Equanimity

In surgery, as in many fields of endeavor, it is never a good idea to panic.  We strive for equanimity, the ability to remain calm and effective despite surprising or difficult circumstances.  We never curse or say “Oops” after cutting the wrong structure or getting sprayed in the face by an unanticipated fountain of blood, for instance.  The well trained surgeon merely says, “Well, that’s interesting,” or something similar.  (Anesthesiologists know that when the surgeon says that something is interesting, it’s time to start transfusing blood pretty rapidly.)  This particular personality trait was drilled into me throughout my surgical training, but never so effectively as by my senior resident and mentor, Ben Jeffries.  Ben at the time was new to our program, having been tossed out of the Johns Hopkins surgery residency as part of the pyramid system they use and because he wasn’t a dick.  You gotta be a dick if you’re going to succeed in the Hopkins surgery program.  Fact.  Anyway, Ben was a skilled surgeon and a positive influence in our program after he joined us in his third year of training.  We still stay in touch.IMG_1154

A lot of what we do in surgery is done because that’s the way we do it.  Of course, what we do is based upon careful scientific research.  How we do it, however, is often done because we do it that way.  Not always the best way, as it turns out.

The surgical procedure of tracheostomy is frequently performed upon critically ill patients in the intensive care unit who require long term support on a ventilator.  It is dangerous and uncomfortable to maintain a breathing tube down the patient’s throat for longer than a week or two, so the patient is eventually scheduled to undergo the routine procedure of making a surgical opening in the windpipe, the trachea, and inserting a special tracheostomy tube.  This tube is much more comfortable for the patient and is less prone to becoming blocked or dislodged.  Research has proven over and over again that it is a valuable surgical procedure.

Research has not clearly addressed just how this valuable procedure is to be accomplished, however.  A couple of options are available to the surgeon about to embark upon the procedure of tracheostomy.  The safest and most enjoyable manner for all concerned, surgeon and patient, is to perform the tracheostomy in the operating room.  Everything is more fun in the OR.  In the OR, the surgeon is surrounded by skilled, helpful personnel, a trained anesthesiologist is carefully managing the critically ill patient’s respirations and sedation, the lighting is optimal, and every tool one can possibly need is readily available.  So, of course, we often don’t do tracheostomies in the OR.  We frequently perform this surgical procedure in the patient’s bed in the ICU.  This is much more efficient–which means, it’s much cheaper.  Can’t honestly think of any other reason.

As part of my surgical training, I rotated through a very busy community hospital.  This hospital had a large, pleasant Pulmonary Intensive Care Unit, the PICU, which cared for patients who required ventilator support because of emphysema, lung surgery, or other severe pulmonary illness.  These patients often required tracheostomy.  On this occasion, I was a second year resident, having been a doctor for about eighteen months.  My service was consulted to perform a “trach” on an elderly, robust man who had been requiring high levels of ventilator support for over a month.  He was overdue for the procedure and our attending, an ebullient thoracic surgeon named “Tex” Dallas, felt we should get this done ASAP.  Tex was a skilled, flamboyant thoracic surgeon, who had the practice of wearing a cowboy hat while doing hospital rounds.  Nobody knew why he had to leave Texas, but he cut a loud and colorful swath through the Midwestern surgical society while he was here.  Tex told Ben, my senior resident, to get the trach done “today” in the PICU and he’d staff the procedure.  Which meant that Tex would be flirting with the PICU nurses (one of which would go on to become a skilled physician and my wife) while we did the procedure at the bedside.

Ben and I prepared the patient for his tracheostomy by setting up the instruments that we borrowed from the OR.  We recruited the Respiratory Therapist to help, as there comes a point in the operation when the tube already in the trachea and supporting the patient’s respirations, called the endotracheal tube, needs to be removed from the patient’s mouth so that the surgeon can put in the new tracheostomy tube.  This role is usually filled by a trained anesthesiologist or anesthetist in the OR, of course.  We, as I mentioned, weren’t in the OR.  But the Respiratory Therapist was enthusiastic and anxious to help, especially since she’d never seen this done before.  Ben and I instructed her on when and how we’d like her to remove the tube when we said so.  She nodded enthusiastically.  This was exciting.

