Sunday, November 27, 2005

The Color of Nerves

This is a letter I received from N., whose national identity clearly weighs heavily, asking a great question that reminded me that there are lots of people who do NOT see parts of the human body exposed all day long.

My name is N. and I come from Austria not Australia! I would like to learn what colour nerves are.I am studying the nervous system and I know that we have trillions and trillions of nerves in our body.I hope you have an answer to my question.

So I told her:

Thanks for clarifying where you're from. People must get that confused a lot, and expect you to know a lot about kangaroos and things. How bothersome.

We certainly do have a lot of nerves in our bodies. Far too many for anyone to count. Most of them are so tiny that you can't see them at all, but the ones that you can see are a very pale yellow, almost white! I wish that things in the body were as clear in the operating room as they are in the books, but in reality it can be really hard to tell what's what, since most things are sort of pink/red and they are all stuck together. We have to be very careful to make sure that we don't cut things we're not supposed to, obviously, so we dissect very carefully to find all the nerves, arteries, and veins. The nerves look and feel a lot like rubber bands, while the arteries feel like little garden hoses, and the veins feel like floppy tubes.

Sometimes we have to cut nerves in order to be able to do the surgery properly and make the patient better. What do you suppose patients with cut nerves feel when they wake up? Actually, most of the time, they never even notice! There are so many nerves that even if you cut some of them, the skin is still covered with plenty of others. But sometimes, people have a little bit of numbness over the skin where we cut the nerve. Even then, other nerves will sometimes grow into that area and the numb feeling will go away with time. Pretty amazing, huh?

I hope that helps to answer your question. Please let me know if you have any more questions, and I'll do my best to answer them too!

Pulmonary Circulation

This is a letter I received from a fourth-grader named C. , asking a question that has plagued legions of scholars through the years and was only recently made clear:

My name is Carmella.I would like to ask you if you could tell me why the pulmonary artery is blue and the pulmonary veins are red . When the veins are blue they take the blood back to the heart and the red arterys take the blood to all the parts of the body.

And my response:

Dear Carmella,

This is a great question! To understand the answer, it is important to know that when you see real arteries and veins, they don't look red and blue like they do in books. The actually all look sort of purple, and it can be hard to tell which ones are arteries and which ones are veins. The way we tell in the operating room is by putting our finger on them...the arteries are firmer, and you can feel a pulse in them, while the veins are softer and don't pulse. Why do you suppose that is? I'll give you a hint: it's because of all the capillaries.

Anyway, you're totally right that arteries take blood away from the heart, and veins take blood back to the heart. What the red and blue colors on your picture tell you is not whether something is an artery or a vein, but whether that blood is carrying oxygen or not. When the blood goes from the heart to the rest of the body through the arteries, it carries oxygen to the tissues, so those arteries are colored red. And when it comes back to the heart from the body, the tissues have taken the oxygen, so the blood doesn't have oxygen in it and we color them blue. So how does the blood get oxygen again, to take back to the tissues? I bet you know the goes to the lungs.

So when the blood leaves the heart to go to the lungs, it is going away from the heart, which means it is going in an artery - the pulmonary artery - but it doesn't have oxygen in it - so the pulmonary artery is colored blue in diagrams. Then, when it returns from the lungs through the pulmonary veins, it DOES have oxygen in it, so it is colored red. It's exactly the opposite of the way the blood flows in the rest of the body, which is why we talk about there being two different circulations, the pulmonary and the systemic, and why there are two different pumps within the heart, the right side pump that pumps blood from the body to the lungs, and the left side pump that pumps blood from the lungs to the body.

It's complicated, isn't it! I think the best way to understand it is to draw a picture or make a model, and trace the route of a blood cell from the time it gets oxygen, through the tissues where it delivers its oxygen, to when it returns to the lungs to get more oxygen. That's how I figured it out!

Heart-lung Machines

This is an excellent question from G., in Germany:

I have a question if you would have the time to answer it I would
really appreciate it.If you take out your heart in a operation how are
you going to live ? Are they putting a fake heart inside your body?
When they are changing it how does your blood get oxygen?

