My submission to USA today on Values

Well ladies and gentlemen, Today I am posting the response I sent to the newspaper USA today regarding American Values. They had requested that people send in a response about the so called "values" issue in the recent November elections (President, Congress, state office, local offices, amendments,etc) and its continuing aftermath. There was a limit of 250 words. So here is what I sent in response.

Dear USA Today

I am a trauma surgeon in a metropolitan hospital. Let me tell you about American values at present. Americans shoot and stab one another too often. Americans drink too much and drive killing themselves and one another. Too many Americans take illicit drugs. Americans commit too much domestic violence. Too many American teenagers get pregnant. Americans commit hate crimes. Americans engage in racial prejudice which kills by neglect, poverty and lack of health care. Americans ignore those who are homeless. Too few Americans are foster parents which is why we have so many battered children. Americans tolerate functional illiteracy. Too few Americans visit lonely men and women in nursing homes allowing diseases of neglect to flourish. Too many Americans who could make a difference by donating money to charity and more importantly donating time and work to worthwhile causes don’t. Americans smoke too much causing early deaths. Americans eat too much. Americans exercise too little. Many Americans speak loudly in words about values. Few Americans let their actions show they care about values. Where are American values headed? Americans are developing a value system which does not believe in the worth and dignity of each human being. Americans are indifferent to the idea that all people have an equal claim to life, liberty, and justice. Americans have a poverty of good works (which are the natural product of good faith). I urge every American who is able to volunteer two hours a week to helping others.

James T. Evans, M.D., FACS

Buffalo, New York

Interesting email

Here is an interesting email I recived with my responses.

From: Tim Barounis

Date: Thu, 02 Dec 2004 17:10:01 -0600

Subject: your blog = JoyofSurgery



Hi Dr. Evans,



I found your blog today and enjoyed reading it. Glad you did.

I'm a 3rd year medical student at Rush and, as a matter of

fact, in the middle of my surgery  rotation right now.

Hope you are enjoying it!

Up until a few months ago, I actually had a blog of my

own - very similar to yours.

Good for you, I heartily approve!!

Where was your blog?

I was forced by the administration (which one?)

to stop doing it because of concerns about revealing

confidential information. Like you, I never revealed

names or other identifying data. But I did discuss,

in frank detail, some of the interesting cases I had seen. 

That is appropriate.

What do you think about this? 

Concern for patient data is everywhere!

Like you, I was not blogging anonymously and I was

asked by more than one person - What if one of your

patients saw your blog and recognized him or herself?

Well the obvious ironclad solution is to have obtained

permission from the patient then there is

no dispute by anyone.

I didn't have a response for them other than  that

I believed what I was doing was both within the confines

of the law  and medical ethics.

I agree.

Do you think there is an ethical question here?

No ethical question whatsoever.

Maybe a HIPPA patient privacy question.

What would you do in my place?

A - either get patient permission or B- transfer my

blog to an area not controlled by administration.

What would you do if hospital administration asked

you to stop blogging?

Explore all my options. Since so many sites such as

Medscape, etc. have message boards which actually

discuss cases, it seems far fetched to be concerned

as long as there is no identifying information.



Also, if you want to share my blog for your surgery

cases we can discuss that.



Tim

Southern Medical Association Surgery Section

Well fellow readers I am off to the Southern Medical Association. I have two presentaions an oral presentaion before the section of surgery and a poster for the general meeting at large.
The oral presentaion is the Soul of the Surgeon : Annotations

Here is the presentation in RTF from the Powerpoint:

The Soul of The Surgeon
• Annotations
• Southern Medical Association,
• Surgery Section
• New Orleans, Louisiana
• Friday November 12, 2004
• James T. Evans ,M.D., FACS
• jamestevansmd@medscape.com


Annotate
• To furnish a literary work with critical commentary or explanatory notes
• From The American Heritage Dictionary, Fourth Edition, copyright 2000.

• http://joyofsurgery.blogspot.com

The World’s Best Known Surgeon
• Author = Alexander J Walt
• Journal = Surgery 1983 Oct:94(4)582-90.
• Presents the case that Henry Norman Bethune should be acknowledged as the world’s best known surgeon.
• Bethune was Mao Tse-tung’s Army surgeon immortalized in “The Red Book”

Most Important Surgical Address
• The Soul of the Surgeon
• By Rudolph Matas, M.D., FACS




• jamestevansmd@medscape.com

The Soul of the Surgeon
• First delivered as the Annual Oration of the Mississippi State Medical Association in Hattiesburg, Mississippi, May 1915.
• Published in the Transactions of the Mississippi State Medical Association.
• Published serially in the Mississippi Doctor
• Published as a limited edition book in 1921 by Touro Infirmary, New Orleans

The Soul of the Surgeon
• Revised, updated, shortened for Dr. Matas’ Presidential Address of the American College of Surgeons Oct 30, 1925 in Philadelphia.
• Printed in the Yearbook of the American College of Surgeons, 1926, p 71-78.
• Reprinted in book form in 1955 and labeled the Third Edition, Including an Introduction by Dr. Matas, himself.

The Soul of the Surgeon
• Portions included in French in address to French Congress of Surgeons 1926.
• Matas’ address was so well received that he was made Honorary President of the French Congress of Surgeons.
• A portion of Matas’ address to the Southern Surgical contained material from The Soul of the Surgeon.

Content and Context
• “I will, therefore, permit myself to indulge in some rambling thoughts on a subject with which, form the very nature of my life-work, I am most familiar, if not best qualified to speak – I mean the Surgeon, or, rather, the Soul of the Surgeon himself.”

Content and Context
• “…the Soul of the Surgeon – if we may define the soul as ‘the ethical and emotional part of man’s nature, the seat of the sentiments and feelings as distinguished from pure intellect’ – is a part of his makeup that is unknown to the masses; and the profound emotions which agitate him and with which he is rarely credited…”

Content and Context
• “But, in the presence of the cynical and grossly material concept of the surgeon’s role in the social fabric, it is only fair that something should be said to prove the baselessness of the charge that he is mercenary, soul-less, indifferent to the fate of his fellows, greedy of gold, and thirsting for publicity and notoriety.”

Content and Context
• “In spite of our modernity or up-to-dateness, we still live in an atmosphere which has not been depurated of all the somber traditions which hang around the memory of practitioners of surgery of past generations.”
• “…unfeeling or cruel, if not actually brutal”
• “…callous heart and indifferent sensibilities

The Soul of the Past Surgeons
• “What we learn by the writings and the teachings of Guy de Chauliac, Ambrose Pare and their contemporaries, their predecessors and successors, is, that the Soul of the True Surgeon has remained ever faithful and quick to the call of pain of humanity, and that the harsh friction incident to his calling, has never, through- out the ages touched or tarnished the surgeon’s motives.”

Names - 1
• 1- Prentiss
• 2- Davis
• 3- Lamar
• 4- Williams
• 5- Chaille
• 6- Pasteur
• 7- Lister

Lamar - 1
• Lucius Quintus Cincinnatus Lamar was born in Putnam County, Georgia, on September 17, 1825, into an aristocratic planter family. He attended Emory College and became a lawyer. He was elected to Georgia State legislature. He then decided to move westward to Mississippi to seek his fortune. He took up residence and opened a law practice in Oxford, MS.

Lamar – 2
• After marriage, he became a faculty member at the University of Mississippi, a position he no doubt secured with the help of his father- in – law, Augustus Baldwin Longstreet, the University President.
• During the Civil War, Lamar formed the 19th Mississippi regiment of volunteers and fought against Union General George McClellan in Virginia.

Lamar - 3
• C.S.A. President Jefferson Davis appointed Lamar ambassador to Russia but he was never recognized since the Confederacy’s sovereignty could not be obtained.
• Lamar returned to Mississippi after the war and resumed both his law practice and faculty position, as Head of the Law Department at the University.

Lamar – 4
• 1872 – elected to Congress, first Democrat since Radical Reconstruction.
• 1877 – United States Senate
• 1884 – Cabinet member Grover Cleveland’s administration.
• 1888 – appointed United States Supreme Court. Authored major decisions for States Rights and limited Federal political power particularly in civil rights.

Names - 2
• 8- Horace
• 9- Bernard Shaw
• 10 -Dr. Chalmers Da Costa
• 11- Zola
• 12- Fecondite
• 13- Gaude
• 14- Napoleon

Horace
• Horace was a Roman poet who lived from 65 to 8 B.C. We call him Horace in English, but to his contemporaries and fellow countrymen he was Quintus Horatius Flaccus. Among his poetry are four books of odes (known in Latin as "carmina"), containing just over one hundred individual poems (103, to be exact). In one of these odes (3.30) Horace bragged that his poetry would live as long as Vestal Virgins climbed the Capitoline Hill in Rome. You won't find any Vestal Virgins in Rome today, but Horace's odes are still read and enjoyed, more than 2000 years after he wrote them.

Names - 3
• 15- Dr. John B. Murphy
• 16- Dr. Charles A.L. Reed
• 17- J.M. Finney
• 18- Dominique Larrey
• 19- Ambroise Pare
• 20- Prometheus
• 21- Pierre de l’Estoile

Finney
• Biography
• J. M. T. Finney, Jr., was born in Natchez, Mississippi. He received his B.S. in 1915 from Princeton University and his M.D. in 1919 from the Johns Hopkins University School of Medicine. He was a surgeon and faculty member at Johns Hopkins, as well as a partner with his father in private practice in general surgery. Finney was a member of several medical associations including the Baltimore City Medical Society, serving as its president in 1950. He was also vice president of the Finney-Howell Cancer Research fund. Finney authored several published papers and delivered a Hunterian Lecture to the Hunterian Society in London in 1949.

