Category: Surgery News

Big Cancer Cases

“You’re a bad ass” he said as I walked into his hospital room, making post op rounds from the previous day’s surgery.

Yesterday I spent five hours excavating this huge tumor from his neck. A local spread from a poorly differentiated squamous cell skin cancer previously removed from the back portion of his neck, just behind and below his left ear.

These poorly differentiated cells are the worst; wild cancer cells running amok in the lymphatic system, multiplying and invading locally, infiltrating into surrounding muscle and skin.

Pre op exam revealed an 8 x 5 x 3 cm mass, firm, fixed, right up under his ear. Big and stuck!

I told him there were no options other than cutting that monster out, and he gave a big thumbs up.

In the OR, I placed a nerve monitor with subcutaneous electrodes about his eye and mouth, just in case I needed to dissect around his facial nerve. We prepped and draped his neck for a big procedure.

I excised the scar from his previous skin cancer removal, cut in front and below his ear and looped the incision into his neck below his jaw line, raised skin flaps, and started dissecting the mass from surrounding tissue, including many lymph nodes in the neck below it and in front of it (technically what we call a supraomohyoid neck dissection). It had invaded the sternocleidomastoid muscle and totally compressed his jugular vein. Both of these structures needed to be removed along with the mass. I carefully preserved his carotid artery and vagus nerve (to the vocal cords), dissected the hypoglossal nerve (motor to the tongue) and the parotid gland from the superior extent of the tumor. I went through the deep fascia into the levator muscles which support the cervical vertebrae. Any further removal would have left his neck weak and unstable. This level of invasion could never be handled with surgery alone, and there was no surprise that microscopic remnants of the cancer were seen in the pathology specimen. Post op radiation therapy should be able to kill the residual tumor cells.

I put in a drain to collect tissue fluid post op for a few days, sewed him up nicely, using his own expanded skin from the tumor mass to cover the area excised, and then on to recovery. All nerves working fine, eating and drinking well with a good night, and then the next morning: “you’re a bad ass.”

So I had him clarify that statement. He had been seen at the VA, and referred to me, because “No one else there wanted to handle this. And you could, and you did!! I feel so much better with that goose egg thing out of my neck”. Actually more like an ostrich egg.

Years of study at Univ of Iowa, doing big tumor work. Years of experience taking care of federal inmates referred cross country with their large, growing tumors, had put me in a great place to help out this Vet.

Cut and sew right, preserve the vital important structures, and all will be well. Great anesthesia, experienced nursing crew. My team was ready, and we performed.

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Collaborative Healthcare Solutions, an alternative to medical malpractice lawsuits

Very little is more contentious in medicine than the topic of medical malpractice, lawsuits, and tort reform. The large number of stakeholders with financial and emotional capital are immense. There is little need for me to further describe our current state of ‘deny and defend’, with fear of malpractice cases by healthcare workers, limited to no discussion after a bad outcome, defensive medicine, and assertions by plaintiff’s attorneys that they alone represent the interests of an injured patient.

Until now, when all the rhetoric and verbiage can be called to the carpet, and real justice and communication and responsibility and learning and growth and apology and forgiveness and justice can come among us. Sound too good to be true? Well, it is good, and it is true, and it is here now (not just pie in the sky), but it is not everywhere. Thanks to a few hard working pioneers, it will be in North Carolina soon. It all comes under the umbrella of collaborative law.

So, a patient is under medical care and a poor result happens. With total transparency, the ‘poor result’ is investigated and a determination is made if the standard of care was met. If care fell below the standard, then all parties are brought to the table, records and relevant data are open, apologies are made, discussions are held concerning injury and further care, and a settlement is reached. Just like that. Perhaps not in one meeting, and perhaps not at all, but that is the goal.
Now this is the simplistic description, as many meetings and discussions and proposals may be involved. If the patient is still not happy, then the traditional tort reform system can be entered.

But the beauty of this approach is that real communication occurs, the patient is heard, physicians can explain their actions and if appropriate, apologize, and healing can begin. Healing for the patient, and healing for the doctor. Bad outcomes, as catastrophic for the patient as they can be, also take their toll for the medical professional in the form of stress, doubts, sorrow, remorse, and guilt. Collaborative solutions allow the doctor and the patient to heal.

If care was appropriate and there was no error, then this is disclosed and empathy about the patient’s condition is still expressed. If there is still no resolution and a case is brought, then the case is vigorously defended.

