Читать книгу Understanding Surgery - Dr. Joel Psy.D. Berman - Страница 3

Chapter 1

INTRODUCTION

I sat one day in the library and looked at a surgical text,

It weighed too much, had rarely been used,

and left me quite perplexed.

Now why in heaven would anyone want

to wade through all those pages?

It seemed so dull, though I must admit,

it was written by dozens of sages.

So I said to myself, I know what I'll do,

I'll write a book just plain and simple

Explaining to every man, woman and child

the art of removing a pimple.

Surely a book about cutting and sewing

would be to the layman's liking,

As long as the words were quite simple,

and the subject and writing were striking.

So here is the tome that I've written for you,

it's been more than a minuscule chore.

And if when you're through, you don't like it, don't tell me,

or I will be hurt to the core.

The major texts of surgery, written for students and physicians, are usually upwards of two thousand pages and filled with complex medical vocabulary, and this makes it all but impossible for the layman to understand the procedures and the bases for surgical practice. It is my intent to give a simplified but comprehensive presentation of surgery for the general populace.

The objectives will be to offer information and guidance to patients and family about the most common surgical procedures, which physicians have often failed to make sufficiently clear to those whom they are treating.

This is not a textbook for surgeons or students, but a guide for all individuals who want to understand the basics of surgery. While the focus will be primarily on what is called general surgery, I will also include sections on the most common sub-specialties, such as Vascular (dealing with blood vessels), Cardiac (heart surgery), Pediatrics, Orthopedics, Neurosurgery (Brain and spinal cord) and several others.

I am not interested in giving you only a reference text, but in presenting you with a pleasant read about the past, present and future of surgery, hopefully in such a way that it is not just filed away on a shelf, only to be used when one has a surgical problem or question. A study of the human body, its function, failings, and surgical correction can be fascinating, even exciting, when set forth in the appropriate way. I hope this book will let you marvel at the beauty, the complexity, and the ability of the human body to be repaired in the hands of the trained physician, and perhaps when you finish you may glean some of the fascination and excitement I have found in my day in and day out experience as a practicing surgeon.

Chapter 2

HISTORY OF SURGICAL PROCEDURES

When Will and Ariel Durant wrote their Story of Civilization

In thousands of pages and eleven large books, 'twas a massive publication

But using my art of brevity, I'll write this medical history, as I should,

And only use eight pages...’cause, damn’ I'm really good!

Let us look through a mythical telescope back to the earliest days of creation and see what we can conjure up about the ability of primordial creatures to take care of themselves. Imagine some slimy thing crawling across the ocean floor, getting bitten by another slimy thing or somehow becoming injured. Our little creature had two outlooks: dying or somehow repairing the damage and surviving, albeit probably for a shorter period of time. Now we can postulate that the repair took place, most assuredly without conscious understanding by Mr. Slime, either by secretion of some internal healing substance or by an instinctual reaction by the organism which caused it to repair the injury. Sound farfetched? Well, maybe, but this same process is going on millions and millions of years later throughout the animal kingdom of today. Creatures have some inherent ability to heal themselves without conscious awareness, and this type of healing has led to the eventual development of present day medicine and surgery. Big step in reasoning, you may say. Possibly, but it leads us to that day millions of years ago when man first became able to reason, even at the most fundamental level.

When a “lower” species was cut or injured, it depended on the body to heal itself. Blood flowed from a wound until the blood vessel went into spasm and allowed the coagulation system to form a clot. Then one day a primordial humanoid found he could stem the flow of blood by applying pressure to the bleeding site...and surgery was born! He then showed his discovery to his cohabitants, who showed it to their offspring, and so on through the ages.

The beast of the forest that injured itself and developed an abscess, somehow knew through instinct to chew upon the area until it opened and drained. Drainage, even today, is the treatment of an abscess or locked in infection. But it took the conscious intellectual human mind to look at the abscess on a limb and know that it must be poked with a sharp stick in order to drain and allow him to survive.

And because man could not understand the reasoning behind his sickness he probably attributed it to spirits, spells (put upon him by other people, animals or demons), or the unknown and thereby began to perform incantations along with his early surgical and medical exploits. So now let us put away this mythical scope and jump to the dawn of civilization. We know that, in ancient Peru, France, and Britain, human skulls have been discovered showing that trephining or trepanning was done, which consisted of making a one- to three-inch hole in the skull. This apparently allowed evil humors to get out, and scientists examining the skulls say that the “patient” often lived long after the procedure! This practice may still exist among some primitive peoples of the world. So we can look at aboriginal or South American tribal cultures and possibly see what the prehistoric or primitive man used for healing. This included vegetable drugs, binding wounds and removing foreign objects (such as sticks or arrows!), and also included charms, talismans and incantations. A great deal of early medicine was done by the “medicine men” and witch doctors with much of the result being the effect of fear or belief, such as we see in placebo effects even today.

Now, in reviewing medical and surgical history, there are great gaps highlighted by the masters of each age, usually individuals who collected the history of medicine to that date and wrote it down as their own treatise. Surgical care progressed very slowly over the early millennia and over the last several centuries. To give you a brief background of historical highlights is to give you the names of the individuals who made these compilations in the early periods and to note the innovators and geniuses of the last five hundred years who made the sentinel achievements whereby medicine and surgery took giant steps forward.

Let us start with the invention of writing and the information found on clay tablets, which we call the Code of Hammurabi, apparently written by a Babylonian king 3800 years ago. One such pillar tablet is preserved in the Louvre Museum in Paris and gives rules about treatment and also the punishment of physicians whose patients die in the course of treatment —they would have their hands cut off! (Fortunately, our rules are somewhat less severe today.) And in ancient Babylon the sick were placed in the street for anyone to offer help or information about treatment (the first curbside consultations!). Sacrifice and incantation was a major part of medicine.

Moving on to ancient Egypt we find the name Imhotep, a chief minister of King Zoser, who not only designed the pyramid but was an early “healer” and became immortalized as the Egyptian God of Healing. The Edwin Smith and Ebers Papyri discovered in the eighteen hundreds in Egypt, gave voluminous information about treatment, incantations, and notably a long treatise on the care of wounds and battle injuries.

In India we find ancient writings, two to four thousand years old, about a medical system called Ayurveda, mostly spiritual; this was followed from 800 B.C. through the first millennium A.D. by the more advanced ideas of two individuals, Caraka (an internist) and Susruta (a surgeon) with writings about wounds, tumors, and abscesses as well as medical diseases. Early Hindu surgeons drained abscesses, removed simple tumors and did crude treatment of fractures and sewing up of wounds.

In China, the culture extends back several thousand years with traditional Chinese Medicine and its dualistic theory of the Yin (female, dark and passive the earth) and the Yang (male, light and active the heavens) principles. The human body was made up of five elements (fire, water, earth, metal and wood) and these, with balances between yin and yang, determined health or illness. The Chinese described tying off (ligation) of arteries, the presence and importance of the pulse, and said the body consisted of five organs: heart, lungs, liver, kidney and spleen. We all have heard about acupuncture; the Chinese also used hydrotherapy (i.e., cold baths for fever) and had a great pharmacopoeia of herbal medicines, many of which are still used today, such as castor oil, camphor, and iron for anemia.

Western Medicine progressed slowly over several thousand years from Early Greece with Asculapius slowly drifting away from the supernatural. By the fourth century B.C., Hippocrates, often called the father of medicine, had written his “Aphorisms” (the best known being the first: “Ars Longa, Vita Brevis Art is long and life short”) with many descriptions of observations and diagnosis, but only the most basic in the way of surgical intervention. He left us the famous Hippocratic Oath, which has been stated by graduating medical students for many years. I include it for you to peruse, since it is universally known about, but rarely seen.

“I swear by Apollo the Physician, and Asclepius, and Health and Allheal, and all the gods and goddesses...to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and to relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation, and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and to those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion... Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females and males, of freemen and slaves. Whatever, in connection with my professional practice or not in connection with it, I see or hear, in the life of men which ought not to be spoken of abroad, I will not divulge, as reckoning that all should be kept secret.”

Another Greek, Galen, in the first century A.D. postulated an entire body of medicine, much of it false, which was to be followed, essentially unchallenged, for fifteen hundred years. He stressed the importance of anatomy but, since dissection was forbidden, the anatomy of the day was often poorly conceived or completely in error.

The Muslim empire produced the genius of the Persian, Rhazes, who wrote many texts and actually distinguished between measles and smallpox. He was later followed by another Persian, Avicenna, who wrote the “Canon of Medicine.” But as much as these tomes expounded on diagnosis and medications, there was a surprising paucity of knowledge in the area of surgery.

You may ask “Why?” and the answer is actually quite simple. A good basis for surgery depends on a firm knowledge of accurate human anatomy. Up to this point, dissections were carried out on animals or on parts of human beings; the anatomical knowledge was often based on centuries-old texts, which were often incorrect or flights of fancy of the author. During the late fourteenth and fifteenth centuries new anatomy texts appeared and were much more complete than those we had seen for two thousand years. In 1543 Andreas Vesalius published his “De Humani Corporis Fabrica” (On the Structure of the Human Body), which was based on careful human dissection, and the diagrams are, for the most part, as accurate as anatomical treatises of today. His work was followed by a host of books on anatomy and physiology, and this may well be considered the beginning of modern surgery. Within the next one hundred years there was an explosion of scientific and cultural advancement with the likes of the genius philosopher Rene Descartes (“I think, therefore I am.”), Isaac Newton (Laws of Physics—remember the apple falling on his head?), Galileo (the telescope), Robert Hooke and Anton Leeuwenhoek (the discovery and use of the microscope), and the great discovery and publication of “De Motu Cordis” on the circulation of blood and the function of the heart by William Harvey (1628).

Surgery then took great strides forward when the physician could understand the anatomy and some physiology, and attempt to correct its problems. Likewise, there were advances in the parallel field of medicine, such as Edward Jenner's description of Smallpox inoculation in 1796, Johannes Muller's description of physiology or how things work in the 1830s, and the description of the bacterial cause of disease by Semmelweiss (child bed fever—women dying of infection after being examined by physicians with dirty hands) and Robert Koch (who discovered the organism that causes tuberculosis).

The most famous contribution to surgery and its advancement came with the discovery of anesthesia by several individuals, including Crawford Long, Horace Wells, and William Morton (who first demonstrated a painless operation at the Massachusetts General Hospital in 1846). Nitrous oxide, ether, and chloroform became the drugs of choice and led to the advancement of more complex surgery. In the end of the nineteenth century, Conrad Roentgen's discovery of Xrays led to the opening of new horizons in the field of diagnostics.

With the twentieth century came the development of chemotherapy for syphilis by Paul Ehrlich, followed soon by the discovery of Sulfonamide and the discovery and use of Penicillin by Alexander Fleming in 1928, and its purification and widespread use at Oxford by Howard Florey and Ernest Chain, ten years later.

Liberated from the time-warped problems of pain and infection, and armed with a host of new techniques, surgery came of age in the twentieth century. I won't go into much detail about the advances, but suffice it to say that because of the two World Wars, medicine and surgery were “forced” to make great strides, including immunological advances and a whole host of support technologies including the invention of plastics and inert metals which could be used in surgery. Advances in technique, that started during the last decade of the nineteenth century by such surgical giants as the Viennese Theodor Billroth (abdominal surgery, including ulcer surgery on the stomach) and William Halsted (the radical mastectomy), propelled surgery into the twentieth century and the development of neurosurgery by Harvey Cushing, and thoracic surgery (removal of part or all of a lung) by Harold Brunn, Rudolph Nissen, and Evarts Graham. By 1944, John Garlock in New York City was able to successfully remove an entire esophagus for cancer using part of the colon as an interposition “graft.” In the early 1920s and 30s surgeons began operating on the heart, but successes were rare and true cardiac surgery didn't start until the 1940s with the early development of extracorporeal circulation—first in animals, then in humans—by John Gibbon Jr. Soon it was possible to put the heart completely at rest, stopping the “beating,” and allowing surgeons to remove and replace damaged heart valves and bypass blocked coronary arteries. Alexis Carrel had perfected the suturing of blood vessels back in 1905, and vascular surgery has made great strides since that time. This led to experimentation with organ transplantation, and victories over rejection came with greater understanding of immunology and immunosuppression. In 1967 the world was made aware of the first heart transplant by Christian Barnard in South Africa, a procedure that has now become routine and standard at medical centers throughout the world.

This has been a very brief outline of four thousand years of medical and surgical history, and we should be happy that we live at a time when most of the pain and suffering of surgical intervention has been all but relieved. Let us move on now to understand more about the training that these physicians have in preparation for taking the patient into consultation and the scalpel in hand.

Chapter 3

EDUCATING THE SURGEON

In thirteen hundred and forty two

To become a doctor, there was little to do.

Climb a hill, raise your arms in a humble position

Yell once and dance and...you're a physician.

The training today is much more intense,

The course work is hard and it just makes no sense

To work all those years with no compensation,

And wondering when you will bring home the bacon.

The days are so long and rewards long in coming,

The work is quite hard and the hours are numbing.

The MD degree is just too hard to reach,

I think I'll just go be a bum on the beach.

Now I can imagine that most people don't give two hoots and a holler about the education of a surgeon, but I want to spend a little time on this subject so you know what the surgeon has gone through for the privilege of taking out your gall bladder, repairing your heart or removing your cancer. I have mentioned that the first doctors or “medicine men” were more connected with the “spiritual,” using chants, incantations and “witchcraft,” with folklore passing down from one individual to the next, such as the art of repairing fractures and treating wounds.

The education of the healer was through observation and a type of apprenticeship that lasted for centuries, up until the development of great schools of learning. The first of these appeared in Salerno, Italy in the early 1200's, with the support of Holy Roman Emperor Frederick II. At the Salerno school, the physicians were taught how to fix hernias and fractures and perform amputations. For the most part, they were taught diagnosis for diseases they could do little about. They often prescribed rest, bathing or diet, or gave emetics (drugs to make people vomit), and frequently “bled” patients to remove evil humors. Their knowledge of narcotics allowed them to give opium for pain relief, along with near toxic doses of alcohol.

In the Middle Ages, great hospitals were established throughout Europe, usually affiliated with religious institutions, such as abbeys, convents and monasteries. Most of the physicians were religious personnel, since they usually represented the major portion of the educated populace who could read during that period. Books were all hand written, making them rare and expensive, and information about medicine and surgery, if not passed down from person to person, could only be read by those who understood Latin (in which most books were written). The literate few during this period were the monks and other ecclesiastics, and healing was a combination of physical and spiritual modalities. Throughout this period, childbirth and what we know as obstetrics today was practiced only by the midwives.

With the invention of the printing press and moveable type by Johannes Gutenberg and the first printing of the Bible in 1455, books became more available. The first fortyfive years saw a tremendous upsurge in the writing and printing of books, called incunabulae (the first of anything is called an incunable), and these books often were printed to look like hand written manuscripts. With the massive increase in relatively cheap books, the populace became more literate, while the universities and medical schools grew rapidly and were inviting, not just to the clergy, but to the many upper class individuals who, prior to this time had, for the most part, been unable to read. Great medical schools arose in Europe with major centers in Pisa, Leiden, Oxford, London and Edinburgh, to name a few. By the seventeenth and eighteenth centuries, regular curriculae for anatomy, physiology, pathology, and pharmacology (the study of drugs) were established, and the remaining specialties found their way into the medical schools over the subsequent two centuries.

In the United States a sentinel occurrence was the Flexner report in 1910, supported by the Carnegie Foundation for the advancement of teaching. Flexner essentially took medical education out of the closet of mystery and outlined the need for trained fulltime academic teachers in medical schools, emphasizing the need for libraries, laboratories for anatomy and science, lecture rooms, and access to a hospital where students could learn by being in contact with physicians treating “real” patients.

Now I won't bore you with more details about the history of the schools because I want to outline for you briefly the education of a physician and surgeon at the beginning of the twentyfirst century. It is important to recognize that, until that last quarter of the twentieth century, most medical students were male, whereas now a significant percentage of women graduate with M.D. degrees.

The requirements for entering medical school vary slightly from college to college, but the basics are pretty much the same. Except for the rare program that combines undergraduate and medical school in a single facility for only six years to the M.D. degree, most undergraduate college students will be required to achieve a Bachelor of Arts or Science degree (B.A. or B.S.) and usually a good grade point average (A's and B's) and in the top ten percent of their graduating class or higher. This does not take into account the many programs established throughout the United States to help minorities get into medical school, and for many years special emphasis has been placed on recruiting African American, Native American, and other minority groups to fill a noticeable cultural and ethnic gap in the physician force of today. Although the premedical courses may stress the inclusion of biology, physics, inorganic and organic chemistry, and zoology, the medical schools are also seeking well-rounded individuals with an additional knowledge of literature, history, English, and philosophy. In addition to the grades of an applicant, the medical schools usually require recommendations from teachers and community leaders and a personal interview, as well as the scores from the Medical College Admission Test. To all this I must add that many Medical Schools only accept 5% of the applicants, and students may have to take further postgraduate studies or work in laboratories or hospitals to make their application “look better” before reapplying. Getting into a medical school is only the first hurdle!

Most medical colleges have a four-year curriculum divided into two sections, the first two years being preclinical, namely, the studying of the science of medicine, and the last two years being the clinical years, where the student learns by being in contact with patients and practicing physicians.

