The Hands of a Surgeon

A young Vietnamese immigrant wandered into the inner city clinic where I trained as a student and subsequently worked for several years. Although he spoke little English, his chief complaint was obvious:  an unsightly mass protruded from the right side of his face along the jaw line.  He had been to a number of medical facilities for treatment, but no one wanted to excise the cluster of bumps just beneath the skin.  In retrospect, the reason was obvious—he had no medical insurance.

I asked my supervising physician to have a look. He agreed with my assessment: a cluster of subcutaneous cysts. “You could do it,” he said. “Incise directly over the blebs. It should be fairly straightforward. You won’t be able to get them out without breaking them, but no matter. It should pull together nicely.”

In those days we performed minor surgery in the clinic. I scrubbed and prepped the area, positioned the drape, infiltrated the region with anesthetic and with a scalpel made the incision. Our nurse stood by, ready to assist, as I began the dissection.

When I was an adolescent over the course of three summers I worked on the staff of a local camp. One year I taught camp craft and pioneering. Under my supervision my young charges felled a number of tall tulip trees, lopped off the branches and laid them out according to plan. We spent several weeks that summer constructing a signal tower, using only braided rope for the lashings that bound the spars together.

As we labored one afternoon in the hot sun, the camp director wandered into the meadow to observe the progress. He stood with his hands on his hips, watching me demonstrate a standard lashing to the boys. Afterwards, he paid me a compliment: “You’ve got the hands of a surgeon,” he said. Carefully chosen or not, his words stuck in my head.

Several years later I learned how to close simple lacerations when I worked as a hospital corpsman aboard a high-endurance cutter. One night during a layover in Lisbon I was called to attend a sailor who had been stabbed during a fight that broke out in a bar. The man was drunk. They hauled him into sickbay and stretched him out on the table. I explored the shoulder wound (not as deep as it first appeared), irrigated and surgically closed it. The next day we put out to sea. Ten days later I extracted the sutures. The wound never suppurated; I counted both him and myself lucky.

Several of my classmates in PA school elected to pursue careers in general surgery. I opted for a track in general medicine instead. Even so, I found myself standing over this young Vietnamese man that afternoon, excising a mass that other clinicians more experienced than I had refused to touch.

I dissected the mass in toto and closed the wound, using vertical mattress sutures. The following week the young man returned to have the sutures removed. Only a hairline scar remained. I showed him the result in a hand mirror. I remember his smile—the only thing he had to offer in payment.

I still close minor lacerations on occasion in the office. These days I use Dermabond for the most part. It’s quick, easy and painless. They say that the results are every bit as good as surgical closure.

That may be the case. But I take some satisfaction in knowing that somewhere out there today, an older Vietnamese man remains grateful for the gift I was given in my youth: the hands of a surgeon.

Author to speak at 2010 AAPA conference in Atlanta

Author and practicing Physician Assistant Brian T. Maurer will be co-presenting “What Charlotte’s Web Can Teach Us about Caring for Critically Ill Children” at the 2010 American Academy of Physician Assistants national conference in Atlanta, Georgia.

The workshop, to be held on Monday, May 31st, will explore lessons in humane medical practice that clinicians can draw from E. B. White’s classic children’s story about a pig and a spider.

For further information, click on the link below.

What Charlotte’s Web Can Teach Us about Caring for Critically Ill Children

Memes and the evolution of medical practice

A meme is “a postulated unit of cultural ideas, symbols or practices, which can be transmitted from one mind to another through writing, speech, gestures, rituals or other imitable phenomena.” The British evolutionary biologist Richard Dawkins postulated this concept in his 1976 book The Selfish Gene to explain the spread of ideas and cultural phenomena in evolutionary terms. Susan Blackmore, the British psycho-theorist, further developed Dawkins’ theory and believes that we are moving toward a new form of meme, the teme, which is spread by the technology we’ve created.

If we consider for the moment that memes do indeed exist (and their existence is far from certain), we could postulate that medical memes propagate through the medical community via medical journals, lectures and mentors. Published research eventually generates new approaches to the diagnosis and treatment of disease. Much contemporary medical research in the U.S.A. is underwritten by the pharmaceutical industry.

Nowadays, children routinely take medication for chronic conditions such as allergic disease, asthma, ADHD, depression, diabetes, gastroesophageal reflux and hypercholesterolemia. A spate of recent articles documents that 1 in 4 children covered by health insurance took some form of prescription medication in 2009. Annual spending for prescription drugs in children increased by 10.8 percent the same year, and the price of branded prescription drugs increased by 9.2 percent. Clearly, someone besides the patient is benefiting enormously from these trends in medical practice.