Names - 4
• 22- Archbishop of Lyon
• 23- Catherine de Medici
• 24- King of France
• 25- Guise
• 26- Guy de Chauliac
• 27- Conan Doyle
• 28- Juggins
• 29- Archer

Names - 5
• 30- Dr. John Brown
• 31- Dr. Cheever
• 32- Bob Sawyer
• 33- Terence
• 34- Joseph Pancoast
• 35- Velpeau
• 36- Pirogoff

Names - 6
• 37- Gross
• 38- Raphael
• 39- Michael Angelo
• 40- Leonardo
• 41- Murillo
• 42- Faure

Elie Faure
• Faure, Élie 1873—1937, French art historian. Trained in surgery, he brought his scientific knowledge to bear in his study of the history of art, relating it to the progress of human culture. Of his long list of critical and historical works, the best known is his History of Art (5 vol., 1909—21; tr. by Walter Pach, 1937).

Diego Rivera’s La Operacion
Jean-Luis Faure
• Diego Rivera’s sketch La Operacion in Paris in 1920 reflects the skill of Jean-Luis Faure, the brother of Elie Faure. It was this skilled surgeon to whom Matas referred.
• Others might have thought that Dr. Matas’ fabled art collection would have cemented the reference to Elie. However, among Dr. Matas notes is a reference to Jean-Luis as a French Surgeon who performed his aneurysm procedure!

Epilogue - 1
• The life of a surgeon though a hard one, is indeed a beautiful life. Let me repeat reverently these lines from Faure: “When the last hour comes to the conscientious and honest surgeon, no one can lie down to sleep the slumber of eternal night, with greater composure and peace. Happy is he, who, listening to the voice of his conscience, shall hear her murmuring

Epilogue - 2
• In his ear the comforting words which tell him that, whatever his failings and shortcomings, he has done more good than evil; that on this earth, where joy and misery travel side by side, his hands, though blood stained, not unlike those of the Savior, have relieved more suffering than they have caused pain.”

Conclusion
• Rudolph Matas was a genuine scholar, orator, founding member and President of the American College of Surgeons. His lasting contributions to surgery are numerous; however, his lasting fame can be attributed in large measure to his ownership of the world’s most famous surgical speech: The Soul of the Surgeon

• jamestevansmd@medscape.com

Lagniappe
• A famous Louisiana tradition.
• Getting a little extra.




• jamestevansmd@medscape.com

Photo Of Matas

Rudolph Matas
• 1860-1957
• Rudolph Matas was born in New Orleans on September 1, 1860 . In his childhood,
• he spent several years with his family in their native Spain ,as well as France, but returned to New Orleans and in 1877 enrolled in the Medical College of Louisiana, now known as Tulane University .

Rudolph Matas
• In 1879, Matas, a medical student, was chosen to travel with the U.S. Yellow Fever Commission to Havana to serve as laboratory assistant and interpreter.
• There he met Dr. Carlos Finlay, the first to suggest the mosquito as the yellow fever
• vector.
• Matas was, for a time, the sole supporter of the theory.

Rudolph Matas, M.D.
• Matas received his degree in medicine from the Medical Department of the
• University of Louisiana, now Tulane University, in 1880.
• Matas' first landmark paper was published in 1885; in it, he unequivocally defined the cecum and appendix as intraperitoneal organs.

Rudolph Matas,M.D.
• Subsequent milestones include his use of spinal anesthesia in 1889, the first in the United States ,
• his development of the intravenous drip,
• and his use of endotracheal intubation with positive-pressure ventilation to ramatically improve the safety of thoracic surgery.

Rudolph Matas,M.D.
• Matas’ most renowned achievement, however, was his development of the intra-saccular technique for the surgical treatment of aneurysm.
• Previously, surgical treatment of aneurysm was limited to proximal and distal vessel ligation.

Rudolph Matas, M.D.
• Matas' technique, initially an improvisation to control bleeding from a brachial artery aneurysm fed by numerous collaterals, involved opening the sac and obliterating the ostia of the collaterals from inside; it was later refined to preserve the patency of the parent artery in favorable cases.

Rudolph Matas,M.D.
• Matas' career was one of distinction from the outset: at 23 he was appointed director of the New Orleans Medical and Surgical Journal.
• In 1895 he was elected Professor of Surgery at Tulane University, a post he held until he became Emeritus Professor in 1927.

Rudolph Matas,M.D.
• He was also active as surgeon and consultant at Charity Hospital, Touro Infirmary, and the Ear, Eye, Nose and Throat Hospital - all in New Orleans - throughout a long career.
• Matas continued his surgical practice and
• civic and academic pursuits until the age of 92, five years before his death.

Rudolph Matas,M.D.
• Dr. Matas was a pioneer of the first rank in the surgery of the blood vessels, chest and abdomen. His introduction of the suture for the cure of aneurism won him international fame and caused Sir William Osler to hail him as the "Father of Vascular Surgery" and the "Modern Antyllus".
Antyllus
• Antyllus' method :
• An operation for aneurysm whereby is applied two ligatures to the artery and cut between them.

Antyllus
• Antyllus was one of the most important physicians in Greek antiquity, particularly famous as a surgeon. He lived after Galen, but before Oribasius, late third and early fourth century AD. Little is known about his life and his works have been lost, but writings of various authors, particularly Oribasius, Aëtius and Rhazes, enable us to get some impression of him.

Antyllus
• One of the most daring and accomplished of surgeons, Antyllus is particularly remembered for his work on the surgery of aneurysm. He was first to recognize two forms of aneurysm – the developmental caused by dilatation and the traumatic following wounding of an artery.

Antyllus
• Antyllus operated on the eye, did tracheotomies and performed a radical operation for hydrocele. He also gives detailed advice for the operation of tumours, and in a chapter on resection he presents evidence he was a keen and skilful operator.

Content and Context
• Three Themes
• 1 – Economic evils = fee-splitting
• 2 – Peer review and control =
• American College of Surgeons
• 3 – Emotional, ethical, psychological
• aspects of the life of a Surgeon

Content and Context
• “But, in the presence of the cynical and grossly material concept of the surgeon’s role in the social fabric, it is only fair that something should be said to prove the baselessness of the charge that he is mercenary, soul-less, indifferent to the fate of his fellows, greedy of gold, and thirsting for publicity and notoriety.”

Content and Context
• Classification of Evil Surgeons
• 1- Quacks
• 2- Imposters
• 3- Knaves

QUACK
• An untrained person who pretends to be a physician and dispenses medical advice and treatment.
• From American Heritage Dictionary

Quack
• “The quack is a loud-mouthed pretender, a person who seeks to gain confidence by unworthy methods or an individual who claims to have a specific for various disorders of manners, morals, finance, and politics.”
• “Advertises undisguisedly in newspapers”
• From Rudolph Matas’ Soul of the Surgeon

Impostor
• One who engages in deception under an assumed name or identity.
• From American Heritage Dictionary

Impostor – from Matas
• “…regarded as regular practitioners…”
• “…trained in safe methods …”
• “…desecrate their ministry and their art for purely sordid, sinister motives.”
• …see an operation in any and every complaint”
• “…a patient’s pathology shrivel into a negligible quantity when it is discovered that the pocket-book is empty…”

Knave
• An unprincipled, crafty fellow
• From American Heritage Dictionary

Knave from Matas
• “…insanely ambitious for reputation and prestige as marvelous operators…”
• “…allow their vanity to eclipse their reason and their morals…”
• “…multiply one’s successes, with even modest surgical training, by removing healthy organs…”
• “…not included within the …Faculty.”

Fee-splitting
• Classification
• Dr. John B. Murphy
• “57 varieties”
• “…band of looters and outlawed camp followers…”
• “…relaxation of the moral conscience…”

American College of Surgeons
• “The American College of Surgeons was organized with the express purpose of doing away with these very evils of which we have been speaking.”
• “…eliminate commercialism and graft…”
• “… raise the standards of morals, of ethics, and of education…”

Annotated Alice
The annotated Alice:
• Alice’s adventures in Wonderland &
• Through the looking glass
• Carroll, Lewis 18-32-1898
• Tenniel, John 1820-1914
• Gardner, Martin 1914-
• The groundbreaking text which exposed the mathematical puzzles and word riddles.

Prentiss
• Sargeant S. Prentiss was in the flower of his forensic fame. He had not, at that time, mingled largely in federal politics. He had made but few enemies; and had not "staled his presence," but was in all the freshness of his unmatched faculties. At this day it is difficult for any one to appreciate the enthusiasm which greeted this gifted man, the admiration which was felt for him, and the affection which followed him.

Prentiss
• He was to Mississippi, in her youth, what Jenny Lind is to the musical world, or what Charles Fox, whom he resembled in many things, was to the whig party of England in his day. Why he was so, it is not difficult to see. He was a type of his times, a representative of the qualities of the people, or rather of the better qualities of the wilder and more impetuous part of them.

John Chalmers Da Costa
• John Chalmers Da Costa (1863-1933)
• Jefferson Medical College Class of 1885
• John C. Da Costa was the successor to W. W. Keen as the chair of the Jefferson
• Medical College Department of Surgery in 1907 and, in 1910, became the first Samuel D. Gross Professor.