The first year, the student is bombarded with a massive amount of information in Embryology (about the development and formation of embryos), Gross Anatomy (which usually involves dissecting a human cadaver under the careful instruction and guidance of the professor, while memorizing all the parts!), Microscopic Anatomy (seeing what the tissue looks like under a microscope—i.e., brain cells, kidney cells, skin, bone), Physiology (functions of the parts of the body—i.e.,, how a muscle works, why kidneys can excrete waste, how the stomach functions and produces acid), and Biochemistry (the study of the chemistry of life processes, i.e., how cortisone is produced, sex hormone production, thyroid function). And that's not all; the first year student also studies Cellular and Molecular Biology (how things work at the cellular level and, even smaller, the molecular level), Neuroscience (the study of brain and spinal cord, and nerve anatomy and physiology), Genetics (the study of genes, heredity, and variation) and then a broad introduction to medicine and society.

The students that complete the first year (and who don't throw in their marbles and go into some other business) can look forward to the interesting second year and a whole new set of courses. These include Microbiology (the study of microorganisms like Staphylococcus and the germs that cause TB or syphilis or a sore throat), Immunology (your body's defense system to help fight off disease), Nutrition, Pathology (the study of abnormal anatomy — i.e., cancer, pneumonia, diabetes mellitus), and Pharmacology (the study of all the drugs used today, like digitalis, pain medicines, and hormone replacements). Then there's Epidemiology (the study of the causes of disease), Introduction to Clinical Medicine (such as how to use a stethoscope to listen to the heart or lungs and how to use an otoscope to look into ears), Family Practice Introduction, and a course of behavioral sciences. Some programs also have lectures in Alternative and Complementary medicine (modalities including psychosocial interactions and the more unusual nonWestern medical practices like acupuncture, diet therapy, meditation, etc.).

So you've survived the first two years, somehow, and are then ready to see your first live patient. Quite a frightening experience for most young physicians-to-be! The last two years of medical school introduce you to the various specialties of medicine (the surgical ones, which we shall discuss in the next chapter). They are Medicine, General Surgery, Pediatrics, Obstetrics and Gynecology, Neurology and Neurosurgery, Ophthalmology (eyes), Psychiatry, Radiology, Orthopedics, Ear, Nose and Throat (Otorhinolaryngology), Anesthesia, Preventive Medicine, and Urology. Additional studies for the fourth year may include Prenatal Obstetrics, Ambulatory Surgery, Emergency Room Medicine, Geriatrics, and Primary Care.

And you graduate and get your M.D. degrees to the sounds of “gaudeamus igitur” and all that stuff, and usually someone reads the Hippocratic Oath, and now you're a doctor. Unfortunately, those are just the very basics, which don’t really prepare you for much because you haven't had enough clinical experience. Most United States medical students take the National Board Examinations before they get their degree, and this helps them to get licenses in states other than where they went to medical school. But in most cases the new doctors go on to get further training in a specialty of their choice, such as Family Practice, Emergency Room Medicine, Radiology, or a host of other interesting areas. We will discuss the surgical specialties in Chapter IV.

Oh! You might reflect on the fact, that while you are sweating away in medical school, most of your college buddies are well established in some business, making a living, and raising a family. (Some medical students are married, but it creates a great stress on the family, and the husband or wife usually needs to support the student for many years.) It's a difficult period to go through and yet, for the individual fascinated by medicine and intent on helping others, it never becomes tedious or boring. After these four years, the new physician may opt for additional training, so that many doctors don't even start their own practices until they are almost thirty years old!

Chapter 4

INTRODUCTION TO SURGICAL SPECIALTIES

When I was young in college, to feel good I had to lie,

To other guys who often seemed much cleverer than I

So I went off to med school, and determined I would find

A specialty that I could use to give me peace of mind.

And after four hard years I found my niche in general surgery

Where I could talk to patients and not be accused of perjury.

And when I meet old college pals (on benches in the park)

I can truly say I always have the final cutting remark.

When the physician has completed his studies for an M.D. degree, he may decide that he wants to go on into a surgical specialty. This will require him to enter into a postgraduate training program called a residency (sometimes including a first year called an internship) and may spend as many as six to eight more years expanding his knowledge and experience. He is generally taken on as a special resident physician at a university hospital, clinic, or private hospital and paid a meager salary during this period of time. Depending on the specialty, he may be on duty thirty-six hours and off twelve hours, including weekends, or may just have an eight-hour day and be available for emergencies.

In Part II of this book, we will discuss the various specialties and each major procedure in more detail. At this time I just want to familiarize you with the main fields of surgery and outline for you the types of procedures they do.

First is general surgery, my own specialty. At one time, about a hundred years ago, this encompassed all the areas of surgery, and the general surgeon could handle all surgical procedures, including the chest, heart, orthopedics, and pediatrics. Over the years each specialty has advanced to the point where one individual cannot have an expertise in all areas, and young surgeons have learned to choose which area is most interesting for them.

General Surgery encompasses Abdominal Surgery (stomach, intestines, colon, appendix and rectum, pancreas, liver, spleen, gallbladder, and adhesions), skin, breast, thyroid, parathyroid, hemorrhoids, pilonidal disease, esophagus, hernias in the abdomen, abscesses, “Lumps and Bumps,” and a diverse selection of cancers throughout the body. Although this is not a complete list, it includes most of the procedures which the practicing general surgeon does today. For this he is usually required to take an internship for one year and four to six years of residency training. In some programs, such as the one I went through, the resident does research in an area of his interest and may write a thesis and get a Masters of Science in Surgery Degree.

The second area I want to address is Peripheral Vascular Surgery. This usually requires a surgeon to take an additional one to two years of training after the general surgical residency, although some comprehensive programs combine the general and vascular surgery in one training program. Vascular surgery includes suturing, repairing or replacing the major blood vessels of the body, such as the aorta in the chest and abdomen down to the smallest one-millimeter vessels in the hands and feet which can be approached surgically. In the arms and legs, the arteries are considered medium-sized and are much more amenable to repair than the tiny vessels of the hands and feet. Vascular surgeons are the ones who sew arteries and veins together for use during dialysis for kidney failure, and place all kinds of artificial shunts and bypasses, either to get around blocked vessels or for dialysis access, as we will explain in a later chapter. This specialty also corrects problems of the carotid artery (which supplies blood to the brain narrowing may cause a stroke), renal (kidney) arteries narrowing of which may cause hypertension (high blood pressure), and vein problems (varicose veins and venous ulcers). The most recent advances in vascular procedures are in the field of endovascular surgery, where a trained specialist can repair an artery using balloons and special devices placed in the damaged arteries through tiny incisions, obviating the need for major vascular surgery.

Urology is the surgical sub-specialty which includes kidney, ureters, bladder, prostate, testicles and internal and external genitalia. In this field we have the kidney, ureteral and bladder stones, prostate enlargement, and various types of cancers specific to this area.

Orthopedics (which literally means “straighten the child”) is the medical and surgical treatment of bones and joints, including the spine (which is shared with the neurosurgeons) and all types of trauma involving the bones and joints. These surgeons handle back pain and joint pain, amputations, and endoscopic surgery on the joints. Some orthopedists go on to further specialize in complex back and spinal surgery or hand surgery, including procedures which require microsurgery (using special magnifying lenses to repair tiny vessels in the hand). A whole field of re-implantation surgery has developed for severed limbs, which requires further expertise and training.

Gynecological surgery centers on the female reproductive organs, the vagina, cervix, uterus, tubes, and ovaries, including hysterectomy (removal of the uterus), salpingectomy (removal of the fallopian tubes) and oophorectomy (removal of the ovary). These surgeons also may do diagnostic or therapeutic laparoscopy (using a small incision and placing a small camera in the abdomen to avoid large incisions), such as tubal ligation or identification of pelvic infections or other problems. A whole advanced field of Gynecologic Oncology has developed requiring two to four additional years of training to learn how to remove all cancers involving female organs.

Next we move on to Neurosurgery, the specialty focusing on diseases involving the brain, spinal cord and nerves. It requires two years of additional training after the general surgery residency, and the neurosurgeon must be well versed in the diagnostic abilities of a neurologist to identify the problems in brain function. We will go much more into detail about neurosurgery in later chapters.

Thoracic surgeons, not surprisingly, operate on the thorax or chest cavity, which includes the esophagus, lungs, ribs, and chest wall. They remove lung cancer and other tumors, benign and malignant, and do surgical procedures for infections in the chest, called empyemas and lung collapse secondary to trauma or emphysema (a disease where the lungs contain abnormal air pockets that may rupture).

The Cardiac surgeons operate on the heart, replacing diseased heart valves and bypassing coronary arteries (the blood vessels that supply the heart itself). They also may surgically correct congenital deformities, although pediatric (children) heart surgery is a sub-specialty all its own. Cardiac surgeons usually require a two-year fellowship in addition to the regular surgery residency.

Plastic and Reconstructive surgeons take several years training in their specialty to do cosmetic surgical procedures, such as breast augmentation and reduction, facial plastic procedures (face lift, brow lifts, rhinoplasty [nose job], and acid and laser skin peels), liposuction, and abdominoplasty. They also do reconstructive surgery after trauma, congenital defects, breast reconstruction after mastectomy, and complex skin grafts and “flap” procedures, which I will explain later and which include Tram flaps, Pedicle flaps and Rotation flaps.

The Ophthalmologists, in addition to the medical management and examination of the eyes, also perform the delicate and often complex procedures including cataracts, retinal and eye muscle surgery, trauma, and the new laser and LASIK procedures.

The Otorhinolaryngologists must learn to pronounce their specialty first and then learn how to take care of problems involving the ears, nose and throat, including sinuses, parotid gland, tongue, tonsils and adenoids, and facial nerve, and have special training in removing cancers in this area.

Pediatric surgery emphasizes that children are not just little adults, but people with special problems all their own. They have a host of congenital deformities, as well as the usual problems of hernia and appendicitis, and these specialists are specially trained to handle the delicate management of tiny infants.

In Part II of this book we will discuss these surgical specialties and their procedures including the diagnostics, anatomy, techniques, and complications.

Chapter 5

THE SURGEON'S OFFICE

My surgeon has an office on the ocean in a barge.

The place is kinda dirty, the reception room is large.

He doesn't have a license, but he has a lot of saline,

He says it's from the ocean, he collects it when he’s whaling.

He's not too highly skilled, and his hands are quite a fright,

But hey, you can't have everything, and wow...his price is right!

When I asked my office manager to list what she considered most important about an office, she gave the following comments. First, she stressed location, and that included parking. If you're sick and not feeling well or if you've had surgery, you don't want to have to travel a long way to see your doctor and then not be able to find parking. Simple but important!

Next, when you walk into someone's home, one glance will give you a good idea as to whether the person is well organized or not. Similarly, when you walk into an office you should get a feeling of professional organization, with decent lighting, seating, and tasteful decorations. If the doctor and his staff don't care enough to take an interest in the details of his office, it may reflect on how he will take care of you! The office should be clean and orderly. Now, this doesn't mean it has to be expensively decorated and superhigh tech; many physicians can't afford this. But it should reflect a care and concern about presenting a good face to the public.

Another point brought up was that this office should have personnel who appear pleasant and happy with their jobs and surroundings. Disgruntled staff may reflect poorly on the “boss” and, in a setting where tests are ordered and surgeries are scheduled, job dissatisfaction can lead to mistakes and unpleasantness. The patient is usually not ecstatic about going to see the doctor, and to have to put up with moody or cheerless staff is unacceptable. The staff should be polite, helpful, efficient, and knowledgeable. Though it sounds banal, YOU are the customer and should be treated well whether you are the CEO of a major corporation, an unemployed day worker, or a single mom with kids in tow.

The last point my office manager stated was that the office personnel should know their business. They should know about disability and health insurance and be able to answer questions to make you feel “okay” about your upcoming surgery arrangements or about problems you are having after a procedure. The office staff is the doctor's upfront representatives, and their failure to be polite on the phone or in person is unacceptable.

I have seen some doctors who routinely keep patients waiting several hours for appointments, and I don't understand why patients tolerate this. Of course there will be times when unscheduled surgeries or emergencies arise, and I always call my office to let the patients know. They can wait or reschedule, as the case may be. When I return to the office, I always personally apologize to any waiting patients and give a brief explanation for my tardiness. Common courtesy is often forgotten by busy physicians and is not excusable!

Now, I wanted to present this chapter for two reasons. First, to let you know what goes on in the doctor's office (what you see and don't see) and second, to give you my own ideas as to what should be the rule of thumb in taking care of the needs of patients.

Most surgeons' offices are located near a hospital complex so that, if any problems or emergencies arise with patients, the doctor will be immediately available and can call for assistance if needed. Different surgeons have different types of facilities in their own office, in some instances, complete operating suites or maybe just the ability to remove small lumps and bumps. This necessitates either disposable instruments or a sterilization unit. Many physicians find it easier to take their work to a nearby emergency room, outpatient surgical center, or hospital and not have to concern themselves with the problems of maintaining a sterile operating facility. Nevertheless, all surgeons have the equipment and instruments needed to remove sutures and skin staples, remove drains, and change dressings. Most also have needles and syringes to do local biopsies, give injections, and aspirate fluids or blood samples. They will have appropriate facilities for disposing of toxic waste materials, and the offices are checked by OSHA which is a governmental agency inspecting for cleanliness and safety provisions. In today's world of serious infections and AIDS, patients deserve to know that the office they are in is safe as well as comfortable.

I think it is important for any physician to have some type of reference library, either consisting of books, journals or computer access to information, for help in dealing with day to day problems and to keep up to date with advances. Many hospitals have excellent medical libraries with librarians available to do searches for physicians on any topics. Affiliation with regional medical centers or university centers and teaching hospitals will assure the interested physician a place for continuing medical education, as well as additional consultation.

Now, why do I mention these things? Merely because medicine is a never-ending educational experience and, if your physician is not on the “cutting edge” of the newest advances, he's soon relegated to the “glue factory” because you shouldn't and won't seek out his opinion and care. When you look for a surgeon, keep these factors in mind and don't be shy about asking questions about the office if you are interested. Proximity to a hospital and a source for continuing education is important.

The doctor's consultation room should be comfortable and private, and the patient should be able to sit and talk if he or she wishes. Understandably, in some high volume clinic situations this may not be possible, but at any time you should be able to say that you want to talk about the proposed test and procedure and have your questions answered to your satisfaction. You're not buying a car or a house; it's your body we're talking about!

We will talk more about the physician-patient interaction in Chapter 10.

Chapter 6

THE OPERATING ROOM

Somewhere between joy and doom,

Lies the operating room.

Many people daily work there,

And some nurses go berserk there.

And in this place of fact and fable,

Stands the operating table,

Where the surgeons work their wiles

With sharpened blades and sneaky smiles.

So if you've made the big decision,

(Watching shows on television)

To have your hernia fixed tomorrow

Go to the hospital without a sorrow.

But be sure to know that factor:

That your surgeon ain't an actor!

In my book, Comprehensive Breast Care, there is an excellent chapter by one of the operating room nurses called “The Masked Strangers,” in which she artfully describes the various people you will meet and the functions they provide. Suffice it to say that you will encounter a number of “masked strangers” in the surgical suite. From the attendant who will transport you to the surgical department dressed in his “scrub suit,” you will be introduced to the “holding room” nurse, who will answer any questions you may have. She will make sure your laboratory work, chest xray, and electrocardiogram are in order, and will assemble all the paperwork, including the history and physical examination, and make sure the consent is properly written and signed. We don't want to take off the wrong leg or fix the wrong cataract! You will also meet the anesthesiologist who will be giving you the anesthetic agent that you, your surgeon, and he, have decided upon. He usually starts your I.V. (intravenous lines) for giving fluids and medicines and will reassure you about any questions you may have, especially if you are going to sleep. We will talk more about the anesthesiologist in Chapter 21.

You will then meet another nurse, who will work with the holding area nurse and accompany you with the anesthesiologist to the operating suite (or room, if it's not fancy!), where you will meet a scrub nurse or technician. During the procedure, the scrub nurse, in sterile gown and gloves, will be handing the instruments to the surgeon; the other nurse, the circulating nurse, will be available to get any needed supplies in or outside the room while you are asleep. The nurse and the anesthesiologist will attach blood pressure and cardiac monitors to you before you are put to sleep, and once you are sleeping, may do other procedures to monitor your vital functions. These might include placing a tube in your stomach (an NG or nasogastric tube), your bladder (a Foley catheter), or a central venous or arterial line (placed in a vein or artery, respectively). Often these tubes are removed before you wake up, but usually your doctor will tell you if he plans on leaving any in place after you have awakened, so it won't be a total surprise.

After the surgery is completed, you will be brought to the recovery room, where a specialist nurse will take care of you for about an hour until you are stable enough to go back to your room. Again, I would recommend your reading Carol Metcalfe's chapter on the “Operating Room Nurse” for her comprehensive and often amusing insights.

But let us consider when and why we use a hospital-based operating room as opposed to office surgery, an outpatient surgical center, or the emergency room. The hospital may be the only fully equipped facility in your community or it may be the only one fully accredited for use by your insurance company. But, aside from these issues, the acuity and severity of the surgery will often determine where it should be done. Whereas small procedures, such as removing moles and simple biopsies, may be done in a well-equipped emergency room with a local anesthetic, hernias will need more anesthesia and a larger number of instruments, and will need a regular operating room, such as in a hospital or surgical center. Understandably, there may be some cases such as hernias which can be done in either facility, and this may be done according to surgeon, insurance, or patient preference. The hospital operating room is the place for major surgeries where the patient may be staying overnight or where there is the potential need for services only available in the hospital. Should any problems or unforeseen complications arise, it's important to have a full staff of trained experts to take care of the problem. Obviously, brain and heart surgery and complex intestinal surgery must be done in a hospital setting. There are also some procedures, as we will see later in this book, which require very expensive, high-tech equipment that can only be found in hospitals.

