It Happens

Many of the surgeries I do are elective. They can and should be scheduled to be convenient. It happens – God laughs at our plans or life interrupts or …..

Last week was such a time for one patient. She called, very apologetic, “Dr Bates, I need to reschedule my surgery. My father is having tests done. He hasn’t been feeling well.”

I quickly assure her that no apology is necessary. Her family comes first. I suggest we simply cancel the surgery for now until the “dust settles.” She can call me back when she is sure things are okay with her family. We’ll reschedule then.

She is still worried. “The surgery center called me today. Do I need to call them? Will I need to pay them or anesthesia or you for the canceled time?”

Again I reassure her, “No, I’ll call them and take care of cancelling the surgery. No, we don’t charge you for surgery we don’t do. It happens. It’s okay to cancel surgery for whatever reason – another family member gets sick, an accident happens, you just get scared.”

It happens on both sides. Sometimes (as for me earlier this year when my mother had surgery) it’s the doctor who has to cancel or reschedule. Sometimes it’s the patient. I once had a patient not show up for surgery, only to find out later she had been in a motor vehicle accident the evening before her scheduled surgery. She turned out to be okay, but it really cemented how I fell about patients who call to cancel or reschedule. It’s okay. No need to apologize. Thank you for letting me know. (video removed 3/2017)

Mama said there’d be days like this

Updated 3/2017--photo/video and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.  

(cartoon photo credit)

The above is a cartoon that was in the paper on December 2, 2008. In reviewing my twitters that morning (prior to reading the paper), I saw this one from Vijay to which I responded.

scanman wondering if @Bongi1, @rlbates & @DrCris have such days http://is.gd/a0dH :P

rlbates @scanman Regarding: have such days http://is.gd/a0dH Fortunately not in the OR, but with quilting and life. Worry about it sometimes.

This has been on my mind a lot lately. I have been trying to find a way to put it into words. Another female surgeon who sews, the Stitching Surgeon, recently had a day like this with her sewing.

stitchinsurgeon spent the last 3 hours with my embroidery machine...every project ruined! going to the YMCA to work out some of this frustration! 1:32 PM Dec 1st

Then the next day she posted some lovely work she had done and said this:

I set up my embroidery machine and while it is working I am hard at work on my Bernina.
I'm just "sew" efficient.

When I am sewing and I find that things aren’t going right, I’m ripping out every other or every seam and having to redo them or making cutting errors and “wasting” fabric, then I just put the project aside for the day. I go do something else just like Stitching Surgeon did. If I had a day like that in the operating room, I would not be able to do that. I would have to finish what I had started. It would have to be done right. I do think that there are days for me, both in the OR and in sewing, where things just seem easy, almost magical. There are other days when I seem to struggle more than I would like, but I haven’t had any days (thankfully) where I have felt like I would (and by extension, the patient would) be better off if I could do the surgery another day. Still the thought lingers with me.

So let me leave you with the song (video) the title was taken from

Patients' Fears and Dreams

Patients will sometime have dreams (nightmares?) before their surgery similar to the "got up to give my book report and I had no clothes on" ones from our younger school days. Some of them are understandable -- you can "see" a thread that connects the procedure and the anxiety and the dream. A good example of this is the 4th Season episode of Roseanne "Less is More" which dealt (very nicely) with her breast reduction surgery. In the episode she had a dream where she woke up after surgery and actually had larger breasts. She was dressed as Madonna in the "cone bra". I've had breast reduction patients tell me versions of this one.

Recently an abdominoplasty patient was talking to me before surgery. I was trying to answer any last minute questions or concerns. She needed to tell me about the dream she had the night before.

Patient-- I remember hearing you say as I went to sleep in the operating room, "I can't make a straight cut with the patient on this water bed."

Me -- A water bed?

Patient -- Yes. I know it makes no sense, but I was on a water bed. And my brother-in-law was assisting you and he was wearing a clown outfit.

Me -- Well, are you okay with going ahead this morning. We don't have any waterbeds here.

Patient -- Yes. I'm just a little nervous, but I really want the surgery.

Everything went well. The incisions were straight as I didn't have to fight the waves of a water bed. I was thankful for that (smiling to myself here).

"My Worst Nightmare"

Updated 3/2017-- photos and all links removed as many are no longer active and it's easier than checking each one.

Recently I have had to deal with a patient who refers to herself as my "worst nightmare". I knew she would be difficult before I ever did her surgery. She had warned me that she always had a lot of pain and it was difficult to control. I knew she would need more TLC than most patients.