Ben and I got started.  The patient was cooperative as we had given him a small dose of sedative, his breathing being entirely supported by the ventilator anyway.  The operation started well, with Ben letting me do everything while he held the tissue out of the way with retractors.  This was critical, as the patient had a bull like neck and the hole to reach his trachea was therefore deep and narrow.  And since we weren’t in the OR with all the special lighting, a little dark, as well.  Tex was sitting at the nursing station, which was around the corner from where we were working, watching the patient’s vitals on the monitor and trying to convince the stunningly beautiful nurse to join him at lunch after the procedure.  (Did I mention that I married the woman about a year later?)  The operation was going smoothly and we had the surface of the trachea cleanly exposed in the depths of the wound.  Ben turned to the Respiratory Therapist standing at the patient’s head, watching with fascination.  “Ready to remove the tube?” he asked her.  She nodded enthusiastically.

At this point, it is necessary to carefully cut into the trachea and create a small window in which to insert the new tube.  As I began this maneuver, Ben suggested that I take care to avoid the small blood vessel just adjacent to the point we had picked for our window.  While it wasn’t a conscious decision (in the dark depths of the wound I couldn’t see from my angle what he was referring to), I ignored his advice and instead severed the vessel just as I cut into the windpipe.  The wound immediately filled with blood.  “That’s interesting,” Ben said.  I was speechless.  “Okay, it’s out,” the Respiratory Therapist said.  We both turned to look at her.  She was smiling as she displayed the endotracheal tube she had removed from the patient.  “Really?” was all Ben said.

Ben and I bravely suctioned and retracted in our efforts to expose the trachea so that we could get a tube into the patient.  At this point, the patient was not receiving any oxygen or any type of respiratory support.  He had, at best, a couple of minutes to live unless he was reconnected to the ventilator.  The blood welling up from the wound became progressively darker as we struggled.  Listening to the EKG monitor, we could hear the patient’s heart rate slowing as he lost oxygenation.

“You boys okay back there?” Tex called from around the corner, watching the pulse slow on the monitor at the nurse’s station.

“Just fine, Dr. Dallas,” Ben called back.  We were not fine.  We were completely fucked, actually.  The wound was so deep that we needed two hands to hold the tissue out of the way, leaving only two hands to suction the bleeding and operate–about two hands short of what we needed.  We couldn’t see shit.  The patient was rapidly deteriorating.  The Respiratory Therapist was looking over, fascinated.  “That’s a lot of blood,” she commented helpfully.  The patient’s heart rate continued to slow.

“Boys?” Tex called from the desk.

The patient’s heart stopped.  He was in arrest.  I looked up at the monitor.  Flatline.  Ben took the tracheostomy tube from me and jabbed it blindly into the wound.  “Ho-ly Shit!” we heard Tex shout from around the corner.  Ben hooked the tube up to the ventilator, having no idea whether the tube was actually in.  It must have been in place, however, because in the next few seconds the patient’s heartbeat reappeared and quickly came up to normal.  Tex came skittering around the corner and pulled up short at the foot of the bed, looking at the monitor.

“That’s pretty weird,” Tex said, scratching his head.  “Poor bastard was looking a little dead there for a bit.  That monitor must be fucked up.  You boys all good here?”

“No problem,” Ben said.  “All good.”

Tex bent down to pick up his hat that had flown off as he ran around the corner.  As he bent down, he noticed the half-inch deep puddle of blood under the bed and lapping at our shoes.

He straightened up, smiling.  “Nice job, boys, nice job.  Now don’t make that pretty young nurse have to clean up after you boys now, you hear?”

“Of course not, Dr. Dallas.  We’re better than that.”  Ben smiled at him.

Not much better, though.

Critic/Critique v. Reader/Review

~first posted 20 Jan 13

We are readers, and we all have opinions. There are books that we love so much that we must tell everyone about them. I remember loving a book so much I actually watched my wife reading it–I wanted to see her expression as she read. She made me stop after the first thirty seconds. (N.B.: I am not referring to that rather bleak time in our marriage when I had my wife read my first novel.) There are other books that disappoint us or genuinely irritate us as readers. There are those books that earn my ultimate and most cutting criticism: I couldn’t finish it. It is impossible to be a serious reader without having serious opinions about what we read.Minolta DSC

In the world of books, we are taught that not everyone’s opinion is equal. There are professional critics, individuals whose opinions are better than ours. For instance, I enjoy reading the NY Times book section every week. I enjoy it, despite the fact that frequently I don’t really understand what the critic is talking about, often to the point where I can’t even tell if he liked the book he’s reviewing. Always, however, the reviewer has some special knowledge or insight that he brings to bear in evaluating the book, some personal relationship with the material or deeply meaningful literary reference. It’s always something way beyond us ordinary mortals, and I always feel that I’m learning something important. What I don’t learn from these reviews, however, is what I want to read next.

