PEOPLE MEDICINE:

Frugal Physician Prescribes
Common Sense and Enthusiasm

Cut to Cure

If drugs form the right arm of modern medicine, surgery makes up the left. The left is surely not as busy as the right arm or half as muscular, but not for the lack of trying. Modern surgeons evolved from the barber-dentist-bonesetters of the past and thus have taken second place to their drug-dealing brother medics. But, they stand proud of their abilities. Surgeons often come to the rescue to bail out their “pill-pushing” fellows in many emergencies. Surgeons have an aura about them, generally macho and aggressive, in a hurry, no nonsense. Even they have changed with the litigious bent of modern society. Overall, surgeons have had to slow their pace, follow more protocols and bow to more paperwork. To be sure that all tests are ordered and Is dotted and Ts crossed. Early on in medical training, students become aware of the differences between medical specialists: Internists (internal medicine) are the thinkers in medicine, thrive on testing and detective work.  Pediatricians are internists in miniature. Obstetrics (and gynecology) is a branch of surgery (more or less), but its practitioners who work constantly with women seem more mellow and compassionate. Psychiatrists, pathologists, and radiologists stand on the fringe of medicine and, it seems, at an even greater distance from people. Most of them rarely get close to patients - other physicians don’t get much closer. Radiologists study Xrays, pathologists read tissue slides, psychiatrists study behaviors. All are generally aloof from real patient involvement. Dermatology is in a class of its own. Emergencies are very rare and business is always booming because everyone gets zits and doesn’t want his face to fall off in front of the boss. So, the skin doctor has a place of relative honor, uses lots of potions and lotions as well as pills, and rarely gets his hands bloody.   The long white medical frock which is almost synonymous with medicine and physician-hood has come to symbolize separation: separate knowledge and power as well the separation between physician and patient. These days, physicians are clean and sterile (interesting word - sterile), as if patients are unclean and infectious. Within medicine as a whole, an aphorism circulates which may put some perspective on the various disciplines. It has a number of variations, but this one is a good approximation: “Family physicians know nothing and do nothing. Internists know everything and do nothing. Surgeons know nothing and do everything.” The adage does justice to none of the specialties, yet it gives valuable hints about how they are perceived. It also tends to empower surgeons. Not that they need more. During most of the surgical rotation of my internship, I spent much of my time following, assisting, and listening to Dr. Elwood Owens. Owens was a large man and looked bigger when he briskly toured the wards in his white, flowing coat. He had dark hair, a round face, and wore spectacles. The glasses weren’t Army issue. Owens had no intention of looking or acting military any more than required. Elwood was a brusque, talkative, proud Southerner. He really was a “good ol’ boy,” an enthusiastic operator with eyes on advanced training in cardio-thoracic surgery at Emory University in Atlanta. He couldn’t tell me often enough in his Georgian accent about his plans: “I’m gettin’ outa here as soon as I can. I’m gonna do hots (meaning hearts).” Arrogant and obnoxious though he could be, it was hard not to like Owens and get a chuckle from his stories - or at least his telling of them. One of his favorite ditties went like this: “When the Army drafted me, they made me a Major doing General Surgery. I told them, “I would much rather you make me a General doing Major Surgery.’” Although Dr. Owens tried to maintain an aura of superiority, his impression of himself was not universally shared. Many people thought him sadly laughable. Prior to my arrival at Martin Army Hospital, the staff had included another surgeon named Haywood Owens, Elwood’s brother. I gathered that Haywood was more productive and less verbal than his younger brother. Tall, red-haired, and good-looking, Haywood favorably impressed many hospital workers. From time to time, the two surgeon-brothers would be seen walking the hospital hallways. A common refrain heard at the time was, “There they go: Redwood and Deadwood.” Elwood was convinced that surgeons were not only the real elite of the medical profession but also God’s greatest gifts to humanity. To become a cardiac surgeon would place him in the highest exalted state. Elwood didn’t think much of internists or most other non-surgeons. Speaking with his round, pompous drawl he used to say, “They just play with their tests and pills. Especially those neurologists. Tests and pills. When they get stuck, they have to call on us. We can do anything an internist can do and cut besides. You know that surgery is the only permanent way to cure. We surgeons cut to cure. Yes, we do. Cut to cure.” Surgery is warranted in many situations, especially in event of trauma. But like the prescription of medication, surgical procedures are much overdone. “My feeling is that somewhere around ninety percent of surgery is a waste of time, energy, money and life.” (Robert Mendelsohn) And, it doesn’t take long for a keen observer to discover that cutting does not make for a sure cure even when indications seem clear. In fact, surgery can do more harm