I always call outpatients the night of surgery. It helps me sleep better and hopefully them/their families too. The night of her surgery (and I have learned to double check phone numbers where they will be), I called three separate times over a 2 hour period to two numbers. No one answered any of them. I left a message that "If there are any problems tonight, please, have me paged through the Medical Exchange at ****. I will check on you again in the morning." That night it was quiet.

I called her the next morning and this time she answered.
"I'm in so much pain."

After going through a list of questions to make sure there were no other issues (no undue swelling, no fever, etc), "Have you tried taking the Xanax with the Percocet?"

"No. I didn't know I could do that."

I had written the Xanax prescription after seeing how she dealt with the pain in the recovery room. Nothing we tried had seemed to make her comfortable until we tried it. I mean nothing including morphine. And physically she appeared okay.

I explained that she could. That the Xanax would help her nerves and help her rest. "So why don't you try that. I'll call you again tonight." She agreed.

I called back that night (Friday). Things seemed to be better. Saturday was quiet. Sunday, just past noon, the pager goes off. I called the number.

"Dr. Bates, it's your worst nightmare. The pain is horrible and I don't have any pain medicine left."

I go through the same list. No undue swelling, no fever, etc. So I offer to call in some Darvocet (and do so). I don't offer to meet her and write a new script for the Percocet. I don't suggest that she go to the ER. Two hours later, the pager goes off again. Same patient.

"Dr. Bates, I'm so sorry. It's your worst nightmare again. I don't know what to do. The pain is so bad."

This time I firmly tell her that she will have to tough it out until tomorrow (Monday) as I can't phone anything stronger in for her. She will have to make due with the Darvocet. (By my count, the Percocet should have lasted her until Monday or Tuesday).

Nothing more from her until first thing Monday morning when she calls the office. "Dr. Bates, it's your worst nightmare. I am in so much pain."

"You are no where near my worst nightmare, but we won't go there. Why don't you come into the office so I can see you. You will have to come into the office before I give you anything more for pain."

She comes in. Her exam is benign. She is healing as expected. I touch the operative area gently--she flinches. I leave it and keep talking to her. She visibly relaxes, as the time passes. I keep up a constant patter. I remove her stitches and tape the incision. I deliberately touch the area again with slightly more pressure. This time there is less flinching. I keep talking to her. Then one more time palpate the area. This time pointing out how she allows me to do so.

I give her one more script for Percocet and Xanax. I caution her to take them as prescribed, not more often. I bring up the young actor, Heath Ledger, who recently "overdosed" on prescription medications. She says she didn't realize you could take too many. She did fine from that visit on.

So for her I think that much of her pain was in her head. I think she "thought" she hurt more than she "actually physically" did. I don't mean to belittle her pain, but she had had a few bad experiences with pain, so she ANTICIPATED that each new event would be as bad or worst. I think that "fear" adds to her pain.

I try to get patients to realize that there will be pain, but that each day will get a little better. I don't try to make "light" of it, but to get them to distract themselves. Or to "reassure" themselves that it is not a permanent state. Postoperative pain (I know there are exceptions) is not a permanent state. It will go away.

As far as being my worst nightmare--not even close. Some of my "worst" nightmares would include an abdominoplasty patient dying of a pulmonary embolism (PE) 2-4 weeks after surgery, any patient getting toxic shock (was consulted after the fact on a patient once who needed a gastrocnemius flap to cover her knee joint after surviving TSS post-knee surgery), or this.

Or if we're talking non-patient related then this (snakes wrapped around you).

Steriod Use in Girls

 Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it's easier than checking each one.

What do anabolic steroids have in common with amphetamines, tobacco, diet pills, laxatives, and anorectics?

They all are drugs used by adolescent girls seeking to stay thin, says Dr. Linn Goldberg of Oregon Health Sciences University.

Call me naive, but I had not heard of non-athletic girls using steroids until I heard this (Cheerleader Drawn to Steroid Use) on Good Morning America (GMA) yesterday morning. I was surprised, though maybe I shouldn't have been. I felt the need to read more about this. Here is some of what I learned.

• Among high school students, the use of androgenic steroid hormones is prevalent, with 1% to 2% of adolescent girls and 4% to 6% of adolescent boys having used an anabolic steroid at least once.
• It is being used in teens as young as 12-, 13-, 14-year-olds.
• Androgenic steroid use has been associated with the use of other illicit drugs, cigarette smoking, and alcohol use.
• When taken in supra-physiologic doses, these drugs are known to cause a wide range of acute adverse effects (well, I already knew this).

