contact strengthened the physician patient relationship and lowered the barriers that existed, but in no way did it actually improve patient care or final outcome.

The current system is more economical and far better for the patient. But, it throws up a barrier of sorts. That is why I refused to have our PA see patients in the office. I am given one chance to create a relationship with my patient before surgery and I do not want anything or anyone to diminish this already limited opportunity.

There is one particular medical condition where I do everything possible to break down the barrier that exists between doctor and patient and that is with breast cancer patients. Of course all patients are important and most every type of cancer is serious, but of all the different diseases I encounter this one creates the greatest emotions and intense feelings for the patient and family and perhaps for the treating physician. I am often the physician called upon to inform a woman (99% of the time it’s a woman) of the diagnosis of breast cancer. Usually I’m the one that has performed the biopsy and often the first therapeutic intervention requires surgery. So, I have to break the news. Most of the time I’ve started to prepare my patient for such bad news even before the biopsy is done.

Probably 98% percent of the time when a woman comes to me with a lump in her breast or an abnormal mammogram or ultrasound it is immediately apparent whether or not the lump is cancerous. At this point I will tell her and her family that the findings are very worrisome for cancer, but that a biopsy is necessary. When I receive the confirmatory biopsy report I always tell her in person and make sure that I am not rushed for time while I explain all the implications and options. After the first explanation I usually explain everything a second and usually a third time, hoping that some of what I say will actually be retained. Even with all this many women hear nothing beyond the two words “breast cancer”. It is very common to get a call a few hours later or the next day asking about all the options again.

In situations like these I do my best to tear down the invisible barrier that exists between doctor and patient. The trust that is built in those moments contributes tremendously to healing for the patient and their family. It isn’t bad for the doctor, either.

Amazing Weight Loss Program

VOODOOWEIGHTLOSS.COM

If you are overweight and want a quick and easy way to slim down then checkout Voodooweightloss.com. This remarkable diet plan is guaranteed to help you shed those unwanted pounds in a matter of weeks and all with a minimum of effort on your part. Too good to be true? Of course, it sounds like voodoo and, the amazing thing is, IT IS VOODOO.

That’s right. Madame Marie, Queen of the Voodoo curse, straight from Haiti, the voodoo capital of the world, guarantees that if you follow her plan you will be a size two in no time. Even better, Voodooweightloss.com weight loss program allows you to eat anything and everything. I know what you’re thinking; this is some kind of scam. But, the tried and true voodoo methods, perfected over thousands of years are now available for your dieting pleasure.

Madame Marie will use her skills to slowly slim your hips, tighten your thighs and arms, firm your chin, eliminate that unsightly cellulite and, for a small extra fee, enhance your breasts and buttocks. For you male customers, she can give you six pack abs, rock hard biceps, a tight shapely butt and a sharp, chiseled face. Other enhancements may also be available (extra fees may apply).

How does she do it? Is it magic? No, it’s voodoo. For a brief time we are offering Madame’s amazing service at the incredibly low introductory price of $69.95. For this initial low fee a miniature voodoo doll will be constructed in proper proportion to your current body habitus. Madame Marie, employing secret Voodoo techniques known to only a few Voodoo High Priestesses will over a period of several weeks gradually mold your likeness into a svelte image of the self you want to be. Want to be Barbie? She can do it. Rush jobs are available for an extra fee.

So, if you have a class reunion coming up and want to show that bully from high school what you’re really made of give Madame a buzz. She will turn those thunder thighs into tight, muscular limbs that will make you the envy of every man and woman that ever made fun of you.
Just send $69.95, plus $12.95 to cover the cost of the dead chicken along with any personal item (Fine jewelry preferred) to www.voodoooweightloss.com and start to see the pounds melt away.

Disclaimer: Not approved by the American Academy of Weight Loss Programs. Once the contract is signed all obligations must be fulfilled. The Voodoo Weight Loss program can also work in reverse. Individual results may vary.

American Express, Mastercard, Visa and Paypal accepted.