All operating rooms are subject to strict quality controls and must have constant checks on sterility and equipment, and the quality control is often a point for competitiveness among the hospital suppliers. If suture material is breaking or stapling machines for intestines are not working well, a competitor will immediately fill in the void with a better instrument or suture. Competition often breeds better quality. Hospitals and surgical centers have committees overseeing every aspect of medical care to bring the possibility of error or malfunction as close to zero as possible. True, mistakes are occasionally made, but most of the time they are very minor and do not impact patient health or safety. In choosing your site for surgery, you can check out its safety record and its relative scoring with an agency called The Joint Commission on the Accreditation of Hospitals. If the facility to which you have been recommended has scored poorly or has a problem with accreditation...go elsewhere. There are many fine institutions. Go where you feel safe and comfortable!

Chapter 7

OUTPATIENT SURGICAL CENTER

Hey, you need a surgery and want it done real quick

Like takin’ out a bullet or a knife that made ya sick?

Well, come on over to my place, behind Gilhooly's bar

My private surgicenter is a souped up ragtop car.

I wantcha to be paying for the service with small bills

And I can get ya any kind a mainline stuff or pills

I use a knife that's pretty clean, I cut you while I drive,

And I can vouch, some of my patients, dey is still alive.

Over the past decade surgical centers have been popping up all over the United States. They are the alternative to inhospital operating rooms when a patient needs more than a minor procedure and will require general anesthesia or anesthesia standby. The operating rooms are much the same as those found in hospitals, offering full nursing facilities and pre-operative, intra-operative, and post-operative care. The patients usually stay for only a few hours and then have a relative or friend take them home since they will have been sedated to some degree. Some surgical centers actually have facilities to keep patients overnight for observation. Frequently, the outpatient surgical center is near a hospital, so that patients who have problems during surgery or the recovery phase can be transferred to the hospital for overnight observation or more specialized care.

In today's world of cost control, many insurance companies prefer to have less serious surgeries done in the outpatient center because the cost is less and the greater requirements for hospitalization do not have to be met or are less stringent. Still, history and physical exams are required, and sometimes basic laboratory work, chest xrays, and EKGs may be needed. Most surgical centers can arrange for a pathologist to be on hand for doing frozen sections (quick stains for evaluating tissue) when a surgeon wants to remove a skin cancer and needs pathological confirmation that all the margins are clear of tumor!

The typical outpatient center has a waiting room for family, a dressing room, and a preoperative area where a nurse takes a brief history, an intravenous line is started, and you have a consultation with the anesthesiologist. (He may call you at home the night before and answer your questions and remind you not to eat anything after midnight). You are then taken to the operating room, your procedure is done, and then you go to a recovery area where you remain at least an hour or until you are stable enough to go home. A nurse will usually help you into the vehicle and give care instructions to your family or friends who are driving.

All in all, the outpatient surgical center is often more convenient for patients because there are not as many patients in the admitting area as in a hospital, and you probably receive more individual attention, purely on the basis of numbers; fewer patients allow the nurses to spend more time with you both before and after surgery. Also, because the acuity and seriousness of the procedures are often much less than in a hospital, the atmosphere is usually more relaxed and thereby more comfortable.

If you are in need of minor surgery such as hernia repair, breast biopsy, removal of small skin problems, or minor orthopedic or podiatric (foot surgery) procedures, you may want to consider an outpatient surgical center.

Chapter 8

THE EMERGENCY ROOM

If you have a touch of plague or meet up with a missile,

Or if your two-year-old has swallowed his brand new plastic whistle,

There is a place that's waiting for your rendezvous with doom...

It's your friendly, local, understaffed... Emergency Room.

The physicians are all dedicated to serve and save humanity

With nurses who are unafraid of squalor and profanity.

And if you have a mother-in-law who's getting on your nerves,

Give her a dose of poison and then call up the reserves.

As long as you can show the world you cared to send for aid,

No one will even ask you why the old bag swallowed Raid.

Just tell the friendly E.R. Doc, old mum was suicidal,

Give him one hundred bucks and he won't call it homicidal!

As recently as twenty years ago anyone with an M.D. degree could apply for and usually get a job working in an emergency room. It was generally a low-paying, thankless job that few physicians wanted, and it was often manned by licensed physicians who were in the residency training and needed the extra money. Now, most of these physicians were adequate, but there was also a whole host of physicians and “new M.D.” graduates who worked in the Emergency Room to augment their income and sometimes these physicians were not well enough trained to manage the more severe problems that presented themselves at the E.R. doors.

Today we are in a new century and emergency rooms have kept pace with all other areas of medicine. For the most part, physicians, working there, are highly trained specialists who have taken an accredited three or four year residency in emergency medicine where most of the programs have trauma center experience. When you arrive at a major emergency room, you can be assured that the staff can expertly handle all types of medical problems, including pediatric emergencies, heart attacks, trauma, lacerations, and gunshot wounds as well as colds, asthma, flu, back aches, and broken bones. It's a whole different world today, and the quality of care has taken a giant step forward.

All major emergency rooms are required to have an on-call panel of specialists who can take over in their specialty after the patient has been seen, evaluated and at least temporarily stabilized by the E.R. physician. These usually include primary care physicians, pediatricians, general and vascular surgeons, cardiologists and cardiac surgeons, neurologists and neurosurgeons, psychiatrists, ear, nose and throat specialists, eye doctors, and orthopedists. These physicians usually have to be available to arrive at the hospital within thirty minutes of being called. Frequently, the emergency patient may be uninsured or minimally insured, and the physicians who take “all comers” are usually donating a significant amount of their time and service “gratis” to the indigent and needy, and should be commended for this.

It is important for the public to realize that the emergency room is not a clinic to be used because it is convenient. If patients have minor problems, they should contact their own physicians during the day rather than crowd an already overused system in the middle of the night with common colds and minor problems, that could wait till morning and be seen to by a family physician or general practitioner.

Frequently, when the place is very busy, the nurse in the waiting room will use a triage selection system to bring the sickest patients in first. This sometimes leaves those bypassed very angry and complaining because they often do not see the urgency of the patient who is taken before them. Obviously, a patient with a heart attack in progress or a stroke needs to be seen immediately as a life-saving measure; similarly, patients who are bleeding or having difficulty breathing, as with severe asthma, must be attended to as soon as possible. So the E.R. physician pleads for understanding and patience from the public.

The emergency room is also the “dumping ground” for the obstreperous, obnoxious, and sometimes dangerous patient who has overdosed on illegal or legal drugs and the alcoholic with one of the many complicating problems of acute alcoholism. These patients are often very difficult to manage and try the most patient, considerate nurses and doctors.

Another use for some emergency rooms is as a minor surgery site. Many physicians, especially those who work in the hospital all day, find it more convenient to meet their patients in the emergency room for giving injections, taking blood, doing spinal taps, removing small skin lesions or checking on problems with surgical wounds. Frequently, I will ask a patient with a problem to meet me in the emergency room so I can evaluate the condition and have the option to run more tests, admit the patient, or send the patient home.

So, if you need to visit your local emergency room, be aware that these doctors and nurses are highly trained and able to help you, but they also have a job which can at times be stressful, difficult and tiring, and they need your understanding too!

Chapter 9

THE PREOPERATIVE WORKUP

I've fallen in love with Betty, the gorgeous preop nurse,

I keep on having surgeries, so we can just converse.

I've had three hundred blood tests and forty EKGs,

And had 600 xrays from my tonsils to my knees.

I think that Betty knows me now, but how shall I explain

The reason I keep coming back, perhaps she'll think I'm vain.

I think I'll have a heart transplant, and then I'll have a chance.

If I give her my own heart, she'll know it's true romance.

Surgery is obviously a stress on the human system. Not only the emotional anxiety of going through a procedure or worrying about whether you have some severe problem that's correctable, but also the physical impact. This type of stress, from the anesthesia to the actual surgery itself can be anticipated by your doctor, and to evaluate the situation he will perform certain tests in the days before you go for your surgery.

The first preoperative workup is the history and physical exam. Sometimes, most of the workup has been done by your primary care doctor, and this has been relayed to the surgeon. Nevertheless, between the two of them a complete history and physical must be done. Briefly, this consists of a description of the present illness (“I have a pain or a lump or a hernia”), the length of duration, and/or how it happened. There must be a past history including allergies, medications you are taking, previous surgeries (such as breast biopsies, hernias, hysterectomy, heart transplants , including complications or drug reactions), and a list of all your medical problems (such as heart disease, diabetes mellitus, high blood pressure, and AIDS). Note must be made of your social history (married, single, divorced, widowed, children, significant other), whether you smoke, and how much alcohol you drink. A review of systems is included, which consists of questions about general health, cardiorespiratory system (heart and lungs i.e., shortness of breath, chest pains, palpitations, coughing up blood), gastrointestinal system (such as nausea, vomiting, constipation, diarrhea, vomiting up blood, black or bloody stools, ulcer history), and genitourinary system (problems with the kidneys, ureters, bladder or other genitalia). This review also includes a gynecological history for women including age at first menarche (menstrual period), age at first pregnancy, whether you're still having periods and their regularity, age of menopause (when you stopped having periods), and whether you're using birth control or hormones. Then there are questions about neurological (nerve problems) and psychiatric history, as well as any orthopedic and skin problems.

By then your physician should have a pretty good history about your risks, and this will be followed by a complete physical examination. Naturally, a specialist such as a heart doctor, urologist or gynecologist will tend to focus more on his/her area of expertise, but a brief physical exam is always needed. This will include a general description of you (young, elderly, weak, in pain, thin, obese, etc.) followed by an exam of the head, eyes, ears, nose, mouth, and throat. Then the neck exam is done, looking for stiffness, lymph nodes, thyroid gland enlargement, and abnormal sounds from your carotid arteries, which supply the brain. General examinations of the chest, breasts of both men and women, lungs, and heart sounds are done, followed by abdominal and flank exams for tenderness, masses, and hernias, to name a few.

A woman should have a regular gynecological exam every year after age 21, and males should have a testicular and rectal exam by their family doctor every year. A limited exam of the arteries and veins in the arms and legs, as well as a neurological evaluation, is recommended. The examining physician will also want to give his impression of the patient from an emotional and psychiatric point of view to help in alleviating fears and misunderstandings. The physician must be sure that the patient comprehends what is being said and the nature of the surgery that is going to be performed.

This is a brief list of what is expected in a history and physical examination, and it should be completed to some degree before a patient has any major surgery.

Obviously, if someone is going to have a minor procedure, such as a lymph node biopsy or removal of a skin tumor under local anesthesia, the physical may not need to be as comprehensive at the time of the surgery. But everyone needs a good, complete H&P (History and Physical) on a regular basis (every 13 years).

Okay. So now that's done. Next, the doctor will need to order some special studies to help in assessing your physical condition and risk for surgery and to further evaluate a condition which he has already diagnosed. I will list a few of the more common studies: chest x-ray, electrocardiogram (EKG = heart evaluation), and a series of blood tests among which may be CBC, which means a complete blood count, including hematocrit and hemoglobin, to determine how much blood you have and whether you have been secretly bleeding. There are the electrolytes, Na (Sodium), K (Potassium), Cl (Chloride) and CO₂ (carbon dioxide); these are measures of the chemistry of the blood and can tell a lot about the status of your health. Blood sugar is measured to determine if you have diabetes mellitus; BUN or blood urea nitrogen and Creatinine to evaluate kidney function; and the clotting factors PT (protime), PTT (partial thromboplastin time) and platelet count, a measure of how well your blood clots. Another study is the urinalysis checking for problems with the kidneys and infections in the urine. These are the basics, but there are a myriad of other blood and urine tests your doctor may order. You can ask him about these and how they apply to your specific problem.

The pre-op tests may cause the surgeon to delay your surgery until certain things have been corrected or rechecked. I always say that when a blood test comes back very abnormal and doesn't make sense...repeat the test! If your EKG is abnormal, you may be referred to a cardiologist for further studies, including a stress test, where you walk on a moving platform while your heart function is monitored to evaluate for coronary artery problems. This, in turn, may lead to the need for coronary angiography, which is an xray with dye, of the arteries to your heart.

An abnormal chest xray may lead to getting a CAT scan (computerized axial tomography) of your chest to rule out cancer, tuberculosis, or other problems.

Be aware that, as we increase in age, the chance for abnormalities in the preoperative workup also increases, and your physician may need further studies to get you cleared for surgery.

This brings up one further issue. If the surgery is an emergency, then obviously it cannot be delayed by laboratory values, but these values will help the doctor to correct problems just prior to or during the surgery itself. If the surgery is elective (does not have to be done NOW!), then the patient should be made as healthy as possible before being brought to the operating room. This means that your surgeon must use common medical sense and never rush anyone into elective surgery without a proper workup.

Sometimes, the patient is such a poor surgical risk that alternative and second best options for treatment must be considered. The adage, “The operation was a success but the patient died,” is a hard one to explain to a family and for the surgeon to explain to himself.

That is the preoperative workup in a nutshell. Arranging for these studies, getting them done, evaluating them and getting surgery scheduled appropriately takes time and usually involves multiple phone calls by an office staff person. And this doesn't include the ins and outs of getting permission from an insurance company or a managed care group. Multiply this situation by ten or twenty in a surgeon's office, and you will understand why getting a surgery scheduled may not be as easy as it seems. Be patient and understanding...eventually, everything will get done safely and completely.

Chapter 10

TALKING TO YOUR SURGEON

Second Opinions, Credentials and Qualifications

You can bet your britches, and I can bet mine too,

That if you become a surgeon, you may rue the day you do.

'Cause every time you do a case someone will go inspect

The whole shebang to see if you have done the thing correct.

I mean, does every workman and contractor have to prove

That every corner done has just a perfect tongue in groove?

So what if you forget to tie a vessel off or two?

Why should everyone come out and point a thumb at you?

In what other profession do we ask for 100 percent?

Why can't these stringent rules, just a little bit, be bent?

Then I could advertise in public and the daily press.

I'm a real surgeon and guarantee 80% success.

Now if you were in school an 80% would be a solid B

Enough to get you by with some respectability.

Unfortunately with surgeons, it doesn't work that way,

Everyone expects you to always have an A.

Your kindly family doctor, Dr. Noodledorf, examines you and tells you that you have a hernia and recommends that you have it repaired. He refers you to Dr. McGillicutty in the suite next door, so you make an appointment to see him and discuss the situation. Now, if you have been a patient of Dr. Noodledorf's for twenty years and have a high regard for him professionally, you may say to yourself: “Hmm. If my doctor recommends this guy, he must be good,” and you may well be right in assuming so. But let me advise you about surgeons so you can make your own informed decision.

Although not trained specifically in surgery, every physician who graduates from medical school has a license which lists him as a physician and surgeon. In other words, anyone is potentially able to do surgery legally. Of course, one wouldn't be able to get privileges in any reputable hospital or surgical center without proper credentials, but anyone can do just about anything in his own office. So beware and look for the training and credentials and be sure your surgeon is indeed a trained surgeon. He should have gone through an accredited residency program in that type of surgery in which he specializes, and this usually means completing the senior residency or chief residency. Then he should be eligible for or have passed the specialty boards in his specialty, such as general surgery, orthopedics, neurosurgery, etc. Board Certification is something all physicians are proud of, and they usually have “board certified” on their business cards, and the certificate is usually displayed in their office. Look for it or ask the secretary about board certification if you want to be sure. It's your one guarantee that the individual has met a least the minimal requirements of the National Specialty Board for practicing his profession.

Next, you should get a general impression from others who may know the community and ask about this surgeon. But be aware that this can be dangerous in both directions. I know a very poorly trained surgeon who has a very good bedside manner. He has more complications than most of his colleagues, but the problems are overlooked by the patients because his personality is so charming. Conversely, I also know another surgeon who is well-trained and highly competent, but is very abrupt with patients and has a poor bedside manner. These are obviously the extremes, but I bid you take caution that you get a well trained, competent surgeon; comments from former patients may not give you the entire story. Do your homework, ask nurses or other doctors, and you may get a better idea with whom you're dealing. And remember, almost every doctor has lawsuits. The number may reflect how busy he is, the type of surgery he does, or the location in which he is working. Sometimes doctors are sued for nonsense reasons, but it's cheaper for their malpractice insurance carrier to settle the case for twenty or thirty thousand dollars rather than put up a defense which may cost twice that amount. And I have known excellent surgeons who have been sued and lost cases when nothing was done outside the standard of practice. The legal system sometimes fails, as we have seen in a recent well-publicized murder trial. No one can predict the behavior of a jury, especially when someone has suffered pain or severe illness, whether or not the surgeon is responsible for doing something wrong. The general impression is that the suffering patient needs to be compensated and a scapegoat is sought. There are many cases where the physician has done grievous harm, and yet the case is thrown out for some nonsensical legal reason. It works both ways.

You might want to look at what a surgeon does in the way of education, lecturing, and what positions he holds in the medical community. How is he regarded by his colleagues? Has he been a chief of surgery or given lectures on some area of his specialty? Most specialties have a highly respected college of that specialty; in general surgery, it is the American College of Surgeons. The surgeon who has been evaluated by this college and accepted into its ranks has the right to use F.A.C.S after his name (Fellow of the American College of Surgeons). There are colleges in several countries, and many foreign physicians have several credentials you should look at. Conversely, there are several initials which can essentially be “bought” and placed after your name just by receiving an application and sending in your membership fee. Be careful what you accept as legitimate credentials!

You should always ask your surgeon what his qualifications are and how often he has done the proposed procedure. There are some cases which I do every week, such as gall bladder or appendectomy surgeries, and then there are some that I may only do once a month, such as thyroid or stomach. And yet I have been well trained to handle these procedures. I have probably done five hundred to a thousand gall bladder procedures over thirty years, and far fewer thyroids. And yet I feel equally qualified to handle each one. If I only did one thyroid a year and only two gallbladders a year, I would probably be less qualified; but, depending on my training, my ability, and my overall competence, I may be very able to do each of those procedures well. So choosing a surgeon is not an easy matter, and a number of factors must be weighed carefully.

