The Ripple Effect

Dr. Marc Rowe is one of the truly great pediatric surgeons of our era. His work in newborn physiology profoundly changed how babies were and are taken care of in intensive care units. His prolific research, along with the many people he trained, has unquestionably affected the lives of hundreds of thousands of newborns.  He has taken on creative work as a writer and wood carver in his retirement. Dr. Rowe is one of my personal heroes and, when I read this essay he recently posted, I asked his permission to post it here to be able to share it with you.

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I am troubled by what is happening to our Country. Principles and ideals – truth, honor, kindness, diversity compassion and love and protection for the people, the creatures and the environment we share has been replaced by selfishness, prejudice, lies and a willingness to compromise in order to gain material wealth and power. What is particularly frightening is the effect the current leadership may have on our greatest gift, our children- the message sent – that you can be dishonest, unfaithful to your loved ones, lie, be a racist, a bully and a braggart and still become the most powerful person in the world and be supported by many of our religious and political leaders. I am confused – does this mean that these political and religous leaders would choose our current president to be a role model for their children and grandchildren?

As I watched this sad period in the history of our country unfold I was overtaken with a sense of powerlessness. I then remembered two lessons I learned during my career as a pediatric surgeon. The first occurred during my first job as an assistant professor of surgery. I was incensed by an episode of academic politics and was tempted to speak out but realized if I did I would pay a price. I vented my frustration to my wise and famous boss, Dr. Mark Ravitch, a battle scarred warrior of the political and academic world. He said – “before Socrates drank the hemlock he began his defense by saying –never let it be said that I had a podium and failed to speak. – You have a big mouth use it”.

The second lesson came later when I became depressed realizing the huge number of children suffering from potentially correctable diseases and abnormalities and how little one person could do. I then began to think about the ripple effect – the ever-expanding effect that even one person can have by teaching and striving to be a role model. I realized that young people are astute observers and learn not by what their teachers say but by the way they act, how true they are to the principles they teach and most important by not selling out when being principled becomes painful and dangerous. Kids spot phonies a mile away.

Three people I have greatly admired, Mother Teresa, the Dalai Lama and Robert Kennedy all have spoken of the ripple effect. To quote Robert Kennedy who spoke of the ripple effect during the tumultuous civil rights strife – “Each time a man stands up for an ideal, or acts to improve the lot of others, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current that can sweep down the mightiest walls of oppression and resistance.”

This carving I call the Ripple. The pond and thrower is carved from a branch and cross-section of bass wood, the shoreline is made from Sanibel sand and the stone in the pond is a small piece of river rock.

Scientifically Superstitious

There is a longstanding superstition in medicine that you never wish someone a quiet call night, sort of the medical equivalent of never wishing an actor a good show. We are trained in science, so all physicians know this is silly…and yet…

There are many theories in psychology about why human beings are superstitious, but the one that I think best explains the superstitions of doctors is that superstitious rituals decrease stress and can improve performance during stressful work.

So, don’t make fun of me when I wear my green socks for Kasai procedures… or when I feign horror if someone wishes me a quiet call night!

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Take the Stairs

When I was an intern, I had an attending who always took the stairs.

Twelve flights.

Fast.

Multiple times a day.

We’d be on the second floor and he’d announce “Let’s go see Mr. Smith.” He would take off to the 12th floor with a trail of panting residents and students spread out behind him. Here’s the punch line: Every summer he would take a vacation to climb a mountain. To get ready for the climb he did…nothing. Climbing the stairs was enough.

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Why you should take the stairs

It is a great way to keep from gaining weight during med school and residency since it burns three times the calories of a brisk walk (even at a slow pace)

As little as two flights of stairs climbed per day can lead to losing 5-6 lbs of weight in a year.

You burn 8-11 kcals per minute climbing stairs.

Climbing stairs is essentially a series of vertical lunges.  You’ll tone your leg muscles – good for both strength and appearance.

55 flights of stairs/week = overall decreased risk of mortality.

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Tips on taking the stairs instead of the elevator

Even if you are fit, you’ll be out of breath climbing stairs. It’s normal.

Make sure you don’t overuse your calf muscles to power up the stairs – use your quads, hamstrings and gluts to protect your knees.

