One Sinusitis Sufferers Story

Sinusitis affects some 37 million people annually and is more prevalent than heart disease and asthma.  There are medications to help with symptoms but 20% of patients do not respond favorably to them.  In this video, one chronic sinus infection sufferer tells her story of ongoing attempts and failures to cure her ongoing affliction until she found a remarkable new treatment that is far less invasive and risky than the standard recommended treatments for this condition.

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

ENT & Audiology Associates Launches New Website

Dr. Holmes and his staff are proud to unveil their new website! The site features a WordPress content management systems that allows the staff to upload and change content whenever they like. Raleigh-based internet marketing company TheeDesign Studio worked with the team at ENT & Audiology Associates to create a business-class web presence for the office.

A surgeon finds his heart

If you are lucky, one day you will fall in love. It happens to most all of us at one time or another. It’s actually a psychosis, this falling in love thing. Endorphins bathe our brains with that top of the world, nothing can hurt us euphoria. And there are physical signs and symptoms: the stomach ache that occurs when we are not near the one we love, the lack of appetite that has us drop 10 pounds out of nowhere, can’t sleep, can’t think straight … in short, a psychosis.

Some of us will fall in love more than once, and the really lucky ones (like me) will fall in love all over again with one’s spouse. With your spouse ?!? Oh yeah, with your spouse. My story:

From a very hot and torrid dating and engagement, my wife and I were married Sept 11, 1999. A very meaningful, fun wedding and party with our families and friends gathered. What could ever go wrong?

Enter the blending of the families (my kids, her kids) and it became readily apparent why such unions suffer 70% divorce rates. And we were once on the brink. But something, I think it was a very deep love and perhaps even more importantly at the time, lust for each other that prevailed. We weathered the storms, the kids got older and actually became friends, and life improved greatly.

But the last two years has seen work pressures, financial pressures, other pursuits weave their way into our union, or better said, I allowed such to take place. I never doubt that Randi ever put our marriage second to anything. But I must have. Because three weeks ago she had had enough, and in no uncertain terms (we husbands all know what this looks like), she let me know. Her style when angry or disappointed is to process her feelings over days or a week. During this processing the indoors temperature approaches 32 degrees F and at times I could see the frost from my breath. And as a surgeon, I am accustomed to the quick cure, let’s expose the pathology and deal with it. Not here, not with her. My God, how excruciating for me. So, when we finally discussed our issues, it was quite clear what an ASS I could be and was, in words and acts and deeds and lack of words and acts and deeds. There were sins of commission and omission.

And I got it.

And I took it to heart. And I was given space to think, consider, make amends, and decide what I wanted to do, and to do about it. So I did. I was told to clean up my act, and by God, clean up my act I would and did and have. 180 degrees.

No more off color ‘jokes’ and references that embarrassed her. Consideration of her rest needs, very quietly getting ready in the morning for the OR or office, paying attention to her needs and wants and desires by respecting our date nights (no more medical conferences or late OR cases on those days), letting her know how special she was with coffee in the morning, notes, messages, flowers, hugs, and kisses. And I carefully, deeply, thought about the woman she is and the wife she is, and I fell in love with her all over again. Incredible, amazing.

This last three weeks I want nothing but to be with her, to please her, to love her. And thank God, she wants me too. I don’t exactly know why, but I’m taking it. Over this time my appetite has disappeared as have the pounds, most likely due to the stress of thinking that my wife had had it with me and was leaving me. Man, was I distraught. She says that would have never happened, but you couldn’t have convinced me of that at the time. In any case, I wasn’t taking any chances.

So what now?? Now is a new lease on life, loving and being with the woman I have chosen to be with (chose her 12 yrs ago, and each minute of the day choose her again). What a blessing. What a lucky man I am.

And perhaps you my friends can see it. I’m a man head over heels in love with his wife. It’s in my smile, my walk, my interactions with others, my care of my patients, and in my hands in the OR – extending from me to the world.

I dearly love my wife.

Posted by Douglas K. Holmes, MD

Taking care of veterans, active duty, and their families

Many of my patients and their families find it very ‘interesting’ that I served in our military. I considered serving in the USAF to be my duty and my honor.