In summary, the strongest basic recommendations I would make are: (1) A completed residency program, (2) Board Certification by the American Board of that specialty, (3) Fellowship in the American College of that specialty, and then take into consideration all the other factors I have mentioned.

To get onto another topic, I want to talk briefly about Second Opinions. In today's world with patients much more informed, especially with the Internet availability, the surgeon will be asked more questions and the patients will demand more information and answers. Remember that the Internet information is not screened and edited by experts, and a lot of what you see may not be “the truth and nothing but the truth.” Don't believe everything you read. Often, it takes a physician to clarify medical situations to you, and you shouldn't be afraid to ask about conflicting information. Some patients always want a second opinion and that too is a double-edged sword. First, a patient may ask around until he or she receives the answer that is wanted, whether it is the best medicine or not. I have seen some surgeons undermine the opinion of another just to get the business of a patient (sounds bad and is bad—people are sometimes greedy and unethical).

When seeking a second opinion, if the recommendation is very different, maybe you need a third opinion to straighten out the confusion. I always tell my patients to seek out second opinions, if they wish, but I also give them some guidance as to where to go. I select a few prominent surgeons in the community and then also offer the names of large teaching hospitals and medical centers, which may be in the patient’s area—names like City of Hope, The Mayo Clinic, Scripps Clinic, Norris Cancer Center at USC, etc. This will protect the surgeon as well as the patient and, if your patient comes back, he/she will be more comfortable with the surgeon's recommendations in the future.

In conclusion, I recognize that there are many confusing areas in this presentation. Suffice it to say that it is important to do your homework, follow the guidelines I have given, and then you will have the best chance of being satisfied with the surgeon and with the surgical outcome.

Chapter 11

POSTOPERATIVE CARE

You've had your operation; now please get up and go.

This ain't a never-ending cheerful horse and pony show.

I've done my job, you've got your pills, so will you please be fair,

Get dressed, and say goodbye, good luck; just get out of my hair.

When you go shopping for a car, you take your car and drive,

That's just the kind of action that a patient should derive.

Take your body, leave the body parts that I excised.

And scram, be happy you got out in one piece and alive.

Does that sound like your surgeon? (I'll clue you you've got the wrong guy!) There is an expression we use in the profession called “the itinerant surgeon.” Basically, he is the guy who “cuts” and runs. It probably evolved at the time when the surgeon was the only trained guy for many miles around and would go from town to town plying his craft, then leaving the patients in the care of a primary physician or a skilled nurse. If problems or complications arose, the followup personnel would have to handle them, sometimes with disastrous or even fatal outcomes!

Today's surgeon is expected to follow up on each of his cases himself or else sign out to a qualified partner or colleague who can handle any problem that might arise, and do it with about the same skill as the operating surgeon. In most cases this holds true, but there are some surgeons who are only interested in the “surgical case” and disappear after it is completed. I know a heart surgeon who is very busy, and after he finishes each case, he leaves the followup care to any other doctor on the case. Now, he is responsible enough to have a skilled backup person available, but the ethics of the situation are strange because he does not treat the patient as a whole, he just treats the heart. Nevertheless, he is a skillful surgeon and generally his patients do very well.

In one sense, he is doing his job as a technician, but in another, to my eyes, he is failing miserably as a physician. This, of course, is my own view, but I like to think of the physician, whether he be a heart surgeon, family practitioner, general surgeon, or other specialist, as a person who reflects a long tradition of concern and caring for the patient as a human being. And to this end he should be available and concerned for his patients, except when he is out of town or in some way incapacitated. Is that a big responsibility? Yes. But that is the responsibility each physician, in my humble opinion, takes when he completes his education and takes on the caring for the sick or injured.

So what does postoperative care mean? Of course, it means writing the appropriate postoperative orders for the patient, which includes some type of diet or, if the patient cannot eat, then intravenous fluids. It also includes pain management, such as intravenous or intramuscular Morphine, Demerol,and Dilaudid, and oral Vicodin, Percocet, or Tylenol. There may be need for antinausea medications, such as Compazine or Zofran, and the physician may want to check for bleeding or treat infection with one of the hundreds of available antibiotics such as Penicillin, Cephalosporin, and Erythromycin. There are also many appropriate blood tests to follow the patient's progress (see Chapter 25). The orders after major surgery usually include a plan for activity which may include being out of bed or bathroom privileges. The surgeon should take precautions to prevent pneumonia with breathing exercises, and pulmonary embolism (see Chapter 19), and to assure that emotional needs are met. The doctor should discuss the patient's surgery and the orders with the recovery room nurse, who will convey the information to the “floor” nurse. In the case of outpatient surgeries, the surgeon will usually discuss his findings with the patient and the family, and give written postoperative instructions and prescriptions for pain medications, antibiotics, and other medicines.

We will talk more about the postoperative care for specific surgeries in Part II of the book. The surgeon will need to follow the patient in his office for varying lengths of time in the recovery and postoperative period, and deal with any minor or major complications which may occur. This part of surgery is often the most pleasant for me and sometimes the most difficult if I am dealing with incurable cancer or complex problems. But that, to my understanding, is a major part of my being a physician. It is sad to see so many modern “itinerant surgeons” who have given up their role as comprehensive “healers” and have become mere skilled technicians. It reflects poorly on the profession and perhaps is one of the reasons physicians are not regarded with the high public esteem they had seventy-five years ago.

Postoperative care, like others aspects of surgery, is an art that unfortunately, has been given less attention in our hurried world with crowded clinics, HMO's, and volume-oriented specialists rather than individual patient-oriented physicians. Don't feel uncomfortable about asking your surgeon how often he will be visiting you after surgery or if he will be visiting at all, and for how many weeks or months you can rely upon him for any problems after the surgery is completed. After all, when you build a house or have plumbing work done, you expect your contractor or plumber to be around after the job in case problems arise. Expect at least this much from the person who is operating on your body!

Chapter 12

COMPLICATIONS

Though an earthling, made from sod,

The surgeon thinks he's just a god.

So if you mention complication,

He may ask what drugs you're takin’.

Crazy as it all may seem,

This perfect person cannot dream,

That in some way his operation,

Caused some major aberration.

Now I can tell he shouldn't oughter

Think that he can walk on water.

But you see the facts remain

He walks on water in his brain.

Okay. I hate to burst your bubble. But your surgeon is not a god, does not walk on water and unfortunately makes mistakes and has complications. Now, we should say at the outset that there are many causes of surgical complications, and actually very few are directly caused by surgeon error or incompetence. They are, of course, usually in direct proportion to the patient's overall health, the type, length and severity of the surgery, and a host of pre, intra and postoperative factors that we will discuss as briefly as possible. The ever-troubling question of the patient to the surgeon, “Why did I have that problem or complication?” should be answered by your surgeon as completely and simply as possible. Once a problem or complication arises, the patient may begin to lose faith in his doctor, and this can be prevented by careful and timely explanation.

First, I should emphasize that the surgeon must plan his surgery, and outline to the patient and his family the potential adverse events that can occur. I do not mean to frighten a patient who is already concerned about a procedure, but it is important that he have a realistic understanding of the possibility of problems, such as anesthetic problems, wound infection, or less-than-perfect surgical results.

The surgeon, of course, must plan carefully, have experience, be meticulous about procedural items and have minimal blood loss and a timely surgery. I have seen some surgeons who take three to four times as long as the average surgeon for a simple procedure, claiming that they are taking care not to let any complications occur, and yet the longer a patient is asleep, the greater the risk for anesthetic problems and the longer the exposure to microorganisms that could cause infection. Surgery should be done carefully, artfully, and swiftly for the best results! In the postoperative period, he should anticipate the potential problems as we have outlined in Chapter 11.

Now, let us go down the list of complications and problems with which the patient and the surgeon must contend. I emphasize the physician also because we surgeons do lose sleep worrying about problems and complications; it's not like changing a muffler on a car and then going on to the next repair!

The only true surgical emergency is hemorrhage. Of course, I am not minimizing all the medical problems such as cardiac arrest, respiratory arrest, or other acute medical emergencies. I am just stating that the purely surgical emergency is hemorrhage, and every surgeon is aware of this potential problem and knows he must handle it swiftly. When an artery is cut, the natural response is for it to constrict. Evolution has graciously given us a method for our bodies to stop minor bleeding by having the muscles in the artery wall cause the vessel to retract and constrict. During the short period of time that this occurs, the body's coagulation (clotting) system works to plug the open end of the artery so that, when the artery muscle relaxes in a few minutes or hours, no more bleeding occurs.

Unfortunately, the clotting system is sometimes not good enough to clog a cut artery and, when the muscles in the artery relax, bleeding may start again and result in life-threatening hemorrhage. Now, no surgeon is going to knowingly leave a surgical site with bleeding still occurring, so when he leaves a dry field, why does bleeding occur one or two hours later, sometimes necessitating taking the patient back to surgery? It may be caused by a clip or tie coming off a vessel, but it may also be from inadequate clotting in vessels that the surgeon cauterized during surgery. Sometimes bleeding is minimal and can be observed but, if the patient shows signs of falling blood pressure, increasing pulse, and falling blood count such as hematocrit and hemoglobin (see Chapter 25), the surgeon must take the patient back to surgery and stop the bleeding.

Aside from the problem of bleeding or hemorrhage, the first thing commonly seen after surgery is an elevated temperature or fever. Many experts claim that a mild fever is a natural response to surgery for the first twentyfour to forty-eight hours, but it is always important for your doctor to evaluate the cause of the fever. The most common cause during the first two days after surgery is usually due to a pulmonary or lung problem. During surgery or in the period directly afterward, the lungs may not be completely expanded, and this condition, called atelectasis, can cause fever. It is corrected by deep breathing or a procedure known as incentive spirometry, where a patient breathes against a resistance to fully expand the lungs. Inspiring or breathing in through a tube has this effect and will clear the atelectasis and prevent the development of pneumonia. As you can imagine, in some children, debilitated, and older people, this can be a major problem.

The next most common cause of postoperative fever is urinary tract infection, which may be due to catheterization or preexisting problems and is treatable with antibiotics.

Wound infection problems come next. First, let's consider minor phlebitis, which may be as simple as an infected site where an IV has been placed, to a more extensive involvement of the veins in the arms or legs. The problem at the IV site is usually managed by changing the site of the IV and applying warm compresses, but antibiotics may also be indicated. Other wound problems may be infections in the surgical site skin, and leakage at a connection in the intestine. These kinds of infection usually occur after three or four days and may lead to actual separation of the wound, called dehiscence, or a more serious condition called evisceration, where the whole wound closure breaks down and the abdomen opens up.

Other less common but serious postoperative causes of fever are pancreatitis and parotitis.

The next problem the surgeon must watch for is major phlebitis in the large veins in the legs or pelvis. More common in obese patients, this problem can occur in anyone, especially if they are in bed for prolonged periods. That is why many surgeons use special compression stockings and foot pumps which keep the blood circulating in the legs and prevent blood clots in the veins that may cause blood clots to go to the lungs (pulmonary embolism). In Chapter 19, we will discuss this potentially lethal complication in more detail, along with another similar problem called fat embolism.

After surgery, other complications may be related to heart function, such as arrhythmias, (abnormal heart rates where it beats too fast, too slow or irregularly,) heart attack (myocardial infarction), or an acute problem called “shock..” Now the word “shock” is bandied about by everyone, while to a physician it has a more specific meaning, namely, a failure of the blood circulation with poor blood flow into the tissues. Obviously, this leads to failure of many organs, such as the heart itself, the kidneys, lungs, liver, and brain and can cause death rapidly. We won't go into the complex management of shock except to say that we try to prevent it by anticipating problems that may lead to it. These include heart failure, severe infection throughout the body called sepsis, and hypovolemic shock due to rapid loss of large volumes of blood or severe dehydration by loss of fluids from the blood into the tissues.

Another group of postoperative complications is psychiatric in nature. I have seen many patients, especially those who have to be in the intensive care unit for any period of time, develop what we call postoperative psychosis. They become disoriented and act “crazy.” Frequently, they are individuals who are normally in very good control of their emotions and also in control of their own lives. When placed in a situation where they are totally dependent on doctors and nurses for their every need, something inside them “clicks,” and they develop this psychosis, which often requires help from a psychiatrist, or special medications and sedatives. The condition almost always clears when the patient recovers fully from the operation.

We will talk more about the specific problems and complications of surgeries in Part II of the book under each heading rather than discuss them here. Additional general problems, however, can include kidney failure, gastric distention or failure of the stomach to empty (it enlarges and causes you to vomit), acidbase imbalance, (a complex problem with the fluids and chemicals in your blood,) liver failure, and abdominal abscesses. Anesthetic problems will be covered completely in Chapter 21.

So I admonish you to be aware of the fact that surgery is an art and a skill, that the human body is not like a machine, and it may not always react to the stress of surgery as we expect. Be realistic and understanding and know that the well-trained surgeon may have complications with a patient even under the best of conditions.

Chapter 13

INFECTIONS AND ANTIBIOTICS

“On the Antiseptic Principle in the Practice of Surgery”

Written in 1867 by Lister became a sort of liturgy,

When physicians learned about nasty small “bugs”

And then learned how to treat >em with drugs.

This was the third of the three great discoveries

That opened the door for surgical recoveries.

The first, you recall, was the tying of vessels.

Number two, anesthesia, by Morton and Wells.

So now we will challenge the worst of infections,

With drugs we have made with some complex confections,

And E. Coli, Staph and Strep can be driven,

When antibiotics correctly are given.

In the mid-eighteen hundreds some remarkable research was done by Louis Pasteur in the study of bacteria that led eventually to the publishing by Joseph Lister of his book, “On the Antiseptic Principle in the Practice of Surgery.” We have to imagine back one hundred and fifty years when it was considered normal for physicians to go from patient to patient without washing hands and to perform surgery with the very minimum of cleanliness. Ignasz Semmelweiss noticed that the wealthy women patients in the obstetrical ward where babies were delivered had a much higher incidence of puerperal sepsis, or infections during childbirth, than the poor women, and he discovered that the reason was that doctors were frequently examining the wealthy women in labor without gloves or washing hands, and carrying bacteria from one patient to the next. The poor women were rarely examined and surprisingly had almost no puerperal sepsis. He tried to convince his colleagues to wash their hands between exams but they scoffed at him, and he was ridiculed to the point where he eventually went crazy! In retrospect, we owe him a great deal of gratitude and credit for his pioneering work in antisepsis.

Penicillin was discovered in 1929 by Alexander Fleming and began to be clinically used by the 1940's. Since then, there has been an explosion of drug development, so that today we have a very large armamentarium of drugs to use in the treatment of infections. There is even a specialty in medicine called Infectious Disease, and I frequently use these physicians to help me in managing particularly difficult infectious disease cases.

Now, I don't propose to give you a course in the use of antibiotics, but rather to give you some understanding of the types of microorganisms that are found, how they work, and some factors that influence whether patients develop infections and what influences their recovery or demise.

In general, bacteria are divided into two groups that are called Gram Positive and Gram Negative, depending whether they stain red or blue when prepared on a slide with a Gram's stain.

Bacteria produce substances called toxins, which are poisonous compounds, and these toxins act in the body to make you very sick. Living Gram positive bacteria often produce exotoxins, and dead bacteria produce endotoxins. These toxins may alter your body's ability to fight off or destroy bacteria or may cause bacteria which normally inhabit your body to become pathogenic and cause disease. Still other toxins may cause tissue to die and become liquefied, may cause blood vessels to clot off, or may cause swellings, bleeding, and shock.

What happens when you get an infection? We will call an early infection cellulitis, itis being a suffix that means “infection of” or infection of the cells. The old Latin words associated with infection are tumor (meaning swelling), dolor (meaning pain), calor (meaning heat), and rubor (meaning redness). If you take a moment, you can think of many English words which come from these basic Latin words, such as tumor, dolorous, rubious, and caloric. When a physician sees any of these signs, he must determine whether there is an infection and treat it appropriately. If the infection is allowed to progress, pus will form; an enclosed space with pus is called an abscess. The treatment of abscess today is much the same as it has been for thousands of years—open it and drain it.

When an infection spreads from one area, it may travel by way of a system called the lymphatic, which is just another type of vessel to carry waste from any area of the body, and this brings us to local collections of lymph in structures called lymph nodes. When you have a sore throat and it is red and painful, the infection may spread to the lymph nodes in your neck, and we say you have swollen glands.

When pus and bacteria get into the blood stream, this is called sepsis and can cause high fever and rapid and severe progression of illness leading to death if not controlled.

Well, what things lead to infection? From the point of view of the surgeon, he must be careful in his handling of the tissue, avoid injuring the blood supply to an area and do his utmost to avoid getting a buildup of blood called a hematoma in the operative site. In certain patients there may be an increased risk for infection, and these will include underlying diseases such as Diabetes Mellitus, Cancer, Anemia, Chronic diseases, certain medications such as steroids, and radiation therapy.

First, we should think of a situation where bacteria can get into the body. This is called contamination, such as may occur when you get a cut and the skin protection is breached, during an operation, or when someone suffers a knife or gunshot wound that injures the intestine and contaminates the surrounding body.

Several things will influence whether you develop a severe infection. First, how strong or dangerous are the bacteria which have entered the system? Next, we need to understand that the amount of bacteria is also important, as well as the length of time of the contamination. The method of contamination is important, i.e., was the patient stuck with a dirty nail, or splinter of wood that is still in the body? We will talk about different parts of the body in Part II of this book and will touch briefly on the types of infection that can occur there. The general health of the individual and the part involved will make a big difference. When there is good blood supply to an area, then the body's own defense system can get to the involved area and fight off infection. If the area has poor blood supply because of arteriosclerosis or hardening of the arteries, tissue damage, diabetes mellitus (which affects small blood vessels) or just general debility in very old or chronically ill people, then the bacteria may have an easier time growing and cause severe disease.