It’s ok to take the elevator down if you want to. Walking down stairs is actually much harder on your joints than taking the stairs up.  If you choose to walk down, use the rails (it’s stupid to fall).

It’s ok to use the rails going up the stairs. It provides a little upper body workout and doesn’t really diminish the advantages of climbing stairs.

Want to add more?  Find a more isolated stairwell and do additional exercises on the landings (e.g. crunches, burpees, pushups). Do “ladders” – up and down one flight, then two, then three, etc.

Want to go to the next level? There are actually “races” to climb the stairs of tall buildings.

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The Tools We Hold: The Senn Retractor

The Senn retractor is a small, relatively delicate retractor that is used extensively in hand surgery, vascular surgery, plastic surgery and other procedures involving the skin and soft tissue.  I hold this instrument most days I am in the OR and yesterday found myself wondering about this beautiful tool.

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Nicholas Senn was an early adopter of Listerism and performed his operations under a fog of carbolic acid spray. He felt that smooth surfaces on surgical instruments were important to help prevent infection.1  That, plus the need for retraction in superficial wounds undoubtedly led to developing the Senn retractor.

Surgery being performed under carbolic acid spray

 

Nicolas Senn was born in 1844 and emigrated to the Fond du Lac, Wisconsin from St. Gaul, Switzerland  in 1852.  He graduated from Chicago Medical School in 1868, completed his residency at Cook County, started his academic career at the Medical College of Wisconsin, studied in Europe at the University of Munich and then returned as Professor at the University of Illinois. He served as president of the American Surgical Association in 1892, and was named president of the AMA in 19872, Dr.Senn was a military surgeon who served in the Spanish-American war and the Russo-Japanese war. Importantly, he founded the Association of Military Surgeons.2,3 He died in 1908 at the age of 64, five years before the American College of Surgeons was founded.  There is little doubt that he would have been a founding member of the American College of Surgeons as he was the first Editor-In-Chief of SGO, which later became the Journal of the American College of Surgeons.4

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In addition to his truly extraordinary resume, there are other facts and stories about Dr. Senn worth knowing.   So, the next time you find yourself handing a student, resident, or assistant a Senn retractor you might want to share some of this history.

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  • Dr. Seen taught elementary school for a year and then studied with a local GP in Fond du Lac before entering medical school. 1
  • There is a high school in Chicago named for him. He was known as an outstanding educator, so this is a particularly appropriate tribute.
  • He was a collector of historical medical documents which resulted in a collection of over 10,000 volumes and 14,000 pamphlets and articles now stored in the John Crerar Library.2
  • One of his most famous quotes is “The fate of the wounded rests with the one who applies the first dressing”2
  • In 1904 he wrote a beautiful tribute to Father Damien who lived in the leper colony of Molokai which can be read here.
  • He strongly supported early operation for appendicitis, which was not the practice of the time. “The principal object in writing this paper is to call the attention of the profession to the necessity of treating the primary disease of the appendix by radical measures before the advent of incurable complications, that is, before disease due to perforation has occurred.”5
  • He was probably best known for his studies on intestinal perforation. To set the stage, Dr. Senn was a military surgeon in an era of transition. This was literally the time that it was finally “proved” that suturing a bowel perforation resulted in a better outcome.  Senn used an animal model to instill hydrogen via the anus to see what kinds of pressure would result in bowel perforation.6  (The full text of Dr. Picher’s article, published in 1888, can be found here and is a fascinating read). He went beyond animal studies to show that this could be applied to humans by doing the same experiment on himself (short of the perforation we assume!).  “Senn used a rubber balloon connected to a rubber tube inserted in his anus to pump 4 US gallons (15 L) of hydrogen gas into his intestinal tract. An assistant sealed the tube by squeezing the anus against it. The hydrogen was inserted by squeezing the balloon while monitoring the pressure on a manometer.” 2 This technique was subsequently used in soldiers who had been shot to determine if bullets had punctured the bowel.7
  • Many of his experiments were carried out in the Nicholas Senn Building. He had this building serve as a place where students and medical professionals would gather to learn from one another. In the basement of the building he experimented with medical procedures that he would later carry out on patients.”8