From day one, I was interested in the military. It was in my blood (my grandfather was a Navy seabee who served in both theaters in WWII and my dad was a training officer in the same conflict). I loved to watch Sunday afternoon TV shows about airpower, and seapower and whatever. One of my favorite dramas was ‘Combat’ with Vic Morrow and any war movie was spell binding.

When applying to college, I tried my best to go to the Air Force Academy. I was going to fly planes, big transports or fighters, it didn’t matter. That of course would transition into flying for the airlines or whatever. A pretty good plan for a kid coming of age in the 60’s. Then a routine vision test in the 8th grade revealed an eye abnormality that would alter my plans forever. Turns out I had a bit of a weird cornea in my left eye, very steeply shaped, a condition called keratoconus. Easily fixed for near vision with hard contacts, but totally disqualifying for any service academy. Despite this what I interpreted as a minor issue, I pursued my dream. I contacted my congressional representative who had all their applicants take a pretty grueling exam one Sat morning. Apparently I did well enough to get his blessing to take the next step, a physical exam at Seymour Johnson AFB in Goldsboro, NC. So off my dad and I went from Gastonia to Goldsboro for my first real military experience. Dad dropped me off and visited clients in eastern NC. We applicants were housed in the visiting officer quarters and hob knobbed with pilots and other crew, ate in the mess (wow, all you can eat, nirvana!), and went through several days of physical and athletic testig. Now, I had just finished my senior year wrestling season and was as fit as ever. The Sgts. there said I set the two minute sit up record (when asked how many I thought I could do, I asked how high could they count!). Apparently my more than adequate self confidence was firmly in place at age 18. But no number of sit ups or push ups or mile runs could make up for less than 20/20 vision without correction. Oh come on I wrote, after receiving the rejection letter, surely you need good officers who don’t fly!! I don’t recall getting a reply to my supplication.

So, when one door is closed, look around. It is often said that when one door is closed, others open. But I would add that these other doors were always open, it’s just that we were so focused on the one that closed that we failed to see the other openings.

By the grace (and I feel confident the direction) of God, and the influence of Ayn Rand and marine biology (ask me about my Morehead interview), I attended the University of North Carolina at Chapel Hill. When I decided to attend medical school (a decision worthy of another posting), I sought funding from the Air Force or Navy health professions scholarship program which traded service time for scholarship money. Turns out docs don’t need 20/20 without glasses.

21 years later I returned to Seymour Johnson as a lieutant colonel, board qualified ENT surgeon with 17 years of military service (8 of active duty and 9 in the reserves). I was looking for that son of a bitch who said I wasn’t qualified to serve.

13 years later, prophetically on Sept 11, 2006, I retired from the USAF reserves with 30 years of service, having attained the rank of full colonel, commander of my reserve squadron with the following tribute to the USAF medics, composed and delivered by me to my squadron members at my retirement ceremony:













Is it any mystery that our civilian practice, ENT & Audiology Associates serves our military family in any way, shape, or form? From entrance physicals to retirement disability evaluations, from the infant family members of deployed soldiers to the long retired WWII vet, including current service members injured in Iraq and Afghanistan.

It is our duty and our honor and our sacred trust.

by Douglas K. Holmes, MD

A Challenging Day

When I finished my residency training in 1985, I had the impression that all the great, interesting, challenging cases could be found only at the tertiary care university setting. How wrong I was, how naive I was.

In reality, every day presents the challenge of cases that defy the routine. There is a running debate among surgeons, as to who is best to take care of these patients. The young buck newly out of residency with all the latest technology, or the more experienced surgeon who may not use the latest in techniques or technology. I’d challenge the young buck to handle the following cases (and I do use the last technology).

Take last Thursday at WakeMed:

Case #1 was a 5 month old with recurrent ear infections who needed tubes. A routine diagnosis, but with small 5 month old ear canals and bulging TM’s, making an appropriate incision in the TM and inserting a tube was quite challenging. Mark up success #1

Case #2 was a 2 month old with respiratory difficulty and stidor due to collapse of his epiglottis over this airway (laryngomalacia) due to short aryepiglottic folds. After direct laryngoscopy and section of those folds, he was stridor free. Success #2

Case #3 was a child with frequent sinus infections, maxillary (check) sinuses. Her irrigations required poppin into her sinus below her eyes and irrigating with saline. Success #3 as the eyes were successfully avoided.