When I buy a book based upon its prominence on the first page of the NYT book section or a particularly glowing review, I’d say I end up being happy with the book about one time in twenty. And that’s when I understood the review and thought the reviewer was a making a good (understandable) case for reading the book. They loved it, I hated it. We just don’t think alike.

Something different happens when a reader reviews a book. When my wife, or one of my children, or a coworker, tells me about a book, they are telling me their opinion of the book as something worth reading for the same reason that I read books: Is it entertaining? This is almost never the criterion that critics use to evaluate the worth of the book, but is the one judgement that is all important. Sometimes another reader will tell me about a book that he thinks is important, or meaningful in some way–but it is always well written and entertaining, or else he wouldn’t have read it and he wouldn’t be recommending that I read it. It is that level of opinion that leads me to my next great book.

Not all reader reviews are equal, of course. Great books get reviews such as the one in my last satirical blog post, which makes good authors crazy. Readers are more inclined to read the one star review than any of the five star reviews, no matter how many more of the five star reviews there may be. Maybe the guy has a really big family or something. (Plural marriages are a known method for writers to get lots of positive reviews. Amazon is currently cracking down severely on this practice.) These reviews are no less meaningful, however. A well written reader review tells us as much about the reviewer as it does the book; if the reviewer sounds like a whack-job, or admits to never having read the book, or admits to being a fan of Fifty Shades, I know that the reviewer and I differ in what we consider good. On the other hand, if I read a review on Goodreads by a fellow reader that has a bookshelf full of books that I like as well, I value that opinion, and I just might buy that book.

It is that level of opinion, the reader review, that will hopefully one day become the new gatekeeper to a book’s success. We are not there yet. Currently, the best and most important new fiction can simply disappear without a sound, because the gatekeeper authorities–the publishing houses, the major professional critics, the big book awards, all the major media outlets that tell us about the next great read–still are told what is worthy by a literary industrial complex which has existed for half a century. Perhaps not for too much longer, however. Keep reading, and tell people what you think.  Write reviews.  It’s the next great thing in publishing.

* “DONT READ THIS”

~first posted 9 Jan 13

This blog post sucks.inconceivable I cannot believe that I almost was willing to spend my hard earned money buying this crap right up until I realized that it was free. BUT I’M STILL PISSSED OFF because I spent a lot of my very valuable time reading this because I’m a very slow reader, but don’t think that makes me dumb because it doesn’t! I just take my time so that I can think about stuff but this blog post is just so stupid I should never have even started reading it but it looked interesting and the title was really cool but it really isn’t so don’t you start reading it too, especially if you’re like me and you just have to read everything until the end even though you know you’re just wasting your time but you can’t stop, not because I’m compulsive or anything but because I just keep hoping that the joker will have something really good to say but he NEVER DOES! So don’t read this. Read Fifty Shades instead because I think that was the best thing ever written since the Twilight series. Really. IMHO.  “Angry Face Emoticon”

