Thursday, November 24, 2011

Grateful on Turkey Day

When not celebrating with family, I spend Thanksgiving in a hospital. There I’m reminded what a generous and caring culture America is.

I spent one Thanksgiving sharing the meal with the Native American staff of a tiny rural hospital in the four corners of the Southwest. I walked into the break room and found the only anglo child present wearing a feathered headband of construction paper. My first thought: well, this is uncomfortable - who let that kid dress up as...Then I noticed the Native American children wore, indiscriminately, headbands and pilgrim hats. The staff were festive and welcomed me wholly. I soon forgot I was the minority guest on a reservation, who’d brought nothing to a potluck. The turkey, fry bread, and irony were delicious. That was a classic Thanksgiving.

Today’s was classic too. I hadn’t thought much about how to get a meal on a 48-hour shift spanning a holiday. Vending machines, I figured. But an invitation to a meal was announced overhead. A local motorcycle club, fully dressed for the road, brought and served a turkey meal for patients, nursing home residents, visiting family, and staff. The relief and gratitude of hungry diners, especially out-of-town family, was palpable.

Hours later I’m stuffing stuffing again, thanks to the gracious ICU staff.

Hospitals and holidays combine well to show me America's best face. Makes me grateful.

Tuesday, November 22, 2011

Favorite Case

What’s your favorite operation to do?

Whenever a non-medical person asks me this, I suspect he/she views surgery as an art form or a sport, where intense people develop a knack and passion for watercolor landscapes or the fast-break.

I want to supply a passionate response:

Gallbladder! Because, as one great physician said, it’s better to die on your feet than to live on your knees, with jaundice…

My answers routinely disappoint, especially when I’m honest. I file through operations and organs in my head searching in vain for the standout. Learning various lap colon techniques was awesome, but telling non-medical people that the colon is your favorite area? Nope. You’ve just underwhelmed them, grossed them out, or convinced them you’re creepy. Conversation over.

Instead, I try to keep the conversation alive:

I enjoy advanced laparoscopic techniques. You know, using small incisions to access the abdominal cavity and inserting a camera…

Oh, that sounds very interesting.

It is. It sure is. Very.

So, did you try the crab cakes? They’re great.

Yes, they sure are. Very.

Recently, though, I realized I processed the favorite surgery question incorrectly. For me, the fascinating part is not the operation but the exploration – the sorting, the diagnosing, the solving of crimes and mysteries.

Here is my new answer:

I live for the mysterious abdominal catastrophe. Viva la gangrene!

Indeed, I’m particularly fond of cases which begin at the scrub sink, taking bets with the resident:

What do you think, Chief? What are we going to find?

Perforated sigmoid. Totally.

Really? A six-pack says it’s not. I mean, a latte. A double grande caramel macciato says it’s ulcer.

You can’t exactly fill your operating schedule with acute mysterious catastrophes. It’s poor form to book a gunshot wound two weeks in advance. Nor can you develop a subspecialty in the look-see, unless inclined to take call at nine hospitals at once, consulting only for operative trauma and those emergent non-trauma belly cases in which the CT scan hasn’t clinched a diagnosis.

Those are the interesting ones, however. Bullet paths that make no sense. Abdominal cavities full of turbid fluid, a fibrinous slime coating every surface, and no visible perforation.

Opening a belly full of deadly mystery is indeed a fast-break. A clock is ticking, people are watching, and you must perform – now. This basket counts.

The exploratory laparotomy is also a puzzle. Often most of the picture is immediately apparent – something’s leaking, but what? You just need to root around for the few remaining pieces to have the whole picture.

Then there are the brainteasers. Obstruction, but no mass, no band, no hernia. Dang. Should I remove this twisty scarred part? Or, this whole intestine looks awful, but I can’t take it all out – it’s a necessary organ, after all. Or, everything looks normal. What explains the pain and the fluid? Can we just close up and report that everything under the hood looked just fine?

Solving these mysteries is supremely satisfying. Finding them unsolvable is even more intense. And deciding on the spot how to proceed is a commitment with consequence. It’s crazy thrilling, and I hope my new answer conveys the thrill. If not, I’ll work on my timing and delivery.

Sunday, November 13, 2011

Be an Excellent Bystander

This piece appears at OnSurg.

My personal blog at On Surgery, etc. will continue to feature my more personal stories while my blog at OnSurg.com will carry pieces aimed at healthcare professionals.

Thanks for tuning in. Please comment here or there, regardless of your healthcare background.

Friday, November 11, 2011

Thank you to our Veterans

I interviewed for six jobs in 2007. One was in a palatial facility which hadn’t yet opened. The recruiter said I could have any equipment I wanted - the department would be mine to build.

The next day I interviewed at the Veteran’s Hospital, a facility built in the sixties. Like most med students I’d worked rotations at a couple of VA’s and heard much mocking.

The day of my interview, I arrived early and walked the halls. Displays of fallen soldiers, of uniforms, of flags and weaponry caught my eye. The glass cases, in an empty corner of the hospital, seemed forgotten. Walking on I saw a man in a wheelchair, buzzing toward the end of a long empty hall. Outside, two more men in wheelchairs, chatting in the shade of a smokestack, surrounded by cement and cigarette butts. Forgotten, I thought.

My interviewers asked the important question: Why are you interested in working at the VA? As if perhaps I’d never visited one, or heard the word on the street.

I have great respect for military service, I answered. I feel grateful and indebted to those who’ve served. My father and grandfather served, and I’ve never served - military or in any other way that I can think of.

I got the job. Kept it four years before my family moved east.

One day in clinic I was examining a quiet nineteen-year-old man with a bothersome cyst. His gaze was odd and he looked young for nineteen. I notice a scar on his neck and cheekbone.

Roadside bomb. I’m blind in this eye, he explained.

Thank you for your service to our country, I said.

Sunday, November 6, 2011

Love your Freedom of Choice, if not your Job

At age 20, I awoke summer mornings in a sleeping bag under blue sky. My best friends and I then drank coffee while making pancakes and bacon for our twenty-four guests. After loading the rafts, we crashed class-IV rapids till the blazing sun left the canyon. Twenty miles downstream we set up tents again, grilled steak, baked apple cobbler, and played guitar by light of fire and stars. The beer was free, and we guides got our money's worth.

We got tired of this routine.

By late August, mornings were too cold and dark for our hangovers. Our backs ached from heaving rafts off exposed rocks. We missed girlfriends and newspapers. Our inside jokes grew stale and our cassette tapes were eaten or river-soaked. We finished all the beer halfway through each trip, leaving us dangerously thirsty for a couple of days. Then, just when spending 24/7 with the same few friends brought us close to throttling one another, we parted ways and went back to school.

Nine months later - best friends again. New jokes and mixed tapes, rested backs - thirsty boys, thrilled to be alive on the river again.

A short time ago, I was one cranky surgeon. Our three-man practice had lost one. For eighteen months, there were just two of us. With the extra work, I stopped writing notes; instead I simply co-signed resident notes. I starting trusting residents more, and seeing fewer patient with my own eyes. I got pretty good at supervising, I thought, as I did less and less doctoring.

While I was taking on more work with tremendous efficiency, everyone around me continued at the unbearable pace of always. What's more, every change of resident teams brought dumber and lazier residents. The nurses became incompetent. The hospital operators, useless. Hospital admin? Don't even get me started. Patients became more entitled. The residency program director took away our ICU intern. The processes and protocols of patient care were grinding to a halt, as I struggled ever more to meet my responsibilities. The government, insurance companies, and empowered patients all stood in my way, more all the time, without an end in site. Even my family failed to understand how much my patients and the whole department depended on me. I had no choice but to remain available, reliable, responsible. Right?