Case #4 Exploration of a post radiated neck for recurrent tumor. Tissues planes were non existant, necrotic tissue everywhere. I avoided opening into the carotid artery. Success #4

Plus the usual parade of tonsils, tubes, sinus cases, etc that are very routine, yet so very special to the patient and their families (and I clearly recognize and honor this). All went well and I went home a happy camper.

Every day presents new, so very interesting case. I’m blessed to be in a dynamic field that constantly requires me to search for more information and to extend my education.

Here’s to tomorrow and its challenges.

Posted by Douglas K. Holmes, MD

Morehead Alumni Forum

This is a blog for my fellow Morehead alumni that attended this weekend’s forum. All other readers enjoy, but there are references that you may not understand. I request your indulgence.

In my life there have been several extraordinary experiences that have led to the creation of the human being that I am. The man that I am. The person that I am. Take note that I have not said the ‘surgeon’ that I am. Because surgery is what I do, and I am a surgeon, and it is a huge part of my identity. But this weekend I was reminded that my life and sphere of influence and connectivity extend far beyond the operating room.

This weekend I joined the alumni of the Morehead foundation, now the Morehead-Cain foundation, in a tri annual alumni forum that featured entertainment, scholarly presentations, panel discussions of the issues of the day, networking with the movers and shakers of the world, and words of wisdom from alumni from the 1960’s to our newest millennium colleagues. To top off the day today, our alumnus PhD philosopher presented a wonderfully entertaining talk on “change.” At our dinners, my wife and I had the opportunity to interact with current scholars. Our seating strategy for Saturday night involved going to an open table and seeing who we would attract. To our delight, we attracted a whole gaggle of young scholars. We attributed that to our youthful appearance (despite being in our 50’s), and our even more our fresh outlooks of possibility and creation and innovation.

We loved it.

To say that we are totally juiced about attending the forum in 2012 is an understatement.

So what were the take away messages and what will I do differently in the future? It’s of worth to sit back and listen and enjoy the scholarly discourse, but how will I be different, what do I know differently about myself, what will I do differently? In no special order other than how they come from cortex to fingertips:

We said hello to each other, total stangers except for a common background, and found common ground and pleasure and delight outside of being Morehead scholars.

Everyone in the world is 6 steps or less from being connected to you. Countless examples of these relationships came up. But our actions and influences have significant affect on your friends, your friend’s friends, and your friend’s friend’s friends.

Vampires demonstrate to us that we live by our desires, we are what we want (you have to trust me on this one, ie, you had to be there). Anyone who was is smiling now.

Despite being smart as hell and very capable, we too experience set backs and disappointments, illness and injury. But we also have the resources and connections to recover, but not only to recover, but to experience the pain and disappoinment and the abyss, and then take the steps to pick ourselves up and drag ourselves out of the mire, only to rise and achieve greater heights than ever before.

Twitter, facebook, and other social networks are our friends.

If you want to play basketball for UNC, be nice to your parents.

We were incredibly impressed with our current Morehead-Cain scholars (we have two college freshman of our own at App State, of whom were are also quite proud). One Saturday night scholar dinner ‘guest’ was a student from a Lebanese family. He is fluent in English, Arabic, and French, and plans to study international relations with a Middle Eastern emphasis. I feel better already about that part of the world. Sunday lunch we met scholars who had traveled and taught in Latin America and Africa, and who had challenged the wilds of the Yukon and Mt Kilamenjaro. OMG!! When I was a scholar I challenged the wilds of Interstate 85 and 95 and really out there I spent two months (on my own dollar) in Europe perfecting my German. Ya, sicher.

For your kids to be world citizens, they should be proficient in English and Spanish at least, and then add Arabic or Mandarin Chinese. I guess I missed the mark with my German (and I’m working on my Spanish).

A great job or great profession isn’t great if it is not personally rewarding and fulfilling, if it doesn’t leave time for personal and family growth, or it’s not your passion. Even if you’re the CEO. So if it doesn’t fit, change the paradigm (the questions). For example, should you strive to have profits top $1,000,000 or should the real goal be a profitable company that exudes proper values and respects the values of conservation and sustainablitly? etc, etc

Taking the individual reponses of a difficult question from a crowd of people and combining their answers can lead to an accurate solution. (go figure, or go read the book, Wisdom of Crowds).