Da Costa
• His skills as a teacher of surgery were unsurpassed, and his Wednesday afternoon clinic in the amphitheater before the combined junior and senior classes became a memorable event. Born on 15 November 1863 in Washington D.C. the Da Costa family moved to Philadelphia when Da Costa was fifteen.

Da Costa
• Da Costa entered the University of Pennsylvania at the age of seventeen where he studied chemistry for two years. He then matriculated at Jefferson Medical College and graduated, as class valedictorian, in 1885.

Da Costa
• In 1887, Da Costa began his academic career at Jefferson Medical College with an appointment as Assistant in the surgical outpatient department and as Assistant Demonstrator of Anatomy. This began an affiliation that would last for over forty years.

Da Costa
• While at Jefferson, Da Costa wrote Modern Surgery, General and Operative (1894) a work that became a classic throughout U.S. medical schools going through ten editions; the last in 1931.
• During World War I, Da Costa served as a junior lieutenant in the Navy and eventually rose to the rank of commander.

Da Costa
• In 1919, Da Costa sailed on the George Washington on a special mission to
• tend to ailing U.S. President Wilson during negotiations for the peace treaty of World War I and the League of Nations.

Da Costa
• But it was Da Costa's lectures in the "pit" that students remembered years afterward. Mixing history and literature into
his lectures, Da Costa was also remembered for numerous pithy aphorisms such as "A surgeon is like a postage stamp. He is useless when stuck on himself."

Da Costa
• Da Costa also held a life-long interest in the Philadelphia Fire Department probably due to his father and uncle's membership in volunteer fire departments. Whenever he could, Da Costa would ride out with the Fire Chief in order to render aid to injured firemen. In addition, he served for over 30 years as surgeon to the Firemen's Pension Fund.

Medical student amazement

Well bloggers, I was on call last night and we had an unusal case of multiple neck lacerations = 21 in total wtih a cumulative length of 49 cm. The third year medical student on call was "amazed" that such a wound could be self-inflicted. We spent time in the OR doing the appropriate exploration of a zone 2 neck wound and then multi-layered repair. It is always refreshing to realize that what we do as surgeons can be viewed as amazing by those who do not regularly deal with the challenges of the surgical area. JTE.

ACS Clinical Congress

Well fellow bloggers, I am at the 90th Clinical Congress of the American College of Surgeons. The meeting seems better organized than in previous years. Also, being in such a large convention center makes the meeting seem roomier. No problems from the fire marshall like in S.F. Well, the idea of the Sunday convocation seems to make much more sense than having it on Thursday. The exhibits are as good as usual. Some very interesting sessions so far. The session on the surgeon and the law was quite good. Today I went to the session put on by the informatics committee. There is really great potential for the college in this arena; especially for education. The scientific posters were a pleasant surprise now that they are being reviewed rather than just accepted automatically. Another session I attended was by the program committee on tissue adhesives. This was a very well done scientific session. Also, went to the Scudder oration by Richardson. He obviously had fun doing the review, but I was shocked that he omitted any mention of the hemostatic products such as fibrin sealants. Anyway, two more days to go then back to work. JTE.

Ruminations of an Immediate Past President

Tonight was my first meeting of the Buffalo Surgical Society as the immediate Past President. I sat at the table with the current President and Secretary and two other past Presidents. The needs of the organization continue to be very challenging. The pleasure I felt at knowing that I had done a good job as President for the past year was significant. What gripped me most was the sense of history which seemed so strong as I reminisced with Dr. Leonard Berman about the Society's great traditions. The pre-dinner "cocktail" hour was most interesting as there were no cocktails just wine, beer, and soda. Clearly a reflection of the ever changing landscape of rising costs and diets. The presentation by Dr. Vasquez was very good as it represents "a good model' as so eloquently described by Dr. Dayton, the Department Chairman. However, from the salad on thru the dessert, the conversation turned to politics. The upcoming election seems uppermost on everyone's mind, not so much the election itself as what it is coming to represent as a "sign of the times". Everyone is worried and not about the same things. There seems to be more than enough worries for each person to have his own and then some. There was one unanimous feeling = everyone hates the War in Iraq. After that, the diversity begins. One person is overwhelmed by the deficit run up by Bush's administration. He fears for his children and grand-children as he knows based on his children's current employments that they will never do as well as he has done financially. More about this meeting later. JTE.

Toxic Success and the Mind of a Surgeon

Well folks, today I have decided to discuss a journal article of the listed title. It is from the August 2004 Archives of Surgery. The author is Paul Pearsall, Ph.D. It is an invited lecture from the 75th Annual Meeting of the Pacific Coast Surgical Association. Pearsall lists two of his own books in the references for the article. The guy is a real self-promoter. Just check out his website paulpearsall.com. He has no fear of talking about something with which he is relatively unfamiliar = his own quote from the article "My admittedly limited number of interviews of surgeons..." He clearly ascribes to the theory of when you have no data try to feed the suckers baloney. I suspect the real problem with Pearsall is that he is infatuated maybe even addicted with being a "peddler" and what he peddles is pablum. I also suspect he has "Dr. Phil envy". I chalk this up to being just another pop psychology piece. The sad part is that it found its way into a peer reviewed surgical journal. Hope others who happen to have read this article will comment; however, if you have not read it don't waste your time doing so. JTE.

It is comments like this found in a recent comment to a post on this blog that keep me excited about continuing with the effort.

"wow, that's pretty interesting.I'm actually a medical student, and been considering to do neurosurgery in life later, so I was quite amused and glad to bump into this blog. Giving me -you can say- another side of the life of a surgeon/doctor.Wish there were more blogs like this around"

I wish there were more people willing to add to this blog! I have offered the possibilty of co-authorship to others, but am still waitng for any takers.
JTE

Tie Experiment
Well folks - here is the description of my tie experiment.
What tie experiment you say?
The Christmas tie experiment!
Hypothesis = people will notice Christmas ties worn in August and September and make outrageous comments.
Materials and Methods - for 5 consecutive days (August 30 - September 3) a different Christmas tie was worn to work, shopping, restaurants, etc.
Estimated number of persons viewing a grown man wearing a Christmas tie in August/September = 1000+
Results - exactly one person recognized that it was a Christmas tie.
Several people stared at the tie but did not comment.
Possible explanation - their brains refused to process the concept of a Christmas tie in the Summer!!
Null hypothesis just plain out the window.
No statistics needed!!!!
So, what an interesting comment on the seasonal control over brain processing.
JTE.

Funny Clinic Story. As many know, clinics in large urban teaching hospitals are filled with interesting stories. My weekly surgery clinic is on Tuesday. Here is a story from yesterday. One of my assigned medical students went in to do a work up on a new patient with a complaint of a hernia. I reviewed the history and physical with the medical student and she reported that as part of the past history the patient reported being "bipolar". I reviewed the outpatient chart and then checked the EMR. There was no previous documentation of this disorder. So I went in to see the patient with the student. I said to the patient, your student doctor has reported that you have given a history of being bipolar. Could you tell us where the diagnosis was made? The patient very matter of factly replied. "Oh, my mother is bipolar and I took her medicine and felt a lot better. So. I am bipolar just like my mother!" As Dan rather says - "we don't make this stuff up folks!" JTE.

Complications in Surgery. Every surgeon has experienced complications from doing a surgical procedure. Dr. James Hardy even wrote an entire book entitled complications in surgery. The question I want to address today is not a specific complication, but how does a surgeon feel when a complication arises following a surgical procedure which he has performed. Generally, it seems to me that most of us surgeons put on our intellectual hats and recognize that complications do occur. Most often we view it as a continuation of the disease process. However, what about those times when it does not seem related to the disease process. What about when those nagging thoughts of doubt come creaping in "did I do something to permit the complication to happen?" Surgeons are not able to function optimally if constantly confronted by self-doubt. The emotional safety net is to simply acknowledge complications as part of the activity of doing surgery. However, when complications do occur, I believe the usual emotional response is to feel angry. Angry that we are not so much in control as we would like to think and that even with meticulous attempts at hemostasis, hematomas occur; even with careful attention to anastamotic technique, leaks occur, etc. The anger arises out of a sense of helplessness to control the ultimate outcomes of our own physical performances. How great was the insight of Ambrose Pare, the father of modern surgery, who so carefully summed up his surgical endeavors = "I only put on the bandages, God does the healing." So often, we tend to forget that the natural and Divine forces with which we contend far exceed our mortal powers. Looking forward to some responses. JTE.

Work Rules & Ethics. Today's entry has to do with the current work rules and ethics. As everyone knows the State of New York years ago imposed the 80 hour work week for residents in training. This 80 hour work week has now been expanded to the entire country by the ACGME through its power over the RRC's. Anyway, the crux of the matter is that sometimes the question of the letter of the law is sometimes difficult to keep. I had an interesting discussion with a couple of Chief residents who confided in me that they are being as careful as possible to obey the rules but that on occasion they don't; mostly they overstay the limit (particularly on the go home early day) to get to do index cases. Anyway, they are advocating a "don't ask, don't tell" approach. I was never sure where that concept came from when I first heard it with regards to homosexuals in the Armed Forces. I suppose I need to dig a little deeper in to the ethical considerations; however, when I pressed the point, the residents likened it to "a tree falling in the woods". As for my part, since it seems that the system is really like the "honor code" used in college to foster honesty in test taking, I am certainly not going to infringe on the honor of the residents. And since like many trauma attendings my work week almost always execeeds 80 hour, I can not say well follow my example. It will be interesting to see if anyone studys the long term effects of this 80 hour rule. That's all for now. JTE.

