Archive for the ‘Surgery’ Category

Tell me your cosmetic secrets

I live and work in Los Angeles, one of the plastic surgery capitals of the world. Quite a few of my patients have “had a little work done” — the blandly euphemistic term you’ll hear for plastic surgery makeovers of all kinds. That’s fine. Plastic surgeons have children to feed too.

The problem is this: many of my patients want to convince everyone that their “look” is entirely natural. They don’t want to admit that they’ve had a tummy tuck, an eyelid lift, or breast implants. One patient tried to tell me that the perfectly matched scars behind her ears were the result of a car accident, not a face lift. In front of family members, patients will even deny having dentures. That’s understandable, but unwise from a medical point of view.

The fact is that plastic surgery has implications for future medical care. Your anesthesiologist needs to know about it, and your surgeon does too. It may be cosmetic, but it’s still a bigger deal than getting your eyebrows waxed.

Here’s why we need to know the cosmetic secrets our patients may NOT want to tell us.

Why does a tummy tuck matter?

One of the worst complications I’ve seen after plastic surgery happened to a lovely patient who, years before, had an abdominoplasty, popularly known as a “tummy tuck”, with a very good cosmetic result. Many women request this procedure once they’ve finished having children, to tighten up the skin and smooth out the appearance of the abdomen. The incision is similar to the one for a cesarean section, across the lower abdomen, though it extends further to each side. Once it’s well healed, it may barely be visible.

Years later, the patient needed major surgery on her liver, and the surgeon made an incision known as a “chevron” or “rooftop” – an incision across the upper abdomen, just below the ribcage. The surgical team didn’t realize she’d had a prior abdominoplasty, and the patient never thought to mention it.

The blood supply to her abdominal wall had been interrupted from below by the abdominoplasty incision, and now was interrupted from above by the chevron incision. The skin and soft tissue of the patient’s whole abdominal wall essentially died and turned black from lack of blood flow and oxygen, a condition called tissue necrosis. The patient needed extensive skin grafting and several surgical procedures for reconstruction.

What about breast implants?

For the most part, breast implants don’t matter much in terms of subsequent surgery – unless you need an operation that involves your chest. Surgery on the lungs or esophagus often is done today with a minimally invasive technique called video-assisted thoracoscopy, where the surgeon inserts slender instruments and a tiny camera through small incisions in the chest wall. It would be easy to rupture a breast implant unless the surgeon knows it’s there and can work around it.

Chin enhancement?

Chin enhancement surgery, or genioplasty, may involve inserting a small plastic implant to improve the appearance of a receding or “weak” chin. It may seem like a trivial procedure, and the tiny scar beneath the chin may be hard to spot. But please tell your anesthesiologist if you have a chin implant! A receding chin is a facial feature that can alert the anesthesiologist to possible trouble inserting a breathing tube. It’s important for us to know if a patient’s chin didn’t always look the way it does today.

(As an aside, it’s not uncommon for men to grow beards as a cheaper, easier way to conceal a receding chin. An experienced anesthesiologist knows to look for this feature when evaluating the patient’s airway prior to surgery.)

Eyelid lifts? False eyelashes?

Eyelid lift, or blepharoplasty, is done to remove excess or sagging skin from the eyelids. It’s also popular among East Asian patients (both men and women) who want to alter the shape of their eyelids for a more “western” look.

After a blepharoplasty, the eyes may not close completely if a patient is sedated or unconscious during another operation. If the eyes aren’t fully shut, they may dry out because the patient isn’t blinking normally. The delicate corneas may develop micro-cracks, which cause pain when the patient wakes up just like any other corneal scratch or injury. Oxygen from a face mask blowing past partially open eyes may also cause the corneas to dry out and become red and painful. If we know that you’ve had a blepharoplasty, we can take extra precautions to protect your eyes and keep them moisturized.

False eyelashes or eyelash extensions can easily be damaged during surgery. This is because the anesthesiologist usually protects the patient’s eyes from corneal scratches by putting tape or a transparent dressing over the eyelids. When the tape comes off at the end of surgery, the eyelashes can come with it. If you’ve just paid $150 or more for a full set of lashes, I can understand why you’d be upset. If you mention that you have them on, we can use goggles to protect your eyes and leave the eyelashes undisturbed.

We promise not to tell

The take-home message to patients? Please tell us your cosmetic secrets. Send your family members off to get coffee before you talk to us if you don’t want them to know. But what we – your anesthesiologist and your surgeon – DON’T know about your cosmetic history, unfortunately, can hurt you. We promise not to tell.

If physicians are “muggers” and co-conspirators in “taking money away from the rest of us”, then journalists and economists are pontificating parasites who produce no goods or services of any real value.

I don’t think either is true, but the recent attacks on physicians by economists Anne Case and Angus Deaton, and “media professional” Cynthia Weber Cascio, deserve to be called out. You could make a case for consigning them permanently, along with the anti-vaccination zealots, to a healthcare-free planet supplied with essential oils, mustard poultices, and leeches.

My real quarrel with them — and with the Washington Post, which published their comments — is that they have the courage of the non-combatants: the people who criticize but have no idea what it’s like to do a physician’s work. More about that in a moment.