To which I say:

Dear G.,

What an excellent question! We take hearts out when we transplant them, which means that we put another one back in to replace the heart that isn't working. That happens pretty fast, so people don't go without a heart for very long. But for the short time (usually about three hours) that their heart is disconnected from their veins and arteries, and isn't pumping blood around their bodies anymore, we have a machine called a heart-lung machine that does the work of the heart for them. It's really cool.

The machine connects to the biggest artery that comes out of the heart, which is called the aorta, and to the veins that come back to the heart, which are called the vena cavas. It takes the blood from the veins, puts oxygen into it, just like the lungs do, and then puts the blood with the oxygen in it back into the aorta, where it gets pumped back to the rest of the body. So it does the same job as the heart and the lungs while the patient's heart is being operated on.

You couldn't have the machine on when you're awake and walking around, though, because it is very big and would hard to move around with. Here's a picture of what it looks like in the operating room:

Can you imagine having to have that whole machine and the guy to run it following you around when you went out to the grocery store?! So for the moment, you still need to have a heart in your body most of the time. We are working on making artificial hearts for people whose hearts don't work and who can't get a transplanted heart from another person, but so far they don't work nearly as well as the real thing!

I hope that helps to answer your question! Let me know if you have more questions. It would be a pleasure to do my best to answer them.

Wednesday, October 12, 2005


I'm returned from a long vacation, much enjoyed, and, to my mind, much deserved. And so I resume my trumpeting into this great silence-with-promise.

Being away from this place, in a place where there were no great demands on my time, only reinforced the madness of my daily life as a surgical resident. Why is it that this job seems to feel it appropriate to maintain a tradition of indentured servitude? How is it that one of the most modern, advanced professions in the world still holds to the feudal premise of serfdom. The truth, I think, is pathetically pecuniary: this is the way that attending doctors insure a high income...if there were enough residents to make a resident's life easy, or even reasonable, there would be too many doctors. This is changing, slowly, as mid-level practioners -- nurse practioners and physician assistants -- who can write prescriptions and handle basic problems, but won't threaten to dilute the patient base, are made more common. Now that we are, in principle (though very rarely in fact) limited to 80 hours per week of work, these folks are much more common. But only enough to keep us right at, or over, the line.

Welcome back.

Tuesday, September 20, 2005

A Simple Act

Today I did one of the most theraputic things I've done in a long time. I bought one of my patients a newspaper.

Granted, there have been a couple of times in the past few months when I may have had a more direct impact on someone's health...there were some tense times in the emergency room early on, where a chest tube or central line, guided by my hand, was the difference between life and death. But the reality is that these moments, occuring between each commercial break on the television version of my job, are actually rather few and far between. So often the best things we do for patients is not subscribing a new medication of dubious benefit (and most of them are, I think), but the little things we do to restore the humanity of someone who has been lying in a bed for a month, wondering about how the horse races have been going in his absence.

Still, I happend through our emergency room this afternoon just as a couple of serious cases were coming through, with the oiled machinery of our trauma apparatus swinging into action and smoothly handling the influx of some tremendously ill patients. I was proud to belong to that system, and to know that the people I saw at death's door in the ER will in all liklihood (and against all odds) walk out the doors again, someday.

Monday, September 19, 2005

The Pile of Babble

Once, a few years ago, after college and before medical school, I worked as a reporter at a daily newspaper in the Northeast. My career plans were well-known to my editors, and they gave me the paper's health beat. I had some good scoops -- tainted food, a pertussis outbreak -- and got my share of the general news beat -- hostage takings, vineyard openings. But my favorite thing was to write feature stories.

While I was working at the paper, the Institute of Medicine released one of the most quoted analyses of modern medicine in modern history. Called "To Err is Human," it laid out how up to 100,000 people each year are killed by medical errors. Now, notwithstanding the purists who say, that everyone who dies is killed by a medical error, that's a big number. And the reality, if you read the text closely, is that it's probably inflated from what any reasonable standard of error-related, or iatrogenic, death actually is -- many of the patients in question would almost certainly have died quickly no matter what modern medicine had done to help or harm them.