Obesity is a problem that pervades our society. In medicine and, particularly surgery, whenever there are a large number of techniques for a particular operation it is generally accepted that none of them is perfect and each has a drawback or flaw. The number of diet programs available suggests that there is no one program that works better than any other. The glycemic advantage, low carb high fiber, high carb low fat, high fat low carb, Adkins, South Beach, Jenny and all the others all seem like voodoo to me. Proper diet and exercise, although archaic and requiring some determination by the individual are the keys to safe and effective weight loss. But if you are looking for a safe, albeit unorthodox weight loss program check out Madame Marie and Voodooweightloss.com.

Man's "Best" Friend

The Noble Basset Hound

All through my life, as long as I can remember, I’ve had a dog. Growing up my family had Sammy, then Curly and Fang, later Sebastian, Java, Cruiser, Merlin and Strider. Some were owned by one of my brothers, but all were part of my life for a period of time. After I married, almost twenty five years ago, my wife and I went about two years with just the two of us. No kids and no pets, except for two Lady Gouldian Finches affectionately named David and Laura. Surgical residency and my wife working full time as a nurse kept us too busy for a dog with only a minimum of time together.

However, in 1987, as a fourth year resident at Nassau County Medical Center on Long Island, we decided it was time to make an addition to our family. We still weren’t ready for children, but a dog seemed like it would be a proper addition to our household. We spent hours studying different dog books, considering breed temperament, ease in training, need for attention, friendliness with children and every other quality we could think of. After all this studying we settled upon the Basset Hound; quirky, wrinkled, short and crooked, stubborn, lovable, devious and noble. We never knew what hit us.

We started studying the classified ads and soon found a breeder in Eastern Long Island that had a red and white female available and a few weeks later Pokey T. Basset Hound joined our family. (The T stood for “The”). Pokey instantly made herself at home. She marched into our one bedroom apartment, peed on the paper we had laid out and curled up in the doggy bed we had set up in the kitchen and went to sleep. I think this was the first and last time she slept in the kitchen.

She was a very intelligent beast who never believed that she was a dog. As far as she was concerned she was another person. She preferred to eat food from our table, to sleep in our bed and spend her free time staring out the window and barking at any dog that happened by. But she was devoted to us, as long as we did things on her terms. Almost every day, after dinner, she would sit next to me on the couch and look me in the eye as if to say “Well, aren't you going to play with me?”

At that point I was expected to get up and run around room with her. Of course it didn’t matter if I’d been up for thirty six hours; she came first.

I'd tell her to find her squeaky toy, and then she'd run around the room, searching under all the furniture until she found the elusive toy. She would hand it to me and I would throw it in different spots and she would race after it and bring it back. The fun part for her was the tug-of-war that ensued as I tried to extricate the squeaky toy from her powerful jaws.

After Pokey had grown and settled in to her routine; becoming accustomed to her life as the object of devotion for my wife and I her orderly schedule was rudely interrupted by the arrival of our first child. Pokey wasn't sure what to make of this new addition to the family but she knew she didn't like it. However, being the intelligent dog that she was she quickly learned that our daughter was something to be cherished and protected and they soon became fast friends.

Like all dogs Pokey could not live forever. About a month before she left us Pokey's life was turned upside down by the arrival of Genevieve, our second Basset hound. Genevieve is a tricolored Basset who joined our family when she was about seven weeks old. She did her best to become friends with Pokey, but Pokey remained aloof, refusing to fraternize with a mere dog. After Pokey's departure our third Basset hound, Bonnie, became part of the family. Bonnie is a red and white Basset hound, similar to Pokey, but with a very different personality.

Bonnie and Genevieve have been with us for more than 10 years now. They both have an uncanny knack for finding the most comfortable spots on couches and chairs in our living room, ignoring the cushioned dog beds that are spread throughout the house. They both perfected the art of the Basset beg. Bonnie will jump up, put her front paws into your lap, stare into your eyes until your resistance is shattered and you give her a treat. Genevieve will rub her backside against the cabinets and cry until you come and see what's wrong and finally reward her with one of her favorite treats.