Apparently our middle school experiences had much more to do with our future outcomes than we know, or would like to admit.

So much for the small list of take aways.

Personally, I plan to read Don Quixote and to further study Spanish.

I’m also considering creating a DVD of the transition from middle school to college to med school to the OR. (see above)

And I’m planning to get together with my fellow Moreheads in the Raleigh area, hopefully on a regular basis.


The real value of this weekend was connection and friendship and respect and adulation that we all shared. And in the possibilites that these connections will create.

Already my wife and I are arranging a golf game with a fellow alumnus couple, and a dinner with a current scholar.

And if you’re reading this, we are connected so much more than the stated six degrees.

Come on 2012.

Posted by Douglas K. Holmes, MD

The Uninsured

I have treated and continue to treat many uninsured patients in my practice. And invariably, when thinking about diagnostic and treatment options for their condition, I come to think how on God’s earth am I able to provide the medical care they need without totally running up a huge bill and huge debt for them!!! Many times I feel totally handicapped, especially when faced with a child who would really benefit from an operation, such as a T&A for a kid with severe obstructive sleep apnea, when there are really no good alternatives, and the family just does not have the $$$$. Does a family then need to go into severe debt or risk bankruptcy to get their child the care they need? Are surgeons and hospitals forced to give charity care? Who decides????

For the record, my practice charges medicare rates for self pay patients and will work with anyone, including payment plans, to help them pay their bill. I have also written off many balances for students, military members, teachers, preachers, etc.

In Wake county, under the program Project Access administered through the Wake County Medical Society (of which SITT was president many moons ago), surgeons like me and area hospitals provide ‘official’ charity care. But there are only so many of these programs in the USA and only so many dollars that businesses like hospitals and surgical practices can donate.

This weekend, an uninsured 40 yr man hit Rex ER with a peritonsillar abscess. I was on call for ENT for the hospital. An operation (acute tonsillectomy) later he was cured of his life threatening problem and the next day sent home to recover. I really have very little expectation to be paid for my service in full and within a reasonable amount of time. And this man is working, in a bar, that just doesn’t provide insurance for its employees. And most likely the cost of an individual policy is beyond his reach. This scenario is played out countless times across America.

In these times when Congress and America is struggling to get a handle on the health care beast (and may I mention what a professional and personal loss I feel with the passing of Senator Kennedy), we should be able to agree on a few basic ideas:

1) Let’s at least in some way, shape, or form cover all the children in our borders for their basic health care needs.
2) Cover our seniors along with their medications. No senior citizen should need to decide between food and their medicines.
3) Then start the hard work to figure out what to do with everyone in between.

Last year I put some of these thoughts to verse:

No insurance!
Self pay!
Oh my God
What a pity!
Unmet needs
Meds & procedures forgone
Helpless kids, victims
Also the docs – do we get paid?
What are your expectations?
That we’ll provide for free?
Time after time?
Isn’t there a better way?
Unmet needs,
too much suffering,
What a pity!

Posted by Douglas K. Holmes, MD

Golf and the Operating Room

It is certainly no mystery that golf and surgeons go hand in hand. Most surgeons play golf, or at least it seems that way by the animated talk and expressions by those golfing surgeons when the topic arises. Other non golfing surgeons (God help them) simply retreat from the conversation or act uninterested. This love of golf goes beyond the surgeons to include many other operating personnel. One of my favorite CRNA’s (certified registered nurse anesthetist) is Paul G., who is living his dream of working from 0730 to 1530 hrs and then hitting the links. He states that he limits his play only to days that end in the letter ‘y’. Paul has given me some of the best golf tips I’ve ever had. I’ve played with Paul twice on his home course, but these tips were given to me in the OR. Probably after watching my game in person he felt that no tips would be helpful. But seriously, any up and down out of a sand trap, I owe to Paul’s advice.

