Medical School, Part 2: The William O. Lombard Memorial Lecture on Flatus

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As mentioned in Part 1, the medical school I attended was of the classic, old-school mode.  Like all the great medical schools before it, the “University Of” medical school required their students to spend the first two years of education reading approximately two million textbook pages and attending lectures and labs for over eight hours a day.  Our only clinical, real medicine experience during this time was in the personal discovery of hemorrhoids.  Classic.Minolta DSC

It was tough.  It was effective.  It was boring.  As one would expect of such a prestigious school, the students were smart and hard working.  Having succeeded in undergrad, a large number of the students found they could replicate their approach to their bachelors degree by skipping all the lectures and just reading like a madman, then acing the exam.  As a consequence, attendance was sparse.

The one year course on physiology was no exception.  The lecturer for this course was an elderly, white haired, world famous professor of physiology named Horace W. Rockport, III, or something like that.  He was the author of the most prestigious textbook of physiology at the time, a nine volume tome that was used in nearly every university.  He was a curmudgeon, to put it nicely.  Rockport would stride around the stage in front of the large lecture hall, emphasizing his points by banging his cane against the lectern or the whiteboard behind him.  Visual aids were not employed.  The idea was to sit and take in the grand wizard’s fountain of wisdom.

Rockport was not a shy man.  He lectured with great volume and authority, not only on physiology.  The great one would often include his pronouncements on politics, or society, or the world at large.  He began his lecture on lung physiology with the statement that, “Fully ninety percent of the world’s population performs no notable function other than the conversion of valuable oxygen to carbon dioxide.  That includes you people here, by the way.”  Great guy.

As the year went on, students began to realize that the lectures–besides being misogynistic, racist, and a bit loony–contributed nothing to their education that couldn’t be gleaned from the required reading of the great man’s textbook.  The audience grew more sparse.  This bothered Rockport not one bit, as he often pointed out that he was paid to talk, and he got paid the same no matter how many people were listening.  It became more hazardous to be in the audience, however.  The smaller numbers made for a more intimate experience despite the large auditorium, prompting Rockport to engage students directly, pointing his cane at somebody in the audience and questioning them vigorously.  This was okay when the questions concerned physiology, as we were prepared for that.  We weren’t prepared to answer questions about our parent’s possible infidelity leading to our conception, however.  Or why we thought ourselves smart enough to cure illnesses that God Himself had deemed appropriate to inflict on individual’s who, by this definition, deserved to suffer.  Tough questions.  The audience grew sparser still.

By the end of the academic year, there were about twenty of us left attending the lectures on a consistent basis, out of a class of just over one hundred.  This included the large German Shepard who attended every lecture accompanied his house mates from the medical student commune.  These students had to attend because they had drawn the responsibility of taking lecture notes for the class (at a cost of $100 to each student–I believe these guys went on to become entrepreneurs of narcotic prescription mills in various states).  And me, of course.  I was one of those guys that felt that I had to attend because on my schedule it said “Physiology Lecture 10:00-11:30,” so that’s where I was, usually trying to look inconspicuous somewhere in the middle rows.  I couldn’t sit in the back because the German Shepard did not like me one bit.

Rockport announced the topic of the final lecture with great solemnity, even going to the trouble of writing the title on the white board: “William O. Lombard Memorial Lecture on Flatus.”  He began his lecture with a lengthy and touching tribute to Lombard, a fellow physiologist who had evidently devoted his entire professional career to researching every aspect of the physiology of gastrointestinal vapors.  For some reason which I still do not understand to this day over forty years later, I thought the great wizard was making a joke.  I don’t know why I thought this, as the man had never displayed the slightest sign of a sense of humor during the entirety of the preceding academic year.  “What a sap,” I chuckled appreciatively from the middle rows.  I guess I thought that Rockport meant to contrast the greatness of his own career with that of lesser, mortal physiologists.  I was wrong.  Turns out that Lombard was his friend, or father-in-law, or something.  Never found out exactly what the connection was, but the “sap” comment was noted.