Well, today I have decided to enter a post on my teaching experiences with residents in the OR. Today, I had three cases.
The first case was a severe case of infected anal condyloma. I used the CO2 LASER as is my usual custom in such cases. I had the opportunity to explain about the LASER in general and the use of the various power settings in particular. The concept of understanding power settings in Watts and what that means as you use the instrument is not so easy to communicate. My second year resident was able to do some of the case satisfactorily.
The second case was a straightforward case of excision of a sebaceous cyst.
The third case was a very obese man with an umbilical hernia. This case presented an opportunity to teach several important operative techniques. First, the principle of incision design for optimum exposure. Second, the use of well directed blunt dissection to seperate hernia sac from desmoplastic reactive tissue.
Well this concludes my log of teaching entry. JTE.

Hello colleagues, residents, students, friends and guests. Well I guess you are wondering why there has been such a long absence. Well here is the answer. I fell victim to one of the occupational hazards of being a surgeon. I sustained a needle stick in the OR while operating on a patient who was positive for HIV as well as Hepatitis C. I have just recently finished my prophylaxis with the triple drug cocktail for prophylaxis. Let me give you a first hand report. The drug regimen is a real wipe out. What side effects did I suffer = nausea, constant abdominal pain, weakness, tiredness, and headache. So let me remind everyone to always be careful about OR needle safety. The critical opinion question you are all wondering about is when will you know the outcome. Well folks it will be a very long year. However, now that the drug part is over, I am definitely feeling better. So, I shall very soon be back to my regular postings here on the Joy of Surgery. All my best. JTE.

This entry is a result of some "over the OR table talk". While operating the other day I asked my medical students and residents if they knew who Albert Schweitzer was and what he was famous for doing. To my shock, none of them knew. So I am posting a brief bio of Schweiter here; mostly to remind me to keep telling others about him.

Born on January 14, 1875 in a country village in Alsace (then part of Germany; later part of France), Albert Schweitzer was the son of a Lutheran pastor. A little-known fact is that Jean Paul Sartre was Schweitzer's cousin. Because of the difference in their ages, Sartre referred to him always as "Uncle Al."

From an early age he showed a passion and talent for playing the organ, and was accepted as a pupil by some of Europe's finest professionals. He later went on to become the world's leading expert on organ building. In 1893, Albert Schweitzer began his studies at the University of Strasbourg, receiving a Doctorate in Philosophy in 1899; his studies also took him to the Sorbonne and the University of Berlin. Later that year he was appointed to the pastoral staff of St. Nicholai's Church in Strasbourg. In 1900 he obtained an advanced degree in theology, and within the next two years was appointed principal of St. Thomas College in Strasbourg, Curate at St. Nicholai, and to the faculty in both theology and philosophy at University of Strasbourg. Along the way, Dr. Schweitzer published several books on theology, including the most famous, The Quest for the Historical Jesus, as well as books on Kant, perhaps the definitive biography of Bach, books on organ building, and others.

Schweitzer had always felt a strong yearning towards direct service to humanity. In 1904, he came by chance upon an article in the Paris Missionary Society's publication indicating their urgent need for physicians in the French colony of Gabon. [The following and all subsequent quotes are from Schweitzer: A Biography (1971), written by George Marshall and David Poling (published by and available from The Albert Schweitzer Fellowship)]:
"Of all the hundreds of young men and women who read this piece, none could have been more affected than Albert Schweitzer. When he had finished the article, he put the magazine aside and quietly began his work. But his search was over. He saw his time and place; his future, his life, took clear shape... Schweitzer reached the point of view that atonement for the wrongs that the Christian -- the white man -- had done to underdeveloped peoples -- the black man -- was in itself a justification for missions. The following Sunday the sermon he preached included these words: 'And now, when you speak about missions, let this be your message: We must make atonement for all the terrible crimes we read of in the newspapers. We must make atonement for the still worse ones, which we do not read about in the papers, crimes that are shrouded in the silence of the jungle night.'... Later he wrote, 'Our institutions are a failure because the spirit of barbarism is at work in them... Our society has also ceased to allow to all men, as such, a human value and a human dignity; many sections of the human race have become merely raw material and property in human form.'

"The first major moves began on October 13, 1905, when he posted some letters to his parents and certain close friends, informing them that at the beginning of the winter term he would enroll as a medical student. His destination was to be Africa. His profession would not be music or philosophy or theology, but the practice of medicine... The reason he desired to study medicine he explained as the desire 'to work with my hands... For years I have been giving myself out in words' but 'this new form of activity' would not be merely talking about 'the religion of love, but actually putting it into practice.'

"Shock, puzzlement, and alarm were the first responses to those letters. The faculty of St. Thomas was stunned. The administration officers felt that he had made a serious mistake in his decision and expressed their disapproval. Friends around Europe could not accept it either and wrote him of their immediate, strenuous objections. ...Schweitzer's father could only express disappointment. The family suggested that the whole enterprise was foolish. They could not conceive that he could bury his life and his talent in the jungle while there were others who could easily take the Congo assignment... A lady friend told him that he could do much more for the Africans by lecturing on the need for medical assistance... What irritated Schweitzer more than anything else was the unexpected shallowness and conservatism of so many Christian friends and acquaintances... Schweitzer was to remember the struggles and the letters of protest and scolding... Only Helene Bresslau [at the time, a close friend] understood and supported him... When Schweitzer arrived at the medical school administrative office, he created a sensation. He recalled the occasion with these words, 'When I went to Professor Fehling, at that time dean of the medical faculty, to give my name as a student, he would have liked best to hand me over to his colleague in the psychiatric department.'"

Despite all the resistance and protestations he encountered, in January 1905, at the age of 30, Albert Schweitzer began his studies in medicine, receiving his degree with a specialization in tropical medicine and surgery at the age of 38. What he had not anticipated was that, even though Dr. Schweitzer had rearranged his life to meet the most urgent need expressed by The Paris Missionary Society, they turned him down! On the basis of his theological views, Albert Schweitzer, minister and now physician, was rejected by the Society on the grounds that "it would only intensify their problem by encouraging intellectuals and freethinkers who could only disrupt the mission enterprise and confuse the natives with their theological improvisations... They were not about to sponsor Schweitzer and open the floodgates to other liberals and radicals." Today, we would characterize the Paris Missionary's view of Albert Schweitzer as a person who was "politically incorrect!"

Yet, as Marshall and Poling have characterized it, "he was learning that controversy could not destroy him. Delay him, yes, but not defeat him... He would return to the Paris Missionary Society not as a beggar soliciting support but as a self-sufficient doctor offering his professional services. They, not he, as he saw it, would have a chance to redeem themselves; there would be another confrontation with the Society." Helene Bresslau, by now Dr. Schweitzer's wife and a trained nurse, "eagerly joined her husband in a program of fund-raising to supply a hospital and underwrite the expenses for its first two years. They compiled lists of friends who might help... And if they could successfully raise the money, they could tell the Society that it would cost them nothing... Their list of names expanded... For eight years he had studied and prepared for his journey. He had resigned from his academic posts, canceled long-term concert and lecture contracts and was totally dependent on a small band of friends for help. Only their love, support and encouragement made it possible for him to go forward... 'Thus,' he later wrote, 'on the understanding that I would avoid everything that could cause offense to the missionaries and their converts in their belief, my offer was accepted with the result that one member of the Committee sent his resignation.'"

In March 1913, Dr. and Mrs. Schweitzer left for Africa to build the hospital at Lambaréné in the French Congo, now Gabon. They began their health care delivery in a chicken coop, and gradually added new buildings, so the hospital now treats thousands of patients.

The rest of Schweitzer's life experiences and history have literally filled many volumes. One year after their arrival at Lambaréné, World War I broke out. Because of their German citizenship, the Schweitzers were enemy aliens in the French colony. From the first prisoner of war camp in the Pyrenees, they were taken to a camp in St. Remy. Here, Schweitzer had odd feelings of déjà vu, feeling as though "he knew the room from some past experience. He could not lay his finger upon his strange sense of acquaintance and intimacy with the room, and began to wonder if he was losing his mind... Then awoke one night, the mystery solved: a Van Gogh picture glowed in his mind's eye... he remembered the Van Gogh drawing of which he had vaguely been thinking and recalled that the tortured artist had once been confined for a mental breakdown in the south of France. Upon inquiry in the morning, he learned that the building had previously served as a mental institution and was indeed the very same building where Van Gogh had spent four miserable, hopeless months before his suicide."

In 1918, Albert and Helen returned to Alsace, where their daughter Rhena was born on January 14, 1919. In 1920, he was invited to give a lecture in Sweden and there he described how, while being rowed up the Ogowe River from Lambaréné, his search for an expression of his philosophy was answered: "There flashed upon my mind the phrase Reverence for Life." "Man's ethics must not end with man, but should extend to the universe. He must regain the consciousness of the great chain of life from which he cannot be separated. He must understand that all creation has its value... Life should only be negated when it is for a higher value and purpose -- not merely in selfish or thoughtless actions. What then results for man is not only a deepening of relationships, but a widening of relationships."