Both of them look forward to going out on walks, a time when their noses will lead them to bizarre and delectable treasures. Dead animals, discarded food, foul-smelling patches of grass that must smell sweet and enticing to the sensitive Basset nose are some of the prizes that await them in the outside world. Traces of scents from hundreds of other dogs all require close scrutiny. Bassett hounds have one of the most sensitive noses of all the dog breeds. Probably only the bloodhound has a superior sense of smell. Walking the Basset's after a summer shower provides an endless stream of odiferous delights for these dogs. They are built low to the ground and those long floppy ears fan the varied scents to their waiting nostrils. The Basset hound is truly a remarkable bit of engineering; perfectly designed for their primary task of tracking by scent.

Occasionally, Bonnie and Genevieve will get out of the confines of our backyard and investigate the neighborhood independently. Once the escape is discovered, I will go out and try to find my wayward hounds. Of course they are aware that they are AWOL, and when they hear their names they will look up, acknowledge your presence, and then go back to what they are investigating. When they are finally finished, and only when they're finished, they will slowly saunter towards home, on their terms, stopping along the way to investigate any new smells that may pass through their nostrils.

If the pursuer tries to chase them, unlike other dogs, they won't run away; when approached, they will roll onto their back and want you to rub their tummy. At this point, you have a choice: carry the wayward Basset home, drag her or allow her to finish her studying and come home when she is good and ready.

I'm reminded of one time when we went to the big dog show at the Reliant Center here in Houston. This show allows spectators to get very close to the dogs and see them in their preparation area as the handlers groom them for the upcoming performance. One can stroll among the various cages and pens, watching the different breeds obediently await their time in the show ring. The Bassett hounds, however, are not content to merely lie down in their cage or sit in their pen. When they see an unwitting spectator stroll by, they begin their routine. They will present their saddest, most depressed looks in an attempt to entice the unknowing passerby to come closer, then they will jump up on the edge of the pen and expect to be rewarded. Show dog or home dog, a Bassett hound is still a Bassett hound.

Such behavior isn't the mark of nobility, you may say. However, the regal confidence and majestic appearance of the Bassett hound certainly can be summed up as noble. The dictionary defines noble, as “of exalted rank, or impressive or stately appearance.” Nothing can define a Bassett hound better than these words. Although they are often presented in the media as slow and fat and lazy, the reality is that this regal canine is none of these. So, if an independent, stubborn, clownish, clever, lovable dog is on your wish list, take a close look at the “noble” Basset Hound.

Heard in and Around the OR

Heard in and around the OR

In Pre-op:

The pre-op nurse will ask, “What Surgery are you having today?”

“Repair of my Hi-anal hernia” Hiatal Hernia

“Doctor is going to remove the fireballs from my eucharist” Fibroids of the Uterus

“Fix my Piles” Hemorrhoids

“Suck out my Gallbag” Laparoscopic Cholecystectomy

“Fix my Erotic Aneurysm” Aortic Aneurysm

When asked “What’s your surgeon’s name?”

“I don’t know, he’s the one with red hair and glasses.”

Before starting Surgery:

When a general surgeon says “This will only take thirty minutes.” It means “It will take me thirty minutes assuming this tumor is in the sigmoid colon where the GI doc said it’s supposed to be and not in the stomach like last time, so call Dr. Smith, who’s following my case and tell him he’ll have plenty of time for lunch.”

When an Orthopedic surgeon says “This will only take thirty minutes” it means, “We’ll fix this and then get an X-ray and then do it again until I figure out which bone is connected to what; it will be at least three hours.”

When a Plastic surgeon says “This will only take thirty minutes” it means “it will take me thirty minutes to set up my camera. The surgery will probably four or five hours.”

Things heard during surgery and what they really mean.

Anesthesiologist to surgeon “Is everything OK down there?” Translation: “The EKG is flat, there’s no blood pressure and you’d better start CPR.”

Surgeon to Anesthesiologist “We’re having a little blood loss.” Translation:

“I just cut the vena cava and you’d better call the blood bank, get the cell saver and a priest.”

Surgeon to no one in particular “that’s not supposed to be there” Translation: “Call my lawyer, malpractice carrier and my mother, I just cut the Common Bile Duct.”