The physician will evaluate his patient for the presence of infection daily by looking for any of the four Latin word symptoms we have mentioned and, if they are present, he will perform certain laboratory tests to help him in the diagnosis and treatment. These may include chest xrays for signs of pneumonia, CAT scans, special radioactive injection studies called nuclear scans (such as Indium or Gallium), or a whole host of other radiological studies. In addition, he will do certain laboratory tests, which we will discuss in Chapter 25. Suffice it to say that a blood count, urinalysis, and cultures of any pus or wounds are very important in determining what type of antibiotic should be used.

Sometimes the organism causing a disease is not a bacteria but a fungus, such as in athlete's foot or “yeast” infections, or a virus as in AIDS, and these need different tests and different medicines for treatment.

This has been a lot of information to digest, but I do want to touch on some other points. First of all, some individuals are very allergic to certain drugs. They may have a bad reaction, which can be anything from a mild rash, to itching, breathing trouble, and sudden death. Physicians always ask a patient about any side effects from taking a medicine, and this is always highlighted on a medical chart. In the case of severe reactions, many patients have “Medic Alert” bracelets to inform anyone treating them of the danger.

When you have an infection, your doctor wants to treat you with the best drug with the least toxicity or side effects. One does not use a Cannon to kill a fly, and conversely, a peashooter will not kill an elephant. Physicians learn what types and amounts of drugs are best for each situation and, when it involves stronger drugs, which are much more dangerous to use but may be the last resort. They have to watch for hearing loss, kidney, liver and other problems. The field of infectious disease has become so complex that, when I have a patient with a ruptured appendicitis or ruptured colon, I often get consultation from the infectious disease specialist.

Just for your interest, I'm going to name some of the bacteria we see in a surgical practice. GramPositive organisms are Staphylococcus aureus, Pneumococcus, and Streptococcus. GramNegative organisms include Me-ningococcus, Escherichia Coli, Salmonella, Klebsiella, Haemophilus influ-enzae, Proteus, Clostridium, Pseudomonas, and Aerobacter. And these are only a few of the many, many organisms we find in human infections.

Some of the antibiotics used are Penicillin, Ampicillin, Flagyl, Erythromycin, Cephalosporin, Gentamicin, and Floxin, just to name a few. Take a look at the “Physician=s Desk Reference,” which lists all the drugs we commonly use, and you will find hundreds of antibiotics. You will also see a listing of the dosages and side effects, which can be very scary.

Treating infections can sometimes be very simple, but other times it may involve intravenous medications and, frequently, multiple combinations of medications.

Often a surgeon will give you what we call prophylactic antibiotics in anticipation of contamination or possible infection to prevent or lessen the impact of the bacterial contamination. Examples are gall bladder and intestinal surgery and certain orthopedic procedures.

This has been an overview of infection and antibiotics, and I hope it helps you to understand some of the problems that a physician will encounter in dealing with this situation.

Chapter 14

KNIVES, LASERS, AND CAUTERY

Knives, scimitars, dirks and cleavers

Daggers, shivs and snickersneevers,

Jackknives, rapiers, spears and krisses

Tomahawks, swords, stylets, cutlisses.

These all are very fine for fighting,

And if you slay enough, for knighting,

The saber cuts from guzzle to zatch,

But I thinks it's finally found its match.

For all the above are good for killing,

But I've got one that's used, God willing,

Instead of for wounding or taking of life,

It's used to cure the scalpel knife.

Why on earth write a chapter on knives, lasers, and cautery?

Just cause I oughtery!

I can vaguely recall the first time I held a scalpel in my hand and drew it across human skin to make an incision. I was an intern at a prestigious hospital in New York City and was doing my first appendectomy with the guidance of a gray-haired surgeon who couldn't keep his hands out of the wound. I cut his hand! Just a tiny nick but it was enough to make me the laughing stock among my colleagues. That was the last time I did that, but to me it seemed like an inauspicious start to my surgical career. Reminiscing brings back many good and bad moments during my training program; I digress. We're talking about knives, lasers, and cautery.

The first two are methods of cutting. The first of these is timeworn, used since man first made stone tools, and the second is a child of the late twentieth century. Many of my patients inquire whether I can do their surgery with lasers and are somewhat disheartened when I tell them that a laser is just another method for cutting. Laser is an abbreviation of the first letters of Light Amplification by Stimulated Emission of Radiation, and its use in general surgery is actually very limited. It was early on used for cutting and coagulating during certain laparoscopic procedures, but the side effects and complications made it fall into minimal usage. However, in certain procedures, such as hemorrhoidectomy, eye surgery, and certain brain operations, it has become an important tool for the surgeon. Lasers can cut, coagulate, vaporize and selectively destroy tissue. There are several different types of lasers including CO₂ carbon dioxide, Nd:YAG - neodymium (yttrium-aluminum-garnet), Ho:YAG holmium, Er:YAG erbium, and the KTP potassiumtitanylphosphate.

Anyway, the word laser sounds good and many surgeons, who advertise, use the word laser in their “ads” because it sounds high-tech, modern, and has a catchy patient-appealing sound to it. “Hey doc, I want my surgery done with lasers.”

I feel like saying, “We'll bring in Dr. McCoy from Star Trek and use ultragammaneutrinolasers for your surgery, sir! Beam me out.”

But to get back to real cutting, scalpels—some completely disposable and the handles of some often reusable—are very fine, ultra-sharp instruments that can become dull cutting through tough tissue and frequently have to be replaced several times during a surgery. They also come in several sizes and types, some broad, some tiny, some with round or pointed tips, and others adapted to certain special operating conditions.

Another modality used in the surgical operation is electrocautery; this can either be monopolar or bipolar. Cautery is used for cutting in place of a scalpel or for cauterizing or sealing off bleeding vessels with heat, a modern adaptation of the Middle Ages technique of using boiling oil or fire to stop bleeding, but they didn't have much for anesthesia! It has become an irreplaceable modality for many surgeons to cut, and then dry, the operative field using this tool, whereas many years ago the surgeon had to tie off each bleeding vessel with a suture, requiring much more time and prolonging the surgical procedure. Another relatively new device is the argon beam coagulator, which uses the gas argon and electrons to seal off bleeding areas, has a very minimal tissue depth penetration and can be used on the surface of vital organs without damaging the organ, as may occur with standard electrocautery.

I am sure, in the years to come, new and even more efficient tools for cutting and stopping bleeding will be discovered and used in surgical operations, but somehow I think the scalpel will still hold sway in the hands and minds of the surgeons.

Chapter 15

LAPAROSCOPY

They say that Isaac Newton was sitting under a tree,

When an apple fell upon his head, and he found gravity.

And likewise, after centuries had passed, to please society,

Someone sat under that very tree and found laparoscopy.

It's just the product of a brilliant and inquiring mind,

That finds a new idea and leaves the old ones far behind.

With laparoscopic surgery we have turned a brand new page,

And ushered in a new and different type of surgical age.

We put a camera in a joint or abdomen to see,

What was causing all that person's symptomatology,

And without making big incisions we can take out many organs,

With such success that we'll be known as surgical J.P. Morgans.

When I first heard about laparoscopic cholecystectomy—taking out the gall bladder using four tiny holes, a camera, and some strange instruments—I said, “It'll never fly. Too risky! Not me!” Now I do two or three every week and rarely do the old type of procedure using a large oblique incision under the right rib margin. My patients are done as outpatients, coming to the hospital and going home the same day, and have minimal pain and almost no incisional scarring. They are usually back to work in a few days and eat normal food. It's the closest thing to the invention of the wheel I have ever seen.

The first laparoscopic cholecystectomy was performed in Germany in 1985 and, though pooh-poohed by surgeons like me for years, by 1993 nearly half a million procedures were done that year alone. Laparoscopy is a method of operating which uses only a few small openings into the abdomen. A special needle is inserted into the abdomen, and carbon dioxide gas is insufflated into the peritoneal cavity inside of the abdomen, allowing an interface between organs and the abdominal wall. Then a ten millimeter camera attached to a television screen is inserted through this port and a general exam of the intra-abdominal contents can be done. Under direct vision, at least three more ports are placed and using special clamps, scissors, and cautery, the gall bladder can be dissected out, the veins, arteries, and bile ducts sealed with staples, and the gall bladder can be dissected out of its location under the liver and brought out through one of the ports. Then most of the CO₂ gas is removed. Any remaining CO₂ may sometimes get caught temporarily under the diaphragm, and this may cause some patients to have an annoying aching pain in the right shoulder after abdominal laparoscopic procedures. The gas gets absorbed by the body in about six to twelve hours, and the pain goes away. I have known some patients to get very worried about this, and knowing its cause and that it will soon go away is usually all they need to hear!

Abdominal laparoscopy is not without complications, and I will mention a few of the general considerations now and more specific ones under the particular types of surgery later in the book. The trocars that are placed in the abdomen can be very dangerous in untrained and uncareful hands and may result in severe injuries to the intestines and, more seriously, injury to major blood vessels such as the aorta, the vena cava, the iliac arteries or their accompanying veins, or may just cause nonspecific bleeding. These injuries usually require making a large incision in the abdomen and repairing the damage. However, sometimes the damage is not immediately apparent. As an example, a surgeon made a hole in an artery during what should have been a routine laparoscopic appendectomy. Because the blood vessel had a lot of peritoneum and fat around it, the bleeding stopped temporarily when the vessel contracted and closed off. The procedure was completed without any warning signs and in the recovery room the patient went into shock from sudden loss of blood when the vessel began bleeding again. Only an emergency surgery saved the young man's life. It should not have happened!

In general, laparoscopic surgery saves the patient a big incision, the dividing of abdominal wall muscles, and affords a much more rapid recovery, much less pain, and less tissue damage. The patients are often only in the hospital for the day and are back to work in a few days. We will discuss other laparoscopic procedures under their appropriate specialty in Part II, along with diagrams showing where the holes in the skin are made. Laparoscopy is relatively simple and much less invasive with less tissue morbidity than the older methods, but does require expertise and special training.

Once laparoscopic cholecystectomy became popular, several other procedures were tried and several specialties began using the same basic method for their procedures. We will go into specifics under each specialty in Part II. As of now, the laparoscopic procedures that have been accepted by surgeons are: cholecystectomy, diagnostic laparoscopy—which means just looking around inside—including those for cancer diagnosis, appendectomy, hernia repair, liver biopsies, and hiatus hernia repairs. There are also small and large intestine resections, taking away adhesions, and lymph node biopsies.

Surgeons have also done the following procedures, but to a limited degree, and their acceptability will be increased in the coming years. These include: cancer operations on the colon, stomach operations, ulcer operations, and certain bypass operations. Gynecologists are now using the procedure to make diagnosis of gynecologic pathology, both benign and malignant, and can frequently remove lymph nodes and small tumors laparoscopically. Of course, tubal ligations have been done this way for a long time. The chest surgeons use scopes to examine the lungs in a procedure called thoracoscopy and can do some biopsies and other procedures in this manner.

Orthopedic surgeons are now looking into joints with arthroscopes to repair ligaments and clean out disreputable joints.

Laparoscopy and its cousin procedures have made a strong impact on several different kinds of surgery, and we shall discuss this more with each specific subspecialty as indicated, including an overview of the types of complications which may ensue using this modality.

Chapter 16

PERITONITIS

Before the time of Lister and Pasteur,

Opening the belly would cause a disaster.

If one allowed germs to get inside us

We patients would die of a peritonitis.

Before we can talk about peritonitis or inflammation of the peritoneum, we had better clarify to the non-medical person what the peritoneum is. Imagine a room filled with chairs, tables, dishes, and other objects. Then take an imaginary plastic spray gun and cover everything with a thick plastic coating. This coating would essentially make a contiguous connecting sheet around everything and leave the center of the room inside the plastic coating or balloon. That is essentially what the peritoneum does. It covers all structures in the abdomen as if we had blown up a balloon inside.

The peritoneum is a real structure with blood supply and nerves and can be important to a physician when something causes it to be disrupted or get infected. Inflammation of the peritoneum, or peritonitis, has many causes. The more common causes of peritonitis are ruptured appendicitis, perforated diverticulitis or hole in the colon secondary to infected diverticulae (see the chapter on Colon), perforated ulcer of the stomach or duodenum, problems of infection in the abdomen secondary to injury (as by local “knife and gun club activity”), and breakdown of connections called anastomoses made by a surgeon.

The symptoms of peritonitis are abdominal pain, fever with chills, and sometimes diarrhea, nausea, and vomiting. The abdomen will often be distended and very tender and, when the physician listens to the belly with his stethoscope, he may not hear any sounds. Normally we can hear bowel sounds, indicating the normal back and forth movement of the intestines. A silent abdomen is often indicative of something wrong.

Why, then, have a chapter on peritonitis? Mainly, because it can act to warn the patient and his doctor that something is going on inside, that some one had better do some studies and find out what it is! Although most people recover from peritonitis when the underlying cause is treated, as with removing the diseased appendix or colon, it remains the greatest cause of death following abdominal surgery. When a patient comes to the physician with abdominal pain, one of the first things the doctor will do will be to determine if the patient has peritonitis, looking for peritoneal irritation signs of pain, tenderness, fever, or silent abdomen. He will look for something called rebound tenderness, which means that, when he pushes in on the abdomen and lets go suddenly, there is a sudden, severe pain due to sudden movement of an inflamed or infected peritoneum.

If the doctor determines that there is peritonitis, then he needs to do xray and laboratory studies to pinpoint the cause and make plans to correct the problem. He will generally want to start an intravenous line, since the patient is often dehydrated from vomiting and not eating, and will give pain medication and some broad spectrum antibiotics.

Peritonitis means something is wrong

Inside us!

Chapter 17

REHABILITATION

Habilitate means to make one suitable,

Especially those who haven't a cluetable.

So to re habilitate,

Assumes you were once in a suitable state.

Now most people I know are downright strange,

With behaviors and actions that they oughta change.

They wouldn't do well with rehabilitation,

For that would only cause more frustration.

Instead of re anything, I would suggest

Buying a large metallined chest,

And take all the people you want to rehabilitate,

And ship them all off to a totally different state.

There's an old expression that has become overused: “Let nature take its course.” When surgeons in days past completed their handiwork, the patient was sent home to heal and, more often than not, nature took its course—right to the grave. In the twentieth century we developed the concept of rehabilitation, which focuses on the individual as a functional member of society. It was not enough just to have a successful surgery; it was the responsibility of the physician to bring the patient, as close as possible, back to his prior normal physical and emotional status.

Over one hundred years ago it was shown that early ambulation of patients reduced complications, and yet it took another fifty years for physicians and patients to believe this line of thinking. It's almost as if, when you treat the patient as being sick, he will continue to be sick; if you try to get him functioning again, he will recover more rapidly.

In situations where patients have been critically ill with tremendous weight loss and thereby muscle loss, the program of rehabilitation may take months, whereas after simple surgeries it may take several days or weeks.

We need to understand that rehabilitation nowadays is a comprehensive program involving the patient, but also with direct or indirect assistance from nurses, psychologists, physicians, physical therapists, occupational therapists, speech therapists, and sometimes prosthetists, the people who make and apply artificial limbs or other replacement parts. The sooner these individuals are involved in a case, the sooner the patient will get the optimal amount of improvement. I was surprised to find that several of the major surgical texts included almost no information on this important aspect of total care for the surgical patient. And yet, it is perhaps the one aspect of the case that interests the patient most. “So you're gonna remove my zingwatch and my dohickey, Doc? When can I resume my golf game, go back to work, and resume sexual relations?”

Any surgical program in a major hospital prides itself on the quality of its rehabilitation program. I will give you a brief outline of some of the things you should look for as you are recovering from surgery.

First, and most well known and utilized, is physical therapy. The objectives are to use exercise to bring back as much function as possible. Obviously, this may be more apparent with orthopedic cases, but it applies even to the patient who's had an appendectomy or a gall bladder removed. The objectives include exercises for strength, coordination, range of motion, and endurance, just to name a few. The therapist will work with the patient in an active or passive way: from the simple activity of getting out of bed and walking, to a complex set of active exercises where the patient moves himself, to passive ones where someone else moves the patient or his limb, and everything in between!

Physical therapists use massage, heat therapy, (which can include many different types hot-packs, whirlpool, infrared, and water therapy), electric currents stimulating nerves called electrotherapy, cold therapy with ice compresses, and just plain encouragement.

Occupational therapy helps get the patient back to doing things that will be worthwhile for him as a functional member of society and the work force, or just to be able to get along in daily life, whether it's managing a colostomy, a wheelchair or at home activities. This is very important for recovery, and the surgeon must be aware of all the modalities available to help his patient in the postoperative period.

Psychiatric and social work rehabilitation is also an area where we as physicians often fail in our care. With our focus on the surgical problem, we may ignore major emotional or psychosocial problems that leave the surgically-healed patient effectively incapacitated.

If you or a loved one is anticipating major surgery, be sure you ask about the rehabilitation services in your hospital; frequently, it's better to arrange for help before the surgery rather than afterwards. I will talk about amputations and prosthesis in the orthopedics chapter, about paralysis and dealing with the problems of the paraplegic and quadriplegic patient in the chapter on neurosurgery, and problems with urination in the urology section.