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  1. El-Sedfy A, Chamberlain RS. Surgeons and their tools: a history of surgical instruments and their innovators. Part III: the medical student’s best friend-retractors. Am Surg 2015;81:16-8.
  2. Nicholas Senn. Wikipedia. (Accessed May 5, 2018, at https://en.wikipedia.org/wiki/Nicholas_Senn.)
  3. Smith DC. Nicholas Senn and the origins of the Association of Military Surgeons of the United States. Mil Med 1999;164:243-6.
  4. . (Accessed May 5, 2018, at https://www.facs.org/about acs/archives/pasthighlights/sennclubdinner.)
  5. Senn N. A plea in favor of early laparotomy for catarrhal and ulcerative appendicitis, with the report of two cases. JAMA 1889;13:630-6.
  6. Pilcher JE. Senn on the Diagnosis of Gastro-Intestinal Perforation by the Rectal Insufflation of Hydrogen Gas. Ann Surg 1888;8:190-204.
  7. Senn N. The Modern Treatment of Gunshot Wounds in Miliatary Practice. JAMA 1898;31.
  8. Nicholas Senn Building. 2009. at http://genealogytrails.com/wis/milwaukee/nicholassennbuilding.html.)

 

If you are starting the think you might be depressed, or that your brain is out to kill you, here’s what you do…

The following is an “unrolled” Twitter feed from Mark Reid, MD on depression.  It’s solid, important advice that I thought should be shared. Dr. Reid  is an internist from Denver, who is very active on Twitter as @medicalaxioms. He is also the author of Medical Axioms, a delightful book of medical wisdom

Interview with Dr. Reid about @medicalaxioms

If you are starting the think you might be depressed, or that your brain is out to kill you, here’s what you do:

1. Find or call your primary care IM of family MD. When you call for an appointment and they ask what for, say “depression.” Notice how the scheduler doesn’t flinch. They get this call 4 times a day!

2. When you get to the doctor, and they ask what’s wrong, just say, “I want you to do those screening tools on me to see if I’m depressed.” Let them do their thing. If they say you’ve got it, let them tell you how meds and counseling work. Let them tell you what they know about pills and which one might help you. Decide together if pills are worth a shot. Tablets really work for some people.

3. You also need a counselor. Ask the MD for a referral. That might work. If not,

4. Go to your insurance and find out their preferred providers for counseling. I suggest you pick someone your same gender. Counterintuitive for some but works better for many.

5.  If that doesn’t work, go in the internet and type in counselor or therapist and the name of your town or city. Read ratings and reviews. Cross reference them with yelp. Look for someone nearby who writes a bio that sounds okay. Figure you’ll see them once a week and it will cost $100. Give them 4 tries. If you don’t feel like you are getting anywhere, ditch them and try again. I’ve seen 3 people in the last 10 years and in retrospect I can rank them.

6. With tablets and shrinks, the trick is resolve. If they aren’t working or give side effects, don’t just quit. Try again. Different shrink. Go back and try a different tablet with your MD.

You can feel better and you are worth it. You deserve it.

There’s lots of other stuff that helps some people: support groups, sobriety, exercise, sleep hygiene, self help books, spiritual practice, ALANON. If your shrink is any good they will recommend this stuff and know something about it.

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To add a few more comments to Dr. Reid’s advice….

  • Depression is a disease, not a failing. You wouldn’t judge yourself for a sprained ankle.  This is the same…. except for one thing.  The disease of depression includes not being able to objectively see what’s going on.  That’s why it’s so important to get started on treatment.
  • If you are a medical student or resident, counseling is available for you and it’s free. The same rules hold, though.  If the first person you see isn’t helping after 3 or 4 visits, it’s ok to make an appointment with someone else.  This is not personal and you don’t have to worry about “hurting their feelings” any other consequences.
  • The National Suicide hotline is 1-800-273-8255. You are loved.  You matter.  This is a disease not a failure.  Please seek help.

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#BanTheBouffant

If you don’t work in an operating room, you may not be aware of the controversy going on about OR caps.  To get right to the point – the surgeons think they should be allowed to wear the cloth hats they have worn forever.  The Association of Operating Room Nurses (AORN) developed guidelines which included covering the ears and all hair (which means a bouffant paper hat). These guidelines were then implemented by JACHO which means they became “law” in every hospital in the United States.

Anonymous surgeons demonstrating extremely effective covering of all hair with bouffant hats.