Advice to senior residents: negotiate lifestyle early in your career. Whatever job you take, you'll be asked to do more. You'll take it on because of your work ethic. Then you'll get a partner who does bariatrics or vascular and you'll be covering their patients on the weekend, though you don't care much for those cases or their complications. The senior partner then decides to take off all of August. The OR closes two suites for renovation. The other level one trauma center closes. Your new recruit bails last minute. Your favorite patient gets an enteroatmospheric fistula - and you get a long-term relationship with said patient.

Professionalism demands you be flexible and sacrifice plans to keep your patients well.

But, is it necessary to work years in a job barely resembling the one you signed up for? (Much less the one you envisioned?) Nope. Even the free-beer dream job of a summer rafting guide demands a re-set, and eventually, moving on.

Americans have freedoms unlike 99.9 percent of humans who ever walked the earth*. When you run out of choices in the land of opportunity, you've probably actually run out of imagination or energy - or miscalculated what your loved ones want for you.




A related post, Optimism, appears at OnSurg.com



*This observation is borrowed from Christopher Hitchens who, though facing a diagnosis of esophageal cancer, commented to an interviewer on his relative long life and good fortune.

Monday, August 22, 2011

Residency vs Life After - Part One

How are residents supposed to prepare for real life as a surgeon if they can’t even work twenty-four hours straight now?

I hear this complaint about once a month from a someone trained in the Golden Age of hazing. Outside of anecdote, we’ll never know if surgeons are better trained now or twenty years ago, or fifty. But it’s too painful to imagine every-other-night-call wasn’t of critical importance.

Residency resembles the real life of a surgeon in important ways, but working thirty-six hours straight all the time isn’t one of them. You pick your lifestyle after residency. The frequency of your thirty-six hour days is determined by this choice, not by the commitment you made as a third-year med student.

Besides the work routine, other pleasant surprises awaited me after residency. The first was a return of cognitive function. The second was the freedom of choice. Third was that a surgical career was not like managing a patient factory.

Part One - My Coma

For me, chronic under-rest was like living with a head injury. The bits I recall went like this:

Chief, grabbing unfamiliar chart on rounds: Who’s this patient? Porter, did you admit Mr Jensen?

Me: Nope. Must’ve been the off-service intern.

Chief, pointing at admission note in my handwriting: Isn’t this you?

Me: Uh, yes. Hold on.

I’d pull a half page of scribbled notes on Jensen from my pocket to jog my memory. Still nothing. I’d read straight from my notes for three minutes, having no independent recollection of the two hours I’d spent with the man.

I’d walk in the room with the chief, see the patient’s face and boom - oh yeah, this guy. He’s the owner of the Chili’s on Woodward. His wife is worried he’ll miss his thirtieth class reunion. Every time he gets a lab draw somebody wants to work him up for polycythemia vera, which was ruled out at Mayo in the eighties.

End of the day, our team is reviewing our patient list.

Chief: Porter, anything new on Jensen?

Me: On who?

Chief: The diverticulitis patient you admitted, that you couldn't remember this morning.

Me: That must’ve been the off-service intern...

Later, I open my Schwartz textbook to start a chapter I’d been meaning to read. Finding yellow highlighter streaks all over, I wondered: Who the hell..? I turned to the cover page to make sure the book was mine. Sure enough. So I started again with blue highlighter. A month later, pink.

When residency mercifully ended, I spent two months doing no thinking whatsoever. For fun, I resumed my old college summer job as a whitewater guide. I’d leave my neomammalian brain behind at headquarters and we’d go out camping and splashing for a week at a time. There was absolutely no call for higher cortical function in the rapids of the Middle Fork of the Salmon. Brainstem, spinal reflexes, and some parahippocampal gyrus and you’re good to row.

When summer ended, I started my surgery job and hit the books in prep for boards. I felt like Charlie in Flowers for Algernon: I'd picked up about thirty IQ points over the summer. Not only did I recall having highlighted Schwartz the day prior, I remembered the topic and some of its substance. And my patient list was almost superfluous - I remembered admitting them, their names, their labs.

Can I do residency again, I wondered, in a better-rested environment? It would be nice to recall what I’d learned.

Wednesday, August 17, 2011

Thanks for Studying

Suffering excruciating belly pain and actively dying, the man appeared nevertheless to fully digest the scene: an operating room scurrying to ready for something serious, complex, and emergent. Plus, for him, this event was extraordinarily personal - intimate, even.

Thank you, all of you. For studying and everything; I mean it. And thank you, in advance, for doing your best.

This is what a man with a ruptured abdominal aortic aneurysm said as we shoved him from gurney to operating table. It’s the only time I’ve been thanked for studying. I like to pass the gratitude along to current students and residents.

Patients give out little thank you’s all the time. They’re not accustomed to being so dependent, after all. They ask many tiny favors.

Can you push that table a little closer? Can you shut the door please? Can I get a cup of ice water? Thank you, thank you, thank you.

Big thank you’s usually come during the post-op visit, after recovery. These are the sweet ones. The patient takes your hand then adds his/her other, making yours the middle of a hand sandwich.

Dr Porter, I just want to say thank you, for everything.

Only once did I get the big thank you before surgery. The man’s insight still strikes me. I thought about it a great deal during the days that followed.

I recalled certain nights I stayed home to study:

  • When a good friend called with Sonics/Jazz tickets. Self-absorbed in med school, I’d lost track of him. Didn’t know he was starting forward for the Jazz. 
  • When a roommate announced that Nirvana was playing a secret gig under a pseudonym at a local club. 

I recalled the test-every-Monday fourteen-week semester and falling asleep on the bus, passing my stop and walking home miles in pouring rain in a bad part of town.

In the late nineties, my siblings prospered ridiculously, started families, had every weekend off, gathered for holidays without me, and never got up before 6 AM.

The patient with the fifty-fifty chance of overnight survival was thanking me for these sacrifices.

He acknowledged everybody with sincerity. He seemed to judge he'd never been the focus of so much trained attention, so much expensive technology and inventory. He knew the seven masks surrounding him possessed the moxie to open his catastrophic abdomen. But he hoped even more, I'm sure, that we were the kids in the libraries on Friday nights, trading young years for the chance to one day staunch hemorrhage in a dying man.

He thanked us for preparing for this moment.

Friday, August 12, 2011

Natural Childbirth

The uterus was not my usual territory. It took a minute of gentle exploring to sort things out. I found the little scrunched face. I scrunched my own eyes closed, like the copycat game you play with babies. Instinct was to pull my hands out of the mess, but I resisted. I couldn’t open my eyes again though; I worked by Braille. I pulled. My hand slipped off. Gripping the tiny head more firmly, I felt the chilling wrongness I'd expected.

A surgeon's duty throughout training is to learn what feels like what. Every new texture and sensation is recorded deliberately somewhere in white matter. The fingers and brain teach and learn together: This is the smooth inflamed inner wall of mature abscess; this is dense, scarred adhesion; this is liver parenchyma; this is thickened appendix; this floppy one’s normal. The hands have to know: Can I pinch between these inflamed organs and separate them? Or, will they burst between thumb and finger, spilling disaster?

My hand only knew the auspicious firmness of healthy baby heads. My brain was recoiling, as this head was not that. Recoiling because this new texture, of a soft, yet swollen, collapsing ball, dense, but not firm, confirmed tragedy off the charts - an unfamiliar brand of tragedy for a surgeon accustomed to deaths nearer the other end of life expectancy. Death before birth was too much. I couldn’t look.

Worse yet, I couldn’t extract the baby.

He was a home birth, like 99% of South Sudanese deliveries.