My other best medical golfing buddy is another CRNA, Dean, who works in the other hospital in Raleigh. While Paul is a straight hitter and incredible around the greens, Dean is a long ball hitter with very impressive drives. Dean and I play at each other’s courses about every other month, and we seem to bring out the best in other’s games. One day at Brier Creek (my home course), Dean shot a 76 and I posted a 78. Really good golf for amateurs.
In fact, as little as I play, it is scary how well at times I can do it. Last month I was 2 under par after 6 holes, only to have the golf god’s reclaim everything at hole 7.
Well, if you’re not a golfer, you’re probably no longer reading. So be it, but the real meat of this story is yet to come. What insights and nuances are there that tie together golf and operating beyond the banter of the weekend rounds and the charity tournaments?

Strange as it seems, it is ETHICS and CHARACTER.

Golf is the only game in which the player calls a penalty upon themselves, whether another person or official is watching or not. All other games (except an occasional tennis point blow off) a player gets what they can get away with. Only if the official sees it and calls it is there a penalty. But not in golf, no way. If the balls moves on the green after addressing, penalty. If the ball is just out of bounds by an inch when a simple little kick of the ball will put it back in, penalty. If you tee up your ball in front of the tee markers, penalty. And on and on. And some rules are just really silly. If your caddy (those that have them) puts an extra club in your bag that you don’t even know about and you don’t even use, penalty. If your club momentarily touches the ground prior to your swing in a hazard, penalty. But the key here is not the rule, it is the fact that the player, upon recognizing the infraction, calls the penalty upon themselves. EVEN IF THE ONLY ONE SEEING THE INFRACTION IS THEMSELF. There is a famous situation in which a profressional player called a penalty on herself, incurred a two stroke penalty, and ending up losing the tournament by a single stroke. When asked why she called it when no one else saw it, she replied “Yes, but I saw it.”

And at the end of the day, the player signs for their own score. And if that score is higher than the one they actually shot, the higher score stands. If that signed for score is lower, then the player is disqualified. Not the one who wrote down their score incorrectly, it is the player themself.

So what does this have to do with the OR?

The same ETHICS and CHARACTER that are demanded on the course, apply to the operating room. The unfortunate rules ‘infraction’ event of the golf course, culminating in a ‘penalty’ stroke, is the ‘complication’ in the OR. Just as the golfer must recognize and call the ‘penalty’ on themselves, so the surgeon must recognize and make known the complication to his OR team, the patient (when they are awake), and the patient’s family. Because everything that we do in and outside the OR should be done in the best interest of the patient, it is incumbent on the surgeon in certain situations to ‘call a penalty on themselves”, ie, to announce to the world that a complication has occured and that extra steps must be performed to correct or ameliorate the effects of the complication. Only after this full disclosure can the effects of this complication be addressed.

It is not the purpose of this blog to jump into surgical complications, the reasons for such, the correction, etc. That could take a book or even a full library. It is the recognition, the announcement, and the ‘penalty assessment’ that I wish to address.

So why is it that the golfer calls the penalty on themself and the surgeon announces their complication to the world? The golfer will say that it is for their own peace of mind and integrity, and while that is true, others will say that in the final analysis it is for the ‘good of the game’, ie their profession. While the surgeon will talk about honesty and integrity, in the final analysis it is for the ‘good of the patient’ and the honor of our profession. While a penalty causes a higher score and perhaps the loss of a tournament for the golfer, a complication can mean the loss of function or even life for the patient and subsequent liability/malpractice and discipline actions for the surgeon. The stakes here are not even comparable. Once the surgeon discloses the complication, steps are taken by the entire team under the direction of the surgeon to do the best thing for the patient. Everyone takes a ‘hit’ in terms of time, effort, blood and sweat to achieve the best outcome possible. The same ETHICS and CHARACTER that are developed and employed on the golf course are also employed in the OR for the good of the patient and the good of the profession of medicine and surgery.

Golf is not only recreation and ‘rejuvenation’ time away from the office and the hospital, but also in its higher form the practice of honesty, integrity, and honor. So, next time you need an operation, ask your surgeon about his game.

by Douglas K. Holmes, MD

Intraoperative Decisions & the Holy Grail of Nerves

What happens in the OR, or more specifically what happens in my head, when an unexpected intraoperative situation dictates a change of direction? It is much better to have considered all the possible scenarios, to have a contingency plan, and to have discussed these plans and possibilities with the patient and family. Small variations are easily handled, with or without pre op discussion. It is the rare patient that would not want something addressed in the here and now when anesthesia has been induced and the incision opened, versus coming back to the OR at a later date. But what about a major, major life changing condition?