Rockport stopped dead in his tracks.  “Who said that?” he demanded, scanning the large lecture hall.  “It was Geller,” the owners of the German Shepard said.  “Right there, in the middle row.”  Evidently, they felt the same way as the dog.  Rockport rounded on me, jabbing violently from the stage with his cane.  “You think this topic funny, Mister Geller?” he demanded.  Yes, I didn’t say, I find this topic rather ridiculous.  But I just sat and tried not to nod.  “You think the scientific investigation into the nature and physiology of intestinal gases is unimportant?  Not worth your time or study?  Is that what you think, Mister Geller?”  By this time Rockport had come to stand just in front of me, standing at the very edge of the stage and stabbing out with his cane, trying to hit me.  I was, I thought, a safe distance away.  Unless he decided to throw the cane.  Or jump from the stage to attack me.  He had turned bright red and looked like either was a distinct possibility.

“Let me tell you, Mister Geller,” he continued.  “Let me tell you what kind of doctor you’re going to be, unless I can help it.  You, sir, are going to be the kind of doctor that thinks you know enough to get by.  That you don’t need to master the details, do you, Mister Geller?  You’re going to be a gastroenterologist, I think.  Yes, Mr. Geller, a gastroenterologist.  A doctor that makes oodles and oodles of money shoving rubber hoses up the arse of your patients, all day, dozens of times a day, every day.  Getting paid lots and lots of money to shove colonoscopes up the rear end of society’s elite, every day.  And one day, Mr. Geller, one day you’ll be looking up some poor patient’s arse with your fancy colonoscope and you’ll see something!  Do you know what you’ll see, Mr. Geller?”  I had to shake my head at this point, as it was clear he wasn’t going to move on until I did.  “You are going to see a nice fat, juicy polyp, that’s what you’re going to see.  A nice fat, juicy colonic polyp, Mr. Geller.  And I know you’ll want to take out that juicy polyp, Mr. Geller, because you can charge a lot of money to take out the colonic polyps of our society’s elite colons.  So you’ll position your colonoscope, and you’ll ensnare the nice, juicy polyp with your electric cautery snare, Mr. Geller, and you’ll tell your pretty young assistant to turn on the current to your electric snare.  And do you know what will happen then, Mr. Geller?  Do you know?”  I had to admit that I did not know.

“No, Mr. Geller, you will not know.  You will not know that flatus contains 2% methane gas, a highly inflammable compound.  You will not know this simple physiological fact, Mr. Geller, because you think it unimportant.  Laughable, even.  You will not appreciate the significance of the fact that the gas within your patient’s colon is highly inflammable.  You will not.  And because you are an idiot, Mr. Geller, do you know what will happen?”  I think I might have been smiling at this point as I admitted that I really did not know.  “Your patient, Mr. Geller, will EXPLODE!  Yes!” he said gleefully, “Your high society, polyp possessing patient will explode in your face!  Pieces of your patient will spray across the endoscopy suite, bits of flesh will spatter the walls.  And then do you know what will happen, Mr. Geller?”  I shook my head.  The dog may have barked at this point, I wouldn’t be surprised.  “Then, Mr. Geller, the poor patient’s widow will sue you for medical malpractice.  And then a jury will pronounce you guilty of being a stupid, ignorant git.  And then your malpractice insurance company will cancel your policy.  You’ll be out of a job, Mr. Geller.  Out on the street, destitute!  That’s what going to happen to you, Mr. Geller, because you don’t respect science!”

“If that does happen, Professor Rockport,” I said, “I’ll still be sucking your precious oxygen.  And I’m pretty sure you won’t be.”

Medical School, Part One: Feeling Bad for the Patient

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Long ago I attended medical school in the midwest.  It was a public “University Of” school that enjoyed an excellent reputation, especially amongst the members of the school itself.  At the time (this was the early part of the last century), they claimed to be “the number six medical school in the country.”  I have no idea how they came up with this fact.  Suffice to say, they have spent every moment of the last one hundred years striving to overtake every institution above them on that imaginary list.IMG_1139

There was a unique dynamic in my midwestern state when it came to medical education.  In addition to “The University Of,” there was also a long established medical school in the city, as well as a brand new upstart medical school at the State University.  The State University already had a well respected veterinary school and one of the best osteopathic medical schools in the nation.  This fact led the brilliant State University administrators, faced with the task of naming the newly accredited allopathic medical school in a hip and distinctive way, to call it “The School of Human Medicine.”  I’m not sure what organisms the administrators thought their graduates from the osteopathic school were treating up to that point, by I’m assuming something distinct from animals or people–aliens, I guess.