Good luck, or science and public policy, had spoiled me. I’d taken for granted the public health moon-landing which brought us from Nature’s criminal childbirth statistics to the expectation of perfection for every mother and child.

In South Sudan, childbirth is a one-in-ten risk of death to the child, and one in a hundred for Mom. I’d forgotten - and it’s just been a few generations since American settlers faced the same statistics.







The baby boy I was delivering had come, at home, arm-first. Tribe midwives, doulas, friends, and family all failed in bringing forth anything but the little arm. Three days later, when Mom arrived by emergency air shuttle, the arm was a grotesque eggplant, dislocated but still connected to his shoulder by skin. Dead skin. His mother’s vagina was dying too, by my guess - that was the urgency, in fact. I’d seen plenty of obstetric fistulas. (Stories for another day.)

I’d made a C-section incision and gone through the usual steps, plus a three-inch incision in Mom’s bladder on accident. Her urethra was crushed closed with her swollen child’s arm and she hadn’t voided her bladder in three days. I confused the massive bladder for uterus and made a nice cut that demanded repair before getting back to the business of delivering a dead baby boy.

When I finally had head in hand, I pulled, slipped off, pulled, slipped again, etc. In a humid hundred-degree inflatable operating theatre, I was sweating through my cloth cap and gown.

I hadn’t looked at the little corpse in minutes. Having a one-year-old girl of my own at home, this was unbearable.

Esther?

Yes?

Grab his arm with both hands and push it back up the birth canal. Try to squeeze some of the fluid out of the arm as you go.

Working together, my eyes still closed, we loosened him up. He came free all of a sudden. Trying not to appear stunned to my new medical colleagues, I looked at the ceiling and passed him immediately to Esther, the Kenyan midwife who knew these terrors too well. I opened my eyes again, and began the pleasant simple business of sewing, fixing, repairing, restoring. Concluding a case. Getting her off the table. Curing. Healing. Saving. Helping - a little, maybe. Who knows.



South Sudan - Mabior's Scholarship

Saturday, July 9, 2011

Happy Birthday South Sudan



If you can find a medical school that will accept you, my wife and I will support you financially.

That's what I told Mabior when I left Sudan. He was the best student I'd ever seen - he'd unknowingly earned a scholarship invented for him, on the spot.

The Nile

Mabior’s whole education had taken place in refugee camps in Somalia and Kenya. Instead of a formal degree, he held a certificate of training as a medical assistant (from UNHCR, I believe). He was a Lost Boy of Sudan. Mabior had lost his family and his home in the Sudanese civil war of the nineties. MSF (Doctors Without Borders) had taken over an abandoned building, inflated a tent as an operating theater, and become the only functioning hospital in an area the size of England. Mabior had returned to serve his childhood home community in South Sudan.

Bor was a Nile-side shanty town doubling in population every couple of weeks with returning refugees. I operated with MSF there, mostly on victims of inter-tribal gun violence and on infants who’d crawled into cooking fires.

Bor

At six-foot-nine, Mabior wasn’t the tallest of his trainee colleagues (many Dinka among them), but he distinguished himself as their natural leader. Easy charm, photographic memory, and tenacity served him well. After his daily twelve-hour shift, he’d come to the operating room to pass his free time learning anesthesia and surgery. In a couple of weeks he was doing inductions, unpaid in his spare time.

Mabior arranged for me and our Hong Kong anesthesiologist to lecture his young colleagues, who functioned as interns after a high-school education and a course in medicine. He took roll and helped his mates to understand our English.

Shortly after I flew out of Bor in a four-seater, Mabior left for Kenya with a bag holding his world.  He was bound to plead his case at Nairobi med schools. Election-time mass violence held him up, so he took a right turn for Uganda instead.  He was having trouble crossing the border – little surprise, given the lack of formal government, much less travel documents in his departing land. Absence of a bank in a two-hundred-mile radius also held up our plan.

I was in Phoenix drinking a Margarita under umbrella and cooling mister when Mabior called to update me from malarial African hinterlands. Our communication was poor, but I made out that he lacked money, a travel pass, and food. He had no school interviews pre-arranged and was bound for a city unfamiliar to us both. He'd never seen a city before. And now he was rafting the Nile or something - I couldn't really tell. Our scheme was a long shot, but I hadn’t intended to send Mabior to his death by crocodile. Best I could understand he was stranded halfway on a marshy 300-mile cow-trail between Bor and Kampala. (His phone service was a mystery, but noise from the Chandler Chihuahau races and my sizzling fajitas made hearing impossible.)

Mabior was a survivor, accustomed to long foot-journeys, hunger, and making his own way in a violent world without roads, leaders, or services. He walked back to his shanty town with its one bank, picked up my deposit, stocked his bag with bread and started again.

Weeks later, he called again. He’d been accepted conditionally at the third school he tried. I was ecstatic!

Just one problem Dr Chris.

Yes?

I was robbed while speaking to the admissions officers. I left my bag outside the office and all my things are gone. I’m very sorry.

Mabior. I said, Find a Western Union and buy yourself a stethoscope.


---------------


July 9, 2011, South Sudan became our planet's newest nation, after decades of civil war killing millions. I'm hopeful Mabior will become the first native doctor in a new nation of peace.

Happy Birthday, Sudan - Mabior's education is a gift from my family.

Mabior, holding roll-book on right. Porter, white guy, second from right.

Thursday, July 7, 2011

e-Patient Dave on TED

I had some issues with this TED talk -  Dave deBronkart: Meet e-Patient Dave

Information is power. I'm all for patient networks - support groups are crucial for helping patients help themselves. I agree patients are an underutilized resource in health care.

The speech strikes me as adversarial, however (give me my damn data..,) when we should be striving for doctor-patient collaboration.

I'm also troubled with parts of the speech suggesting ignorance and conspiracy on the part of the medical profession. Such as,

Most hospitals don't offer it so they won't even tell you it exists...don't let them give you anything else first...Four years later, you can't find a website that gives you that information...this amazing substance...

Many of the comments on the TED page suggest the same. This jaded view (plus one terrible doctor) were behind the empowered-patient-led anti-vaccine movement which set back public health a great deal.

I'm doubtful that any oncologist in the US was unaware of Interleukin for RCC in 2006. Also doubtful that oncologists would keep it secret from a patient. I just googled and found it everywhere.

I would love to know how common or rare Mr deBronkart's result is - is the Interleukin amazing for many or for few? Useless or even tragic for the rest? Miracle cures are usually a miracle for very few, while anecdotes carry great persuasive power.

As many faults as our health care system has, I believe that promoting distrust (You people can't be trusted to keep [my data] clean) on TED of all places, is a disservice to provider-patient relationships and to public health.

Let's cooperate, please, for the greater common good.

Added 2 AM July 8: 
To be clear, I believe his frustrations with our system are common and well-founded. My concern is the speech demonizes not a system but 'they' and 'you'. 'They' and 'you' are people trying to help him.

I nevertheless praise the lecture as inspiration for patient self-advocacy. Clearly most listeners took it as such.

Saturday, July 2, 2011

Hospitals in July


Me, as an intern:

Hello? This is Porter, general surgery intern.
Yeah, this is Engel. What’s going on? The nurse said you’re treating a tachycardia.
Hi, Dr Engel. Yeah. There’s a post-op heart patient here…um…64-year-old man who is status post…
Did you call the cardiologist?
No.
How did you know what to give?
From the ACLS algorithm. I just took the class.
You just medicated a post-op CABG patient with an ACLS card?
Um. Yeah, was I sup…
You didn’t call the cardiologist, the surgeon, or your senior resident? Man, you got some balls. The nurse called me cuz some cowboy intern was pushing drugs…
Sorry. I didn’t know I was supposed…

Besides clinical medicine, new computer software, cutting, sewing, and where to find a Kerlix, a fresh surgery intern has to learn his/her expected scope of practice, communication protocols, chain of command, and social norms in hospital culture. It takes time.