As a clinician who has worked on the front lines in ambulatory pediatrics for 30 years, I can vouch that these statistics seem to be supported by what I have observed over the past decade. The sheer number of children who take daily prescription medication for chronic conditions is astounding; and in my opinion these numbers will only escalate exponentially.

What drives these trends? Are clinicians becoming more astute at recognizing and diagnosing these conditions in children? Are the conditions themselves growing at an alarming rate secondary to cultural influences such as high fat diets, readily accessible food, over consumption of calories, unlimited access to TV and video games? Are parents themselves at fault, seemingly unable or unavailable to rear children with their best interests in mind?

Although any or all of these factors could potentially contribute to these disturbing trends, might medical memes—those ideas which seem to infiltrate medical practice and become acceptable norms—also play a role here? Are we clinicians too quick to reach for the prescription pad at the expense of taking time to offer wise counsel to our patients?

Some memes may replicate effectively even when they prove detrimental to the welfare of their hosts. According to Dawkins, “systems of self-replicating ideas can quickly accumulate their own agenda and behaviors,” which ultimately might prove to be good or ill for society, culture and the population at large.

Perhaps the medical profession needs to examine itself and take a closer look at what drives contemporary medical practice. In the meme, that might be a good thing.

Tongue in Cheek

Olga opens the door that leads to the reception area, careens her neck to scan the empty waiting room and calls my name. I rise to my feet, drop the magazine onto the corner table and follow Olga’s massive frame through the doorway and down the narrow corridor that leads to the open room at the back where the dental chair waits.

She motions for me to sit down and fastens a paper napkin around my neck with a small beaded chain. The metal chain is cold on my neck; instinctively, I reach up and adjust it so it rests on the outside of my shirt collar.

“The doctor will be with you shortly,” Olga says in her heavy Eastern European accent.

Sometimes I find myself involuntarily fantasizing about people. Secretly, I’ve got Olga pegged as an ex-KGB agent.

Soon the dentist appears. His lanky frame strides into the room with a hand extended in greeting. “How are you?” he says. “Here to have that tooth restored today?”

I nod my head. “I think that was the plan.”

“Ah, yes—well, let’s have a look.”

I open my mouth wide to accommodate the instruments that he inserts to pick at my molar.

“Good,” he says, matter-of-factly. “We’ll put a little numbing medicine on your gum before injecting the anesthetic. This new preparation is really neat. It’s manufactured with a vasodilator, so it’s cleared from the area quickly. Instead of walking around with a numb jaw for three hours, the time is cut in half.”

Once again I open my mouth and close my eyes. I feel the needle stick into the back of my mouth. Slowly, the solution is pumped into the tissue. Soon my cheek begins to feel heavy. “Now then, we’ll give that a few minutes to work.”

“I understand you were in research before you went to dental school,” I say, recalling a little known fact that his hygienist divulged to me at my last cleaning.

“That’s right. I worked in steroid hormone research with male hamsters for two years. After that I switched to molecular research. My boss was credited with decoding the genome for retinoblastoma.”

“Interesting stuff.”

“Well, yes and no. Research is very tedious. The thing I remember most was having to extract the food pellets from the cheek pouches of the male hamsters after anesthetizing them. These pellets were as big as your thumbnail.”

He picks up the drill and slips it into the back of my mouth. “Olga, suction please.” Olga inserts the plastic tube into the back of my throat. The drill whirrs like a tiny jackhammer. I can taste the fragments of newly pulverized tooth enamel on my tongue.

“I couldn’t believe how many pellets some of those males could salt away in their cheeks at one time,” he explains as he works. “I used to have to dig them out with my thumb. Suction, Olga.” Once again the plastic tip darts into my throat.

“Now open wide,” he says. “I’m going to pack the back of your mouth with cotton.” He inserts a pledget under my tongue and tucks another one inside my cheek. “Now we’ll slip this little metal collar around your molar.” He cinches it down tight. “O.K., Olga—mix.”

I hear a small whirring sound behind me, then Olga hands the dentist a miniature version of a caulking gun. Afterwards, he inserts a pen-like instrument with a blue light at the tip. It emits a small beeping sound every few seconds. I half expect my body to be atomized, molecularly transported to another dimension.

“Everything O.K.?” he asked. “How are you feeling?”

I utter the first phrase that pops into my head: “Like a male research hamster,” I say, making an effort to smile; but, like the patient suffering from Bell’s palsy, only one side of my mouth turns up.

I am eternally grateful that he doesn’t use his thumbs to pop the cotton pledgets out of my mouth.