Side Effects of Anabolic-Androgenic Steroid Hormones

Since I wanted to write this for my dear nieces (whom I don't think are using these drugs) and others like them, I will skip over the life-threatening side-effects (serious liver problems, serious heart problems, etc) and concentrate on the body-shape alterations. To me, these side-effects aren't worth the perceived benefits (increased muscle mass, "leaner" body) that might be gained by the use of androgenic steroids. The increased muscle mass and leaner body can be gotten by eating healthy and going to the gym.

Being thin is not worth these side effects:
VIRILIZATION (girls/women)

If given to women in high enough doses for a long enough period, the anabolic-androgenic steroid hormones cause virilization. This includes

• excess facial and body hair
• male-pattern baldness
• acne (including on the chest and / or back)
• deepening of the voice
• increased muscularity
• an increased sex drive.

GYNECOMASTIA (boys/men)

• Fibrocystic masses, usually immediately deep to the nipple, may develop in men and adolescent boys who take anabolic-androgenic steroid hormones. This gives an increased breast size. The lesions are painful and may not resolve with discontinuation of the drug, but may have to be removed surgically.

ALTERED GROWTH (shortened stature in teens)

• This is only an issue in adolescents. There may be premature closure of the epiphyses (growth plates in the bones) with prolonged use of high-dose anabolic-androgenic steroid hormones. This results in a shorter stature than would have been attained if there had not been interference with natural growth.

PSYCHOLOGICAL EFFECTS

A small percentage of users of high-dose anabolic-androgenic steroid hormones appear to exhibit clinically significant psychological signs and symptoms, including

• highly aggressive behavior ("roid rage")
• psychoses
• depression (sometimes to the point of suicidal)

For MORE INFORMATION
Steroid Prevention Program Scores with High School Athletes; Robert Mathias; NIDA Notes, Vol 12, No 4, July/Aug 1997
Anabolic Steroids; NIDA for Teens, 2000

Use of Steroid for Self-Enhancement: An Epidemiologic/Societal Perspective; Charles E Yesalis, MPH, ScD; Medscape Article (AIDS Read 11(3):157-160, 2001. © 2001 Cliggott Publishing, Division of SCP Communications ) -- very nice article

Steroids in Sports: Questions Answered: Get Answers to 16 Questions About Performance-Enhancing Drugs in Baseball and Other Sports; Miranda Hitti, Louise Chang MD (reviewed by);
WebMD Medical News, Dec. 13, 2007

Threatened

 Updated 3/2017-- photos and all links removed as many are no longer active and it's easier than checking each one.

Recently I was "threatened" by a patient. So the news of therapist Kathryn Faughey being slashed to death in her Manhattan office Tuesday evening has really stayed with me. And it wasn't even her patient. Was my patient's threat serious? Here's the story.

A few weeks ago I saw two women, good friends, together in consultation. Both wanted procedures done (non-facial), similar goals but different procedures needed. Patient one (Uno) had lost a family member to an unexpected (car accident) death within the past year, but assured me that she was through with most of her grieving. We spent time discussing this. I wanted to be sure she was ready to proceed. The second patient (Dos) was Uno's best friend and had taken care of her while her friend grieved. She wasn't so sure her friend was through grieving. I finished the consultation and sent them home to think things over with instructions to both to be sure. They called back a week later and scheduled a day when both could have their procedures done on the same day. Their husbands would come and sit together in the waiting room. I once again, voiced my concern about the timing of surgery for Uno. Still I could not find anything "solid" to hang a refusal on.

Two days prior to surgery, Uno called and admitted she was not ready. She canceled, but her friend, Dos, had her surgery. All went well. Both came back for Dos' followup visit. Uno was so impressed with Dos' outcome, she wanted to reschedule. But as I finished removing stitches, Uno told me that her husband was afraid of her dying if she had surgery. She then told me "If anything had happened to Dos and she had died, I would have killed you." We discussed her husband's fear of her dying. I ask her if she could understand his fear better in light of her fear of her friend dying. I told Uno, in front of Dos, that I really thought she needed to wait for six months or more to grieve more (both she and her husband) before we considered re-scheduling her. I encouraged her to talk to her minister or a counselor without directly acknowledging the threat.

Did I handle it correctly? I'm not a psychiatrist, but I hope I did.
My condolences to Kathryn Faughey' family and friends.