My instinct was to do whatever anyone asked me to do. As I result I packed bleeding noses I had no business packing, admitted patients without calling anybody, ordered x-rays without checking results.

Chief would tell me to order a CT on our inpatient and I would, without bothering to tell the patient or the nurse. I’d hear later the patient was refusing his CT scan.

I wrote transfer orders to the ICU without checking if a bed was available.

On speed rounds, an attending handed me a chart and said, put her back on Coumadin, whatever dose she was on, and discharge her. See you in the OR in five minutes.

I looked at her last Coumadin order – 10mg – wrote it in her discharge orders and ran to the operating room.

Asleep on the couch after a thirty-six-hour day, I was paged by a very excited internist and schooled on Coumadin dosing. (The woman’s usual home dose was 2 mg.)

It’s July. Remember who’s watching the flock.


Monday, June 27, 2011

The Part-Time Doctor

This is how I meet people:

Them:  "Nice to meet you."

Me:  “Nice to meet you, too”

Them:  “Dave said you’re a doctor.  What kind of doctor are you?”

Me:  “Mediocre, I guess.  Most of my patients do okay.”

Them:  “No, I mean what specialty…”  Then they apologize for the confusion or offense.  Rarely do I get the laugh I wanted.

The Dr Sibert piece in the New York Times got me thinking.  Or, mad, then thinking.  I couldn’t figure out why it rubbed so wrong.  Thanks to the many responses and the NPR discussion, my thinking took a direction.

What is a good doctor and what makes a doctor valuable?  Doctor value is productivity times quality plus happy patients, right?

 V = PQ + H
Or is it,
V = PQH
Or maybe,
V = PH + Q

Should we factor in benefit to society as a whole?  Doctors serving indigent populations get a large B and Beverly Hills cosmetic surgeons get a zero, unless of course I lose an ear there someday.  The equation becomes: 

V = PQ + H + B
Right?

My own view of what makes a good surgeon changes with the weather.  As a resident I knew first-hand which surgeon in our hospital had the most technical skill with a given procedure, and I would have chosen ten different surgeons for ten different operations.  Presently, I’m helping choose a surgeon for my nephew in consideration of cross-country travel, rapport, insurance coverage, ancillary service quality, subspecialty availability, and my nephew’s changing needs as he grows up.  I have no way to judge the technical competence of his docs.  And I couldn’t care less if his surgeon is part time if he/she has room on the clinic schedule for my nephew.  A part-time surgeon has a smaller patient load than a full-time, so continuity of care in the long term isn't affected.  In the heat of battle, such as a long hospitalization or a complication, continuity is also valuable, but so are the fresh eyes and rested hands of a partner.  The fears of the so-called shift mentality are overblown, in my opinion.  In fact, maybe the next generation has recognized that a system totally dependent on the continual presence of a single surgeon is a flawed system.

My qualm with the Sibert view is:  the number of hours worked is one factor among many determining a doc’s worth.  To focus on work hours alone is to miss the complexity of good care and debt to our benefactors. 

Imagine handing a career timecard to the taxpayers on the day of your retirement.  What if you’re a terrible surgeon who worked a hundred hours a week for forty years?  Did the taxpayers get their money’s worth?  Yes, if work hours are your only currency.

Qualm number two relates to her response on the NPR interview seeming to equate love for one’s work with willingness to work long hours.  I’m a part-time surgeon working forty hours a week.  I love all forty hours (minus documentation).  I also love sushi.  But even if I could afford it, I would not live on sushi alone, because I also love pizza.  I work part-time because I love my wife and daughter, I love my endeavor at OnSurg, I love writing, running, music, news, and travel.  I even love sleeping in.  I love taking care of patients and I sympathize with the generation who has re-framed work obligation in the larger context of life obligation.  Does this generation of doctors have to answer to the taxpayer?  Not really – this life-balance frame-shift is nationwide and crosses all professions; the taxpayer understands.

Qualm three:  Discouraging a potential doctor from medicine, part time or big time, only worsens the physician shortage Dr Sibert bemoans in the piece.

I welcome the future part-time doctor to our wonderful evolving profession.  Openly planning to balance work life with family life is mature and admirable.  Your contribution will be valuable.

Bring your kids to work, if your hospital doesn’t offer daycare, leave your toddler at the nursing station or in the admin suite while you round.  Management will come around.

I will now make a list of (largely overlapping) variables I consider relevant to a surgeon’s value to the community.  Math whizzes are welcome to provide me the quadratic equation of surgeon awesomeness:

Outcomes
Operating for the right indications
Acumen
Adherence to proven processes/protocols
Availability
Affability
Ability to operate
Adaptability
Efficiency
Cost effectiveness
Teaching
Research contribution
Experience
Dedication to an institution
Service to an underserved population
Development of programs or new services
Charity
Mentoring
Department leadership
Hours


PS – I am an above-average surgeon.



Sunday, June 19, 2011

Chimborazo - Lessons from my Father


My father fell on his face for the thirtieth time.  I hoped he would stay.  I had fallen a lot too – I could only bear this so long before breaking into tears.  Luckily I was last on the line; nobody would see the frozen streaks on my face.

The snow was corn on the surface and rock-hard somewhere below.  You never knew where.  Each step varied – you’d crunch along a few steps catching grip six inches below, then scrooosh – your crampons caught nothing and your leg disappeared in slush up to your hip.  Goddamit.  All you heard besides crunch and scroosh was the brush of your balaclava against your parka hood, and all you could think was, Why the hell are we still climbing?

The reason I kept climbing was because my father, just ahead of me on rope, was still climbing.  Seven hours and counting.  He was fifty – if he continued, so would I.  Why was he still climbing?  Pathologic determination.

I couldn’t believe he was still going.  This time was his last fall, for sure.  I was glad.  Resting and watching from a few paces back, I heard him cough and wheeze.  Good.  The wheezing should be a clue it's time to turn around.  But he was the doctor, not me.

Climbing Chimborazo was his idea.  My dad was the adventurer in the family.  His need for adventure brought our family out west, where we lost friends in whitewater, avalanches, small aircraft crashes.  On weekend getaways I watched him treat friends and family on the scene of motorcycle wrecks, hunting accidents, and a fall into a vertical mine shaft.  Dad once butterflied my brother's face closed so he could get back on the ski slope.  If it was outdoors and posed risk of injury, he loved it.

Presently, Dad was the dark rounded figure on the rope ahead of me, half-swallowed in the snow.  We could only manage eight or ten steps at a time before stopping to gulp thin air.  I was always glad when he rested.  But this time he just stayed.  Ten minutes maybe.  Didn't even bother to climb out of the hole he'd created in the snow.  Good.  We'd turn around, I thought.

Everything was white or pale blue:  the mountain, the sky above, the clouds below us.  The colors flashing in the corner of my eye were a nice distraction.   I’d turn my head to follow the crimson and orange bursts.  They stayed just out of view for a second then disappeared.  My headache was gone.  Bonus.  The whole day prior, we'd sat at el refugio nursing headaches with sweet tea, acclimatizing to altitude before the summit push to 20,500.  

I hiked up to my father.  When I got close, he scrambled out his snow pit and moved on.  He's full-on crazy, I thought.  I could hear him breathe till he was five paces away.  I should've known he'd never give up.  Forget breathing.  We were so close.  The gentle remaining slope was so reassuring – so close.  Just a straight hike.

We went on.  Another two hours.