But one thing that was clear was that there were some serious problems with the way medicine was practiced. One of these was the way that much of medicine was still dependent on hand-written notes and prescriptions, which were immensely prone to error. Likewise, there was no standardized way to make sure that patients with certain diagnoses were getting standardized, well-established care -- things like making sure that patients who had heart attacks got aspirins and beta blockers. I wrote an article about doctor's handwriting and the trouble that pharmacists had deciphering it. That was about 6 years ago. Today's New York Times reminds us all that this problem still hasn't been effectively tackled.

I work at one of the finest medical centers in the world. We regularly approach the top of any given ranking system. We are surrounded on all sides by high-tech industry and information services corporations that sell the computing age around the globe. And yet when I write notes on my patients, I scrawl them on pieces of paper and stick them in a binder. When I write an order, I press firmly so as to make it through all three pieces of carbon paper, the least legible of which will be sent to the pharmacy. It's like stepping back in time, and I think it's criminal. Especially when some places have been working with paperless, or near paperless, systems for almost 20 years. How this level of disparity can exist at the highest levels of medicine, when its clear that the way we do business is actively harming our patients, astounds me...and doesn't surprise me at all. Medicine is among the world's oldest industries, and its momentum and trajectory are all but unalterable. And most doctors are totally uninterested in deviating from the path of the way things have always been done. They applaud one another for creating variations on a theme, but are not, as a type, likely to ever look anywhere but straight behind themselves.

Sunday, September 18, 2005

First word from the outside world

I've just received the first comment on this blog. Thanks to the anonymous fellow from Canada who sent it, along with a link to his own site, for anyone interested in Canadian immigration issues.

Because I plan to use this space to talk about some sensitive issues and tell some fairly grisly stories - and because medicine is a heirarchal machine in which I am supposed to be a silent cog - I can't tell anyone I'm doing this. Obviously. So I rely on any and all of you who happen across this site, and tell your friends.

I'd love for this to become a forum for me to answer your questions about what the view is like from inside the American healthcare system. I know there are a lot of questions out there, and a lot of misperceptions. I'll clarify what I can, and tell the stories that seem topical to me, but if you, gentle reader, would like to help direct the conversation, it's most welcomed. Or just drop a note to say hello, you were here.


Surgery as the Marines

I've always heard that the whole premise of military training is to break you down and then build you up in the military mold. That through backbreaking work under adverse conditions, subject to the stricted edicts and capricious whims of your superiors, your individual nature can be crushed into a powder that can be reconstituted, reproducibly, into a generic soldier.

I've always thought this unlikely. The military people I've known have always seemed individuals to me, with identical haircuts. I'm sure it's all hyperbole...that whatever it is that makes a soldier is to some extent the ability to subjugate self to mission, and that this skill, like any other, can be laid to the side when the time comes to be your own person.

I very much hope that this is the same phenomenon that is happening to me, as I go through my own boot camp to become a surgeon. Each day, I feel more and more as though I am becoming a machine, designed to work within a narrow tolerance and without a view of anything beyond the medical. Everything I see becomes filtered through that light. I diagnose people on the sidewalk. I eat foods that will best replete my elemental amino acids, and count calories without even thinking of it. My humanity falls to my considered homo sapienism.

A week ago, I would have said that I had lost something of myself, some spark of creativity, that I would never be able to reclaim. Now, though, I have been off from work for several days, and I feel it coming back, in a welcome rush. Not replenished, but enough to make me think that I might just survive this all intact enough that with a bit of work I'll be able to be a person again when its all over. But that's a long time to wait.

Saturday, September 17, 2005

Surgeons vs. Humans

Today I was reminded of the strange disconnect that happens to us in medicine, the wall that we erect between ourselves and the patients we treat. This is something that happens in all sorts of little ways at first, and progresses.

When you're in medical school, every patient is an individual. You have plenty of time to get to know them, and you any they share about the same level of medical knowledge, really, so at least at first you feel more like them than the medical team you're a marginal part of. (For an interesting discussion of the state of medical education today, by the way, see this recent article from the NYT, which captures the picture very clearly and quotes some people I know very well.)

It doesn't take long in residency to start objectifying. First, I found myself doing something that I abhor in others, which is talking about patients and people "that" do things, rather than "who." It's the first step of objectification. Then, the other day, I was looking at the board in the ER for a patient that -- there I go again -- was coming to the service, and I actually referred to the patient as "it." And I knew then that I had truly crossed over.