But when he returned to Africa in 1924, Helene Bresslau Schweitzer and Rhena stayed behind in Europe. Helene, to her sorrow, was not well enough to accompany her husband. However, they corresponded frequently. Rhena saw little of her father during her childhood, but when her own children were grown, Rhena acquired technical lab skills and left for Africa to serve with her father. Dr. Schweitzer asked her to take over the role of Administrator of the hospital after his death, and when he passed away at the age of 90, Rhena did fill that role for many years. Subsequently she married an American doctor volunteering at the hospital, Dr. David Miller, and lived with him in rural Georgia until his death in 1997. She remains active in and devoted to the interests of her father, and, among other projects, prepared for publication the numerous letters exchanged by her parents during the ten years prior to their marriage in 1912.

Dr. Schweitzer's fame became increasingly widespread over the years, and many journalists and other curious people flocked to Lambaréné to see him in action. But even -- perhaps especially -- here his ingenious individuality asserted itself. Dr. Schweitzer was frequently known to say that "everyone must find his own Lambaréné." He formulated what he lived in the words, "My life is my argument." In 1953, at the age of 78, Dr. Schweitzer was honored for his humanitarian work with the Nobel Peace Prize for the year 1952. After he received the prize, although all his life he had avoided becoming engaged in politics, Dr. Schweitzer was profoundly disturbed by the development of nuclear weapons following the bombing of Hiroshima/Nagasaki. Thus, with the urging of many friends, he studied the issue and in 1957 he issued a worldwide public appeal, "A Declaration of Conscience." Schweitzer published this with two subsequent appeals in 1958 in his book, Peace or Atomic War?, which remains as relevant and compelling today as it was 34 years ago, given the proliferation of nuclear weapons since that time.

One perhaps little-known aspect of Dr. Schweitzer's personality was his sense of humor. To cite just two examples of many: Once, in the middle of a banquet in his honor, Dr. Schweitzer was being pestered to the point of harassment by a journalist who simply did not understand the philosophy of Reverence for Life and repeatedly demanded that Dr. Schweitzer elaborate it for him. "Finally he said, 'Reverence for Life means all life. I am a life. I am hungry. You should respect my right to eat.' With that, he excused himself and returned to the banquet." The second example deals with a very common faux pas which it may surprise you to learn that Dr. Schweitzer was well aware of. "He reported... that once he was traveling on a train in America when two girls came up to him and asked: 'Dr. Einstein, will you give us your autograph?' 'I did not want to disappoint them,' he said, 'so I signed their autograph book: Albert Einstein, by his friend Albert Schweitzer.'"

Physician, lover of animals, minister, scholarly theologian, environmentalist (Rachel Carson dedicated her seminal work Silent Spring to him), musician and musical scholar, anti-nuclear activist, philosopher, husband, father, friend -- these are the many facets of Dr. Albert Schweitzer. Today, although in some quarters history is already painting him as a controversial figure, and several different "ism's" are being attributed to him, one fact remains immutable: In the words of his friend Albert Einstein, Schweitzer "did not preach and did not warn and did not dream that his example would be an ideal and comfort to innumerable people. He simply acted out of inner necessity."

Albert Schweitzer died in Lambaréné several months after his 90th birthday the 4. September 1965.


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© Association Internationale de l'Oeuvre du Docteur Albert Schweitzer de Lambaréné (AISL)

Well, This is another entry in the Joy of Surgery Blog.
This note will focus on my thoughts about medical students and career choices. I will once again repeat my oft given advice to students.
"Life is too short to do something you don't like."
"In choosing a field of specialization in medicine, the wrong choice will make it the shortest life you can imagine."
The trigger for this entry is an article passed out at our departmental leadership meeting. The article is entitled "How medical students define surgical mentors"; appeared in The American Journal of Surgery 187 (2004) 698-701. The survey research was done at University of Utah.
I guess the first thing that struck me about the article was the authors declarative statement under methods = "No definition of the term [mentor] was provided so the definition was open to student interpretation." From my perspective this almost renders surgical mentorship equivalent to pornography. "I can't define pornography, but I know it when I see it." Probably the most often quoted comment ever by a Justice. The next most interesting comment was that 84 of 98 students were able to identify at least 1 attending mentor. So what we have here my friends is a class of third yaer medical students in which more than 15% of the students could not or would not identify 1 attending surgeon. In reflecting on this statement of the inability of medical students to name an attending, I am reminded of how often over the years I have had individuals approach me at medical meetings, charity events, social or political occasions, even airports, and address me by name and then go on to identify themselves as someone who was a third year clerk on surgery under my tuteledge. The majority of the time they did not go into the field of surgery yet they clearly remembered me. I suppose I have considered this remembrance of me as an attending in surgery to students most striking when reported to me second hand. My youngest son, a tennis pro at a famous Southern tennis resort on more than more than one occasion informed me that he had students in his tennis university stroke and drill classes who had been students at a medical school where they were third year clerks and remembered me. So now I am pondering the difficult question - was I a positive or megative role model? Guess I would have to do a survey to find out. Now for the question of relevancy - do I really want to know? Not really, because the survey would have no impact on the fact that I love surgery. So. Looking for comments here. JTE.

Here is a note from the Professor and Chairman of Surgery, Department of Surgery, University at Buffalo.

Subject: RE: website
From: "Dayton, Merril" Add to Contacts
Date: Wed, May 12 2004 11:42:57 AM -0400
View Message Source Print View

Jim,
I enjoyed reading your contributions to the Joy of Surgery. How
refreshing to hear from a surgical practitioner who actually enjoys what he does. I get so weary of hearing from the "Whiners", the "Financilly Disadvantaged", the "Surgical Revisionists", and the "Early Surgical Retirees" who find no joy in what they do. While there are some aspects of our noble specialty that have changed, there are others that never will: the profound reward in seeing suffering alleviated, the great friendships born out of helping others resolve health crises, the sheer fascination of the human body and its systems, the intellectual challenge of a difficult diagnostic dilemma, the pleasure of seeing residents and medical students "see the light" and become real "healers", the joy of life-long learning, applying new advances in surgical care to our own patients, and the triumph
of surgical intervention over cruel disease. For those who went in to
medicine for the right reasons, I suspect much of the joy remains. It
certainly does for me. Sometimes I consider myself one of the luckiest men on the face of the earth to be able to do what I do on a daily basis. I hope the fun never abates. Count me as on who still considers it a privilege and honor to be a surgeon. My life is full and deeply satisfying because of what I do.

Best wishes,

Merril

Hello Folks, Well it has been a long two weeks but the entirely new Blogger website with all it's new and improved features is up and running. If there is anyone who wants to start a blog - it is now very easy. JTE.