He couldn't stand for the summit photo.  We took one sitting together, and a standing group shot with him on his knees in the middle, smiling broadly.

We’d got our picture, our cocktail party story, and a half-minute of exhilaration:  the morning sun melted the clouds below and Chimborazo's long, pointed shadow parted the earth in perfect halves.  I raised my arms and looked for my own shadow at the tip of the tip, a hundred miles west.  Now.  Let's.  Get.  Off.  This.  Mountain.

He’d used everything to make the summit.  How will we get down, I wondered.  Nine hours up.  He was spent.

The self-arrest became very important.  My dad would take big lumbering steps on the frozen down-slope, knees locking and unlocking uncontrollably, then tumble like a drunk and skid to a stop.  No big deal, we were making progress. 

The slope steepened.  He no longer skidded to a stop but had to self arrest after every fall, digging his ice-axe into the mountainside.  I stopped looking back.  I could hear him on the rope behind me scraping to a stop every few minutes.  Then, for a while I heard nothing.  Looking back, I was surprised to see him on his feet for a full five minutes or so.  Caught his second wind.  Thank god.  I’d been worried, and tired of waiting for him.  I wanted off Mount Chimborazo.

I heard his muffled voice just before he hit me behind the knees like an overloaded inner-tube.  I was thrown and landed on head and shoulders, disoriented, yelling to him:  Arrest, arrest!  He was sliding away, listless, accelerating as the slope ahead steepened and disappeared from view.  Before I could position myself, the rope between us lost slack.  After another clumsy jerk, we were both sliding on a disappearing ice slope.

By evolutionary mechanism, the mind breaks moments like this into slow motion.  There is as much cortex storing these ten seconds in my head as the whole rest of the trip.  And while the curved time didn't benefit me in the moment (I couldn't act any faster) I'm sure the prolonged seconds are a self-preservation memento keeping me off future mountain climbs.

As we slid and tumbled, gaining speed on the ice, I recalled a water bottle tossed between us hours before.  It was fumbled and we all watched it for amusement, sliding, sliding and disappearing the same moment it left earshot.  I recall deep anger for the man pulling me over a cliff; I wished for a Bruce Banner moment.  I had whole internal conversations about what to do as I struggled to match pitch and roll with the banking slope.  I held my axe point into the hill, slowing, till the rope went taught again and yanked me out.  Ice plowing from the axe filled my face.  Toes, get the toes going, I thought.  Digging the stuttering crampons into the hillside, I felt us slowing even as the rope pulled.  Then, finally, I got purchase with my axe.


We stopped.  And rested.  Then continued down.

Around noon, we un-roped to move independently through the calving snow line.  I moved quickly.  My father negotiated the glacial cliff and boulders with caution, then stopped completely. 

I stood on the dry gravel slope twenty yards away, looking back.  An ice chunk like a Volkswagen fell beside him, crumbling, and dusting him with snow.  He didn’t even look over.  He just slumped on a round boulder, heaving.  I yelled.

“Let’s get the f**k outta here, Dad!”

He waved me on.  Intense sun worked on the snowline – a cliff of ice and boulders, audible creeks underneath.   The wall fell in pieces left and right; my father was inert among it.

“C’mon!"  I pointed above him.  "That big stuff is coming any time.  You gotta keep walking.”

“I can’t breathe.”

“I know, I’ve been listening to you puff for thirteen hours.  Let’s go. You can’t stay here.”

“You don’t understand,” he said, pausing for air between phrases.

“Understand?  We’re almost down, you’ve got to move!  C’mon.  You stay here and you’re going to die!”

“You don’t understand. Huff, huff.  You’re not a doctor.  Puff, puff.  I can’t breathe…and I can’t walk anymore.  No oxygen."

He was a doctor, and I was not - he just wanted to make that clear before he was killed by falling ice, I figured.  I was a belated college graduate with no career plans whatsoever.

“I can’t carry your ass out of here, Doctor,” I said.  "Hope you have a cure for f**king falling rocks."  I shouldered my backpack, turned and continued downhill.  I started to trot a bit, so he’d know maybe I did have the strength to save him.

I heard him cough and mumble something about pulmonary edema this, partial-pressure that

He saved himself.  I was asleep in el refugio when his tin cough woke me.

"We have to get... to a lower altitude."  He sounded like drainpipes.  I had just enough energy to care again.  Not enough to keep hiking, though.  But I put my boots back on, took a handful of aspirin, drank some sweet tea, and packed our gear.

We continued down the slope.

By the time we got down to 10,000 feet elevation, my dad was breathing easier.  In the morning he was fine, and I’d decided to become a doctor.  I didn’t tell him for a few weeks; I couldn’t stand for him to think he had anything to do with it.




Dr Robert James Porter II - adventurer and father of five

Thank you, Dad, for many lessons and adventures. Happy Father's Day.







Wednesday, June 8, 2011

Sudan - Level One Threats


My first night in Sudan I lay on my cot at midnight, jet-lagged and wired, smiling ironically.  Mission control had briefed me in Brussels:  keep security cash and passport on my person at all times, water and flashlight in a daypack at the ready for urgent evacuation.  Coming here was a calculated risk; now I was re-calculating.  My risk scheme ran from threat level one to five.

The smell of burning garbage occasionally overpowered the squat latrines of our compound.  I lay there, breathing more and more shallow as the stench worsened.  What vapor came from burning batteries and water bottles, I wondered.  Eventually I passed out from hypercapnea or was anesthetized by vinyl chloride or whatever.  I awoke when feral cats entered my tent. Blind in the darkness I waited for them to leave.  They found my stash of cashews and a spinning, slashing fight ensued.  So I emerged from my mosquito net and hissed them out.

I smiled again. Weirdness with a touch of danger were what I’d signed up for, in part. I was overdue to escape the overcomfort of suburbia and hang in the Nile riverbed among the world's most sonorous infectious diseases: kala azar, malaria, trachoma, bilharzia.
A flashlight then shined in my face. The anesthesiologist:  Come quickly.  


A baby was stuck, butt-first, in mid-delivery – mother needed a crash cesarean section.  We woke the on-call logistician by radio:  Fire up the generator for our operating light.  
This was my hospital orientation. The patient was nowhere near our inflatable operating tent.  She was crouched in a dark corner of the female ward, pushing at the nurses’ bidding.  I begged them to stop. (A C-section was a little out of scope for a general surgeon, but I was more comfortable with a scalpel than a breech vaginal delivery.)  The nurses knew better, I suspect. We still had no lights, scrub tech, etc.
The baby moved a bit and I changed gears – I would deliver my first child since med school.  I hooked two fingers at the flexed hip and pulled.  She slid!  Her body was now on the cold cement floor.  I pulled her little blue legs as the mother pushed.  Baby’s head was stuck.  My heart pounded as diagrams from fifteen years prior flashed in my head.  I pulled her, spun her, hooked a finger in her mouth, pulled some more, yelled for mom to push, shoved a hand in mom’s belly, and pulled more.  How much could I pull before..?  Good god, could I separate the..?  Please, no.
And she came.  Lifeless.  Onto wet cement.  The nurses performed a cursory resuscitation and put mom on a cot.  I listened and listened for heart tones, rubbing and pinching the little girl.  The nurses reassured me they’d never heard the infant’s heart beat on arrival, so don’t take it hard.  I was dumbstruck, ill. I’d forgotten how much suffering came to Africans.  And I realized, too, that medicine had changed for me since having my own baby girl. I cried.

