Wednesday, March 29, 2006

Worth the Weight? Part 2

It took just about two hours to complete the renovations. Two hours to make a conceptually simple change--shrink the stomach to the size of an egg and bypass the duodenum, you'll eat and absorb less food, lose lots of weight--that will rank among the most significant two hours of this woman's entire life. In two hours, with a few snips and staples, we waged and won a war on evolution, on our brains, on capitalism, on America--conquering the multitude of "evil" forces that have driven us to eat like we are starving while surrounded by food, to stuff ourselves with calories like a scrooge hoarding money with no intention of ever spending any of it. It was a war against our those perpetually big eyes of ours, driven by those sometimes detrimentally big brains of ours, both of which consistently sabotage our best interests and cause civil wars inside the borders of the country inside each of us. Fighting against a culture of excess, against the capitalistic greed-driven apathy that would ignore Huxley's warnings and allow--even subsidize!--high fructose corn syrup to permeate our food supply, running through our veins like soma, lulling us all into a sugar-coma dreamland until we wake up to the horrific reality of diabetes that has rendered us blind and legless, forced to enslavement under the power of the not so innocent insulin master...

In the recovery room, I met my patient as a person, not just a body, for the first time. She was lying in bed, eyes shut, not moving or talking unless requested specifically by one of us. Are you in pain? She moaned yes, pointing to a spot over her stomach. Do you have any questions? Where's the phone. I need my things, the stuff I brought with me. Nausea? No. Hungry? No. Need anything? No. One last question--Have you been waiting for this for a long time? She opened her eyes and looked straight at me as she gave a long, slow nod in the affirmative.

I cried when I got home. Not necessarily for my patient specifically, because hopefully this will have been a successful operation for her and she will live a happy life. If all goes well, this woman will literally become half of her current self within the year. But what I wonder is: at the end of it all, will she miss her other half--or will she feel like Michelangelo's David, a former blob of stone whose excess has been carved away to reveal the true beauty underneath? If the latter, why was there no other less dangerous way to feel beautiful available to her--and so many other women, for although there are approximately equal numbers of morbidly obese men and women in this country, women far exceed men in the patient population getting this surgery. I cried because I feel in my gut that there's something wrong and twisted about the fact that we live in a world, and subscribe to a medical system, that doesn't have the capacity to support natural weight loss through healthy diet and exercise and acceptance, or to recognize the malignance and addictiveness of our typical diet and make some major changes so these poor patients don't have to bear the brunt of the change. If anything, I cried because the success and popularity of such a grossly unnatural procedure acts as a shocking reflection of the mores of our culture, the toxicity of our nutritional environment, and the lengths people need to go in order to lose weight and become accepted by the rest of society.

Bariatric surgery: the (I can't wait until I can no longer eat) "bread-and-butter" of the Yale GI surgery service.

To Be Continued...

Worth the Weight? Part 1

Lights, Camera, CO2...Action!

The Setting: Abdominal Cavity
The Actors: First, we encounter the Gatekeeper of the Abdomen: the thick fluffy quilt of motherly omentum, bright yellow and protective, an endogenous apron covering all who lie inside. Well, everyone, that is, except the Liver, whose bullet-proof vest of ribs is the only protection it allows: the Liver is smooth and still, a flexible wedge of shiny mauve, cool as a steady surgeon controlling all with deceptively powerful silence. Next, the Small Bowel, a bow(e)l of tannish-pink snakes intertwined in a pile, still writhing in their slow, charmed, caterpillar dance along their many feet of length. Off to the extreme stage left, an ominous purplish black Spleen hides quietly in the shadows of the left colic gutter chomping up red blood cells without bothering anyone else, like a good Spleen. Nestled underneath the dueodenum, the enigmatic Pancreas peeks through a window of peritoneum, wanting in on the action but exiled to be forever retroperitoneal, despite being surrounded on all sides to the point of immobility. Up above in the next room, the heart bounces happily on its trampoline, as evidenced by the boingy bulging in and back of the diaphragmatic divider wall. It is a pleasant landscape, overall. But something must be wrong, if we are here. Oh yes, something is very wrong. We are here for the Stomach.

The Main Character: Let's see this hateful Stomach. At first glance, It is as any stomach would be, draped across the left upper quadrant like a hammock, swinging contentedly from diaphragm to liver, dressed in bed ruffles of omentum from above and below. At second glance...well, it is still entirely...unremarkable. Just the right size. Just the right color. Not scooped out by an angry ulcer or invaded by an aggressive cancer. Not bleeding from burst vessels or choking from getting its neck stuck through the hole of the diaphragm. It looks, as we might tell a nervous patient as we peer into her ears or vagina, "healthy, pink, and normal."