Back in my Air Force days, Mr. J came to see me for a painless, fairly mobile, slowly growing lump in his cheek in front of his ear. This was clearly a parotid tumor, a growth in one of our major salivary glands, the one that gets big with mumps. 90% of these tumors are benign. He lacked all the hallmarks signs and symptoms of malignancy – pain, rapid growth, fixation to surrounding structures, and the key issue: involvement of his facial nerve. Ah, the facial nerve, the holy grail of ENT surgery, the nerve that one does not impair or impinge or alter without the utmost clinical need and frank, detailed discussion with the patient. This nerve is the reason that general surgeons stay away from parotid glands. The facial nerve innervates all the facial muscles, and as such is responsible for carrying the motor impulses from our brain to our face, allowing us to make facial expressions: to smile, to pucker our lips, to close our eyes, or to wrinkle our nose. A facial paralysis gives a person a lifeless, drooping face. Facial paralysis is the worse complication an ENT surgeon can have, bar none. Cut the optic nerve, the patient can’t see out of that eye, but they still look the same to other people. Cut the hearing nerve, the patient can’t hear out of that ear, but they still look the same to other people. Cut the recurrent laryngeal nerve to the vocal cords and patient has a weak, breathy voice, but they still look the same to other people. Cut the facial nerve, OMG, the patient looks terrible to themselves in the mirror and other people every minute of every day for the rest of their life!! Not to mention problems with closing the eye and having a dry eye with cornea problems or the possibility of food dribbling out the corner of their mouth in the restaurant.

The facial nerve exits the head out of a small foramen (hole) in the skull beneath our ear and branches out in several major trunks within the parotid gland to go to our facial muscles. So a tumor in the parotid will be in very close proximity to one or several of these branches. Parotid surgery involves carefully finding the main trunk of the nerve and tediously dissecting the tumor away from the nerve branches. A routine parotid mass operation (if there is such a beast) can require three to four hours of very intense work under loupes magnification (glasses that magnify the field anywhere from 2.5 to 8 times). So back to Mr. J:

Mr. J’s mass was located underneath the nerve in the deep lobe of his parotid gland. The nerve was carefully elevated away from the tumor, and the mass was delivered and sent to pathology for a frozen section analysis. If this showed a malignancy, I was contemplating sampling some lymph nodes in his neck to determine if a formal neck dissection to clear metastases would be necessary. To my dismay, the pathologist returned the diagnosis of a ‘highly anaplastic neoplasm’, in other words, a very malignant mass with a high chance of spread and involvement of surrounding tissue, including the nerve. So when faced with this new information and an unplanned contingency, I did what all experienced surgeons do: stop and think. What is the situation and what are my options? The current situation involved a stable patient (under anesthesia that was uneventful, stable vital signs, no bleeding, nothing life threatening), a frozen section diagnosis that even in the best hands is a preliminary diagnosis, and a clinical situation that might require sacrifice of the facial nerve to clear his tumor of microscopic disease. And next I did what all experienced surgeons do: seek more information. I talked with the pathologist who stated that although the mass was definitely malignant, he could not tell me specifically what type or even if it was primarily from his parotid, ie it could represent a metastasis from a different site. Then I decided to obtain an intraoperative consultation from a noted head and neck surgeon based at our referral university medical center. Thought I, “He most likely had faced this situation several times, would know what to do, and would offer sage advice.” So I had the nurse call his department and his secretary tracked him down within a few minutes. Holding the phone with a sterile towel, I listened carefully: “No question here,” he said. “You must sacrifice the nerve, do a radical neck dissection, drill away the mastoid tip where the nerve exits the head, and resect the condylar head of his mandible.” I replied, “Thanks a lot” and handed the receiver back to the nurse to hang up. I related his message to the OR team of anesthesiologist, nurse, and scrub tech, then paused momentarily to consider his advice. I then returned to the table and asked for closing sutures. “No way in hell,” I said. The proposed course of action by my consultant violated several sound operative principles I had learned in training and in practice. It would have created a major post operative functional deficit (the dreaded facial paralysis) without consent from patient or family and it was based on tenuous data (a frozen section). So I closed and his post operative facial nerve function was totally normal. Three days later the permanent pathology revealed a metastatic malignant melanoma, further surgery would have been unhelpful and unnecessary. Further work up disclosed the primary at a distant site, and chemotherapy was started.