On my second night, I zipped closed my canvas tent to keep the wildlife out.  I still hadn’t slept since arrival.  I lay on my cot a few hours then got up to find a core of our mission drinking and chain-smoking.  I estimated the second-hand smoke to be a level one threat, and I joined them for a beer. Then because I was on-call, I refused the second beer.  Instead, I covertly poured an inch of whiskey into a tea-cup and got some sleep.
In the morning, chicken-sized grasshoppers in our mess tent, plump frogs grazing on flies in our latrines, noxious burnt-garbage fumes, and ever-present cigarette smoke all faded to background. I sat in the mess tent waiting for hot tea water. The cook came in, shook rat turds off the tablecloth and returned the same cloth to the table. I ate my toast without mentioning the level-one threat of infectious scat to my colleagues, who I presumed were accustomed.

In a short hospital day and a quick walk about town, I learned how war turns poverty into abject devastation.  People bathed in and drank from Nile. On the wards most of the adult patients were malnourished and had been shot with high-velocity rifles. The children's ward was all pot-bellies, stick legs, flies and diarrhea.  I learned that no virtually no food is produced in an area the size of England – a whole generation of farmers was lost before passing on their knowledge to the next generation. There was no water, sewage, or electrical service. The only concrete structures were our hospital, aid organizations, and a police station.  Thousands of displaced refugees were spontaneously building a haphazard city of tin and tents on the flooding banks of the Nile.  Who is in charge? I wondered.



Next - Threat Level Two

Saturday, June 4, 2011

Sudan - Arriving

The South Sudan mission has urgent need for a surgeon, said the memo.  Please respond by late in the week if you accept the mission.  A far cry from Darfur, I assured my wife.  I thanked her for her blessing and kissed her and our tiny girl.

I was briefed in Belgium a few hours then shuttled to Nairobi, then to the de facto capital of South Sudan. 

The airport was a single, crowded cement room serving as receiving terminal, passport control, and baggage claim.  A giant mirthless man at a card table smashed my passport and travel pass with an inkless rubber stamp.  I collected my bags from the tin slide.  When I turned around, the immigrations man was now a customs man rummaging through my things.

Always the optimist, I assigned the urgency of the surrounding crowd to claustrophobia or heat.  Still, I was nervous. 

“What is here?” asked stamper-man in Darth Vader’s voice.  He shook some wrapped boxes I was carrying.  I had no idea what they contained – they were given to me by mission headquarters to deliver.

I have no idea seemed like the worst possible answer, so I guessed.

“Some books and some sweets.”

The bustling crowd went quiet and watched – let’s see what the white guy brought – as the huge man picked at the strapping tape with huge thumbs.  He handed a package to me and I pretended to be a surgeon completely stumped by devilish wrapping.  What happens when I unwrap a box of hand grenades in a crowded African airport? I wondered.

He got bored before the surprise was revealed and pointed at the door.  Before I got there, a man calling himself Lazarus took my passport and my travel pass and disappeared.  I’d been given his name in Nairobi, so I felt confident…

Kidding.  By now I felt confident of absolutely nothing.  Nairobi felt like a country club compared to this Wild West popsicle stand.  Lazarus was nowhere and I was standing in a dusty street outside a dusty airport evacuating like a fire drill.  I put on sunglasses to cover up fear and do some surveillance.

Soldiers.  The only people not leaving the airport were soldiers.  WTF?  I was sure I’d read of a peace accord several times in the briefing literature I was provided.  Peace was relative, I would learn.


Lazarus then appears from nowhere and shoves me onto the floor of an idling Rangerover festooned with mission logos.  He slams the rear door; filling its window is a decal:  a big red circle-slash over an AK-47.  No weapons! is the message.  But for whom?  Volunteer surgeons?  Water/sanitation volunteers?

Lazarus drives me a hundred yards.  He empties me onto the airstrip I arrived on half an hour ago.  There I await a pilot.  Surrounding me are cows, mud huts, tall bushes, and more soldiers.  Like the opening scene of Platoon, a hundred or so troops are filing into bellies of monstrous flying personnel carriers.

So far, every leg of this journey has brought me to a smaller, scarier place.  I’m steeling myself to depart the unpaved capital on a four-seater Cessna bound for a Nile-bank village in the “formerly” contested south:  Bor.


Next:  Threat level one.

Saturday, May 28, 2011

Starting the Journey


I was driving cross-country to internship when I led my first emergency as a doctor.

During my two-day drive I dropped by a tiny clinic in a mountain village.  I’d worked a clerkship there and wanted to say hello/goodbye.

“Perfect timing,” said Marie, the nurse practitioner who ran the clinic. “911 call – near drowning on the river.  We could use your help.”

I hopped in the ambulance driven by a forest-service volunteer.  Having graduated from med school the week prior, I was the ranking member of our three-person team.  We stopped briefly at a warehouse to pick up lifejackets then sped downriver to the mile marker from dispatch.

The setting:  a cliff-side river bend in desert forest.  Pickups and SUV’s filled the narrow highway shoulder and an audience of a hundred spread over the steep rock slide bordering the river.  The scene of my first consultation looked like bleacher seats for a grizzly bear brawl.

Defibrillator slung over my shoulder, I scrambled down boulders through the crowd.  In the center churned a class III rapids – spring melt-off overflowing banks, soaking tree trunks.  A rubber raft, bobbing and twisting, was tethered to a douglas fir.  Rafting guides in the boat, soaking hip-deep, gave mouth-to-mouth and chest compressions. 

“Make room for Dr Porter,” said my forest-service companion, as I waded into the ice water.  Eyes of the first-responders and boatmen met mine with great expectations.

The ambu bag didn’t seem to work.  Chest wouldn’t fill with air.  I was soaking from chest down, pondering the path of the electrons, when I got the defibrillator pads in position.  No wave whatsoever on the screen.  Back to airway – why couldn’t they get air in him?  I tried.  Each squeeze honked incompetence, escaping between the man’s face and the mask.  He was deep blue, but then, so were the river guides helping me.  My hands were white and trembling, like my mind.

“Want to try this?” asked Marie.  She handed me a fourteen-gauge needle.  “Laryngospasm, maybe?”  Thank heavens for wise Marie, the only care provider for a rugged winter village and the only ER service for thousands of summer hikers.

My stiff fingers found thyroid eminence and slid down to cricothyroid.  I knew the importance of airway and of airs of confidence, and I knew I was at the membrane.  I pushed the needle in a quick, sure motion, threaded the catheter, and withdrew the needle.  I took the mask off the bag and laid the nozzle on the man’s throat over the cath hub.  Pumping the bag again, I heard all the air escape his mouth and nose in a horrific snore.  I asked someone to cover his mouth and nose and squeezed again.  Useless.  Tried bag over mouth and nose again.  Watched the EKG tracing.  Nothing.  The man was cold as the river.  I moved from task to useless task over several minutes, racking my brain, trying mask again, re-starting defibrillator, re-checking the man’s pulse, as more traffic stopped and joined the crowd.  I silently pleaded for an EMT or ER doctor to happen by.

“Do you think we should call it, Dr Porter,” asked Marie.  The swollen river crackled,  rushed, and slapped the tympanitic tubes of the raft.  Further away the low thunder rumble of bigger rapids was just audible.  The sound was beautiful – it had put me to sleep under starlit skies all summer in my river-guiding youth.  I heard Marie, but still needed stall time.

“What, Marie?”

“Do you want to call off the resuscitation?”

It would be the first doctor’s order I ever gave.  I felt again for a pulse.  Stood there a full minute pressing fingers in the man’s neck. 

“Hold the bagging a sec,” I said. 

What am I missing, what else can we do?  Could he possibly be alive, and I’m missing it?  I switched hands on the neck, and put a palm over the man’s sternum.  On the riverbank I spotted a woman sobbing.  She was crumpled between boulders, almost choking, waving away would-be comforters.