The Plot: And yet, perhaps unfairly, it is the Stomach that we have come for today. It has been singled out and convicted, scheduled for mutilation, public humiliation, and a lifetime of deformity as punishment for its role in the situation at hand. The situation is severe clinical obesity, and like it or not, the Stomach is going to pay. Is it really the responsible one? Or just a scapegoat chosen to bear the brunt of the guilt, and the pain, felt by everyone involved? Who really reaps the benefits of this procedure, and who suffers the consequences? Today, as I witnessed, and assisted in, my first gastric bypass surgery, I began to hear, louder and louder, until I could no longer ignore its plaintive growls and heartfelt gurglings, the Mourning Cry of the Modernday Stomach.

To Be Continued...

Monday, March 27, 2006

Everything I Needed to Know About Surgery I Learned In Kindergarten

It's true. Scarily so, in fact. First round observations and lessons gleaned from POD #0 (post-op day zero, shorthand for the day of a surgery) of my surgery rotation:

Top 10 Rules of the Operating Room:
1. Wash your hands.
2. Always wear your coat and gloves or you might catch something.
3. Don't forget to pee before you get dressed up to go.
4. Keep your hands to yourself.
5. Don't touch dirty stuff if you're clean.
6. Don't touch clean stuff if you're dirty.
7. Do whatever the teacher tells you to do or you might get yelled at.
8. Don't ask too many questions or you might get yelled at.
9. Don't play with knives or someone might get hurt.
10. Clean up after yourself.

Top 5 Items I Have Used in Surgery as a Medical Student:
1. Scissors
2. Staples
3. Glue
4. Bandaids
5. Napkins

Top 3 Things We Ask Patients After Surgery:
1. Did you fart?
2. Did you poop?
3. Did you pee?

The #1 Thing Missing From Surgery To Make It Truly Like Kindergarten:
1. Naptime

Tuesday, March 14, 2006

Piece of Mind

You know how people say "hey, it's not brain surgery..."? Well today...It was.

After a late night return from a trip to NYC for Purim merrymaking with friends old and new, I was less than thrilled when my alarm went off at 6am this morning, a mere three hours after I'd set it and fallen into bed. Luckily, anesthesiology has brought with its other perks a Return to Pajamas, as in the shapeless, colorless, imminently nonflattering, yet infinitely more comfortable than most other professional attire I've ever worn scrubs that I am obliged to sport while in the hospital. Still operating in slow wave sleep mode, I chugged coffee and downed some vitamins on the way up to meet my fate for the day.
The verdict: neurosurgery operating room! In addition to completing my first successful intubation per anesthesiology requirements, I also had the unique opportunity to observe as a woman quite literally got back her piece of mind--she had had a stroke a while back, and her brain swelled to unhealthy dimensions in response to the insult. So at that time the doctors had done a craniotomy, taking a China-shaped piece of skull out of her all-important globe in order to let the brain swell and heal without choking itself to death inside the otherwise rather tight quarters of the cranium. Now, some time later, she was ready for the docs to give her back a piece of her mind (which, incidentally, had been resting comfortable at a "bone bank" with all the other craniotomy survivors--it seemed rather nonplussed by its unique out of body experience). All went smoothly, and the piece was restored to its rightful resting place.

Brain surgery? Easy as pie, I thought after this first case. That's when the aneurysm walked into the OR. No, no joke here. Just a relatively young middle-aged woman with a bulge in one of the arteries in her brain that had just burst, bled for a bit, and then magically clotted itself, buying her enough time to get to get intubated and rushed to our hospital. We (and by "we" I mean everyone but me--the surgeons, the scrub nurses, the other anesthesiologists) were progressing along fabulously, almost ready to seal the sucker and call it a day when suddenly--like the New Orleans levees--the aneurysm broke open! Instantly, the blood waters rose up, up, up in the cavity of brain, almost spilling right out onto the floor . Each time one of the neurosurgeons suctioned out the excess, the other would fish among the tangles of vessels, trying in vain to stop the leak with a well-placed clip. Each time, the clip would hold for half a minute, the field would stay clear, and then--like a just-flushed toilet--the hole seemed to stop holding its breath, and blood would fill back up in the space. The situation looked pretty grim to me; but luckily, just as I was wondering whether all was lost, the coolhanded surgeon, with a final decisive clip at the offending artery, nipped the problem in the bud for good. Whew. Wouldn't want to have been in their shoes during the last hour. I guess brain surgery really is...brain surgery.