Surgeon to Anesthesiologist “He’s waking up” Translation: “Put down the Wall Street Journal and turn up the gas before the patient walks off the table.”

Surgeon to OR crew “This is a new procedure; it may take a bit longer than usual.” Translation: “I’ve only seen this done once before and I was hung over at the time.”

Surgeon to assistant “This is a particularly difficult case” Translation: I haven’t the foggiest notion of how to proceed. Take over, I’m going to the bathroom.”

Circulating nurse to Surgeon “We’re out” Translation: “You don’t need that you old fool and even if you do, I’m not walking all the way to Room 12 to get it.”

Surgeon to Anesthesiologist “Put another quarter in your machine” Translation: “I’ve got at least another hour to work and the patient is awake enough to assist me.”

Anesthesiologist to Surgeon “This patient’s very high risk, but I think we can manage” Translation “We shouldn't be operating on such a sick patient, but I’ve got vacation coming up and business has been slow.”

Soft “Whoosh”… (Silence) Translation: I’ve just cut the (choose one or all) aorta, inferior vena cava, portal vein. The ‘whoosh’ is the sound of bleeding; the silence is the sense of doom. It is permissible to replace the silence with ‘Oh Shit! Or any other similar epithet.

Such utterances are, fortunately, extremely rare. When something unexpected happens the greatest effort is made to maintain a calm, workmanlike atmosphere which explains the tendency to seemingly understate the gravity of the situation. As long as channels of communication are maintained between the members of the operating room crew the patient will receive the utmost attention.

Feel free to add to the list.

Fashion Statements

In the world of surgery where I reside fashion rarely is much of a consideration. The isolation of the operating theater does not lend itself to making fashion statements. Indeed, when I first entered private practice twenty years ago I always started my day wearing a dress shirt and tie underneath my white lab coat. Most of the time the professional look was quickly replaced by surgical scrub suits and I found myself changing back and forth three or four times a day. So, the shirt and tie faded away, replaced permanently by scrub suits.

Initially, I wore whatever scrub suit I pulled from my closet where a varied arsenal of scrubs, “borrowed” from almost every hospital I’d ever frequented, was housed. These scrubs ranged from blue to gray to various shades of green. The scrubs from Strong Memorial Hospital in Rochester, New York had a peculiar feature in that the material was 55% cotton, 44% polyester and 1% stainless steel. I always assumed that the 1% was woven throughout the fabric, but it would have been more prudent to concentrate it in certain strategic areas, given the demeanor of some of the surgical attending staff at that hospital.

The cheapest scrubs were those from Nassau County Hospital, where I did a portion of my surgical residency. White scrubs with pink “NCMC” stamped all over and pretty much see-through guaranteed that no one would ever wear a pair out in public. Actually, many did not even want to wear them in the OR, unless one wished to advertise certain assets. These have sat on my shelf for years, but were useful when I was painting our living room with the help of my kids. For some unknown reason I had several scrubs in size small which were perfect covering for my young helpers.

Surgical scrubs, until recently, were never designed to be anything but functional. Loose and drab, they could never be considered flattering. But, to the rescue, come designer scrubs. It seems there was an anesthesiology resident that tackled this problem head on and created her own line of designer (overpriced) scrub suits. As has been done with blue jeans, she added some stitching on the pockets, made them a bit more form fitting and, thus, more flattering; creating a product that has allowed her to give up medicine and become a fashion mogul. Smart move with “healthcare reform” looming large on the horizon.

The other item of surgical clothing that lends itself to fashion statements is the surgical cap. These come in quite a variety of styles. Nurses typically wear the bouffant type, billowy and comfortable. Other types are the tie around skull cap and surgical hoods. Most male surgeons favor the tied skull cap, while personnel that sport beards usually opt for the improved coverage of the hood. Many of our nursing personnel make their own head covering, adding a touch of color or whimsy to the usual drab décor. Personally, I am in the minority of surgeons it seems, because I prefer to wear the bouffant style of head covering. Besides the superior coverage which, theoretically, will decrease the risk of contaminating the operative field, these hats are more comfortable. Never sacrifice comfort for style.