“How long were you doing CPR when we got here?” I asked the river guides.

“Forty minutes.  Forty-five, maybe.  And it took us a while to bring him out of the water.  Five minutes, probably.”  He pointed upstream.  His voice quaked.  “He went out in the rapids two bends back.  Swear he was only under water a few seconds.” 

This was the guide who’d lost his passenger, I just realized; I knew what he felt.  His plaintive eyes blazed red.  Under his lifejacket he was shirtless - sinew and sweat despite the cold.  He wanted instructions, and I had none.  He was coiled for action like when he’d entered the rapids.  He would carry the raft and patient on his back anywhere I said, but there was no place to go.  We were failing our patient.  I fumbled with the defibrillator pads and checked the tracing again.  Nothing.

The quiet was unbearable.  Time and a hundred anguished faces were at a standstill when I realized who I could help, if not this poor wet man in brand-new river sandals.

“Marie, I’m calling it,” I yelled to shore.

“Yes,” she nodded, relieving me a small measure.  I’d lost the first patient I touched as a doctor.

I unplugged the defibrillator and waded ashore, not looking back at the river guide.  The patient’s wife still filled my view.  I walked a wide arc around her, through the crowd now coming slowly unfrozen. With the sound of the river again filling my head, I climbed the steep rock road and resumed my trip east to internship.

Tuesday, May 24, 2011

In the Usual Fashion

Today I began dictating an operative report for an exploratory laparotomy.  Distracted, I accidentally dictated breakfast.
"The placemat, spoon and bowl were arranged in the usual fashion.  The Cheerios ™ box was removed from the shelf and the bowl was filled to approximately one centimeter from the superior lip.
Attention was then turned to the refrigerator.  A one-gallon milk container was removed and brought to the field.  At this point it was realized that the milk was the incorrect lipid percentage and was exchanged for the two-hundredths fraction.  During exchange of the milk containers, a V-8 juice ™ can was inadvertently exposed posteriorly in the refrigerator.  Palpation of the can revealed adequate cooling, however inspection revealed partial disruption of the superior stomal closure and leakage of contents…"
How did surgeons land on this periphrastic passive, third-person, past-tense, objective voice as the op report standard?

I tried less excruciating narrative voices.
"They prepped and draped in the usual fashion.  The surgeon then made an incision from umbilicus to pubis, taking care to avoid the patient’s known incisional hernia.  He divided the subcutaneous tissue with electrocautery."
Active verbs serve for more interesting action and land more softly on the ears, to be sure.  But the third-person, objective narrator maintains the neutral, scientific air.  Bo-ring.  And talking about myself in third-person?  Homey don’t play that.

So I add life with present tense, first person:
"We prep and drape in the usual fashion.  Careful to avoid entering the known hernia, I now incise from umbilicus to pubis.  I divide the subcutaneous tissue with electrocautery."
Inching toward awesome.  Now we'll raise the roof – future tense, first person plural:
"We will prep, and we shall drape. We will then incise from umbilicus to pubis, wary of the hernia. We shall divide the subcutaneous tissue with electrocautery."
Almost there.  Use imperative, second person voice:
Mic the Scallywag - photo courtesy of David Ball
"You!  Prep and drape!  Incise from umbilicus to pubis, missing his hernia!  Divide the subcutaneous tissue!"
Spread the word!  Pirate ship captain is the new narrative voice for operative dictations.

Saturday, May 7, 2011

Happy Mother's Day


“Mom?”

“Mom?”

“MOM!”

Mom:  “I’m in here.”

She was just sitting there.  I asked where my parachute pants were and she told me, having never actually seen them.  She just knew.  I turned to find them, and Mom got up to make dinner.  As I walked away I thought, she looks weird – kicking back, drinking Diet Coke… my pants, parachute pants, in the duffel bag, back of the station wagon, Scorpions concert – two weeks! Here I am, da da, da da, Rock you like a hurricane, da da, are you READY BABY?!

A week later, or maybe a year, there she is again, with a People Magazine, dreamy, munching goldfish crackers. 

“Mom!  What are you doing?”  I make a face like I’ve found her wiring a time bomb.

She slaps her magazine down, half laughing.  “I’m relaxing!  So what?”

“You look like Zsa Zsa Gabor or something,” I say.  “Want me to peel you a grape?  Hey, did you record over Basement Tapes?”

“No.  Look on the far left, in its cover.”

Off I go.

Mom had found a hiding place.  She’d tucked a small couch among overgrown houseplants in the coldest corner of the house.  Looked like Max’s bedroom in Where the Wild Things Are

She had five kids and a full-time job running a travel agency.  We and our fifteen best friends had a mom who welcomed the world, fed it, and gave it a ride home.  She welcomed two rock bands.  Mine practiced nightly in the basement through high-school graduation, when my brother’s band took over.  Mom loaned us her station wagon to haul drums and amps; we’d return it with a flat tire or the windows smashed out by vandals.  She’d fix it up and pass me the keys again.  She went to our gigs and danced – even sang backup on Barbara Ann.

I have a four-year-old girl now.  Just one.  After work we play rough for a few minutes and I’m beat.  When I read her bedtimes stories, I cheat, shortening paragraphs, skipping pages.  When we fly, my girl’s feet reach precisely where they can do nothing but tap and kick the guy in front of her.  Even with DVD’s, iPods, and iPads all in play, we land cranky, and I try to forget that my mom drove the five of us from Oregon to Iowa in summers.

When sibs with spouses and kids visit Mom now, we add up to twenty invaders, hungry, needing sun block, missing a flip-flop, wanting car keys, crying over a stubbed toe, battling over the stereo, slamming doors, hogging the internet, throwing up, wandering off, borrowing clothes and painting faces for a play, missing sunglasses, drinking too much, helping too little.  Mom dries every tear, kisses every sunburn, finds every flip-flop, nurses every patient.  She shops, chops, cooks, and serves.  She plays dress-up and makeup and shuttles grandkids to the fishing boat.  She drives a four-wheeler and a MacBook Pro.  She collects beach shells with my girl; she takes her to church.  If my girl wants a tour of the neighborhood to see cows and sheep, Mom drives a roundup.  And, if I catch my mom sitting, I never fail to tease her about her life of leisure. 

I love you, Mom.

Wednesday, April 27, 2011

Shift Mentality – Kids these Days!



"The children now love luxury; they have bad manners, contempt for authority; they show disrespect for elders and love chatter in place of exercise. Children are now tyrants, not the servants of their households. They no longer rise when elders enter the room. They contradict their parents, chatter before company, gobble up dainties at the table, cross their legs, and tyrannize their teachers."  - Plato, 400 BC


Plato probably never said that.  But I love to tell people he did, as wise Mr Douglas told ranting Uncle Charlie in My Three Sons.

If Plato or Uncle Charlie were retiring surgeons today, we might hear:

“These residents have no commitment to their patients, it’s all about lifestyle now.  I tell you, the eighty-hour workweek has lowered the bar, and all we get is shift-mentality residents trying to hand-off their patients before lunch.  And if the Residency Review Committee (RRC) imposes nap time, and cookies and milk, we can just hand over the whole profession to radiology.”

I’m 44.  Old enough to repair a hernia without mesh, but not mean enough to do so except when no mesh is available (on Neptune, for instance.)  I’m also young enough to be down with Twitter.  And if you think being down with and saying, “Down with Twitter,” are the same, well…

I admire the surgeons who preceded me for their commitment to the profession. 

I admire the incoming generation of surgeons more.  Eighty-hour workweek notwithstanding, they have more on their plate than the generations before.