I’m a real believer in evidence based medicine (and policies) so I decided, like others, to look into what is really known about the issue.  Because it is a conflict of interest, I need to disclose that I can’t stand the bouffant hats and I really, really miss my (clean and washed) cloth hats. (which BTW cover all my hair!)

What do the data say about the use of bouffant hats and infection rates?  

 

Why don’t surgeons like bouffant hats?

It’s harder to keep them in place when wearing loupes or headlamps. If the goal is to keep the hair covered, this is a real problem.  When moving headlamps, operating microscopes or loupes, the bouffant hat often moves substantially – or even comes off entirely.

They are hot. Many surgeons feel (me included) that the bouffant hats are uncomfortable and are hot.  One can argue that anything that increases surgeon discomfort could affect concentration, which might be reflected in less focus on the operation.

Bouffant hats are expensive and bad for the environment.  On Amazon, 100 bouffant hats cost $7.45.  There were 48 million inpatient operations performed in 2009.  When you add the 48 million outpatient procedures performed, that means there are roughly 100 million operations performed per year.  (Mind you, these data are almost 10 years old, so it’s likely to be more now).  If we assume an average of 4 cases/day by an average surgical team (nurses, CRNA, anesthesiologist, assistants/resident) and they all wear their hat for the day, the number of hats needed per year would be 100 million cases x 6 members of the team = 600 million hats/yr. 600 million hats divided by 100/box = 6 million boxes x $7.45 = $44,700, 000.  Over 44 million dollars a year for the bouffant hats… all of which (600 million/year) end up in a land fill or are incinerated.  p.s. Given that hats are often changed during the day, this number is probably on the low side.

It affects morale.  In a survey of young (<45 years of age) surgeons, 71.2% stated that the new rules had affected surgeon morale.

They are inferior in blocking bacteria when compared to other caps.  In a study of bouffant hats, disposable skull caps and cloth hats, the bouffant hat was the worst in preventing airborne bacterial contamination in the operating room.  “I expect our findings may be used to inform surgical headgear policy in the United States,” he said. “Based on these experiments, surgeons should be allowed to wear either a bouffant hat or a skullcap, although cloth skull caps are the thickest and have the lowest permeability of the three types we tested.” Troy A. Markel, MD, FACS

 

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I’m confident that in the very near future we will be back to wearing our clean, cloth hats.   When you look at the data, and weigh the pros and cons, it seems pretty obvious what needs to be done….

 

 

 

 

 

 

Does the Fetus Feel Pain?

I teach embryology to wonderful first year medical, nurse anesthetist and PA students.  Last week, one of my students asked me, humbly and thoughtfully, if (and when) a fetus feels pain. Because of recent publicity concerning late term abortions, I knew this was a question about more than fetal physiology.

Let’s talk embryology.

I am very, very confident that the blastocyst doesn’t feel pain. I am equally confident that babies at the time of birth do feel pain. So, there must be a moment during development when nerves to sense the pain, nerves to transmit the pain, and a brain to perceive the pain come together to make it possible to perceive noxious stimuli. I’m not a developmental neurologist, so I can’t claim to be an expert, but based on published research, those three things are present somewhere around 22-24 weeks gestation. For those that are concerned about abortions that happen after 22-24 weeks, It’s important to realize that only 1.3% of abortions occur after 21 weeks gestation and 80% of these for serious birth defects.

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 Let’s talk suffering.

As healers, we seek to relieve suffering. Let’s be clear – that’s not the same thing as the “pain” I mentioned above. Let me give you a couple of (real life) examples.

A developmentally delayed 15 year old is raped by her cousin who threatens her if she tells anyone. Over the next two months, the girl becomes progressively withdrawn, depressed and even suicidal. Her mother takes her to her pediatrician who is able to convince the girl to tell her what happened. She sends the appropriate labs, including a pregnancy test, which is positive. Her pediatrician recommends termination of the pregnancy, and refers her to a gynecologist and a pediatric psychiatrist. Because of her depression and suicidality, both of these physicians also recommend termination of the now 14 week pregnancy.