So the key message here was to stop and think, seek more information, filter that information through your years of training and experience, and to observe the age old mantra ‘primun non nocere’ – first do no harm. I saw Mr. J in routine follow up to remove his sutures and then about a year later at the base exchange. Funny thing about melanomas, they can lay dormant for years on end and then for no reason flare up and become quite aggressive. But that day he was feeling great, smiling, and he thanked me for removing the tumor and sparing his face.

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

Father’s Day, personal and professional

On this most holy of days, we honor our fathers and forefathers. I had the good fortune of attending church and having brunch with two of my three grown children (the oldest is in Europe pursuing her graduate studies). My resident step son honored me with a beautiful book of a collection of golf photos (all really good surgeons play golf, beware those who do not). My other step son is on a two week mission trip to Costa Rica, building a music center at our sister Moravian church in Puerto Limon. I honored my deceased father with a contribution to Heifer Project International with a donation of honeybees to some third world spot. He wasn’t perfect, as Lord knows I am not the perfect dad, but still it is an honor to be his son.

Surgeon in the trenches (SITT) thinks this would be a great day to honor not only our biologic fathers but also our father figures. For many these father figures are teachers, coaches, etc. For many surgeons, our surgery professors represent those paternal figureheads (increasingly women are joining the ranks of surgery faculty, but 25 years ago when I finished it was dominated by men). Their teaching and mentoring styles, just like real fathers, reflect the entire gamut from detached stern taskmasters to openly caring supporters. Once a surgeon leaves their residency training program, we also leave the umbrella and nest of our surgery professors and ready or not, fly on our own to create our own practices, experiences, and careers. Yet just as we carry the genetics from our biologic fathers, we are marked by our makers.

Still an identifying characteristic of all surgeons is where and under whom one trained. Me, I’m a McCabe man. Brian McCabe, better known as Brian the Lion for how loud he would roar if displeased, and one seldom saw him otherwise. One merely experienced the level of displeasure. Yet, despite the overly stern teaching style (read into this brutal at times) he was the consummate teacher. If as a resident I could detach from my disdain for his style, then pearl after pearl of surgical wisdom could be found in his discourses on ENT disease and management, and to this day his sage advice and sayings permeate my mind in the OR if the right situation arises (in the middle ear “move one hand a time”, “take your lumps in the OR, it won’t get better in the clinic”, “fix it right and fix it right, right now!”, oh a few chills just went down my spine).

So today SITT honors his dedication to surgical education and SITT honors him, all of him despite his curmudgeon ways; and honors his professor and his professor’s professor, all the way back to Galen and Hippocrates. It is an honor to be his son.

Posted by Douglas K. Holmes, MD

Healthcare Reform

The pressing issue of the day is the shape and form of the upcoming healthcare reform. Unfortunately, none of the current proposals actually reform healthcare. They merely increase the numbers of insured that will be eligible to have their healthcare bills covered by whatever insurance (government sponsored or private plans) these reforms provide.

True reform of healthcare would change the current emphasis from treating illness to actually sustaining or improving health. Such measures involve preventive care (vaccines, mammograms, etc), incentives to people and institutions to reduce poor choices (smoking, drinking excessively, overeating, unprotected sex, sedentary life style), and education that improves health (diet, exercise, accident prevention). Engineering a financial methodology that pays for this type of system instead of our current reimbursement for illness care will be even more challenging. Surgeon in the trenches (SiiT) does not predict such a system will see the light of day in our lifetime. Rather, we will see some type of change in how our country pays for illness care extended to more of our citizens, if not all of our citizens if health insurance is mandated.

SiiT looks forward to the day when people can have their healthcare needs (as opposed to wants) met without regard of financial status and free from the current regulatory environment that chokes our offices with paperwork and redtape that delays needed care and deserved reimbursement. SiiT is not holding his breath.

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.