Just a note about the discussions at today's m&M conference; a main teaching point was use of radiocontrast media. As usual I was prompted to check fro recent articles. Here is one of the best I found.
Comments are welcome on this topic.
JTE.
Chapter 32. Prevention of Contrast-Induced Nephropathy
Lorenzo Di Francesco, M.D.
Mark V. Williams, M.D.
Emory University School of Medicine
Background
Radiocontrast-induced nephropathy (RCIN) represents an increasingly common cause of treatment-related renal failure1-3and increases mortality independent of other risk factors.4 Major risk factors for RCIN include chronic renal insufficiency,2,3,5 diabetes mellitus2,3,5 (especially when accompanied by renal insufficiency1), any condition associated with decreased effective circulating volume,6 and use of large doses of contrast media.2,3,5,6
For at-risk patients, clinicians must use their judgment to determine if imaging modalities that do not involve contrast media are an acceptable alternative to contrast studies. In many cases, however, such alternatives do not exist. Moreover, RCIN occurs in patients without obvious risk factors. Thus, strategies for reducing the incidence of RCIN include not just risk factor identification, but modification of these risk factors, choice of contrast media less likely to cause RCIN, and administration of therapeutic agents that further reduce the risk of RCIN.
Practice Description
The specific practices reviewed in this chapter are:
Use of high versus low osmolar iodinated contrast media to prevent RCIN.7
Use of a standard intravenous or oral hydration protocol for patients with risk factors for RCIN.8-10 Typical intravenous protocols evaluated consist of normal saline administered at 75 mL/hr beginning at 12 hours before and ending 12 hours after the procedure. Oral protocols require ingestion of 1000 mL of water during the 10 hours prior to the procedure, followed by intravenous normal saline at 300 mL/h for 30-60 minutes and continued for a total of 6 hours after the procedure.
Use of a standard hydration protocol supplemented by pretreatment with theophylline11-15 (various doses and schedules).
Use of a standard hydration protocol supplemented by pretreatment with N-acetylcysteine16 (600 mg bid one day before and day of procedure).
Single studies evaluating atrial natriuretic peptide, prostaglandin E117 and captopril18 were not reviewed, as the data are too preliminary, despite findings that suggest a reduction in the risk of RCIN. Although the evidence supporting the use of N-acetylcysteine largely comes from a single study as well, we do review this practice because the study was large, published in a prominent journal, and has received considerable attention among clinicians.16
The use of calcium channel blockers in preventing RCIN was not evaluated, as the existing literature predominantly indicates the practice is ineffective.19-23
Prevalence and Severity of the Target Safety Problem
While definitions of RCIN vary, most study definitions include a 25% increase in serum creatinine (SCr) and/or at least a 0.5 mg/dL increase in SCr within 48 hours of contrast administration. Using this definition, one large community-based study of 1826 patients undergoing invasive cardiac procedures reported a rate of RCIN of 14.5%.2 A controlled prospective study of the onset of RCIN after contrast-enhanced brain CT found an incidence of 2.1% in low-risk patients without diabetes mellitus or chronic renal insufficiency versus 1.3% in a similar control group that did not receive any contrast (p=NS).24 In comparison, patients in a prospective controlled study undertaken to determine the risk of nephrotoxicity from contrast radiography in patients with diabetes and renal insufficiency (SCr >1.7mg/dL) found a 9% incidence of RCIN.1
The cumulative effect of multiple risk factors increasing the risk of RCIN was demonstrated in one uncontrolled study that evaluated the effect of 5 factors (contrast volume >200 mL, albumin <3.5 g/L, diabetes, serum sodium <135 mmol/l, SCr>1.5 mg/dL).3 When all risk factors were present the risk of RCIN was 100%, compared with just 1.2% when none were present. While most patients with RCIN suffer little morbidity and recover to near baseline renal function within 7-10 days (and thus we characterize it as a Level 2 outcome), rare patients require temporary dialysis. Two studies suggested that the development of RCIN may lead to longer lengths of stay8,11and one large retrospective study showed that hospitalized patients who develop RCIN had a mortality rate of 34% compared with 7% in control subjects, even after controlling for underlying co-morbidities.4 The development of RCIN appeared to increase the risk of death from non-renal causes such as sepsis, bleeding, respiratory failure and delirium.
Opportunities for Impact
Few studies have rigorously evaluated current practice patterns among radiologists or cardiologists with respect to evaluation of a patient's threshold creatinine prior to ordering contrast procedures. One survey study of academic and private practice radiology departments found that only about 20% of practices routinely obtain serum creatinine levels before contrast administration.25 Interestingly, when patients were known to have a high-risk condition like diabetes, approximately 60% of the same practices would require a serum creatinine before contrast administration. Therefore, many high-risk patients are not identified prior to undergoing contrast radiography studies. In addition, no studies have evaluated the frequency with which physicians recommend pre-hydration for patients prior to contrast studies. Overall, physicians and institutions do not follow a consistent practice in screening patients for risk factors for RCIN prior to the use of contrast radiography. If rigorous evidence identifies patients at risk for RCIN, and effective, standardized preventative measures are developed and implemented, there is substantial opportunity to reduce morbidity.
Study Designs
The literature on strategies for preventing RCIN includes: one meta-analysis evaluating the nephrotoxicity of high versus low-osmolality iodinated contrast media,7 one randomized controlled study of pre-treatment with acetylcysteine16 for high-risk patients, one randomized controlled trial of pre-treatment with prostaglandin E117 for high-risk patients, and 5 randomized controlled trials assessing the impact of theophylline11-15 in preventing RCIN. Unfortunately, each of the studies of theophylline employed different routes and dosages (and, in fact, one of the studies used aminophylline, rather than theophylline). Table 32.1 summarizes the salient features of these studies.
One randomized trial compared inpatient versus outpatient hydration regimens,26 but we found no randomized controlled trial that evaluated pre-hydration versus no hydration. Thus, support for the standard use of pre-hydration to prevent RCIN is extrapolated from randomized controlled studies of saline versus saline plus additional pre-treatment agents like mannitol, furosemide and dopamine8-10 and smaller observational studies6,27,28 evaluating the benefits of pre-hydration.
Study Outcomes
Studies evaluated Level 2 outcomes, primarily by measuring changes in serum creatinine, creatinine clearance or glomerular filtration, and assessing the frequency of developing acute renal failure after radiocontrast infusions. Most studies defined RCIN as a 25% increase in creatinine and/or at least a 0.5 mg/dL increase in serum creatinine within 48 hours of contrast administration.
Evidence for Effectiveness of the Practice
All of these studies (Table 32.1) evaluated the effects of various prophylactic measures to reduce the incidence of RCIN. Use of low-osmolar contrast media was supported by one large meta-analysis 7 that compared low versus high osmolar contrast media. Low osmolar contrast media was found to be less nephrotoxic than high osmolar contrast media, with an odds ratio for RCIN of 0.61. Among patients with baseline renal insufficiency (SCr >1.4 mg/dL) the odds ratio of developing RCIN was 0.5 if low osmolar instead of high osmolar contrast media was used.
As previously noted, no randomized controlled trials have evaluated the efficacy of pre-hydration versus no pre-hydration. Data from 3 randomized controlled trials8-10 using pre-hydration versus other pre-treatments and pre-hydration revealed that pre-hydration alone was equivalent to pre-hydration and low dose dopamine or mannitol,8 and, in one study, superior to pre-hydration and furosemide.10 The incidence of RCIN in patients with SCr >1.6 mg/dL or creatinine clearance <60 mg/min treated with pre-hydration alone undergoing cardiac catheterization was 11%; excluding the patients with SCr >3 mg/dL, the incidence was only 4%.8 One retrospective, observational study of high-risk patients undergoing cardiac catheterization supports the benefit of pre-hydration (>500 mL of 0.9% NS in the pre-catheterization period, p≤0.01) in reducing RCIN.6 In addition, 2 observational studies without controls27,28 showed that pre-hydration in high-risk patients was associated with low rates of RCIN, although one of these studies27 used a stricter definition for RCIN (increase in BUN by 50% or 20 mg/dL, and/or increase in SCr of 1 mg/dL within 24 hours).
A recent study of the oral antioxidant acetylcysteine in combination with pre-hydration in high-risk patients with renal insufficiency showed significant protective effect against RCIN versus pre-hydration plus placebo.16 This protective effect appeared to be even more significant among patients with more advanced renal dysfunction and SCr >2.5 mg/dL. The overall relative risk reduction of 90% observed in this study is so large that it raises the possibility of some sort of bias or other explanation for the observed results. Additional studies of this practice would be valuable, despite the safety and low cost of N-acetylcysteine.
Studies employing theophylline are more controversial. Three randomized control trials showed a significant protective effect of various dosages and administration routes of theophylline among low-risk patients with relatively normal baseline renal function.12-14 All 3 studies showed theophylline to be protective against a decrease in glomerular filtration rate (GFR) or creatinine clearance (CrCl) after contrast administration. On the other hand, 2 studies conducted in high-risk patients with renal dysfunction showed no effect for theophylline in reducing RCIN.11,15 Thus, insufficient evidence supports the use of theophylline as prophylaxis against RCIN in high-risk patients.
Potential for Harm
The impact of a system to identify high-risk patients prior to contrast radiography and implement aggressive prophylactic measures to reduce the incidence of RCIN has not been studied. While most patients will not experience any harm from contrast, the potential for "harm" due to delayed or cancelled investigations may be greater than the harm prevented by screening for risk factors, aggressive hydration, or use of particular pre-treatment regimens.
Costs and Implementation
At least 4 studies have evaluated the cost-effectiveness of low-osmolality versus high-osmolality contrast media.29-32 In all 4 studies, the selective use of low-osmolar contrast media was more cost-effective than its universal use because of the overall small benefits were outweighed by the considerable increased institutional costs. Alternatively, a standardized system to identify high-risk patients and implement the simple prophylactic treatment of pre-hydration would diminish the frequency of the target problem. It would require collaboration between the patients' own physician and the personnel performing the particular contrast study (radiology department, radiologist, diagnostic/interventional cardiologist). This type of intervention could be implemented as part of a hospital-based pathway (see Chapter 52) targeted at reducing radiocontrast-induced nephropathy.
There are no cost-effectiveness or feasibility studies that evaluate protocols for aggressive identification of high-risk patients undergoing contrast radiography and utilization of standardized hydration protocols to reduce RCIN. Two studies suggest most patients with normal renal function (SCr <1.7 mg/dL) can be easily identified by simple questionnaire, resulting in significant cost savings from a reduction in the number of routine serum creatinine levels obtained prior to imaging.33,34 The cost-effectiveness of using pharmacologic pre-treatment with N-acetylcysteine or theophylline has not been studied.
Comment
In summary, patients with multiple risk factors for RCIN who need radiography with contrast media should receive pre-hydration and low osmolar iodinated contrast. Overall, there appears to be indirect evidence that RCIN can be attenuated by pre-hydrating high-risk patients. Clearly, the use of low osmolar contrast media is associated with less RCIN, but its high cost militates against routine use in all patients. We believe that it should continue to be reserved for the patient with multiple risk factors for RCIN. While newer pre-treatment regimens like N-acetylcysteine, prostaglandin E1, and captopril look very promising in preventing RCIN, these results need to be replicated in further studies. Finally, many institutions would benefit from a hospital-based pathway that identifies patients with multiple risk factors for RCIN prior to contrast radiography. Guidelines (Chapter 51) for appropriate pre-hydration and the timely use of low osmolar contrast media to reduce the development of RCIN would be beneficial.
Table 32.1. Studies of strategies for preventing radiocontrast-induced nephropathy (RCIN)*
Study Setting Study Design, Outcomes Results
Low osmolar contrast media Meta-analysis of the relative nephrotoxicity of high (HOCM) vs. low (LOCM) osmolar iodinated contrast media7 Level 1A,
Level 2 LOCM less nephrotoxic than HOCM; pooled p=0.02
Odds of ARF with LOCM 0.61 times that of HOCM (95% CI: 0.48-0.77). Patients with RF at baseline, odds of ARF were 0.5 (CI: 0.36-0.68).
Pre-hydration plus diuresis Patients with SCr >1.8mg/dL randomized to IVF, IVF + furosemide, IVF + furosemide + low dose IV dopamine +/- mannitol (if post-cardiac catheterization, PCWP <20 mmHg)9 Level 1,
Level 2 No differences in rates of renal failure between groups. Rates of RCIN 21.6% if UOP >150 mL/h, 45.9% if UOP <150 mL/h.
Patients with SCr >1.6mg/dL or CrCl <60mL/min randomized to IVF, IVF + mannitol or furosemide pre-cardiac catheterization8 Level 1,
Level 2 No statistically significant difference in RCIN, among the three groups. After exclusion of patients with SCr >3 mg/dL, RCIN in patients with IVF alone 4%, IVF + mannitol 24% (p=0.02), IVF + furosemide 25% (p=0.02). LOS increased by 4 days in RCIN group.
Patients with SCr >1.7 or CrCl <60mL/min randomized to IVF + furosemide vs. discretion of treating physician during contrast radiography10 Level 1,
Level 2 SCr increased by 0.42 mg/dL +/- 0.20 treatment group vs. 0.023 mg/dL +/- 0.073 (p<0.01) controls. Significant weight loss in treatment group vs. controls (p<0.03)
Observational study of "high risk" patients with SCr >1.9 mg/dL who underwent cardiac cath6 Level 3,
Level 2 Statistically significant risk factors for RCIN: volume of contrast used (168+/- 11 vs. 122+/16 mL, p=0.001) and use of prehydration (>500mL 0.9% normal saline in preceding 24 hrs, p<0.01)
Table 32.1. Studies of strategies for preventing radiocontrast-induced nephropathy (cont.)*