This triumvirate of medical schools led to a great deal of competition on multiple levels:  for patients to care for in order to train their students, for prestigious residencies once their students graduated, and faculty.  It was a constant war, with faculty members being stolen back and forth amongst the three schools.  In response to this competition, each school developed its own unique personality.  “The University Of” simply made sure that everyone knew that they were the best and the most prestigious.  For a while they would spout the tag line “The Harvard of the Midwest,” until one marketing savant realized they could do better.  They then claimed that Harvard was just “The University Of” of the East.  You get the idea.  The urban medical school prided itself on its gritty reputation of training “real doctors,” emphasizing their large caseload inherent in a predominantly indigent population.  The State University emphasized their new, modern teaching approach. The curriculum incorporated an emphasis on compassionate care and alternate, New Age type approaches. The teaching method was also new and different.  Instead of the classic lecture for two years followed by two years of closely supervised clinical experience epitomized by the “University Of” format (and Harvard, of course), they developed a computer based, “teach yourself to be a doctor” curriculum.  It was very ahead of its time.  It was also a disaster.  The graduates of this system could always be identified by their inability to  pronounce any medical term over two syllables correctly, since they only interacted with a computer screen for two years.  They were cruelly mocked when they finally hit the wards.

This dynamic was exemplified in a joke popular in the state at the time.  A recent graduate from each of the medical schools is asked to evaluate a patient in the emergency room.  The patient is a seventeen-year old male with a one day history of worsening right lower quadrant abdominal pain, nausea, and fever.  Physical exam demonstrates exquisite tenderness over the appendix.  The first student, a recent graduate of “The University Of,” says, “I’m quite familiar with this type of patient.  I have read over a dozen journal articles on just this problem and given a Grand Rounds lecture on this exact condition.  This patient has acute appendicitis and needs an emergency appendectomy.”  “And how would you do that operation?” the “U of” graduate is asked by the professor.  He shrugs.  “No clue,” he says, “we don’t actually go to the OR.  That’s just technician stuff.”  The second student, from the urban training program, snorts derisively.  “The dude’s got a bad problem in his gut.  I’ve never read anything in a book about this, but I’ve taken care of twenty of these.  I need to get him to the operating room.”  “What’s your preoperative diagnosis?” the professor asks.  The urban graduate shrugs.  “Who knows?  Doesn’t matter.  Never let the skin of the patient stand between you and your diagnosis, that’s what we always say.”  Finally, the “State University” graduate is asked his opinion.  He looks distinctly uncomfortable when asked for his diagnosis.  Finally, he answers, “To be honest, I’ve never read anything about a patient like this.  As a matter of fact, I’ve never even encountered a patient with this problem during my education.  However, I do feel really, really bad for him. And I hope he gets better soon.”

Trunk Full of Human Tissue

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Simple elements of life can be a challenge for those pursuing training as a surgeon.  Getting home from work, for example.  In the days when the trainee was expected to take call in a busy hospital every two or three nights, the resident often was trying to drive home in a state of profound sleep deprivation.  This led to significant difficulties.  One of my fellow residents seriously injured her knee by crashing her car driving home after call.  She was on crutches for months, making standing at the OR table a bit of pain.  I can’t even count the number of times I was awakened by angry honking from the car behind me because I had fallen asleep at the wheel while waiting for a traffic light to turn green. I quickly learned to take the car out of gear whenever I stopped at a red light.  Once, I woke up to the sound of my car driving through an abandoned field–had no idea where I was or how I got there.  Most exciting was the time I fell asleep while driving down the merge ramp to the expressway, in the driving rain in the middle of the night–woowee, that was a hoot. You really snap awake when you realize that you are looking at headlights instead of taillights in front of you at sixty miles per hour.Boston City Flow

I found that the only reliable way to get home without falling asleep was to drive as fast as physically possible.  This not only generated the adrenaline necessary to keep my eyelids up, it also shortened the critical period of vulnerability.  Stop signs became optional after one in the morning.  Red lights became optional after three.  You get the idea.

Unfortunately, the police forces of the various localities I drove through were not amused by my technique.  Soon after I adopted my Steve McQueen attitude toward commuting, I began to accumulate significant expenses in the form of moving violations.  While many cops are sympathetic to physicians in training, very few are willing to forego writing the ticket when you just blew through a red light at eighty in a thirty mile per hour zone.  It got to be way too expensive.  I think I was making somewhere in the range of $25,000 a year at the time, and traffic tickets (my kind at least) were over a hundred bucks a pop; they were popping at the rate of one or two a month.  You do the math.