The Zen of Surgery and Bicycle Repair

I spent summers during high school and the first half of college working as a bike mechanic.  I love bicycles, and since I’ve always been the kind of racer with all the natural gifts to consistently finish last, I spent a lot of time fixing and tuning other people’s bikes.  The guys who taught me how to fix bikes were professional, passionate mechanics, dedicated to their craft and absolutely, batshit crazy.  As a young and impressionable adolescent, I was schooled in the ways of life, women, and bike repair by this motley gang.  Amongst other things, they taught me how to kill a fly twenty feet away in midair by creating a flame thrower from a large squeeze bottle of WD40 and a butane lighter.  They also taught me how to put out a fire in a confined space filled with flammable liquids.  And how to swear. Minolta DSC After the first year working with these proud professionals, I began to realize the difference in approach possessed by certain mechanics.  When I was confronted by a difficult challenge, I’d seek advice from one of the older, wiser mechanics.  Of course, they were all older and wiser.  Often, this mentor would advise me to simply remove the malfunctioning part and replace it.  Quick and easy.  However, a couple of the more senior, seasoned mechanics, the guys who were still doing this after many years (with brief interruptions doing time in jail due to other, part-time occupations), would show me how to actually fix the offending part.  Often, this repair would involve the deft application of a hammer and screwdriver, or a hammer and wrench, or hammer and an awl.  Always a hammer, deftly applied.  The repair was elegant, effective, and a lot cheaper than replacing the whole part. It wasn’t long before I realized that there was a world of difference in the approach these two types of completely competent mechanics would take to a difficult problem.  Both would end up with a perfectly functioning bicycle.  The “replacement mechanics,” however, cost the shop and the customer a lot more money.  These guys were also the ones who always were in need of some special tool or wrench, the little used tools that were always squirreled away somewhere.  They spent a lot of time looking for the exact tool that was needed to remove a bottom bracket or a gear cluster.  The other guys though, the “fix-it mechanics,” never seemed to need more than a hammer and a couple of basic tools to make the most intricate repair on the most expensive Italian racing machines.  And they did it cheaply, quickly, and half the time while hung over or higher than a kite.  This impressed me.  I always strove to be a “fix-it mechanic” whenever I could.  I also built myself a damn nice racing bike from all the parts the “replacement mechanics” chucked into the broken bin.  Still consistently ended up last. Many, many decades later, I have found the same phenomenon amongst surgeons; surgeons of every type and specialty.  I can truthfully say that it is very, very rare to find a truly incompetent surgeon.  In my nearly thirty years of practice, I can think of only one, as a matter of fact.  Oh, I’ve run into a lot of surgeons that I wouldn’t let operate on my dog, don’t get me wrong.  Many surgeons are arrogant (see Mommas, Don’t Let Your Babies Grow Up To Be Surgeons post on this blog), lack any semblance of beside manner, or are incapable of admitting when they screwed up.  Some lack good judgement or have personal issues.  But not truly incompetent.  When faced with a sick patient needing surgery, almost every surgeon that has successfully completed an accredited residency will manage to do the right thing. But like in the bike shop, they don’t all do the same right thing. I remember a case during my training that illustrates the point.  I was a fourth year resident on the trauma service.  In my training program we saw a lot of trauma, so by the fourth year we were fairly competent in patching up holes in people made by various firearms.  On a summer Sunday morning, a young man was brought to our ER with a recently acquired gunshot wound to the flank.  I forget the exact story, but I can confidently say that the young man was simply shopping for groceries with the several hundred dollars rolled up in his pants, given to him by his grandma, when he was jumped in the alley by two dudes.  It was always two dudes, because the victim would’ve blown away a single attacker and gone on to the grocery store to buy his grandma’s groceries, no problem.  Pretty much the same story every time. Anyway, this otherwise healthy seventeen year old comes to the ER bleeding pretty impressively from his flank wound and in shock.  My Chief is tied up with a list of operations left over from the night before so he asks the attending to staff me on the case.  Usually, this would be a great opportunity for me as almost every attending surgeon at this hospital was an expert in trauma care and a great teacher.  Almost every one.  On this morning, I have the bad luck to be staffed by a newly hired attending, a young general surgeon fresh out of residency/trauma fellowship at a very prestigious Midwest academic medical center.  Unfortunately, it was the kind of medical center that doesn’t see a lot of penetrating trauma.  The kind of program that writes a lot of textbook chapters, publishes a lot of esoteric medical papers, but doesn’t do a lot of operating. My attending, Dr. Maisy Blue, is not happy.  It is early on a sunny Sunday morning and she was planning on spending the morning in the call room “catching up on work”; she is quite distressed that the Chief has “dumped” this case on her.  As we explore the patient’s abdomen, we discover that he has a through-and-through gunshot wound to the kidney with a collection of blood (hematoma) rapidly expanding within the capsule enveloping the kidney.  The good news, though, is that the bullet has only injured the single kidney and otherwise exited the young man without incident.  Pretty straightforward case, one that I’d participated in on a fairly recent occasion.  I confidently outlined my plan to isolate the blood vessels carrying blood to the injured kidney, to be followed by repair of the organ.  “No way,” Dr. Blue, counters, appearing quite uncomfortable with my plan.  “He’s lost too much blood already.”  She is clearly distressed as we watch the hematoma expanding. “It’s going in the bucket.  He’s got another one, right?”  I quickly check to make sure that this young man is not one of the few individuals born with only one kidney and confirm to her that he indeed does have another, uninjured kidney, but– No ‘buts’ about it, Dr. B has already begun to dissect the capsule surrounding the injured kidney, resulting in a large gush of bright red blood.  She clamps her hand around the kidney, holding pressure.  “Take it out, Geller,” she instructs.  Which I do, clamping and tying the necessary blood vessels.  Once freed, Dr. Blue ceremoniously plops the kidney into a stainless steel basin.  “Done,” she pronounces.   “You can close with the medical student, right?”  No problem.  Young man did great, went home to his grandma three days later with a really cool scar and one perfectly good kidney.  Which should do him nicely for his whole life, really.  Unless somewhere down the line he gets kidney cancer, or has the bad luck to get shot in the other flank.  Should be fine. I just would rather fix it, that’s all I’m saying.