than good, especially when entered into precipitately. “CUT TO CURE,” Owens believed. There are a number of ways to address that idea. Let’s see what surfaces. • First off, we might want to consider the difference between curing and healing. There is a difference, you know. Curing is about fixing and repairing. Curing is more superficial, to my way of thinking, than healing. Some ailments can be cured, yet a healing does not take place. In recent years, different US government administrations have been working at “fixing” the medical system. Something like a cure. But, it will take more than “fixes” to put Humpty Dumpty back together again. People are the same. The superficial patching up of patients never guarantees that the effort will be a whole success. • There may be something to the idea a friend once told me, “You can cure hams, but can’t cure people.” The sentiment points to the requirement for the patient - at some level - to be actively involved in the process. Just cutting - even technically perfect, may only take care of one layer of a problem. Human problems almost always have several layers deep. The physical body alone certainly has many layers, but how many others are there yet for modern scientists and physicians to uncover? • Another friend, Benjamin Franklin is noted for saying, “God cures and the doctor takes the fee.” This idea, which undoubtedly predates Franklin, draws in those layers. It also hints that the physician’s role, although sometimes necessary, is often secondary or even merely window dressing. • Have you ever noticed that “curing” one problem brings another to the surface. That seems to be a common event in home repair. Before you get the original job done, you have created more to deal with than you started. I have noticed the same in writing books. Editing can be very tough. (You might call it part of  “curing” a book.) It seems almost impossible - especially editing one’s own work - to clear errors without making further ones. I have never been able to come up with a perfect copy, even on a relatively brief essay. Only God is perfect, and I wonder about that some times. Just think how much more complicated a human being is compared to a book or a home improvement project. • Simple incision into the human body is more involved than Regular Surgeons know or will lead their patients to believe. It is not like cutting a cooked ham or turkey which may be a chore in itself. Cutting into tissue is like entering a temple. Full preparations and obeisance to holy rites should be followed. That would go far beyond surgical scrubs and draping. Playing rock and roll in the operating theater is probably not compatible with treating the body as the holy temple which it is. The surgeon’s work is most certainly a technical skill. Yet, humans are not just biological machines and surgeons should develop skills which go far beyond cutting and debriding, extracting and sewing. My mind now carries me back to the Surgery Service at the Hermann Hospital, Houston, Texas. The first surgical patient I met was an elderly black man named Abraham Johnson. He had been in the Surgical Intensive Care Unit for some days and was being readied for skin grafting. Abraham had suffered severe burns to large areas of both of his legs as the result of a freak accident. One evening, Abraham was sitting peacefully in his easy chair watching a favorite television program when the TV exploded before his eyes. Unfortunately, Mr. Johnson had some neurological deficit which prevented him from responding rapidly to this emergency. What should have been a minor mishap became a major physical trauma. On that same day, the newbies were introduced to the real oddity of the whole surgical wing, Jeremy Jones. Jeremy was a twenty-five year old man who had been injured in a motor vehicle accident several years previously which left him with all extremities paralyzed (quadriplegic). Jeremy reacted not atypically to his grievous injury by acting out his anger against everyone who came into his aura. He eventually landed in a nursing home. His condition and care deteriorated over time as the aides and nurses “burnt out” trying to deal with both his devastated body and his hostile attitude. Jeremy had been admitted to the University Hospital because of huge gaping, oozing, stinking bed sores over both hips. He had been treated with the gamut of surgical debridement, continuous dressing changes, and a host of antibiotics with no lasting benefit. The surgical staff was at that time making the decision to do a radical operative procedure to “fix” his problem. Radical repairs or even routine operations were never (at least in this lifetime) high on my list of favorite medical interests. Oh, there is a genuine mystique about the Operating Room, but not one powerful enough to hold my attention long. At the present point in my life, I halfway imagine that much of my distaste for surgery comes from myself being a surgeon under horrid conditions during the American Civil War. I tried watching surgeries from the operating theater gallery, looking over the shoulders of physicians, nurses, and students in the OR suite, and even peering into the operative field while holding retractors. But, I never obtained much of a view through the surgical incisions or developed more than a passing curiosity regarding the surgeons’ prowess. I was occasionally called upon to hold retractors and considered that task engrossingly boring. (another oxymoron) It was exhausting to stand