As a result, I had to slow down again.  This worked for a bit, but then one spring evening I fell asleep at a red light and rolled back into the car behind me.  No real damage, but unfortunately the car was driven by a state trooper.  Troopers never let you off without a ticket.  It’s because they have to wear that ridiculous hat, I think.

So driving slow wasn’t working, either.  I needed a solution, as I was facing a problem that would continue for another four years.  At the time of my encounter with the state trooper’s bumper, I was on the transplant service.  One morning, as I was trying to stay awake during attending rounds, I saw my salvation.  It was a styrofoam box just outside the OR, waiting to be tossed in the trash; one of the containers used to hold a kidney being transported between hospitals for transplantation.  The box is about the size you’d expect to hold a St. Bernard, because it needs to hold the ice to keep the kidney cold.  It is impressively marked with multiple labels proclaiming in large, authoritative fonts:  RUSH:  HUMAN TISSUE FOR TRANSPLANT.  I excused myself from rounds (fake page gambit, always handy) and took possession of the box, promising the janitor I’d toss it for him.

From that day on, I never drove anywhere without my HUMAN TISSUE box in the trunk.  Back in Steve McQueen mode, I was again getting pulled over with fair regularity.  Now, however, I greeted the officer with the explanation that I had no time for him, I was driving like this because I had to get a kidney to the hospital for transplant.  This usually elicited quite a bit of skepticism, requiring me to pop the trunk.  Which I would do with profound irritation, pointing at the box and saying, “Okay, believe me now?  Because I gotta get this to {insert name of hospital in general direction I was heading at time I was pulled over) so a little girl will live to see another birthday.  Or is making your ticket quota on my ass more important?  Your call, officer.”  I admit, I usually laid it on a little thick.  What can I say, I was tired. Always tired.

This worked without fail.  I never got another ticket for the rest of my residency.  Only problem was the one time I really gave the cop such a hard time (I was really, really tired) he insisted on giving me an escort all the way to the hospital.  I had to thank him and actually carry the box into the ER as he watched.  I couldn’t leave until he pulled away.

Still better than another hundred bucks down the drain.  Besides, that little girl needed that kidney.

Superman is a Myth

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It was a classic Superman moment.  A train of seventy-two railroad cars filled with highly flammable liquid was poised precariously on a hill above a sleepy town filled with innocent Canadians.  It was dark.  There was no driver or attendant to witness that the airbrakes preventing the train from slipping are slowly draining pressure.  The train begins to slowly roll downhill, picking up momentum as it ponderously but inevitably begins to roll faster and faster towards the center of town, disaster looming–but wait!  Here he comes, streaking out of sky!  A red and blue caped blur, a powerful hand braced against the lead locomotive, a grimace and then, with a squeal–all is saved, disaster averted.Minolta DSC

Only it didn’t happen.  No Superman.  Instead, disaster, death, and destruction.  Innocent lives lost.  The classic Superman moment, one I had witnessed in comics and onscreen since my wide-eyed youth, went horribly wrong.  No Superman.

At first, I hoped and believed that Superman could not save the day because he was otherwise occupied achieving even greater goodliness, saving even larger populations of threatened innocents.  But I checked–it seems that North Korea had not simultaneously launched  a nuclear tipped missile aimed at a New York museum at the exact moment that Lois Lane was visiting with her little nephew’s fourth grade class.  The only other possible explanation, that Lex Luthor had Superman incapacitated under a geodesic dome made of Kryptonite, was also disproved by a quick Google search.  No Superman.

How could it be that Evil had triumphed?  How could the sinister forces of darkness and malevolence succeed, unchecked by our heroes?  Such a situation is contrary to the workings of a moral universe, would require the balance beam of justice to be bent beyond all reasonable fairness.  Not possible; the Fates are not so cruel.

But, hold on a second.  Deep investigation reveals no Fates, cruel or otherwise, in the immediate vicinity at the time of the accident.  Reviews of salient radar logs show a sky clear of evil, flying monkeys.  Overhead satellite imaging clearly indicates that a demonic miasma did not dissolve the critical feedlines to the airbrakes.  Not at all.  No Evil, either, it seems.

No, upon further investigation it appears that a well-meaning crew of volunteer firemen, responding to a fire on the train, skillfully extinguished the blaze.  They did their best, including following the protocol which required them to shut down the engine to the burning train.  The engine that provided the pressure necessary to maintain the airbrakes.  And then they went home.