Study Setting Study Design, Outcomes Results
N-Acetylcysteine Patients with SCr >1.2 mg/dL or CrCl <50 mL/min randomized to pre-hydration (IVF) with oral acetylcysteine or placebo prior to contrast CT16 Level 1,
Level 2 RCIN developed in 2% treatment group vs. 21% control group (p=0.01). Among patients with SCr >2.5 mg/dL, RCIN 0% treatment vs. 42% controls (p=0.02)
Theophylline Patients randomized to theophylline (165mg IV x 1) vs. placebo prior to contrast radiography.12 Level 1,
Level 2 GFR reduced 85.4 +/- 3.8 mL/min controls vs. 107 +/-3.6 mL/min treatment group (p≤0.001).
Patients randomized to theophylline (2.8 mg/kg orally q12 x 2 days) vs. placebo prior to contrast radiography with LOCM or HOCM.13 Level 1,
Level 2 CrCl after LOCM decreased by ~18% at 24 hrs in control (p<0.05) vs. no significant change over 48 hrs in treatment group. CrCl after HOCM decreased by ~40% at 24 hrs and remained low at 48 hrs in controls (p<0.01) vs. ~24% at 24/48 hrs in the treatment groups (p<0.05). CrCl after HOCM significantly lower in control vs. treatment group (p<0.01).
Patients randomized to pre-hydration + theophylline (5mg/kd IV) or placebo prior to contrast CT or DSA.14 Level 1,
Level 2 GFR decreased at 4 hrs and 2 days in placebo (88 +/- 40 to 75 +/- 20 mL/min, 89+/- 41 mL/min to 66+/- 32 mL/min, p<0.01) with no significant change in CrCl in the treatment group.
Patients with SCr >1.5mg/dL randomized to pre-hydration vs. pre-hydration with low dose dopamine or aminophylline prior to cardiac catheterization.11 Level 1,
Level 2 Overall incidence of RCIN was 38%. No significant differences were noted among the groups. LOS was longer in patients with RCIN (7.1 days vs. 3.1 days, p=0.02).
Patients randomized to pre-hydration + theophylline (270 mg q am/540 mg q pm 2d before, 3d after) or placebo prior to contrast CT or DSA.15 Level 1,
Level 2 No significant differences in SCr or CrCl between groups (RCIN 3.4% controls, 5.7% in treatment, p=NS).

*ARF indicates acute renal failure; CI, confidence interval; CrCl, creatinine clearance; CT, computed tomography scan; DSA, digital subtraction angiography; GFR, glomerular filtration rate; IVF, intravenous fluids; LOS, length of stay; NS, not statistically significant; PCWP, pulmonary capillary wedge pressure; SCr, serum creatinine; and UOP, urine output.

References

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2.McCullough PA, Wolyn R, Rocher LL, Levin RN, O'Neill WW. Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality. Am J Med 1997;103:368-375.

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9.Stevens MA, McCullough PA, Tobin KJ, Speck JP, Westveer DC, Guido-Allen DA, et al. A prospective randomized trial of prevention measures in patients at high risk for contrast nephropathy: results of the P.R.I.N.C.E. Study. Prevention of Radiocontrast Induced Nephropathy Clinical Evaluation. J Am Coll Cardiol 1999;33:403-411.

10.Weinstein JM, Heyman S, Brezis M. Potential deleterious effect of furosemide in radiocontrast nephropathy. Nephron 1992;62:413-415.

11.Abizaid AS, Clark CE, Mintz GS, Dosa S, Popma JJ, Pichard AD, et al. Effects of dopamine and aminophylline on contrast-induced acute renal failure after coronary angioplasty in patients with preexisting renal insufficiency. Am J Cardiol 1999;83:260-263, A5.

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14.Erley CM, Duda SH, Schlepckow S, Koehler J, Huppert PE, Strohmaier WL, et al. Adenosine antagonist theophylline prevents the reduction of glomerular filtration rate after contrast media application. Kidney Int 1994;45:1425-1431.

15.Erley CM, Duda SH, Rehfuss D, Scholtes B, Bock J, Muller C, et al. Prevention of radiocontrast-media-induced nephropathy in patients with pre-existing renal insufficiency by hydration in combination with the adenosine antagonist theophylline. Nephrol Dial Transplant 1999;14:1146-1149.

16.Tepel M, van der Giet M, Schwarzfeld C, Laufer U, Liermann D, Zidek W. Prevention of radiographic-contrast-agent-induced reductions in renal function by acetylcysteine. N Engl J Med 2000;343:180-184.

17.Koch JA, Plum J, Grabensee B, Modder U. Prostaglandin E1: a new agent for the prevention of renal dysfunction in high risk patients caused by radiocontrast media? PGE1 Study Group. Nephrol Dial Transplant 2000;15:43-49.

18.Gupta RK, Kapoor A, Tewari S, Sinha N, Sharma RK. Captopril for prevention of contrast-induced nephropathy in diabetic patients: a randomised study. Indian Heart J 1999;51:521-526.

19.Seyss C, Foote EF. Calcium-channel blockers for prophylaxis of radiocontrast-associated nephrotoxicity. Ann Pharmacother 1995;29:187-188.

20.Khoury Z, Schlicht JR, Como J, Karschner JK, Shapiro AP, Mook WJ, et al. The effect of prophylactic nifedipine on renal function in patients administered contrast media. Pharmacotherapy 1995;15:59-65.

21.Russo D, Testa A, Della Volpe L, Sansone G. Randomised prospective study on renal effects of two different contrast media in humans: protective role of a calcium channel blocker. Nephron 1990;55:254-257.

22.Neumayer HH, Junge W, Kufner A, Wenning A. Prevention of radiocontrast-media-induced nephrotoxicity by the calcium channel blocker nitrendipine: a prospective randomised clinical trial. Nephrol Dial Transplant 1989;4:1030-1036.

23.Cacoub P, Deray G, Baumelou A, Jacobs C. No evidence for protective effects of nifedipine against radiocontrast-induced acute renal failure. Clin Nephrol 1988;29:215-216.

24.Cramer BC, Parfrey PS, Hutchinson TA, Baran D, Melanson DM, Ethier RE, et al. Renal function following infusion of radiologic contrast material. A prospective controlled study. Arch Intern Med 1985;145:87-89.

25.Lee JK, Warshauer DM, Bush WH, Jr., McClennan BL, Choyke PL. Determination of serum creatinine level before intravenous administration of iodinated contrast medium. A survey. Invest Radiol 1995;30:700-705.

26.Taylor AJ, Hotchkiss D, Morse RW, McCabe J. PREPARED: Preparation for Angiography in Renal Dysfunction: a randomized trial of inpatient vs outpatient hydration protocols for cardiac catheterization in mild-to-moderate renal dysfunction. Chest 1998;114:1570-1574.

27.Eisenberg RL, Bank WO, Hedgcock MW. Renal failure after major angiography. Am J Med 1980;68:43-46.

28.Teruel JL, Marcen R, Herrero JA, Felipe C, Ortuno J. An easy and effective procedure to prevent radiocontrast agent nephrotoxicity in high-risk patients. Nephron 1989;51:282.

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32.Steinberg EP, Moore RD, Powe NR, Gopalan R, Davidoff AJ, Litt M, et al. Safety and cost effectiveness of high-osmolality as compared with low-osmolality contrast material in patients undergoing cardiac angiography. N Engl J Med 1992;326:425-430.

33.Tippins RB, Torres WE, Baumgartner BR, Baumgarten DA. Are screening serum creatinine levels necessary prior to outpatient CT examinations? Radiology 2000;216:481-484.

34.Choyke PL, Cady J, DePollar SL, Austin H. Determination of serum creatinine prior to iodinated contrast media: is it necessary in all patients? Tech Urol 1998;4:65-69.

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Well it was another interesting night on call. This was one of thoose rare times when the main teaching objective was when not to operate. We admitted a middle-age male with an attack of presumed diverticulitis. He had a CT scan that was not indicative of an acute free perforation, his abdominal exam showed mostly localized left lower quadrant tenderness, but no signs of peritoneal irritation. He was started on IV fluids and antibiotics and after 12 hours shows some improvement. He will continue to be observed for improvement or worsening. JTE.

Well, it is another day of call. The ER has been modestly busy and there have been floor consults as well. I had a chasnce to help on of the residents on his way to being credentialed to do central lines. JTE.