Patients with new colostomies and ileostomies—where for medical reasons the large or small bowel is brought out to the skin level where a bag is applied—need tremendous support from nurses who will tell them about the care of the opening at the skin called a stoma. They may need psychosocial support and also may benefit from talking with other individuals who are living with the same situations. I personally know many famous celebrities, always in the public eye, who function well with their postoperative disabilities including colostomies and prostheses without having them effect their lifestyles or public image to a great degree, if at all. In my book on “Comprehensive Breast Care,” I talk extensively about the problems encountered by women who have had mastectomies or axillary dissections. Similarly, patients, who have a disfigurement secondary to cancer surgery, or temporary problems such as hair loss during chemotherapy, have someone to turn to in a comprehensive program to help them get through the problems of daily living.

In conclusion, be sure that your surgeon and his hospital are sensitive to these important issues and can outline a rehabilitation program prior to and after a surgery.

Chapter 18

HEMORRHAGE, COAGULATION, AND TRANSFUSIONS

Whenever you are angry, you speak of “seeing red.”

To a surgeon this expression causes sirens in his head.

And though the right wing zealots spoke of “Better dead than Red,”

We know that surgically speaking, too much red and you'll be dead.

Ho hum, you say, if blood comes out, then put a little in.

It should be just as simple as to close a safety pin.

And so it is with surgeons, as we ply our nasty trade.

If blood emerges while we work, we get a blood bandaid.

Lose a little, get a little, sounds so simple now,

Yet hemorrhage is a problem, much more complex than the Dow.

For blood is not just colored water, to be put in later,

Much the way you pour the water in your radiator.

Blood is really an organ, with complex and diffuse conjunctions.

We need the volume, but we also must have all the other functions.

There's red cells carrying oxygen, electrolytes, and serum,

Platelets that form blood clots, immune proteins, and right near um...

Are white blood cells that help us fight off some obscure infections

And water and some lipid fats, and Rh fact connections.

So when the blood is gushing out upon an OR table,

Try to remember all the parts, that is, if you are able.

I want to present a simplified chapter on blood, hemorrhage, and transfusions. You should understand that this is a very complex subject that has been covered in large volumes and about which hematologists or blood specialists spend years learning. I will divide it into several sections and give some basic information about each one.

First, the components of blood: As in the poem, blood is a complex of red blood cells or corpuscles that compose about 45% of the blood and carry iron and oxygen to your cells; the white blood cells scavenge debris, fight off infection and contain immunological substances, and platelets or thrombocytes help form blood clots. It also contains many different clotting factors, which I will describe soon, that help the formation of blood clots with the platelets. The blood also contains many chemicals needed by your body to function properly, including electrolytes: Na sodium, K potassium, Cl Chloride, as well as Ca Calcium, Mg Magnesium and glucose, all suspended in a 90% watery substance called plasma. When a physician orders an intravenous solution, he must be sure to order the right components, the right amount of glucose and remember that diabetics have too much sugar in their blood, and electrolytes depending on the results of blood tests he has taken. Similarly, if a patient has been bleeding, we must not only replace blood volume, but also specific blood clotting factors and calcium, which is used up in clotting.

If a patient loses a small amount of blood, say one pint, there may not be a need to replace anything, since the body continually produces new blood. However, when massive bleeding occurs, such as in gunshot wound trauma, ruptured aneurysms (large ballooned out blood vessels), or during surgery, then transfusions may be needed and attention must be paid to all the parameters of the blood components. If the patient has a low platelet count, and you give him blood, he may continue to bleed and not form blood clots. So hematologists are often called in to help us restore normal blood homeostasis.

Now to some other basics: The average adult has about 10 pints of blood—and this varies with weight, age, sex, body build, etc., and can lose about a pint without much problem. When one donates a unit of blood it is equal to about a pint. The volume you lose with the donation is made up rapidly with transfer of fluids from one part of your body to the blood stream, so that the total volume remains the same. It takes about two weeks for your body to produce and replace the red blood cells.

The blood circulates through your body in a continuous circular pattern, driven by the contractions of the heart. It goes from the heart through the arteries to the tissues, such as brain, stomach, kidneys, skin, etc., where it gives off oxygen and other nutrients to the cells, and then returns to the heart by the veins. It is pumped into the lungs, where it picks up more Oxygen, returns back to the heart and then starts the trip again. Simply put, the flow of blood, with a certain volume present, gives us our blood pressure. If the amount of fluid in the system falls, as with bleeding, then the blood pressure falls, and the heart beats faster to keep the total amount of blood circulating at a constant number. So when there is hemorrhage, a patient's blood pressure usually goes down and his heart rate or pulse goes up. Those signs, together with measurements of the blood, will let the surgeon know how much a patient is bleeding and how much to replace. We'll talk more about the actual numbers in Chapter 25, when we will also discuss the white blood cell count (WBC) and other blood factors.

When a patient's blood count, amount of blood, or red blood cells falls too low, he may need a blood transfusion. We generally say that 9 grams of hemoglobin is the cutoff level, with normal being between 13 and 15 grams for most healthy people. But for many reasons, including religious (Jehovah Witnesses refuse any blood transfusion), the choice of no blood or of, under certain circumstances, blood be given. Frequently, when a patient knows he will be needing blood, he will give his own blood in advance or have friends or relatives donate for him.

As far as coagulation is concerned, I am going to show you a schematic version of the clotting pathway, which includes factors IV and VII through XIII. I never remember all the specifics myself and always have to refer to specialists or books to understand all the pathways, but I thought you might be interested to see how much is involved in forming a blood clot and stopping bleeding when you get a scratch or cut. The factors and their synonyms are:

I	=	Fibrinogen
II	=	Prothrombin
III	=	Tissue Factor
IV	=	Calcium Ion
V	=	Proaccelerin (labile factor)
VII	=	Serum Prothrombin Conversion Accelerator Factor (stable factor)
VIII	=	Antihemophilic Factor
IX	=	Christmas Factor
X	=	StuartPrower Factor
XI	=	Plasma Thromboplastin Antecedent
XII	=	Hageman Factor
XIII	=	Fibrin Stabilizing Factor and then there are platelets.

We sometimes refer to the expression “consumption coagulopathy,” which means that, because of continued bleeding and the body's attempt at stopping the bleeding by forming blood clots, many clotting factors are used up or consumed, and this must be managed by physicians with in-depth knowledge of the clotting pathways and their replacements.

In certain situations like hemophilia, kidney disease, and Von Willebrand's disease, special factors are needed and must be supplied by the hematologists. Another problem is disseminated intravascular coagulation or DIC, the name for a number of conditions which cause severe problems with coagulation and can lead to death if not rapidly and appropriately corrected. Some of the things that can cause DIC are massive bleeding, problems with labor and delivery, severe infections, burns, liver disease, crush injuries, and malignancies. DIC is a difficult problem to counteract and sometimes results in death, even in the most experienced hands.

Now let us turn to the whole area of transfusions. Blood contains substances which are called antigens, and, without being more specific, we have to receive a blood transfusion with blood containing pretty much the same antigens as our own. Otherwise, severe “allergic” reactions and even death can occur. The first blood group discovery was made in 1901 with the determination of A, B, and O types. Later on, many other subgroups, such as Rh, Kell, Lewis, and Duffy, were discovered, making it much safer to receive blood transfusions. In the early 1980's, with the beginning of the AIDS epidemic, we were unable to identify contaminated blood. Now we can determine contaminated HIV positive or AIDS blood, making the blood supply safe and dependable.

In conclusion, let me review briefly the hemostatic process, or how bleeding stops without our external help. After a minor injury causes an opening in a vein or an artery small artery called an arteriole, the vessel contracts and partially closes off. Then, a mass of platelets join together to form a plug--like a finger in a dike which stops the bleeding and allows the hole to heal with a collagen scar (see Chapter 21). So the next time you have a cut and are bleeding, think about all these considerations I have mentioned, and by the time you have reread this chapter the bleeding had better have stopped; if not see a doctor!

Chapter 19

PULMONARY EMBOLISM

Blood clots in veins where they shouldn't be found,

Can be a great problem if they should abound.

And if they break loose and go to the lung,

A patient may die with the reason unsung.

More than half a million will get this bad disease,

With blood clots from their pelvis, or their ankles to their knees.

And ten percent will die within an hour, sad to say.

So one must make the diagnosis soon, with no delay.

And of the 90% who live beyond the very first hour,

About a third will die in spite of all the medical power.

So face it, blood clots in your veins, are a very serious matter,

And shouldn't be taken lightly or be treated by a Mad Hatter.

If you are diagnosed and treated with the proper drugs

The doctor can dissolve the most pernicious of the clogs.

And using anticoagulants, (blood thinners to the public,)

You'll probably survive to next New Year and be able to

drink some bubblic!

In reviewing the literature for this chapter, I was surprised to find that so many people have pulmonary emboli and that a large proportion of them die of the disease. When a large clot breaks loose in a vein and travels through the venous system to the heart and through the right side of the heart into the lungs, death may be instantaneous when the body is unable to get oxygen. There are other factors involved that we don't need to consider, but it's important to note that almost 50% of patients dying in the hospital have some degree of pulmonary emboli. If the diagnosis is made, then ninety percent will survive; if the diagnosis is not made, only seventy percent will survive, so it is important to know the signs and symptoms and be sure that your physician knows about them and starts appropriate therapy rapidly.

But let's go back a few steps. Who develops these blood clots, and why do they develop? Normally, blood flows continuously from the legs into the large vein in the abdomen and chest, the vena cava. But under certain circumstances, blood flow is diminished and sets up a background for co-agulation or clotting to occur. As long ago as the 1880s the famous German physician Rudolf Virchow determined that three factors were responsible, for the occurrence of blood clots or thrombosis. They are known today as Virchow's triad and consist of (1) stasis or slowing down of blood flow in the vein, (2) injury to the vein, and (3) an increased tendency for the blood to clot, called hypercoagulability.

The causes of this triad are many, but the main ones that concern us here are those related to surgery. When a patient has an operation, he often is lying down for a prolonged period with no muscle activity; the patient is often paralyzed by the anesthesiologist so that the surgeon can operate in a motionless field. This operative inactivity and the postoperative bed rest are highly conducive to stasis in the veins, and thrombosis or formation of clots can occur more readily. This problem may be more common as we get older, and it takes longer to recover and ambulate.

When a patient gets dehydrated or if there is a decrease in blood thinning factors, then there will be an increased tendency for clots in the vein. Because of the increased pressure in arteries, blood clots are less common, and any clots that occur don't ever go to the lung—it's the wrong direction; as you recall, arteries take blood away from the lungs and heart to the tissue; veins take blood from the tissue to the heart and lungs!

What exactly is an embolism? It is a blood clot carried in the blood vessel. A pulmonary embolism is a blood clot that has gone to the lungs. The risk for pulmonary embolism, PE, is high in patients over 40 years old who have a history of vein problems called phlebitis, a surgery lasting longer than an hour, and with orthopedic procedures on the hips and knees. There is a also high risk after trauma, especially if veins or surrounding tissue have been badly injured.

What should your doctor do to prevent this problem? First of all is the awareness of the problem. Second is an anticipatory treatment of the patient before it occurs. This means applying special stockings or compression apparatus during many surgical procedures. In the very obese or high risk patient, the physician may want to give the patient prophylactic anticoagulant treatment.

The most common anticoagulant is heparin or a similar drug, and one should get repeated blood tests (see Chapter 25) to make sure that the blood is “thin” enough. The patient may be changed over to a pill, coumadin, which can be taken daily at home. The physician must carefully monitor even this drug, for if the blood gets too thin, the patient can bleed massively from the slightest injury to the intestinal tract or the urinary tract.

What are the symptoms of formation of clots in the larger veins deep in the leg? There may be no warning signs and that is the greatest danger, but most of the time the patient will have aching in the leg, a tender cordlike mass when the clot is in the vein, swelling of that leg and occasionally redness, fever and pain on motion. If the patient has already progressed to pulmonary embolism, and it may only be a small blood clot at first, the signs and symptoms include sudden chest pain, shortness of breath, coughing up blood, rapid heart rate, and falling blood pressure. If it is a large embolism, shock and death may occur rapidly!

The physician listening to the heart and lungs can sometimes hear abnormal sounds with pulmonary embolism. If a patient has symptoms even remotely suggestive of thrombus or embolism, the nurse should immediately notify the physician and certain diagnostic tests should be done immediately. Better to have several negative tests than miss a positive one! There are several tests, but three are of major importance. The first, is called ultrasonography, a sound wave study that can show blood clots in a vein. The second is a lung scan in which a picture of normal and abnormal lung can be determined by injecting and breathing in radioactive materials with very low radioactivity and studying a special xray afterwards. The third test is the most specific for embolism and consists of doing an arteriogram, or xray of the vessels in the lung using intravenous dye.

If any of these are positive, then anticoagulation therapy is started immediately. unless there is a contraindication to using a blood thinner, such as bleeding in an organ such as the brain, abdomen or intestine. In that case, the physician may opt to place a filter in the big vein in the abdomen to prevent large blood clots from getting to the lungs. This filter, can either be placed by a radiologist through a vein in the neck or groin called the Greenfield Filter, or can be applied through a surgical incision, the AdamsDeWeese or Miles inferior vena caval clip.

Chapter 20

DIABETES MELLITUS AND SURGERY

In your pancreas, there dwells,

An area filled with Langerhans cells.

These cells called islets, so very small,

Produce insulin, as you may recall.

This insulin is what your body needs,

To use the sugars in tiny beads.

Without the insulin, you may be sweet,

But your cells are getting nothing to eat.

In diabetes the islet cells,

For some strange reason, don't work so well,

And if insulin is not produced,

Glucose in your blood's not used.

So let's give three cheers to Banting and Best,

The two researchers that made the test,

And discovered insulin in dogs one day.

So you can enjoy a hot fudge Sundae.

Diabetes Mellitus is a strange disease, and it affects 23% of the populace. Whether you have childhood or adult onset diabetes, your body has a problem with the islet cells of the pancreas, and they don't produce enough insulin, a word derived from the Latin word “insula,” for island or islets. The insulin helps metabolize and mobilize sugars from your blood into your tissue. Some diabetics may be entirely diet- controlled because they apparently have some insulin, whereas others are reliant on daily injections of one of the many types of insulin available, or they may take some other medication that mimics the effect of insulin.

Just to digress for a moment, when a person has high blood pressure or hypertension, controlling the blood pressure with medications completely corrects the problem. If there is no high blood pressure, it usually means there are no problems related to hypertension!

Unfortunately, the situation with diabetes mellitus is more complex than just elevation of the blood sugar. Even if the diabetic patient maintains his blood sugar at a normal level with diet or other means such as insulin, the disease of diabetes mellitus may still progress, affecting different organs in your body. It is in the latter context that the diabetic patient becomes of concern to the surgeon. Diabetes affects the small blood vessels, narrowing them and decreasing the blood supply to the hands and feet or the vessels in the heart and may lead to tissue damage in these areas, necessitating bypass surgeries (see Vascular Surgery). If very severe and not well managed, amputations of the toes or even a leg may be necessary. Because of the injury to microscopic vessels in the skin, the diabetic may have poor healing of skin wounds and surgical incisions may heal more slowly, with greater chance of infection and wound separation. Somehow the effect on the skin also involves the sensory nerves, and diabetic patients may develop abnormal nerve function and numbness, called neuropathies, in the toes and feet. If the diabetes affects the eyes, a condition called diabetic retinopathy can occur and lead to poor vision or blindness.

Diabetes mellitus is a strange and wide-affecting disease. What are the surgical considerations, and why do I give a whole chapter to the subject? First, the surgeon and anesthesiologist must carefully monitor the blood sugar during the stress of surgery; surgery is a stress both emotionally and physiologically! If the blood sugar gets too low, (hypoglycemia), then not enough sugar is getting to the brain cells and seizures or brain damage can occur. If the blood sugar gets too high, (hyperglycemia), then a serious condition called diabetic ketoacidosis can occur with severe tissue consequences and even death.

The surgeon knows that, because of the diabetic effect on tissue, there is poorer blood supply to tissue and skin and thereby a greater chance for wound infections (see Wound Healing chapter), slower healing, and more complications. Whereas, we usually take out skin sutures after seven to ten days, in the diabetic I may wait twice as long! Sores and ulcers that heal rapidly in the nondiabetic may become a complex lingering problem in the diabetic patient, and even skin grafting will have poorer results.

Patients who have blood vessel problems from hardening of the arteries or arteriosclerosis, or secondary to smoking will have even more problems if they are diabetic. In the diabetic patient with vascular disease, if they don't stop smoking, the outlook for saving a foot or leg is very poor! The diabetic needs to take exquisite care of his skin, and whenever there are even minor cuts or bruises he should seek out medical attention immediately.

New research with pancreas transplants may offer some wonderful treatment options in the future but this work is still embryonic in the transplantation field.

If you have diabetes mellitus, you probably know much about what I have spoken, and it is important that you continue to educate yourselves in all the new treatment possibilities on the market. Sometimes, a general physician may not have the time to be up-to-date on these types of advances and, as a second opinion, you may want to consult an endocrinologist, a physician who specializes in endocrine disease, of which diabetes mellitus is one!

Chapter 21

WOUND HEALING

I wish we'd find a magic way,

For scars and deformity to go away.

Unfortunately, though, the process of healing,

Leaves scars and deformities and some bad feeling!

Healing a wound is like building construction,

It starts with site cleanup and tissue destruction.

Certain cells, the WBC's, remove all the dead and poor tissue,

And then bring equipment to rebuild the issue.

And like any construction, it takes time for achievement,

And depends on the needed equipment receivement.

The roads for supply in the body are arteries.

If you have ‘em in plenty, the work soon gets starteried.

But also you need all the building materials.

Which you get in your body with all the right cereals,

With proteins and lipids and good carbohydrates.

And vitamins, minerals, and adequate heart rates.

And all this assumes you're in top peak condition,

Without Diabetes or heart aches or malnutrition,

Or aged, or fat, or have cancer or infection,

Or jaundice or trauma or lost an election.