No evil.  Not even an absence of good intent.  But no Superman.

It makes me sad.

My heartfelt sympathy to the families of the victims of the Canadian railway tragedy.

Requiem en pace

“Keep Calm And Carry Speed”

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For a very long time, my favorite aphorism was “Don’t panic.”  I am a big fan of Douglas Adams, obviously.  My son and I often threaten his Mom that we’re going to get the phrase tattooed on the back of our right hands, which she no longer considers amusing.  It has always seemed an apt phrase and good advice for us both.  Certainly as a surgeon who specialized for a long time in trauma care, it served.  It also seems appropriate for my son, who is a percussionist.  It seems that unlike any other type of musician, percussionists are constantly coping.  A classical violinist or horn player, performing a difficult piece in a crowded concert hall, is rarely faced with an unexpected technical challenge. They play.  Percussionists, on the other hand, are frequently moving between multiple instruments, changing mallets on the fly, adjusting to alterations in tempo, tuning in mid performance. It makes me nervous just watching, but he loves it.  Every performance is a challenge in real time, every note played is heard without fail by everyone in the hall.  Certainly, “Don’t Panic,” has served him well throughout his career, as it has my own.cropped-156595748-alonso-ferrari-austin_custom-a3b7a8d98fcee01986148e35e0ef3b39c800a9c6-s4.jpg

“Don’t Panic” is good advice in difficult circumstances.  Whether you are faced with a patient bleeding out from a gunshot wound, a conductor who botches the crescendo, or a lethally morose robot (Hitchhiker’s reference), one must first cope.  But not panicking is not sufficient.  In life, as in surgery or musical performance, staying calm in the face of adversity is but the first step.  The real trick, as the famed Formula One driver, Kimi Raikkonen, so elegantly stated in the title of this post, is to keep moving. When faced with a difficult challenge, a sudden catastrophe, the realized mistake–it is necessary to move forward.  Carry speed.  It is almost never helpful or appropriate to stop suddenly, ruminate on why the illness has happened to you, regret the decision/marriage/investment.  In racing, a difficult situation is transformed into disaster by standing on the brakes, every time.  The host of Top Gear, Jeremy Clarkson, once said, “Speed has never killed anyone, suddenly becoming stationary…that’s what gets you.”  Carry speed.

Of course, just moving straight ahead is rarely sufficient to overcome difficult circumstances.  As you are moving through trouble, the driver must see further ahead, fighting the natural tendency to become too focused on what is immediately in front.  “The car goes where the eyes are looking.”  Look down the road farther.  Create space, change course, adapt, use a different technique–DO something.  In surgery, the experienced surgeon knows that the answer is almost always “Make a bigger incision.”  Better exposure, a wider approach, seeking control of the disastrous injury by extending into areas of normal anatomy is almost always the safest course.  Stopping, pausing to consider, trying to figure out why one’s usual techniques have failed; these things do nothing to stop the bleeding.  And there’s only so much blood one can lose before it really doesn’t matter any more.

There are a number of similarities between racing and surgery.  The need for constant focus is the most concrete.  In both pursuits, even a momentary lapse by the operator is often detrimental, and can at times be disastrous.  Team work, skilled colleagues, luck–all are paramount in both avenues of pursuit.  Even the aphorisms seem interchangeable:

“Slow hands in the fast parts, fast hands in the slow parts.”  The routine parts of the operation, opening and closing, can usually be accomplished by an experienced surgeon expeditiously.  Care must taken, however, when maneuvering around the pathology.

“Slow in, fast out.”  Approach the pathology deliberately, intelligently choose your position as you enter the critical phase of the resection–this will make the performance of the actual maneuver straightforward, allowing an easy, controlled exit.

“The fastest line is not always the quickest.”  In surgery, as in racing, it is sometimes much more efficient to take additional time in the approach, allowing the next maneuver to be performed more optimally.

“Drive your own car.”  You can only be responsible for your own actions.  What all the other guys are doing–the other drivers, the anesthesiologist, the other patients, the officials–is out of your control.  Do what you do to the best of your ability, let the others take care of themselves or the patient.