A Silly Millimeter

When I was a boy, tobacco advertisements on television were ubiquitous. I remember sitting in front of our black and white set, watching the Marlboro man drive his herd on horseback through the dust. At some point he’d lean back in the saddle, reach a pack of Marlboros to his lips and extract a cigarette. He was the epitome of a man’s man, masculine to the core.

Such ads worked to introduce millions of young people to the smoking habit. It is perhaps less well known that three of the Marlboro man actors eventually succumbed to lung cancer in their early 50s.

During those years Chesterfield brought out a new cigarette one millimeter longer than the conventional brands. It was christened “101,” and marketed as “a silly millimeter longer.” To this day I can still recall the jingle inside my head.

What difference does one millimeter make after all? In the world of contemporary tobacco sales one millimeter counts for little (the brand was retired long ago), but in the world of medical science a millimeter is anything but silly.

The other morning I read a case presentation of a young woman of twenty years who consulted her dermatologist for a 5 millimeter lesion on her upper back of two month’s duration. The dome-shaped lesion was round, smooth, with regular borders—all of the characteristics usually associated with a benign growth. Because it bothered the patient, the dermatologist excised the lesion. Unfortunately, the pathology studies showed malignant melanoma, with invasion of the dermis to a depth of 3.5 millimeters. At the time of diagnosis this cancer had already spread to two of five sentinel lymph nodes.

Five-year survival rates for patients with malignant melanoma correlate with the depth of the lesion at time of diagnosis. Anything less than 1 millimeter carries an excellent prognosis. Survival rates shrink appreciably as the lesion expands below 2 millimeters—a silly millimeter lower. For the patient with malignant melanoma, morbidity and mortality are determined by millimeters.

Synapses in the brain are measured in nanometers, 1/1,000,000th of a millimeter. These microscopic gaps are bridged by neurotransmitters which trigger the impulses that facilitate thought processes and coordinate motor movement. Yet in the patient with Parkinson’s disease, pathologic processes dictate otherwise. Metaphorically speaking, these minute gaps might as well approach infinity.

Few of us outside scientific research pause to consider the implications of such minutiae in our world, unless we become one of those unfortunate patients who develop such illnesses.  Only then, for us, do minute measurements take on cosmic significance.

“Notes from a Healer” — Sticking to the Treatment Plan

Persistence is a virtue—even if it is sometimes misapplied.

My latest installment of Notes from a HealerSticking to the Treatment Plan — is now online, newly published in the Yale Journal for Humanities in Medicine.

The Yale Journal for Humanities in Medicine is an online clearinghouse for manuscripts dealing with the humanities and medicine. Interested readers can access a list of editorial board members and regular contributors here.

Evening, After a Spring Rain

Spring is a season of transitions.

After a full day of steady soaking rain, the air cools considerably; so much so that you can see your breath on this late April evening.  I wait until the rain has tapered off to take the dog out.

Together we pad down the shiny wet street, past the flowering crabapple trees in the church yard, around the corner to the top of the hill, where yellow forsythia blossoms lie scattered on the sidewalk.  Wild violets hang in clusters over the curbing at the edge of the cemetery.  Sentinel rhododendron pods are swollen with the promise of spring.

As we descend the forest path to the river, the dog straining at the leash, the lonesome call of a mourning dove erupts—a haunting hallowed echo that resonates through the cool evening air.

In the village at the end of Main Street where the gravel road turns off toward the park there sits a tiny shingled house.  At one time this structure served as the village train station, back when the railroad was in its heyday.  The tracks are long gone; only a berm marks the former bed.

The man who lives there now works as a repairman.  Occasionally, I see his old van parked outside the village auto shop.  Sometimes I pass the man coming out of the post office, his work shirt pocket stuffed with a plastic sleeve of pens.  His wife died earlier this month.

The auto mechanic told me that the repairman had approached him about dispersing his wife’s ashes out on the sound.  The auto mechanic has a boat berthed at one of the marinas along the shore.  The repairman has the old van, but no boat.  The auto mechanic said he would do it.  They would take off early one morning in the old van and drive down to the coast to where the boat was moored and head out to sea with the urn of ashes and cast them out over the water in the morning sun.

The mourning dove calls again, and I think about the repairman and his old van and his newly deceased wife and the matter-of-fact neighborliness of the auto mechanic.  The dog strains at the leash as we walk along the path by the river to the pond in the park, then back up the gravel road to Main Street, where the tiny shingled house sits silently in the damp evening air.

The old van is parked in the driveway.  In the shadows of the arbor vitae to the left of the house the side yard is blanketed in a soft wave of sky-blue Forget-Me-Nots.