After further research on blog construction and functions, I am proud to proclaim that there is now a counter in place on the Joy of Surgery. I would like to thank everyone who visits and encourage feedback in the form of comments. JTE.

Well fellow surgeons, here is part of my first foray into tracking down more information on Narrative Medicine.Book Reviews

Stories Matter: The Role of Narrative in Medical Ethics
Reviewed by: Beverly Steinman, MD
Medscape General Medicine 5(1), 2003. © 2003 Medscape
Posted 01/24/2003
Edited by Rita Charon and Martha Montello
Routledge
Copyright 2002
242 pages
ISBN: 0-415-92838-9
$24.95 paperback
Medical ethics is more than a theoretical abstract to be discussed in committees and academic environments. Every human life is at some time affected by this discipline. The collection of essays presented in Stories Matter: The Role of Narrative in Medical Ethics, skillfully edited by Rita Charon, MD, PhD, and Martha Montello, PhD, broadens and deepens the understanding of how medical ethics is interwoven into our lives, through an illustration of the role of narrative in medical care. Readers from all fields -- clinicians, ethicists, and anyone associated with providing healthcare -- will benefit from this book. Those with no previous experience in medical ethics may also find the text stimulating, although its concepts may be challenging for those without literary and/or clinical background.
Both Charon and Montello are at the forefront of the narrative medicine movement, which advocates that physicians must learn to become close readers of their patients' stories (or histories) in order to identify and respond effectively to moral and clinical questions posed. Charon, Editor-in-Chief of the journal Literature in Medicine, and Montello, a Professor of History and Philosophy of Medicine at the University of Kansas, bring together 23 bioethicists and literary theorists, such as Howard Brody, MD (Stories of Sickness), and critic Wayne C. Booth, PhD (The Rhetoric of Fiction), each individually recognized as an expert in their area of focus.
By linking their essays in a logical and iilluminating sequence, the editors have produced a text that educates and inspires. While each author makes a unique contribution, they collectively make the case for the importance of the narrative approach to bioethics.
The editors accomplish their goal of guiding readers "toward a cognitive, practical, emotional, and aesthetic familiarity with the conceptual frameworks, methods, and powers of narrative ethics." (p. x) While the average clinician may find some of the terminology (such as reliability, intersubjectivity, and textuality) and citations unfamiliar, it is well worth the effort to immerse oneself in new territory throughout this text. Many ideas and perspectives are presented that, when incorporated into everyday clinical practice, can change us and our ability to ethically care for patients.
For example, case studies using the narrative ethics approach are presented, aptly illustrating how the concepts work to accomplish the goal of a more complete and accurate consultation. Richard Martinez states, "Narrative methods help us to listen and see with intensified accuracy and reach -- a hermeneutic stethoscope of a sort." (p. 131) This comparison to a common diagnostic tool provides a powerful visual linkage, likely to be understood by all clinicians.
Some of the material is assimilate, such as a section introducing the importance of context, voice, time, character, plot, and reader response in the narrative approach to bioethics. This simple comparison to the basic components of stories is very effective in providing a manageable framework by which we can expand our view and methodology in the consultation process.
It was quite refreshing to find frank and straightforward observations from the authors of Stories Matter, especially dealing with the reality of the current medical world. For example, the authors noted that, currently, a few "experts" often dominate the ethical consultative process in an organization. They suggest that a narrative approach causes a change to a more democratic process, as each person's perspective is valued.
In addition, very practical advice is given on how to train practitioners on the use of narrative ethics, including the range of educational opportunities available. A listing of the specific competences for narrative medical ethics is suggested and is compared to the original competences for ethics committees. Realizing that the work in narrative bioethics has been in progress for 25 years helps the reader to both understand the dedication of those involved and prepare for what is most likely to be a slow transition in one's own organization.
The ever-present issue of time will undoubtedly be one of the greatest challenges. The comprehensive narrative approach involving multiple perspectives will take longer than a "sidewalk" consult or a 1- or 2-sided presentation at an ethics committee meeting. It would have been helpful to have this dilemma addressed more fully.
The book ends appropriately with a look at the future of narrative medical ethics. By reviewing the additional case stories, healthcare data, and concepts presented, the reader will be further convinced that this approach is essential to the provision of quality ethical care. In the last chapter, Joanne Trautmann Banks states it well: "...narrative is fundamental to our bodies, minds, communities, and souls." (p 219)
Through the authors' passionate, logical, and credible sharing of their knowledge and experience, readers will gain the ability to understand and participate in an improved approach to medical ethics, both in their own practices and within their organizations. Incorporating multiple perspectives, understanding "stories" in all their complexity, becoming more aware of what each individual brings to the situation, and managing this challenging methodology in a systematic, thoughtful way, will take medical ethics to a new, more proficient and complete level.
The authors are clear that the previous or current methodology used in medical ethics, usually the principlist approach, is not necessarily to be abandoned, but most likely will be complementary to the narrative approach. Hence, we will be building on the past as we strive toward a future that will be guided by the concepts shared in this book.
Beverly Steinman, MD, consultant and educator in healthcare communication with the Northwest Center for Physician-Patient Communication

First a reminder to any readers, if you want to add comments to the blog all you need to do is click on the blue word comment after each posting and you can add your comments. Second, what a great night this was for me. I had the opportunity to be one of the senior faculty at a dinner meeting with the purpose of recruiting a new faculty surgeon. Well as usual, there was a generous amount of discussion about the profession of surgery. Naturally, a lot of it was centered around job satisfaction. Everyone wants to be sure that a prospective faculty member gets a favorable impression. However, the fact that the surgeons at the meeting really like what they do is just not possible to be supressed. The central focus in surgery is always about the positive and immediate feedback of a job well done and the tangible results of improved patient care. I found the most interesting discussion of the night to center on the coming change of the critcal care to be provided at one of the hospitals to a system of intensive physician monitoring of patients in the ICU by physicians in a command module with protocols of algorithm driven interventions and patient resuscitaion regimens. Wellas hte old song goes "the times are a changin". Since I don't practice in the hospital to be so affected, I will be able to view the result with less personal emotional investment as to the result of such a new undertaking. All my best dear readers. JTE.

Tuesday - one of the always interesting days. Today in clinic, there was one of the major reasons for liking what I do. One of the patients who was an innocent victim of a hold-up was kind enough to leave a Thank you card for everyone. In trauma, our patients are often very grateful. JTE.

It is Monday morning and I am on my way to the OR. I have cases to do and residents to teach. It is another good day for enjoying surgery. JTE.

Well, another incremental increase in my blogging skills. I have now added Blogger Forum and Google Search to the Blog. JTE.

Well it is late Sunday afternoon and I have just finished part of my Sunday ritual - The Sunday New York Times. My attention was naturally drawn to the New York Times Magazine for this week. I was particularly drawn to the article entitled The Writing Cure by Melanie Thernstrom on page 42. This is an article which deals with the topic Narrative Medicine. I admit to not being able to judge if this is a balanced and fair article, but it seems to be. Certainly, it should provide the lay reader and physicians who are neophytes in regards to Narrative Medicine a good introduction. I suppose in many ways what I am setting out to do is utilize this blog to engage in a modified form of narrative medicine about Surgery and to invite others to participate. Certainly would like to hear from those interested in Narrative Medicine!! I certainly hope my college Professor who taught me courses in both creative writing and the modern novel since 1914 is not reading this blog on a computer somewhere in the hereafter. I must say that I am now destined to embark on expanding my horizons in the world of Narrative Medicine. Guess I will be doing some searches and getting some journal articles. Naturally, I found one of those quotes which triggered my " I disagree" response. It was from Jerome Groopman who is quoted as follows: "It's not only students but also physicians who find the structure of contemporary hospital life unsatisfying." and as follows: "They're all looking for more meaningful relationships." Some of you more astute readers may ask " How can you disagree with someting so abstract and poorly defined as 'the structure of contemporary hospital life'? Well, the structure of contemporary hospital life is what I know best. Surgeons who do major operations are required to be immersed in the hospital life. A well equipped and staffed OR is necessary for surgery. Trauma surgeons at a Level One regional trauma center are virtually immersed in contemporary hospital life. Surprisingly, this is where the great rewards are found for myself and others. To further develop the questioning of Groopman's assumptions, we must only guess at what could be 'more meaningful' ? Naturally, from a syntax point of view, since he has to use an adverbial description - he must concede that the relationships of contemporary hospital life are meaningful, just that some are seeking the ever elusive "more". Greener grass has always been prized. I think I will stop at this point and have a cup of tea. JTE.

Well folks today is the third day of this Blog. I was on call from Saturday at 7 AM till Sunday at the same time. Our last case was an interesting one - small bowel obstruction requiring exploratory laparotomy and lysis of adhesions. The case went well and the patient should do well despite multiple underlying co-morbidities. I took the chance of being with my residents to tell them about this Blog. Hopefully, it will stimulate interest in the idea of a surgical blog devoted to the discussion of the joys of surgery and the surgical life. My chief resident acknowledged that he had seen the article in the General Surgery News which details the results of a survey which calls into question the dedication of young doctors. I do not remember recieving the survey mentioned so I guess maybe they knew in advance who to avoid. Well, I am still having fun doing surgery. Looking for those comments. James T. Evans, M.D.

This is my new Blog dedicated to emphasizing the Joy of being a surgeon. I like what I do and I am sure there are others who feel the same way. I think it is very important to be proactive in discussing the positive things about being a surgeon.