“Make room for trouble.”  Try to see the crisis developing ahead, rather than being forced to react once it happens.  Create space in anticipation, extend your line around a car that looks loose entering a turn–if he goes into a spin, the added space may get you past safely.  Same thing in surgery–anticipate that the infected artery may not hold your stitches, may fall apart as you try to clamp it.  Extend into another body cavity if you have to:  if you can’t get control of the bleeding infected aneurysm in the groin, go into the belly to get control.  Anticipate and extend.

Finally, Churchill (though not a racer or a surgeon, he managed to always say it best):  “When going through Hell, just keep going.”

Would It Kill You To Call Every Once In A While?

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The other night, my wife got a call from a relative that she hadn’t spoken to in quite a while.  The woman called during dinner, of course.  Why people capable of calculating compound interest on their mortgage while separating two warring children armed with steak knives  and making dinner for a family of six can’t manage to wrap their heads around the entire concept of time zones is beyond me, but she was happy to hear from her.   When she hung up, my wife said, “I really should call her more often.”  Meaning, ever.northernlights_enl

This got  me to thinking about all the people I know and care about that I just don’t seem to hear from anymore.  Dinner was being reheated anyway, so I had some time to think about this.  It occurred to me that I really hadn’t had a good conversation with my Dad, for instance, in a very long time.  I love my Dad, and I remember when we used to talk pretty much every day.  My wife gave me a strange look when I brought this up with her, however, pointing out that my Dad had died almost twenty years ago.  Like this was a good excuse.

[Brief Aside:  One of my Dad’s favorite sayings was, “Man who trip over same rock twice, deserve to break his neck.”  He’d often admonish me with this gem told in a solemn fake Confucius  accent, in way of educating me about some mistake I’d made for the sixth or seventh time.  The frequency with which he used this aphorism prompted me to write a very short story in fifth grade about a dashing young knight who tripped over a rock in the road.  He was stuck, turtle fashion, by the weight of his brilliant armor, but helped back to his feet by a passing Good Samaritan.  The next day, however, when the incautious knight tripped over the very same rock, resulting in the same predicament, the next passer-by was a robber who killed the knight by breaking his neck and stole his money.  As I recall, Mr. Barno, my fifth grade teacher with breath so bad two students dropped out of school that year to pursue a life of crime, wrote in his comments something to the effect that I should seriously consider pursuing a career in accounting.  Thanks for that, Mr. Barno–hope you’re resting peacefully.]

There are dozens of good friends and beloved relatives with whom I’ve lost contact.  It’s inevitable, I guess, as we get older and get busy with our own, hectic lives, and these other folks just keep moving away or dying.  It makes it tough to keep in touch.  It’s probably my fault, to be honest.  I mean, I’m one of those folks that’s pitifully inattentive to maintaining contact with old friends and relatives.  I don’t think I’ve made a long distance call or attended a seance in a really long time.  And while I hate to admit it, there has been more than one occasion when I’ve returned from a long, tough day at work and looked at that little flashing red light on the answering machine and said, “No way.”  Then I just delete those suckers without even listening.  It’s true.  So it’s entirely possible that my Dad left some kind of message, just touching base, and I erased it.  It bothers me, now that I think of it, because if he left a call back number and I just deleted the thing, no wonder he’s so ticked off that he never called back.

On the other hand, it’s at least as likely that’s it’s their fault.  I know how tough it can be to pick up the phone.  My wife and I were recently traveling in Ireland, and we kept trying to use the cellphone to call back to a friend of hers here in the States.  But who can figure out whether to put the one in front of the number or not, do you include the 01 country code, and all that other jazz that makes it just about impossible if you’re over fifty to make these things work?  (Which is why we almost always travel with a child, just in case we have some technical issue.)  Most of these people are really, really old now.  A lot of them passed away before we even had cellphones or Skype.  What do we expect?

I like to think that they’re probably too busy to call, anyway.  Most of my parents’ friends are dead, and I wouldn’t be surprised if they’re so busy yelling at one another over how their partner screwed up the bidding for their great bridge hand that the subject of how the kids are doing just hardly ever comes up.  Or Samba lessons, or something.  Time just gets away from you, I know.  Dad’s probably still upset I moved so far away that’s he’s waiting till I move back into his neighborhood to stop by.  He hated that drive from Michigan to Long Island, no way he’s coming all the way back from the dead unless someone gives him a damn good reason.

Or maybe it’s just because they’re dead.  I don’t know.  Wouldn’t kill you to call, though.

Equanimity

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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 whom 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

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~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”

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~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

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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.