Sunday, March 12, 2006

Scenes From An Emergency Dept

~Setting: An Emergency Department Near Me~
The man strides into the ED with the purposeful walk of someone who knows where he's going. He makes a decisive turn into an alcove of beds, then realizes he's hit a dead end and pauses, raising his head. That's when I see that he may have just walked the walk, but his eyes talk the talk of someone who is dazed and in shock. We lock eyes for a moment, just enough time for me to think about asking him where he's going...and then the police rush in, spin him around, and guide him quickly to the trauma area. As he walks past me I see that his shirt is soaked in blood...

He gets thrown onto a bed in the trauma room and some nurse deftly cuts off his shirt and pants with a pair of surgical scissors. Turns out he's been, oh, shot in the belly a few times. He says he's not in any pain, and he seems pretty alert and oriented. People are yelling all around him, while he just lays there. Someone demands a hole count. 1, 2 on the front. 3, 4 on the back. Seems like there's a 5th on his side, but it might just be an abrasion. So there's a good chance the little suckers are sitting on a sidewalk somewhere, hanging out after their brief sojourn through our patient. Who, we finally realize, minutes after he arrives, has a name. I'll call him Ron Esdaile (obviously not his real name, or anything like it). In any case, at this moment we care a whole lot more about Mr. Esdaile's blood type than his name, and more yelling and prodding and needlesticking ensues for a few precious more minutes until we can finally send him hurtling down to the OR for a thorough checkup. Whew.

He seemed totally fine this whole time, even though he could have been bleeding internally and was going to crash any second, and even if not, a little piece of his yellow omentum was most definitely peeking out at us through one of the the bubbling little holes in his belly, and my goodness--this man had just gotten shot with a gun!

Throughout the ordeal, while I was standing dutifully behind the thick red line on the floor (in life there are the Haves and Have Nots; in medicine there are the Useful and the In The Way....guess which one I am...), I was struck by the fact that this man was not only alive, but seemingly alive and well. After having gotten shot. Several times. With a gun. And bullets that tore clear through to his other side. I've heard about guns, played video games with guns, seen lots of guns on TV and movies--but until Mr. Esdaile walked in, I had never been so close to the actual firing--and almost killing--of a gun.

I likely could have stayed lost in my philosophical reverie for plenty longer, but just then one of the front desk people came over and said that Mr. Esdaile's wife was in the family room to get an update on his condition. Interested in getting more experience in how doctors tell families good and bad news, I asked my attending, Dr C, if I could tag along. She said sure, so we headed over to the family room, where we found a woman sitting inside. For a split second, it occurred to me that she looked a little bit older than I would have expected Mr. Esdaile's wife to be, but who am I to judge...

Dr. C: Hi, I'm Dr. C. Are you Mrs. Esdaile?
Mrs. E: Yes, I'm Mr. Esdaile's wife.
Dr. C: Ok, so are you aware of what happened to your husband? When did you last see him?
Mrs. E: Yes, I know what happened; I was with him in the ambulance. How is he?
Dr. C: Good, so as you know, Mr. Esdaile was shot several times in the
Mrs. E: ~develops a look of shock/confusion~
Dr. C: Now don't worry, he seems fine. He's talking, awake--we just senthim to the OR to--
Mrs. E: ~interrupting Dr. C~ My husband wasn't shot!
Dr. C: ~develops a look of shock/confusion~ Umm...are you sure?
Mrs. E: Yes, I'm sure! I was with him in the ambulance!
Dr. C:'re Mrs. Esdaile, right?
Mrs. E: Yes, I'm Mrs. Esdaile!
Dr. C: Uh...and what do you think your husband came in for?
Mrs. E: I don't think--I know! My husband came in for a psychiatric issue--they said I could see him, then pulled me into this room!
Dr. C: Oh my goodness, I'm so sorry! This must be a terrible mistake--another man with the same last name--a different Mr. Esdaile--*just* came in here who got shot.
Mrs. E: Oh, wow!
Dr. C: I'm SO sorry--that must have been very strange for you...
Mrs. E: Uh, yeah, pretty much.
Dr. C: Uh, why don't I go find out where *your* husband is so you can see
Mrs. P: That would be great, thanks.
~close scene~

Hey, I don't make it up, I just tell it like it happened. There was also a guy who came in begging for a rectal exam because he was "100% positive I have glass up my ass". The X-rays showed nothing out of the ordinary in his rectum, and he was sent home, grumbling about the incompentance of the medical profession. In contrast to that clearly dissatisfied customer, we had a young woman come in with a history of two weeks of terrible abdominal pain. In her case, the imaging showed a clear cause for her muscular distress: the 12-week-old fetus growing inside her belly, doing some new expansions on its uterine home. After that news, she forgot about her pain altogether, and went home glowing, even though we hadn't actually *done* anything more for her than we'd done for Mr. Glassy Ass.

I'm gonna miss the ED. Sigh. But no time to dwell--coming next....tales from anesthesiology!