A third are women.  Demanding enough is the daily fare of patients doing badly, upset families, overbooked clinics, late hours, early hours, and politics.  Add discrimination, harassment, working for less money, and if inclined, pregnancy and caring for an infant. 

While nothing compares to the challenges facing female surgeons, I’ll venture that men today have it harder than their XY forebears.  My father had it easy.  Yes, I said it.  In his day, a man could fully dedicate himself to career and not face questions about his priorities until his grown children were in therapy.

Men today in all careers are attending recitals, cooking, cleaning, shopping, changing diapers, taking children for vaccinations, planning date night, and moving the heavy boxes.  This morning I poured my girl’s Cheerios ™, brushed her haystack of a hairdo, filled her Hello Kitty™ lunchbox with applesauce, then captained the neighborhood Montessori carpool.  If my dad, back in the day, had any idea where the Fritos™ were stored, he never let on.  (I’m eager for a reader to explain this cultural shift to me.)  Just as the RRC imposed the 80-hour limit, wives and children invoked the 80-hour minimum.

Remember this, Uncle Charlie:  While Chip may seem awfully eager to dump his patient list on the night float, Chip goes home to completely different expectations from his wife, children, children’s teachers, children’s soccer team,..

When I hear shift mentality thrown about derisively, I think of two of my favorite residents – two very dedicated doctors.  They give a hundred percent, they make no excuses, and they are fierce advocates for their patients.  I wouldn’t hesitate to send my mom to them for her lap chole.  Also, these young men freely admit they plan careers with shorter hours than surgeons of yore – in exchange for more time with family.  I admire their mature priorities.  I expect they will choose reliable practice partners and won’t plan their abdominoperineal resections on game days.  When the unexpected happens and they can’t leave the hospital, I hope their families understand.  Bless their broods, and moreso the kin of women surgeons; I hope their families appreciate the career sacrifices their parents made for them.

I’d rather have surgery in 2020 than in 1990 for many reasons – all of them having exactly nothing to do with work ethics or the eighty-hour week.  Laparoscopic advances, ICU protocols, evidence-based practice, checklists, and new anesthetic agents have done more good than a generation of lazy residents can undo.  And they’re not lazy, Uncle Charlie.



*  Note:  I hold particular admiration for women surgeons of the previous generations.

Sunday, April 24, 2011

1-800-GET-SLIM

Thanks @DrFlicker for the Twitter invite on the conversation about Promoting bariatric surgery for teenagers


(@ @ @ Thoughts? RT @ Doctors selling weight loss to teens:

The beef with crass advertising is understandable.  As we learned from the Save the Boobies campaign, eye-catching language succeeds in creating awareness, even enthusiasm.  But do health care providers lose trust through such levity?  The public likes to think serious-minded adults rank higher than Beavis and Butthead in the public health hierarchy.  Billboards reading Dieting Sucks and 1-800-GET-SLIM smack of adolescence and aggressive salesmanship, not quality health care from earnest professionals.  

I support tasteful promotion of bariatric surgery for teenagers as part of the Teen-Longitudinal Assessment of Bariatric Surgery (LABS) ongoing at several excellent pediatric hospitals.  (Here’s a promotion from Cincinnati Children's Hospital)  Outside of that setting, I’m uneasy with the operation and the promotion.  Operating on teens exposes minors to unknown long-term risks and opens up the question of by-proxy consent.  In my opinion, such negatives in individual patients are offset when clinical trials yield answers (and ease suffering) for the population at large.

I suspect we’ll learn that well-selected teenagers benefit a great deal from bariatric surgery.  Compared to a middle-aged patients, young ones with successful surgery should enjoy twice as many years free of weight-related diseases and their cost, plus improved social and work function.

In Promoting bariatric surgery for teenagers, Carolyn Thomas seems uncomfortable with bariatric surgery on the whole, focusing on uncertain outcomes, on cost in the short run, and on growing popularity of the procedure.  In her blog post, expert majority opinions are overshadowed by the minority opinion of nay-sayer providers.  Let's see outcomes data from a large sample, and hear from the happy patients too!

Wednesday, April 20, 2011

When we were Kings


Spent a sweaty week operating in a hilltop Hospital Nacional in Guatemala a while back.

A patient gave me a hat in thanks for her surgery.  It’s a full-brimmed canvas safari number – I’m sure Hemingway shot a rhino in one.  I’m just mature enough now to value sun protection and always grateful, sometimes to the point of pain, for gifts from those who have almost nothing.  I was also given a painting of the neighboring volcano, a tee-shirt depicting a local politician, two kisses, many back-breaking hugs[1], and endless expressions of muchisimas gracias plus the quiche version of same. 

The biggest gift of all, though, was the respect our patients gave us.

You’ve heard of doctor shopping.  This is when a disappointed patient leaves the ER or the doctor’s office in search of a doctor who understands them better.  How about patient shopping?  Doctors have a choice too.  They engage in patient shopping in various ways.

1.     Specialty (ie, a plastic surgery practice has a different clientele than a trauma surgery practice)
2.     Location of practice
3.     Private vs hospital-employed vs public health practice
4.     Exclusion of payer types (eg, Medicare/Medicaid) or limiting to cash-only

If I were to hand pick a patient clientele, they would be Native American Guatemalans.  By dint of history, DNA, culture, nature, nuture, or whatever, our patients and their families treated our mission group as royalty, priests, or benevolent dignitaries.  We were like travelers of long ago, scaring them and making them laugh with our strangeness.  Medicine is a world of hopes and mysteries for them, not a world of choices.  I sensed their prior patient experiences, if any, hadn’t fostered a sense of consumer entitlement.  They trusted us implicitly, even when things went wrong.


We had a complication. On post-op day three after a vaginal hysterectomy, I had to tell Maria's family she would need another operation. I worried about her mere survival. I approached the family as I do in America—firm in my judgment, apologetic that a complication had occurred, and prepared to explain (defend) the sequence of events to date. There was no need. "I'm sure you know best," said the husband.

I found Maria’s husband again after surgery, I explained that indeed she had suffered a near-catastrophic surgical complication, but that I expected she would recover. “Thank you Doctor, thank you,” he said. Sisters and nephews thanked me. I felt guilty from the gratitude, like I had gotten away with something.

At home, medicine has been demystified in the age of information, packaged and marketed in the age of conspicuous consumption, and cynicized in the age of litigation.  When a bad medical outcome occurs, it is reflex to research.  Why?  We are trying to tell  malpractice from mere bad luck – in a world where bad luck is increasingly exposed as bad choices, bad training, bad equipment, bad people, and other controllable bads.  Good science, good will, and good processes have raised our expectations such that any post-op event is suspect.

So, our spirits soared in Guatemala.  We were trusted and thanked and bestowed with gifts.  Between our team and our patients formed an intoxicating chemistry. 

The gynecologist and I fussed and fretted over Maria, our only complicated patient, all week.  She improved.

On our departure, my last goodbye was to Maria.  I brought the incoming surgeon (my replacement) to the bedside to explain her case and introduce patient and doctor.  The gynecologist and team medical director joined us.  Maria, her husband, and their children looked star-struck by our visit.  They thanked us yet again for Maria’s two operations.  They expressed their honor in our last-minute visit and told their children we had come from far away to help their mother.  Maria asked for a kiss.  I held her naso-gastric tube to one side and complied.  I wished all patient hand-offs were this heady. 

During the swerving mountain bus ride to Antigua, I watched shepherds and soaked up a glory which seemed to belong to another century.  As we approached the airport, my mind wandered back to home and work.  Guilt crept in.



[1] Ergodynamics were sub-optimal in the tiny makeshift surgery suite – the operating table only went so high.  Add twelve-hour operating days plus short-statured huggers and the low back cries for bed, or cot, as it were.