The alternative, the current standard, requires us physicians to build a wall between us and the patient, to deny, to withhold; in other words, to stop caring for the patient. To start caring more about us than about them. And nothing could be farther from our duties and ethics and responsibilities as medical professionals than to put up barriers and restraints and just outward remove ourselves from the responsibility of caring for our patients, even those who are angry and hurt and threatening legal retribution.

Collaborative law provides a solution for this all.

Collaborative solutions allows everyone to heal, allows everyone to benefit, and allows everyone to benefit. The lessons learned from these ‘cases’ are disseminated to the entire medical community for educational purposes so that we all are aware of what and how to avoid such a mishap in the future.

And data, good data, from the University of Michigan over the last ten years, shows that this approach lowers the number of claims and amount of payouts significantly.

Collaborative healthcare solutions is coming to Raleigh, coming to North Carolina. Pilot program grants are being written, groundwork is being laid.

Can’t wait.

by Douglas K. Holmes, MD

Nosebleeds, medical advances, medical expense

Severe nosebleeds (epistaxis in medical jargon) are a great example of the secondary, often adverse effects of medical advances which run up the bill for medical costs in the United States.

If you’re on call for ENT at Rex Hospital, the most likely reason to be called to assist the emergency physicians is for a severe nosebleed. Not the little drip, drip from a vessel up front that easily responds to a little pressure or packing, but a real life threatening gusher (life threatening from the blood loss and airway compromise) that just won’t stop despite multiple attempts at packing. By the time I’m called, the patient has just about had enough from painful packing and dealing with a constant flood of blood out the front or choking them from blood running down the back of the throat.

And most of the time the cause of this most uncomfortable, alarming condition can be traced to the advances of modern medicine.

The most typical patient is an older person (70’s or 80’s) who is on multiple medications to treat high blood pressure and some type of cardiovascular condition (atrial fibrillation, deep venous thrombosis, cardiac stents, etc) that is being treated with coumadin (commonly referred to warfarin, or in non medical speak, ‘blood thinners’), aspirin, and plavix. Plavix holds a high position in the drug world as it is commonly advertised in the evening news programs: “Ask your doctor if Plavix is right for you.” These drugs keep people alive who a generation ago would have succumbed from their underlying disease processes. They would have died from stokes, heart attacks, or pulmonary emboli. But now these drugs keep people alive, only to have them suffer the side effects of uncontrolled blood pressure and delayed blood clotting – this combo is the harbinger of a real nasal gusher.

My most recent patient was an 83 year old woman, let’s call her Ruth. Well, Ruth came to emergency center at Rex on a Saturday evening with a blood pressure of 200/100 (we all know that normal pressures historically are more like 120/80, with even more stringent numbers recently) and was on warfarin to prevent blood clots and emboli to her brain secondary to atrial fibrillation with an INR of 3, which means that her blood took three times as long to clot. The care for this type of patient requires multiple docs, me to stop the nose bleed, anesthesiologist for the operating room, intensivist for post op care with need for blood pressure monitoring with arterial line, blood products and vitamin K to reverse the warfarin, and oxygen. Not to mention the nurses, OR staff, ED (emergency department) staff, ward clerks, orderlies, blood bank specialists headed up by a laboratory pathologist. So now does anyone want to discuss the rise in the cost of medical care in the United States?

So, early on Sunday morning I took Ruth to the OR where she was intubated and asleep for nasal endoscopy, cautery of her bleeding site, and extensive packing; all intervention she could not have tolerated awake. I found the bleeder up high on the left side of her nose and cauterized it to oblivion with a special suction cautery that sucked the blood away as I ‘burned’ the offending vessel. All the while looking via a rigid fiber optic scope that magnified the area and took my eye right to the upper nose. These scopes were not available to previous generation surgeons. This was followed by a balloon packing blown up to keep pressure and tamponade on the vessel. Even after this intervention, anytime her very labile pressure got high she would ooze. Finally after 4 days of packing, with control of her blood pressure, and total reversal of her warfarin, I was able to deflate her balloon with no further bleeding. Two days later her packing was removed, two days later she went home after a total of about 8 days in the hospital, several blood transfusions, and a bill that must have been over $100,000, covered by medicare of course.

This cases represents the high tech, highly specialized care available to patients here in Raleigh. It is repeated patient after patient 365 days a year in every specialty. How to scope and cauterize and pack and care for these patients is my expertise; but how our country pays for it and how ‘medical advances’ are applied to our population is not.