In other words, the ideal state is just what it says,

Since most are not perfect in so many ways,

So I have to advise you, and it's not all my fault,

Take this information with a small grain of salt!

The healing process is a very sensible and orderly one, much like building a home. After an injury, which may be traumatic or surgical, the wound, like your building site, has to be cleansed of debris, and the body sends in white blood cells (WBC's) to do this function. The WBC's come in by small arteries (arterioles) and, much like in construction, the body has to build new roads to bring in the heavy building materials. In the body this is called angiogenesis (angio=vessel, genesis=creating), and this allows the entire “repair” team to get into the area for repair.

Most texts describe wound healing in stages, but in actuality many of these processes are happening at the same time. First comes hemostasis and coagulation, stopping the bleeding and sealing off the area from further bleeding. Then comes inflammation, which is a somewhat misunderstood word, because many of us equate inflammation with infection. Not so. Inflammation is actually the process of bringing white blood cells or leukocytes into the area of a wound. They have many roles, but mainly to clean up debris and bring in raw materials for healing. The next stage is the growth of fibroblasts, called fibroplasias, that will go on to form the building block of a strong wound, collagen. During this time another process called epithelialization is occurring in the skin, which means the growth of skin or epithelial or epidermal cells.

Now, how does the body know what to do and how to do it? Recent studies have shown that substances called cytokines appear in the blood stream after an injury or surgery, and these somehow act as messengers to organize this redevelopment process.

A lot of factors will affect your ability to heal properly, as mentioned in the poem, and I will repeat them here for you. If you have any of these factors, you will heal more slowly, and you should understand that the healing process in each individual is different. With a procedure as simple as an appendectomy, some individuals will be ready to go back to normal activity in a few days, whereas others may be incapacitated for a month or more.

The factors are age; general health; whether you have local wound problems such as hematoma or seroma; anemia; presence of malignancy; obesity; trauma; vitamin deficiencies; medications you are on, such as steroids, which markedly inhibit normal healing, diabetes mellitus; chemotherapy; and chronic liver disease, to name a few. Also, if your surgeon treats the tissue badly, it won't heal well. It's also important to keep the wound clean and probably best not to go bungee jumping or play football for a two to four-week period.

In conclusion, I should emphasize that, as of yet, there is no way to make an incision and not end up with a scar. Certain individuals may be scar formers with development of thickened, unsightly scars at the incision site,called hypertrophic scars or keloids. These can sometimes be lessened by the injection of a steroid substance such as Kenalog into the wound, but it usually does not completely eliminate the problem. If you have to have elective surgery, discuss the location of the incision with the surgeon, and he may be able to place it in such a way that it won't ruin your social life!

Chapter 22

ANESTHESIA

Though this profession has its class,

These Docs are known for passing gas.

But you won't know it cause they keep,

All their patients fast asleep.

Actually, that statement is only partly true. Anesthesiology is a profession requiring several years of training after medical school, and these physicians have a whole armamentarium of ways to keep you from experiencing pain during a surgical procedure.

The advent of practical anesthesia in the mid-eighteen hundreds opened the doors for tremendous advances in surgical technique that were impossible in awake or sedated patients. In the last fifty years the advances have progressed to safer and more esoteric methods of dealing not only with eliminating consciousness and pain during surgery, but also to a subspecialty of pain management that allows them to help patients with chronic pain from benign or malignant disease.

The anesthesiologist will take a history from the patient, review the records and do a limited, appropriate physical exam. If you are having a surgical procedure, he will discuss with you the various options, including full general anesthesia, where you are put to sleep, heavy sedation plus local anesthesia, or some type of spinal or regional anesthesia. Except for the completely local anesthetics, most anesthesiologists will need to have an IV started for administration of medications, and he or a nurse will start this in the preop area. Once you have gone into the operating room, you will be hooked up to an EKG monitor. Depending on the seriousness or location of the surgery, he may want to place an arterial line, an IV line in an artery to better monitor your blood pressure and a place to draw blood samples, if needed, and give antibiotics. After you are asleep, he could place a nasogastric tube through your nose into your stomach and a Foley catheter in your bladder to measure urine output. While the surgeon is called the captain of the ship in the operating room, the anesthesiologist is certainly the second captain and manages the patient's vital signs and any non-surgical problems that might arise during the case. This includes a host of medical problems, including heart abnormalities, respiratory problems, paralyzing the patient when needed, and looking for any untoward reactions to the abnormal state of anesthesia.

The patient is usually sedated prior to entering the operating room to allay anxiety, and some of the drugs, like Versed, may cause total amnesia from the time it is given until you wake up in the recovery room. Once in the operating room, the anesthesiologist administering a general anesthetic will give more medications by vein, followed by a combination of intravenous medications and gases, the last of which are given either through a mask held or strapped over the patient's mouth and nose, via an endotracheal tube inserted into the trachea, or a special laryngeal tube fitted into the throat. The anesthesiologist may either breathe for you, if you are completely paralyzed, or connect you to a machine which will breathe for you at a fixed rate and give you a fixed volume of oxygen mixed with several anesthetic agents. We don't need to discuss the specific agents except to say that ether and chloroform, two old standbys, are no longer used.

Some patients may develop headaches, nausea or dizziness after a general anesthetic, but this is all treatable with medications and rapidly passes away.

For those patients who do not need or want a general anesthetic, the anesthesiologist can give a heavy sedation in combination with the surgeon injecting a local anesthetic like marcaine or xylocaine. Many surgeons do hernias, breast biopsies, removal of skin tumors, and many other general and orthopedic surgeries under combined general sedation and local anesthesia.

A third method of anesthesia is the regional block. In this type the anesthesiologist injects local anesthetic agents around specific nerves to block or temporarily deaden the area. The patient feels no pain, although he may still retain a sense of pressure or vague touch.

Still another type of block is the spinal or epidural, another location near the spinal cord, such as used in delivering babies or even to do abdominal or lower extremity surgery. This is usually augmented by some sedation, again to decrease the anxiety during the surgical procedure.

In many medical centers, the anesthesiologists are giving what is called a continuous epidural block, which involves placing a very fine tube in the epidural space in the back and delivering a set amount of medication, such as morphine, even after the surgery is completed. This takes away most of the discomfort after a major abdominal or lower extremity surgery and can be kept in place for several days. It's certainly the way I want to go if I have to have any major surgery, but it takes a specially trained physician to place the tube and to monitor it carefully afterward.

The anesthesiologist and pain management specialist has a large number of procedures he can do to permanently block sensory nerves in individuals with severe pain from chronic diseases and from cancer. There is practically no situation where pain cannot be alleviated, and these specialists are the ones a surgeon will turn to when that expertise is needed. But, remember, it is necessary and important for the patient or the family to be “proactive” and ask about all these types of procedures.

Chapter 23

BURNS

Somehow, with whatever happens inside,

We can retain some personal pride.

Because when our faces and smooth skin are left

We're somehow not completely bereft.

The tragedy with burns appears to be

They can harm our personality,

We can tolerate an inner pain, you'll discover,

But destroy our looks, and we may not recover!

Today most major burns are handled in comprehensive burn centers, with dedicated nurses, internists, and surgeons familiar with this subspecialty. Some estimates indicate that there are more than 200,000 major burn victims in the United States each year, and more than a third require hospitalization. Burns are graded as first, second, and third degree, depending on their depth of penetration and injury to the skin. Most of us are familiar with first degree burns, which are essentially like sunburns, causing redness, pain, and occasional swelling. This type of burn may result in superficial peeling but does not cause any permanent scarring.

Second degree burn is a more extreme extension of this with blister formation, severe pain, and partial sloughing of the outer layer of skin. It takes regular cleansing and care not to get infected, and yet it will heal on its own without skin grafting. However, depending on the depth and location, it will probably leave some scarring and deformity.

Third degree burns indicate full thickness destruction of the skin and are often initially not painful because the skin and its nerves have been destroyed. If the area involved is more than a small percentage of the body surface area, there can be severe loss of fluids and the body chemistries called electrolytes, high chance for infection locally and throughout the body, a shock-type state with possible damage to the lungs and kidney. The involved skin will never recover, and these areas have to be covered with eventual skin grafts or rotation of skin from adjacent or other areas of the body. These situations will result in severe scarring and disfigurement, often very difficult to correct with plastic surgery.

The treatment for advanced burns in a burn center consists of cleansing the areas, debridement and removal of dead tissue in what is often a painful process because of the live skin remaining next to the dead skin, vigorous fluid and electrolyte replacement, antibiotic therapy, and a very strong psychosocial support program.

The skin is the largest organ in our bodies and, if you didn't already know it, it is a vital organ, keeping infection out of your body and keeping fluids, heat, and chemicals inside. Loss of even a small amount of skin can, therefore, be very dangerous, requiring intensive treatment. In spite of this many burn patients die. The problem is more severe in children because they can deteriorate very quickly and don't have the body “reserves” of fluid to withstand such a major insult.

Often, the survivability of a burn patient is dependent upon two factors: the percentage of the body burned and the amount of second and third degree burns. The following diagram shows the percentage of body surface areas and is used by a doctor in determining these factors.

RULE OF NINES

REGION	PER CENT
HEAD AND NECK	9
UPPER EXTREMITIES (ARMS)	18 (9 X 2)
LOWER EXTREMITIES (LEGS)	18 (9 X 2)
FRONT OF BODY	18
BACK OF BODY	18
GROIN (PERINEUM OR GENITALIA)	1
TOTAL	100

DIAGRAM 2

Also important is whether the patient has sustained lung damage, thermal or heat damage, and whether there is damage to the kidneys. Underlying other conditions, such as diabetes mellitus, heart disease, kidney disease, and lung problems, such as emphysema from smoking as well as advanced age and poor general physical condition, may cause an increase in the mortality rate.

Burn care is a very complex problem of management, and my best comment is to insist that any significant burn should be treated in a burn center by specialists. It's better to take all burn victims to the experts at once, rather than a day or two after the incident when complications have already started. It is no longer a condition that a family doctor or general surgeon can manage with anywhere near the acuity of specially trained nurses and doctors in a burn facility with the needed isolation units, debridement tanks, special large holding tanks for bathing and debriding, and specially trained anesthesiologists to control the pain management. The plastic surgery required for even the most basic reconstruction is beyond the expertise of the average plastic surgeon.

When confronted by a severe burn think only BURN CENTER!

Chapter 24

SUTURES, STAPLES, AND DRAINS

Sutures, staples, and drains, I contend,

Are all a means to a surgical end.

And to dispel any bizarre surgical rumors,

They're just to close wounds and drain evil humors.

The choices we have to close wounds are as varied

As the tomb you can choose if you want to be buried.

You can suture the skin with nylon or silk,

Or use something else of a polymer ilk.

And of drains, there are plenty for blood or infection,

You'll find in the hospital a massive collection.

The only big choice is just when to use 'em,

And how to place 'em and not to abuse 'em.

The first question many of my patients have before elective or emergency surgery is: “Will there be a big scar?” It's almost as if it doesn't matter what goes on below the skin level.

Vanity, Vanity—the touchstone of humanity!

Well, let's move on. In the past one hundred years we have developed all kinds of suture materials, each with its own particular advantages and disadvantages. Some are nonabsorbable, like the old silk and wire to the newer Prolene, nylon, Nurolon, polypropylene, Ti-Cron, and other chemical polymers, while others are absorbable, which means they dissolve in the body's tissue anywhere from a few weeks to a few months after usage. Among the absorbable sutures are the old catgut, which comes in plain or chromated varieties, to the newer synthetic materials like polyglycolic acid (PDS) sutures and vicryl. Some sutures used on the skin have to be removed, while others used just under the skin in the subcuticular layer, are placed like hem stitches and never have to be removed; they eventually dissolve. Nowadays, the thread comes attached to the needle, and it's very rare that the nurse has to thread a needle for the surgeon. This saves time and, because the thread is amazingly fitted into the back end of the needle, the atraumatic needle, the hole made while suturing is exactly the diameter of the needle itself.

For suturing the fascia, the strong structure holding in your abdomen, and for suturing tendons and heavy structures, we use heavy suture material, whereas for delicate structures like facial skin, children's skin or blood vessels we use finer material that leaves less scarring. Sutures are graded numerically from the very thick #2 to the very fine, thinner than a human hair, 100 used for some types of eye surgery.

Using too weak a suture material may result in wound breakdown, and the surgeon must take the overall wound healing into consideration as we have discussed in Chapter 21. When an area is under tension, the sutures need to be left in longer; when there is no tension and a more plastic closure is desired, the sutures may be taken out earlier and replaced with paper strips called Steri-Strips to hold the wound together without leaving suture marks.

There are several types of wound closures as illustrated. Simple sutures are for the run of the mill closures, mattress sutures for coapting the skin edges a little more securely, and retention sutures for holding large areas together with huge sutures that can be loosened or tightened as needed. There are subcuticular sutures and Steri-Strips as mentioned above. In deep wounds, such as the abdominal wall, a layered closure is performed as shown in Diagram 3.

Now let's move on to drains. Why do we use them? The simple answer is just as it sounds, to drain something out of a wound, whether it is blood, serum from a seroma, bile, infection, pus, or the expectation that there will be an infection or pus. Examples are as follows: with a ruptured appendix, many surgeons will place a drain in the area of the rupture to drain off debris and infected material with the expectation that pus will form and need to get out of the body. With some extensive cancer surgeries, there may be large raw areas that may drain small but steady amounts of serum or blood for a short time. After certain plastic surgery, such as breast implants, reduction mammoplasties, or mastectomies, tube drains may be placed to assure an absolutely dry operative field and prevent formation of hematomas or seromas. These may be JacksonPratt drains, Davol sump drains, or Hemovacs. Sometimes, the surgeon will place a soft rubber drain called a Penrose in a wound or in the subcutaneous tissue to keep a wound open and allow infection to dissipate. Drains, if left long enough, will form a tract so that, when they are removed, an opening is still left through which fluids such as bile or pus can drain if needed. It usually takes about seven to ten days to form a tract, so that's how long we usually leave drains in an area of infection.

Sometimes a seroma, which is a collection of watery fluid or hematoma, may form several days after surgery, and a patient will need to have this aspirated with a needle and syringe. If the fluid collection recurs, then a drain can be placed under a local anesthetic. This can happen in areas such as the axilla or armpit after lymph node dissection, or after some big hernia operations, when artificial mesh is used to close a weak abdominal wall.

When drains, small or large, are removed, the surgeon will usually give the patient some pain medication before pulling the tube, although most times the procedure is almost painless.

Another method of closing skin or connective tissue is by the use of staples. These may vary tremendously in size and shape, but for the most part they look like staples in a paper stapler. They can be used for closing skin incisions, especially when infection is present and, generally, they leave a very clean incision.

Whereas years ago intestines had to be sewn together in two layers in a tedious procedure, today we have stapling apparatus that can connect one loop of intestine to another in less than a minute, and do so in a more exacting fashion than a surgeon could accomplish with a needle and thread. In laparoscopic surgery (see Chapter 15), special staplers have been devised to clip off blood vessels and the gall bladder duct, to amputate the appendix, and staple off the fallopian tube in a tubal ligation. Neurosurgeons use staplers to clamp off aneurysms in the brain, and general surgeons routinely use staplers to occlude blood vessels in many types of surgery, such as thyroid resections, hernias, liver and spleen surgery. There is even a special device that ligates or ties off, divides and staples tissue in one motion, called the LDS stapler. There are staplers that can connect two loops of colon together end-to-end and even connect blood vessels end-to-end.

The field of mechanization continues to improve each year and makes surgery safer, more rapid and less risky for the patient and the surgeon alike.

Chapter 25

LABORATORY VALUES

You may not want to be a number

But you are, ain't that a bummer.

And if you don't have pretty data,

Well, you're just a second rater!

Face it. We're just a large accumulation of chemicals. Suffice it to say the status of our bodies is often wrapped up in laboratory values, so you might as well know what the major ones stand for! It's not my intention to describe all the laboratory data, but rather to give you the most common ones and show how they reflect what's going on in your body. It may seem boring, but then give it a try. If you don't like it, go on to the next chapter!

First, there's the CBC or complete blood count. This includes the hemoglobin and hematocrit, which measure the amount of red blood cells (RBC's) in the bloodstream. These cells carry, among other things, oxygen to the cells to keep you alive. Normal values of hemoglobin (Hg) range from 1315 grams, and all these values will vary with sex, age, and body habitus; hematocrit (Hct) should be about three times the hemoglobin, or 39 to 45%. Lowered Hct and Hg will indicate acute or chronic blood loss or other conditions, including malnutrition, cancer, or deficiency in the bone marrow, where blood is made, or in the building products of blood, such as calcium (Ca). It is usually the first laboratory data your doctor looks at. The sedimentation rate of red cells (sed rate) is a vague estimation of disease, but can be used to monitor certain illnesses, recurrent disease, or responses to medications; it is normally in the range of 1020.

Included in the CBC is the WBC or white blood count, which is a measure of many different types of blood cells, as long as they're not red, including polys, monocytes, eosinophils, and basophils. The important thing is that, when there is an elevation of the WBC above the normal range of 3,0009,000, it may mean something's going on, such as infection or acute or chronic disease. Usually, the higher the WBC, the more serious the situation! As an example, in appendicitis the WBC may be anywhere from normal to 14,000 or more; with a ruptured appendicitis, where the appendix has burst and caused peritonitis and severe infection, the WBC may be into the 20,000 range. Certain malignancies can cause marked reduction or marked elevation of the WBC. The WBC level is used to monitor the cancer patient's response to some chemotherapeutic agents. The WBC is one measure of our ability to fight off infection. In patients with AIDS or on chemotherapy, the level may drop below 1000 and place the individual at high risk for severe systemic infections. The CBC also includes the platelet count (see Chapter 18), which should normally be in the range of 200,000 to 400,000/mm3. When levels get below 40,000, then bleeding can occur, and the patient may need platelet transfusions!