utterly immobile for what seemed like hours on end doing the job of a very dumb machine - holding a hooked metal bar or two ever so steadily and with the right amount of tension. All too often the surgeon decided that, “You're not holding the retractor firmly enough” or “Damn it, loosen up. You'll tear the guy’s flesh.” It didn’t take long for my feet, back, and eyes to begin to ache. I would selfishly, but unashamedly pray that the surgeon would work rapidly and efficiently. Fortunately, I was never delegated the job of retracting for one of their marathon procedures. In fact, my retracting days were relatively few as a student as well as an intern. Thank God for small favors. As far as I was concerned, they could take those darn retractors and .... Some days along the way, Mr. Johnson was taken to the OR. His legs were grafted with split thicknesses of pig skin in hopes of stimulating recovery from his burns. He was then returned to the SICU for observation. At about the same time, Jeremy’s festering wounds had received maximum medical management and his op day also arrived. When the procedure began, there were more techs, students, nurses, and interns in the OR than I could count. Jeremy was wheeled into the suite on a stretcher and moved to the operating table.  The crew not so dexterously propped him on his left side, anesthesized, surgically scrubbed, and draped him. His wounds were still so wet and pussy that the antiseptic scrub didn’t seem likely to have had much effect. The surgeons and helpers proceeded to flay his right leg, disarticulate the femur at the hip joint, and create a large pad over the hip with a generous portion of thigh tissue. Bluntly put, they cut his damn leg off!! I managed to watch the spectacle for a half hour or so, but could take only so much. The operation was so revolting to me and my sensibilities. I was equally disturbed by the surgeons simplistic assumption that cutting his leg off would be a quick and effective way to get rid of his infected bed sore. Even before he went into surgery, they were making plans to eventually amputate the other limb. Despite his terrible physical disability, his emaciated frame, and depressed mental state, Jeremy must have had some powerful will to live. For, he was soon out of intensive care and on a surgical floor. We made regular rounds to dress his surgical wound and other bed sore. I always joined in on rounds, but from that surgery on, I made myself as scarce as possible in the OR. Apparently, I was not greatly missed. No one ever questioned my whereabouts. Mr. Johnson didn’t fare quite so well as Jeremy. Actually, his life was soon in danger for the second time. Mere hours after his grafting, he was spiking a fever, his blood pressure was drifting south, and he was in deep trouble. Johnson was in a state of shock, source undetermined. The surgeons started doing blood cultures, pumping shotgun antibiotics, and pouring in IV meds to prop up his blood pressure. Yet, they scratched their heads in wonderment about the cause of the episode. It took several hours of fighting a battle with septic shock before the chief resident had the sense to take a look at the obvious source of the problem -- the recent porcine skin grafts. A grisly, oozing mess appeared when Abraham’s dressings were removed. The tissue combination had become a culture medium and the graft was rejected - or was it the other way around? With the removal of the dressings and grafts, the cleansing of the slimy debris, and the administration of lots of IV fluids, Abraham came around rapidly. But, the dangers to his recovery were not yet dismissed. A few days further along, Jeremy was making an amazing recovery. His surgical wound was closing and drainage decreasing. While he still had the gaping sore on the opposite hip, improvement on the surgical side was easily recognizable. He perked up psychologically as well, communicated and cooperated with medics and nurses. Surely, positive hopeful attention had effect. The surgeons seemed to take the effects of Jeremy’s surgery as some sort of universal sign. One morning, we rounded the SICU and passed beyond Mr. Johnson's bed. The staff talked about their success with Jones and lack thereof with Mr. Johnson. The chief resident was so thrilled wtih Jeremy's speedy recovery that he couldn’t resist, “Maybe we could do Johnson a favor and cure him too by cutting his legs off.” Admittedly, that comment may have “just come out” and was never seriously considered. At least as far as I know. I soon passed on to another rotation and have no knowledge of eventual outcomes for Misters Jones and Johnson. Still, some surgeons have this simplistic “cut-to-cure” perspective. They sincerely believe they are specially trained and ordained to do “miracles.” And, the public clearly buys into their spiel, beliefs, and implied promises. Even though, they never make guarantees. Wise Physicians and Prudent Patients realize that there is much more to life than the bodies in which we navigate the planet. That even in the 21st century, much is left to be learned about even the material form, which is just the tip of the iceberg of our being. That life and death, coming into and departing the body is always more involved than a medical operation or decision. And, that real cures - healings - cannot be done to a patient. Such events arise from the inside out. If a physician or surgeon is involved, s/he is just one part of the picture.

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