Today, instead of clinical service, all the residents were due at the local surgical society's annual conference. One part of that was a discussion of medical ethics and disclosure of medical errors, which I've had an interest in since a failed attempt to make a film about that topic in medical school. And what was amazing was the way that the two hundred people in the room seemed utterly baffled by the human condition, trying to devine the simplest, most common sense facts of human nature and common sense from a series of presentations of convoluted data. How is it that they - we - cannot reflect deeply enough on our own humanity to be able to answer the question of how to deal with patients with our own projection of how we would like to be treated. How is it that we can come to view patients as being something totally different from ourselves, mysterious and unknowable?

Sometimes I feel that this program is changing me on some fundamental level. Sometimes I think that's a good thing, a breaking-me-down-to-build-me-up, military model that will allow me to find new depths of strength and ability in myself. But I do want to come out remembering that only time separates me from being the doctor and being the patient in the bed.

Thursday, September 15, 2005


I am a surgeon-in-training. I used to be an actor, and a journalist, and a thinker of indepdendent thoughts. This is a description of what that means. Names and descriptions of specific locations have been changed.


My residency begins in the emergency room at Overlook Medical Center. To put this in perspective, consider that where most hospitals cover the neighborhood around them, or perhaps, if they are large and have helicopters, a part of the surrounding state. Overlook, by contrast, has 5,500 trauma admissions every year from all over the western UA, and well more than that who don't get admitted. It's a thing to see, and something else again to experience. You wake up in the morning and look at the newspaper and the front page is covered with things you saw the day before...plane crashes, bear attacks, accident after accident after accident, flesh-eating bacteria on cruise ships -- news organizations have taken to stationing semi-permanent crews outside of the ER entrance for it's never-ending tide of human-interest human suffering.

The former newsman in me is always interested in comparing my eyewitness account with the renditions on the evening news, and my time at Overlook proves a sobering reminder of the fallibility of journalists, and more importantly, journalism. All of the stories I read about my patients had most of the details wrong -- simple errors of reporting from poor sources. But they also fail to capture the reality of injury in a way that I've never appreciated before, having never been exposed to it to this degree before. The difference between "a man suffered severe burns in an apparent cooking accident and was transported to Overlook Medical Center, where he is said to be in critical condition" and the visual and visceral reality of such a simple sentence is astounding.

The next month is on the Cardiothoracic Surgery service at the University. During the week, I am charged with the care of the patients on the thoracic surgery floor, which keeps me running. On Sundays, I am the sole representative for cardiothoracic surgery in the hospital, meaning that I, with the occasional aid of one of the CT surgery fellows on the phone, am responsible for the care of the cardiac and thoracic floors, all of their respective ICU patients, and all of the patients we'd been consulted on. Sound a little crazy for someone who'd been a doctor for a month? Let me assure you that the difference between that description and the visual and visceral reality was astoundingly more so, and leave it at that.

I emerge from that month with some serious questions about the philosophy of modern medical care, and the suitability of a program in which the intern is charged with making decisions on patients that the attendings never bother to see except when they are unconscious in the OR. I get the feeling that much of my training will prove to be a trial of my faith in the essential nobility of medicine, and of the magic that is possible in caring and providing care. I am committed to pursuing this path in this place so long as those trials act to temper my resolve to practice the kind of medicine that I believe in - a fundamentally joyful and humanistic enterprise. The defense of an ideal, I think, is the basis for its definition. Up to a certain melting point.

Still, I'm glad to have moved on to the General Surgery service at Overlook. Those 5,500 trauma admissions through the ER? Half of them come through my team. But we're a small army of residents, and the system for handling the deluge is, for the most part, efficient and well-planned. And for the first time in my residency, I've had the chance to be a surgeon. One hernia, a couple of abscess drainages (the continued injection of heroin in the face of the ravages of its long-term abuse are a constant marvel to me), and a late-night vascular surgery in an attempt to restore blood flow to a man's dying feet, all over the course of my last (34-hour) shift. Being in the OR, part of a team solving problems and realizing immediate care, is the reminder I need of the fundamental -- and majestic -- privilege of this career.

Where do we go from here?