Ms. Cascio was enraged by the bill from her general surgeon, who wasn’t in her insurance network at the time she needed an emergency appendectomy. She doesn’t care — and why would she? — that insurance companies increasingly won’t negotiate fair contracts, and it isn’t the surgeon’s fault that Maryland hasn’t passed a rational out-of-network payment law like New York’s, which should be the model for national legislation. She doesn’t care that Maryland’s malpractice insurance rates are high compared with other states, averaging more than $50,000 per year for general surgeons. She just wants to portray her surgeon as a villain.

The two economists are indignant that American physicians make more money than our European colleagues, though they don’t share our student loan debt burden or our huge administrative overhead for dealing with insurance companies. They resent that some American physicians are in the enviable “1%” of income earners. But do they have any real idea what physicians do every day?

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The real surprise – to me, at least – came more than halfway through Dr. Atul Gawande’s keynote address at the opening session of the American Society of Anesthesiologists’ annual meeting in Boston.

Much of his talk on October 21 celebrated the virtues of checklists and teamwork, topics that have turned into best-selling books for the well-known surgeon and professor of public health. “We are trained, hired, and rewarded to be cowboys, but it’s pit crews we need,” he said.

Then Dr. Gawande posed this question to the packed room: “What are the outcomes that matter?”

He answered his own question somberly. “The most unsafe operation is the operation that shouldn’t be done,” Dr. Gawande said. “Does the operation serve the patient’s goals or not?”

“We’ve all been there,” he continued. “Taking people to the operating room and wondering what we’re doing.”

Those are comments I’ve heard from anesthesiologists many times before, but I never thought I’d hear them from a surgeon.

Flogging the dead

For any of us who practice anesthesiology in a major hospital – doing cardiac, thoracic, or liver cases, for instance – there are days when all our efforts are spent on behalf of a patient whose health is unsalvageable. “Flogging the dead” is a phrase sometimes used to describe prolonged and futile care in the operating room or ICU.

Sometimes aggressive interventions are driven by a family that wants “everything” done, because in their innocence the family members have no idea how terrible and dehumanizing the process of postponing death can be.

In other circumstances, however, the decision of whether to do surgery is driven by the mission and the financial motivation of the health system to provide care. If care doesn’t occur, if the surgery isn’t done, no one gets paid.

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Is it always wrong for a surgeon to book cases that will be done in two operating rooms during the same timeframe?

If you’ve paid much attention to the overheated commentary on social media since the Boston Globe published its investigative report, “Clash in the name of care“, you might easily conclude that the surgeon who runs two rooms ought to be drawn and quartered, or at least stripped of his or her medical license.

John Mandrola, MD, a Kentucky cardiologist who I’ll bet doesn’t spend a lot of time in operating rooms, weighed in on Medscape with a post called “The Wrongness of a Doctor Being in Two Places at Once“, accusing surgeons of hubris and greed.

Respectfully, I disagree.

The Globe’s story tells the dramatic tale of how a prominent surgeon at Massachusetts General Hospital often scheduled two difficult spine operations at the same time. According to the Globe’s reporters, the surgeon typically moved back and forth between two operating rooms, performing key parts of each procedure but delegating some of the work to residents or fellows in training.

On one particular day, a complex case ended with a tragic outcome. The patient, a 41-year-old man, sustained spinal cord injury at the level of his neck, leaving him permanently unable to move his arms or legs. Another prominent MGH surgeon leaked details of the case to the press, and was summarily fired.

Of course, I have no special access to information about what goes on at the MGH, and can’t comment on the specific cases highlighted in the Globe’s report. But I’ve been giving anesthesia for a long time in first-class hospitals. On countless occasions, I’ve seen surgeons run two rooms, and have administered anesthesia to a patient in one of them.

Have I ever seen a patient come to harm because the surgeon scheduled concurrent cases?  No.

Have I ever been annoyed because a surgeon delayed the start of my patient’s case because of the demands of the case in the other room? Yes, but I always agreed with the decision to delay, and the wisdom behind it. If the surgeon is at a critical portion of the first case, we have no business starting the second case until the surgeon gives the go-ahead.

Have I ever been thankful that the surgeon had two rooms? Yes indeed. Here’s why.

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“Twilight” is a movie

How the advent of propofol — the drug associated with the deaths of Joan Rivers and Michael Jackson — changed the meaning of the term “sedation”

“Twilight! She has to have twilight,” insisted the adult daughter of my frail, 85-year-old patient. “She can’t have general anesthesia. She hasn’t been cleared for general anesthesia!”

We were in the preoperative area of my hospital, where my patient – brightly alert, with a colorful headband and bright red lipstick – was about to undergo surgery. Her skin had broken down on both legs due to poor circulation in her veins, and she needed skin grafts to cover the open wounds. She had a long list of cardiac and other health problems.

This would be a painful procedure, and there would be no way to numb the areas well enough to do the surgery under local anesthesia alone. My job was to figure out the best combination of anesthesia medications to get her safely through her surgery. Her daughter was convinced that a little sedation would be enough. I wasn’t so sure.

“Were you asleep the last time your doctor worked on your legs?” I asked the patient. “Oh, yes,” she said. “Completely asleep.”

“But she didn’t have general,” the daughter interrupted. “She just had twilight.”

Propofol revolutionized anesthesia care

Though “twilight” isn’t a medical term, people often use it to mean sedation or light sleep as opposed to general anesthesia. Most patients don’t want to be awake, even if their operation doesn’t require general anesthesia. They prefer an intravenous “cocktail” to make them oblivious to pain and unaware of anything that’s happening. Today, the main ingredient is likely to be an anesthetic medication called propofol.

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