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 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

*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.