Other blood studies also relate to blood clotting. The bleeding time should be about 4 minutes. If it's prolonged, you may have a bleeding problem. The PT and PTT are special measures of coagulation, and all that's important is that PT should be about 1214 seconds, and PTT should be about 45 seconds. Anticoagulants, such as coumadin, will cause the PT to be elevated, and heparin will cause the PTT to be elevated. The physician must monitor these values to make sure that your blood is not too thin when you are taking these medicines.

Urinalysis is another important study and includes measurement of blood in the urine, since normally there should be none; this may indicate lab error, infection, kidney stone, or malignancy. Pus in the urine indicates a urinary tract infection. BUN (blood urea nitrogen) and creatinine (Cr) help us evaluate kidney function with normal BUN about 718 and Cr about 0.20.8.

Bilirubin is one of the breakdown products of blood and measures the ability of the liver to function properly. An elevated bilirubin may mean liver disease, but is also elevated with gall bladder disease when a gallstone is blocking the main bile duct (see chapter on Gall Bladder and Bile Ducts) or when there is leakage of bile after gall bladder surgery. Normal bilirubin is about 0.1 to 1.1, although there are certain people who have elevated bilirubin because of a strange, otherwise asymptomatic disease called Gilbert's disease. Your doctor knows all about these things. Calcium, Ca, and phosphorus (P) are important chemicals in bone strength, and Ca is important in blood clotting. The blood levels of these elements are controlled by small glands in the neck behind the thyroid gland called the parathyroid glands. There are several benign and malignant diseases of these glands which may be indicated by an elevated Ca and a lowered P. Also, since Ca is used in blood coagulation, when there has been a lot of bleeding and blood clotting, the Ca level may fall. Normal Ca is 911 and normal P is 24.

Amylase and lipase are enzymes or chemicals in the blood secreted predominately by the pancreas. Elevations of these may indicate pancreatitis (see Pancreas) or inflammation in an organ near the pancreas, such as the liver or gall bladder. Amylase normally is 25125, but may rise into the thousands with pancreatitis and, similarly, lipase, which is normally about 23208, can get as high as 20,000 in active disease.

We have already discussed blood type and crossmatching in Chapter 18. We can get blood samples and obtain specific blood products that a person needs rather than just giving “whole” blood. These products include fresh frozen plasma, platelet concentrate, cryoprecipitate, and other complex blood products that's why we have special physicians called hematologists to sort out the problem.

SGOT, normal level 540, SGPT, normal 756, and LDH, normal 100190, are substances which indicate liver disease. It is a complex subject, and all you need to know is that, when they are elevated, the physician has to determine which of many diseases are present, such as hepatitis, cirrhosis, malignancy, bile duct obstruction or a whole host of other diseases. Alkaline phosphatase, normal range 2090, may be elevated in several diseases but is important as an indicator of bile duct obstruction, either from inflammation, stones, or malignancy. Prostatic acid phosphatase is secreted by certain cells in the prostate gland, and elevation may indicate disease of the prostate, while prostate specific antigen (PSA) may indicate cancer of the prostate gland.

There are hundreds of other laboratory tests that physicians order to help in the diagnosis of disease, and not only blood is used in these tests. We can obtain spinal fluid for infections and malignancies and other diseases of the brain and spinal cord; paracentesis fluid, fluid from the abdomen, to be analyzed for infection, malignancy or chronic diseases; pleural fluid, or thoracentesis fluid from inside the chest for the same type of determinations; and, finally, fluid, aspirated from cysts anywhere in the body for diagnosis, including breast cysts, sebaceous cysts, and ganglion cysts. There are many blood studies for rare metals such as magnesium, zinc, and mercury.

The term C&S refers to culture and sensitivity, when samples are taken of possibly infected areas. The culture part means that the bacteria are grown outside the body on a special plate called a Petri dish in a nutrient called Agar. When the bacterial colonies grow, special laboratory workers can identify the organism, such as staph or strep or T.B. The bacteria is then tested for sensitivity to certain drugs, and a report is then sent to the doctor, indicating the name of the bacteria and the antibiotics that will be most effective in eradicating it.

Other laboratory tests (you have heard about and their normal levels) are: cholesterol <200, serum proteins, albumin and globulin, and blood sugar, 60100. The laboratory can also measure blood and urine levels of many drugs, such as digitalis, chemotherapeutic agents, alcohol, and street drugs. Arterial blood gases (ABG's) measure the amount of oxygen in your blood, and pulmonary function tests measure how much air you can take in your lungs and can determine lung function problems caused by smoking, infection, or other diseases.

Now you have a brief overview of diagnostic laboratory tests—I hope it hasn't been too boring and that it has given you some insight into the adjunctive measures your doctor can use in making a diagnosis.

Chapter 26

RADIOLOGY AND DIAGNOSIS FOR THE SURGEON

I won't go so far as to offer an apology

That surgeons are in bed, so to say, with radiology.

But we are quite dependent on what they can show,

And we're often enamored with that which they know.

You see, to find answers and make diagnoses,

We often need xrays, from head down to toesies.

They get complex angiograms and CT Scans rolling,

Sometimes I'm not sure if they're coming or going.

The surgeon is often deeply indebted to the radiologist for assistance in making diagnoses and for therapeutic radiological procedures. You may think of the radiologist as the physician who just reads chest xrays, but you'd be quite mistaken. These physicians have a huge armamentarium of procedures, involving xray, nuclear medicine, ultrasound, computerized scanning, interventional angiography, inserting catheters into blood vessels for diagnosis, treatment, dilating narrowed areas, placing drains, doing xray guided needle biopsies of the lung, liver, or breast, and magnetic resonance imaging, to name just a few. They have a detailed knowledge of anatomy, pathology, surgery, and medicine and often discuss with the surgeon what studies should be undertaken to make a diagnosis.

I want to describe some of the studies listed above just so you will have a better idea what you're in for should you need their diagnostic and therapeutic acumen.

First, there are the contrast studies of the intestinal tract, such as the upper gastrointestinal and small bowel series, where you swallow a special liquid and the radiologist can examine your esophagus, stomach, duodenum or the first part of the small intestine where ulcers sometime occur, and the entire small intestines. A barium enema is an exam of the lower intestinal tract via the rectum. All these studies can identify benign and malignant pathology, sometimes in anticipation of surgical intervention.

Angiograms are studies of blood vessels using contrast or dye. The uses are extensive, from studying vessels in the brain, to those in the heart. The coronary arteries study is done by cardiologists and may include the aorta, the vessels in the arms and legs and any other organ, such as the kidneys, liver, as well as the veins in the body. When pathology is found, it may need surgical intervention, but in the last twenty years radiologists and other specialists have developed techniques for percutaneous angiography and angioplasty. Catheters are placed through the skin without a big surgical incision, opening up closed vessels, dilating narrowings, placing filters in veins (see Pulmonary Embolism chapter), and saving patients from large incisions in the operating room. These procedures are done in the radiology department under a local anesthetic and often with sedation.

The radiologist has access to special techniques for visualizing the inside of the body, and among these are computerized axial tomography, the CAT scan, and the magnetic resonance imaging, the MRI scan. This complex machinery can reproduce images of your body on a computer screen showing almost every part of your anatomy, and sometimes do it in an almost three-dimensional way. They can see pathology, such as tiny lung, brain or abdominal cancers, abscesses, bowel obstructions, and many other abnormalities. They can also tell when there isn't anything wrong, and that's important for the surgeon also. You may have all the signs and symptoms of appendicitis but, with negative radiological studies, the surgeon may decide to hold off on surgery, and the diagnosis actually may be as simple as food poisoning or gastroenteritis.

Another modality is nuclear medicine. In this field the patient is given radioisotope material, though not radioactive enough to cause any damage, which frequently localizes in a special organ or special tissue, and radiologists are thereby able to make specific diagnoses. Examples are special scans for pulmonary embolism, for thyroid and parathyroid disease, brain tumors, and infections, to name a few. These are painless studies which give the surgeon a lot of information. For example, when I first started in surgery, we often had to spend hours in surgery exploring the neck for a 3 millimeter parathyroid gland tumor. Now the parathyroid scan can often localize the tumor so that the surgeon can find it rapidly, saving the patient extra time under anesthesia and saving the surgeon from getting ulcers looking for a tumor, like a “needle in a haystack.”

Ultrasound is another modality used by the radiologist, where sound waves create an image on a screen. The trained technicians and radiologists can diagnose cysts in breasts, liver, pancreas, or anywhere else in the body, gallstones in the gallbladder and common bile duct (see Gallbladder), and hematomas, seromas, and abscesses. The radiologist can also insert tubes and drains in these cysts, if indicated, using ultrasound, CAT scan, or MRI scan. On numerous occasions, radiologists have inserted drains in intra-abdominal abscesses, saving the patient a complex and difficult operation.

The radiologists have been working hand in hand with the surgeons since the end of the nineteenth century, when Wilhelm Roentgen first discovered the x-ray, and each year new procedures evolve that will continue to aid in diagnosis and, hopefully, simplify procedures for the patient.

Chapter 27

ALCOHOLISM, DRUG, AND OTHER ADDICTIONS AND SURGERY

Yo mamma, would you like a hit?

You won't have to worry the least little bit.

A little vodka, some “bennies” or a “toot,”

'Cause the doc will fix ya up, room and board to boot!

We have a wonderful system, health care for the addicted

Even if your complications aren't fully predicted,

No matter how sick you get, just another refrain,

You can just go right out and do it again.

It's always remarkable for me to know that upwards of 40% of all hospital admissions are related directly or indirectly to drug, alcohol, tobacco, and other addictions. It is a subject rarely well dealt with by the medical schools, residencies, and hospitals. It is a serious problem, and yet it is apparent that less attention is paid to this topic even in the medical texts than to relatively obscure diseases, such as Myasthenia gravis and lupus erythematosus.

With international programs such as Alcoholics Anonymous, Narcotics Anonymous, Smokers Anonymous, and many support groups, and with the individual, nursing, physician, and hospital discharge facilities, we are still sorely lacking in appropriate management of this tremendous problem. Smoking alone is responsible for many thousands of deaths each year from lung cancer.

I mention this topic in a surgical text because so many of my patients have this addiction problem to one degree or another. The availability of treatment programs is far below our needs, and the HMO and insurance companies shy away from the diagnosis and treatment because it is so expensive and the success rate is so poor.

Let us just run down a few of the problems associated with addictive disease:

1. Smoking can cause bronchitis, pneumonia, emphysema, cancer of the throat, mouth, lungs, stomach, esophagus and pancreas leading to extensive surgeries and morbidity, vascular disease leading to bypass surgery and amputations, and heart disease, which may lead to open heart surgery.

2. Alcohol can cause esophagus and stomach cancers, or severe liver disease with liver failure, ascites or fluid in the abdomen, which may require surgery, heart disease, and severe neurological disorders. There are a host of directly related problems due to excess drinking, including auto accidents, spousal abuse and injury, knife and gun wounds, and kidney failure.

3. Drug abuse can lead to sudden death, abscesses, liver failure, and bizarre behavior leading to trauma and death to oneself and to others.

Many of these problems require surgical intervention, and yet the addiction is so strong that the patients keep returning and returning, sicker each time, until the problems compound and they die. It's a massive public health problem, yet the public all but turns its back on it. It has taken over a hundred years to make a dent in the tobacco industry in the last few years and, unfortunately, it may take many years to impact the drug and alcohol problem.

If you or a loved one has an addictive disease, you will understand that these are diseases of denial, unlike cancer of the breast or colon. In spite of a deteriorating life in all areas—professional, social, and economic—these diseases destroy the body, often in a slow progressive fashion.

Wake up America! Get yourself or your family member the help needed; don't just treat the sequelae and symptoms of the disease. Too often the patient will gladly undergo surgery, but balks at taking care of the problem that has resulted in the need for the surgery.

Chapter 28

CONTRIBUTIONS FROM THE SUBSPECIALISTS

It seems in most predicaments,

Someone puts in his two cents,

But if you get enough of tuppence,

Soon you'll have a pound of uppance.

As a surgeon I'll accept,

As much good help as I can get,

So I will get a complete list,

Of every well known specialist.

I want to acknowledge that, as a surgeon, I am continually reliant upon the expertise of a number of subspecialists who have helped me in the diagnosis and treatment of patients over the years. We no longer stand as the independent physicians of the nineteenth century. They were the horse and buggy doctors who visited homes and accomplished their remarkable feats of diagnosis and treatment with only a skeletal outline of what we have today. They often failed, and yet they usually did the best they could with the support and tools they had.

With the twentieth century, we saw the emergence of specialties and then subspecialties of medicine because of the complexity of diagnostics and the vast increase in information and interventional procedures. This gave rise to the surgical subspecialties, as we will see in Part II, and also gave rise to the medical subspecialties, among which are the gastroenterologists, pulmonologists, intensivists specializing in caring for patients in the intensive care unit, oncologists, hematologists, cardiologists, infectious disease specialists, radiation therapists, pain management experts, psychosocial support teams, and many others. I will mention a few of the ways these experts help the surgeon and let your own imagination lead you to understand how invaluable all these physicians are to the surgeon and thereby to the patient.

The gastroenterologist, in addition to his medical diagnostic expertise, uses several types of endoscopes; these are lighted tubes that can be inserted into the intestinal tract through the mouth or rectum. They can examine the stomach and duodenum and the entire colon, identifying lesions, taking biopsies, removing some tumors, checking for recurrence of malignancy and even using special devices to stop bleeding that, in the past, required operative intervention. They give the surgeon more information and thereby help us do our work in a more prepared and educated manner. They can visualize bile ducts and remove stones, obviating the need for most common bile duct surgery. They can place tubes in the stomach through the abdominal wall for tube feedings and are trained in giving total parenteral nutrition (TPN) to support the pre- and post-opera-tive patient who cannot take food by mouth.

The pulmonologists use bronchoscopes to examine the lungs and take biopsies, as well as managing peri and postoperative lung problems from pneumonia, to mucus plugs (mucus that gets stuck in the bronchi or tubes in the lungs, which prevents a patient from breathing adequately), and managing respirators and all pulmonary problems with the latest medications.

We have discussed infectious disease doctors and hematologists in prior chapters. Their contributions to the support team are invaluable. The oncologists manage the cancer patients. Many years ago the surgeons would manage all aspects of cancer therapy, but this is rarely the case today.

So the surgical care of a patient is a comprehensive one, and the surgeon who uses all the help at hand will be doing his patient a great service.

Chapter 29

CHEMOTHERAPY AND RADIATION THERAPY FOR CANCER

It's important that we say enough,

That cancer treatment's sometimes rough.

In this chapter I'll be brief:

It ain't all roses, but it's not all grief!

Let me make it clear at the outset: This is not a book about cancer and cancer therapy. It is about surgery. But many times the patient undergoing a surgery for cancer will have preoperative or postoperative chemotherapy or radiation therapy. I want to give you at least an introduction to what you can expect in terms of side effects and treatment of these side effects.

Their effects and complications must be explained to the patient and a decision has to be made about their use. I have outlined the function of an infusion center, a place where chemotherapy and other medication therapy is given, in my book on “Comprehensive Breast Care,” and outlined the prevention and treatment of side effects, such as nausea, vomiting, low red blood count, white blood count, and platelet count. Chemotherapy is very strong medicine and is designed to kill cancer cells. Unfortunately, most chemotherapeutic agents are not completely and solely specific for the cancer cells and attack and destroy some healthy normal cells during the treatment of the cancer. Of course, the pharmaceutical companies and your oncologists understand this and have to weigh the benefits of the drug with the disadvantages and side effects. Although most of the side effects are transient, such as hair loss, anemia, rash, bleeding possibilities, and tiredness, there are some that may be more permanent. Some of the strongest drugs may have toxicity or injury potential to the heart and the kidneys and even the liver, but, when there is no alternative, these potential problems have to be explained. Complications of chemotherapy include lethargy or tiredness, headache, depression, weight gain, skin changes, mouth sores, tingling of the hands and feet, and others. But remember that some patients develop minimal side effects and the side effects, are directly related to the type of medication you receive and the dosage. In the past few years, there has been tremendous progress in treatment of these side effects with new medication for all but eliminating nausea and vomiting. And there are drugs to increase your blood count. It is beyond this chapter to go into all the side effects and their treatment, but your oncologists will explain this to you in detail prior to starting the treatment. The American Cancer Society has wig banks and “Look Good, Feel Better” programs to help with the changes during chemotherapy, and most good cancer treatment programs have strong psychosocial departments to help the patient cope with the stresses of the disease and the treatment. Every surgeon should make his/her patient aware of all the programs available in any comprehensive cancer program.

Radiation therapy may last for up to eight or ten weeks, usually taking a few minutes each day. The radiation therapist will explain to you about the treatment and the side effects. The one I hear about most frequently is tiredness, and rest is very important while going through this therapy. The other side effects will depend on the area being treated. Skin can develop a sunburn or rash, which may be painful. Abdominal radiation may cause nausea and vomiting, diarrhea, urinary symptoms of burning and pain and, if near the pelvis, can cause rectal pain and vaginal dryness. Radiation to the head and neck can cause pain, ulcers, and irritation to the throat and tongue. Again, the physician will clearly outline the course of therapy, the side effects, and the treatments available, and then you can discuss this with all your doctors and decide if you want to go through with it. I find that most of my patients tolerate radiation therapy very well as long as they understand what is going on and get the appropriate psychosocial support and medications to treat the side effects.

Let us now move on to Part II and an in-depth discussion of the surgical specialties and some of their more common cases.