As a surgeon in the trenches, I’m merely waiting for the hospital to call me with the next patient in need. Perhaps one day I’ll trade in my scrubs and operating room arena for transition into a suit and the legislative arena to address the other issues.

by Douglas K. Holmes, MD

Emergency surgery

I was delighted to hear from two people this week that I didn’t post last Sunday. Thank you for noticing.

I didn’t post because I was called out in the middle of my Sunday evening activities for an emergency – bleeding after a tonsillectomy. It is a very scary event to be sitting at home or sleeping about a week after your tonsillectomy, and then suddenly feel a warm liquid in your mouth that you either swallow or let run out, and then look in the mirror or in your hands and discover your own blood. It really gets your attention, and mine too because a ton of blood can be lost quickly. So the story, Bethany (a pseudoname) is 17 yrs old and had had multiple bouts of strep throat this past year. She would get very nasty sore throats that kept her home from school days at a time. So it was quite reasonable to see me to have her tonsils removed. No problem, operation went well, immediate post op no issues, until that 7th day post op and the blood in the mouth thing. I was home doing some computer work when the call came. Out the door two minutes later (and it’s this sudden change of plans that I will address), speeding to the ER, saw her and her panicked mother, called the OR to get ready, took her back and under anesthesia cauterized a pumping vessel. This was emergency surgery at its best, with the entire health care team of anesthesiologist, nurse anesthetist, ER and OR nurse, scrub tech, and yours truly coming to the plate with all their skills in a very hurried yet thorough manner. And Bethany did great, no worse for wear except that she could use a little extra iron in her diet over the next week or two, and certainly no need for transfusion. She went home the next morning feeling fine.

For many community surgeons, being on call for their practice brings this emergency scenario to life on a routine basis, perhaps not the immediate life threatening bleeding or airway issue, but nonetheless very urgent situations that must be dealt with quickly – appendicitis, perforated bowel, hip fractures, blocked coronary arteries that the cardiologist couldn’t stent, and all sorts of trauma. My most common ‘urgent’ problem is a peritonsillar abscess, an extention of infection from the tonsil into the space around the tonsil, creating all kind of swelling and fever and sore throat. The pus must be let out via the throat and if not, the abscess can progress and be life threatening, just ask George Washington if you see him in the afterlife, as its what caused his demise. His physicians applied the proper treatment of their day – ‘bleeding’ him. A recent urgent issue that required an operation on the 4th of July was ankyloglossia or tongue tied in a newborn. Baby Paul couldn’t breast feed because he couldn’t get his tongue around the nipple. But SITT came through by releasing his tongue in the OR early Saturday morning. In the recovery room his mom put him to the breast with immediate sucking of momma’s milk with success for Paul and no pain for mom. Ah another surgical success.

But for SITT and other surgeons, these emergencies and urgencies take their toll – being up at all hours, running out on family and social events, extending the workday hours even longer, weekend forays to the ER and or the OR. One can limit their ‘call days’ by sharing call duties with more docs, but the more docs the more patients and then on the day you are on call you can be guaranteed tons of phone calls and hospital visits. Or you can be solo like SITT and only need to deal with your own misery you helped to create (even if there was nothing to have prevented that post tonsil bleed, SITT did perform the tonsillectomy in the first place).

So, the bottom line for SITT is to cut and sew properly in the first place which avoids complications, and to educate my patients well so that they have appropriate expectations post op (it’s OK to have discharge or swelling or whatever if you know it is the normal post op course).

And when this fails, and I gotta go, well, it comes with the job.

by Douglas K. Holmes, MD

Community surgeon

The trenches, where the real tough, gritty work is done, aptly describes the daily life and work of a community surgeon. ENT (ear, nose, and throat) in my case. I add the description of ‘community’ surgeon to distinguish from academic surgeon, those who teach (and therefore have resident surgeons, ie those in training, available to do much of the daily grind) and have research obligations and in many cases have time and granted $$$$ to travel to conferences and workshops.

It is the private practice surgeon, responsible for not only their patients but also running a small business that I represent. Our trenches are the office exam room, operating room, emergency department, and in-patient floors. Our ‘normal’ workday begins early, ends late, and only leads into the evening and night hours that yield their own demands of urgent and emergency calls. Such calls respect neither weekend nor holiday.

But demanding as it is, the rewards of our trench work are many. Grateful patients and families who are cured of their disorder, respect of co workers and colleagues, generous compensation, emotionally satisfying labor.
It is these experiences of surgical labor and surgical life that I will present in this new blogging endeavor.