Of course, there is more to surgical fashion than scrub suits and caps. Consider our patients. Certain bodily adornments are unique to the surgical patient. In particular, wound dressings, drains, scars and the ubiquitous exam gown embellish the surgical patient.

Modern surgery has evolved to its present state of ambulatory procedures, short hospital stays and rapid return to normal activity. This is all for the best and, ultimately, improves patient outcome. But, a consequence to these advances is the necessity to send patients home with freshly dressed incisions, surgical drains and sometimes open wounds that require daily care.

In the old days, circa 1980, surgical patients remained in the hospital until they had enough time to enjoy significant healing. Specifically, it was routine to keep the patient in hospital until any and all drains were removed. This could mean overnight or two weeks. Indeed, it was a frequent response at surgical conferences, when asked why a patient was still in the hospital, to answer that they still had a drain.

Times have changed, however, and patients routinely are discharged after their outpatient laparoscopic cholecystectomy or removal of soft tissue mass or breast tumor with some sort of drain. These are almost always of the class called “closed suction” drains, a fenestrated or perforated plastic end that sits within the operative site connected to another plastic tube that is tunneled under the skin and exits through an opening in the skin at a location some distance from the wound. The tunneled tube is connected to some sort of self suction apparatus; commonly a hollow bulb that is squeezed flat and provides a source of suction as it recoils to its normal state. Such a drain removes fluids that would otherwise accumulate in the surgical and wound and helps promote proper healing.

However, the patient is left with a dilemma, of sorts. How does one carry such a device in a way that is inconspicuous, functional and comfortable. At least the designers gave a bit of thought to this problem. The collection bulbs (what I call the “hand grenade” because of its shape) has a tab around its neck that allows it to safety pinned to an article of clothing. So, most commonly the drainage system is pinned to a shirt or some other article of clothing or put in a pocket, often discreetly visible but not particularly noticeable.

Some patients are far more inventive. A favorite of female patients, particularly those that are amply endowed is to stuff the drainage bulb into their bra. This keeps it well hidden, but also makes for some adventurous searching on rounds or in the office when it is necessary to check the effluent for quantity and quality. Similarly, male patients will occasionally carry it in their underwear; this works best with briefs rather than boxers.

Wound dressings generally require little attention and are rarely subject to invention. Most often they are white gauze and tape, left in place for 48 hours and simply removed. However, open wounds may require that the patient wear the dressing for weeks and sometimes months. Surgical gauze can be expensive and many patients opt for low cost alternatives. The most common is a feminine hygiene pad of some sort, sterile, absorbent and well suited to the task. Understandably, these are usually utilized for wounds that are out of the public eye.

Alternatives include cloth towels of variable cleanliness, paper towels, adhesive tape by itself and frequently nothing. It is remarkable that so many wounds heal perfectly well in spite of the lack of attention they receive; a testament to the wonderful healing capabilities that are built into our bodies.

Finally, there are exam gowns; a garment that is designed for only one purpose: to make the wearer look and feel as foolish as possible. Hospital gowns are designed with a variety of ties and snaps purportedly to make it easier to examine the patient. But, it is commonly witnessed that these gowns can cause the most learned academician’s blood pressure to rise as he struggles to undo the numerous ties which are invariably knotted and usually lead even the most rational doctor to rip or cut the offensive garment and then exclaim “I guess the hospital can send me a bill”. For the patient the gowns leave them open and exposed and many will sport two to provide complete coverage and not to reveal their “assets” to an entire ward.

In my office we have paper gowns, cheap, somewhat cumbersome but adequate. These gowns do have one unique feature. They come with a plastic “belt”. I think that this belt was designed by a runway model as it is only about twenty four inches long. Usually I find it on the floor of the exam room, sometimes the patient will be holding it with a very confused look on his or her face. Once in a while someone will actually try to put it on and one creative man tied it around his head, similar to a famous painting, a trophy to the scars he had suffered in the course of his surgery.

So the next time you watch celebrities queuing up on the red carpet, being interviewed and asked “who are you wearing?” think about the fashion statements made by the medical profession, perhaps not very glamorous, but certainly creative.