A young couple comes to their gynecologist for a routine screening ultrasound.  Something isn’t quite right, so they are sent to the maternal-fetal medicine clinic for a more detailed ultrasound. They are at 18 weeks gestation, which means 22 more weeks until term. They receive horrible news. The fetus they are carrying has a fatal disorder and will not survive after birth. After a few weeks, they return to their doctor in tears. The emotional burden of carrying the pregnancy to term is causing them immense suffering.

Let’s talk ethics.

We teach our medical students to take complex situations like deciding to terminate a pregnancy and use an “ethics workup” to help guide decision making. The ethics workup starts with defining everyone who might be affected by the decision. For example, in the first case I mentioned above, that would be the 15 year old patient, the fetus, the patient’s mother, and the doctors. Then, based on the possible outcomes (to terminate or not to terminate the pregnancy), we consider the outcomes with appeals to consequences, professional obligations, ethical rights and virtues. What this process does is allow us to understand the complexity of the situation and the choices being made, rather than just going with our “gut reaction”.

Let’s talk about listening.

When I was Dean of Student Affairs, the “Pro-Life” group on campus invited a speaker that the “Pro-Choice” group felt strongly should not be allowed to speak. I asked the leaders of both groups to meet with me. They were pre-clinical students who had not yet experienced dealing with patients and families facing complex and heartbreaking decisions. I recognized that their conflict was a great learning opportunity, a chance to learn to work through a situation where colleagues disagreed. I asked them to develop a plan together on how speakers should be invited, a plan that I insisted reflect the culture of tolerance at our medical school. They did not disappoint. Their plan was amazing and included attending each other’s meetings and reviewing speakers for each other before invitations were issued. They also wrote a beautiful statement to be read at the beginning of each meeting explaining that they were there to learn from each other and to listen. They went even further and added that disrespectful comments or intolerance would result in being asked to leave the meeting. What a great example for us all – to listen to learn, and to do so with kindness and tolerance.

As physicians we are absolutely allowed – even encouraged – to include our personal views when making a thoughtful, ethical decision about caring for a specific patient.  Although it’s not a common event, physicians are allowed to choose not to care for a specific patient as long as they refer them to a different doctor. What physicians are not allowed to do is to impose our views on our patients, or our colleagues.

You’ll never buy stock again

This may be one of the easiest kitchen tricks I’ve learned in the last few years.  I haven’t bought any stock since I figured this out. It saves money, but more importantly, this stock tastes MUCH better than anything you can buy.

Step 1:  As you peel, chop, and otherwise use any vegetables for recipes or salads, save all the pieces you would normally throw away.

The vegetables that help the most with umami (and make your stock great) are the classic mirepox (carrots, celery and onion), garlic bits, and mushrooms.  There are a few vegetables you should avoid using for stock. Some vegetables will make the stock bitter or impart a strong, very specific taste that may not work in some recipes (e.g eggplant, turnips, cilantro, ginger). If you happen to be someone who buys Parmesan cheese with a rind, those rinds are wonderful in stocks. If you use fresh herbs when you cook, make sure you throw the stems in the stock. 

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Step 2:  Keep a big ziplock bag in the freezer and toss the washed bits you saved into the bag.  When you drain beans, tomatoes or other vegetables from cans, put the juice in the bag, too.

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Step 3:  When the bag is full, put the frozen vegetable bits in a big pot with water to cover them, bring to a boil and then simmer for about an hour.

 

If you have an Instant Pot, you can make stock in less time.  I don’t add salt while making the stock because it lets me season the dishes I make to taste.

 

 Step 4:  Freeze the stock you don’t use in a day or two.

 I usually freeze my stock in 1-2 cup plastic containers.  Alternatively, use freezer bags if you want to take up less space in your freezer (Push the air out of the bags and lay them flat on a cookie sheet to freeze).  Another trick is to freeze the stock in ice cube trays or muffin tins and then put the frozen stock in freezer bags.

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In addition to recipes, use this stock instead of water when you make rice or grains. Thaw your stock in the refrigerator (if you remember) or in the microwave (if you don’t).

We eat a mainly plant based diet, so I only make vegetable stock.  If you eat meat, you can save the bits from the meat or fish you cook – or ask your butcher for stock worthy bones and add them to the vegetables to make great chicken, beef or seafood stock.  If you want perfect chicken or beef stock, you may have a bit more work to do… 🙂

Enjoy!