A Surgeon's Notesgolfist
This article went up earlier this year and it was an oversight to not post it here on my blog. It is an article explaining MALS for the lay public drawn from my clinical experience going back ten years. Our approach is still a work in progress as each patient is comes with a unique presentation. Here is the link
A day in my life
Today, I got up at 630, made some coffee, and Zoomed in on our morning report at our main campus hospital. I have a patient there who I will be operating on tomorrow and wanted to know the current status of the patient. Once the report was over, I brushed my teeth and drove into my hospital which is a regional community hospital. I had an angiogram for a patient who was having a problem with blood flow to the leg. The cath lab was ready to go at 0800, and I was done by 0900, where I quickly ran over to to my office for clinic. My fellow who was doing her community rotation helped me with the angiogram, and then came over to clinic where I saw 27 patients from 0900 to 1600hrs, two of them virtually. At 1600hrs, I had a hospital committee meeting where I am the chief of surgery for my community hospital, and at 1700, was done. I ate a snack as I finished up some paperwork, and got on another Zoom meeting of my institute with over a hundred people to have an update meeting. I then drive to my golf club, and got on the range and hit golf balls for 30 minutes, then got on the putting green and practiced for another 30 minutes. Then I drove home and had dinner with my family. I watched highlights of a football (American) game I recorded over the weekend, while reading email, then sat down to write this before I showered and went to bed.
This week I have 9 cases scheduled -several angiograms and interventions, a leg bypass, a few fistula creations, and a laparoscopic procedure (I’m one of the few vascular surgeons who do laparoscopic surgery). As I sit in bed, I listen to a journal article read to me by the voice of Gwyneth Paltrow (it’s AI) -I find it easier than actually reading the thing, and then I watch a few TikToks, read Reddit, and then go to sleep around 2300h. Cycle starts again in the morning, but will wake at 0530 to get to the main campus hospital to perform an operation. Arriving at main campus on a Wednesday, we have a combined grand rounds with the whole Surgery Department prior to operating.
Lifestyle
On weekends, when I am not on call, I still catch up on my patients from a report from my trainees or my nurse practitioner who makes rounds. I even do this sometimes when I’m out of town. Usually, I play competitive golf with members at my club -the more pressure the better. I find competition to be relaxing. Afterwords, I come home and write, read a little, and watch sports depending on the season or golf. My writing is sometimes work-related, sometimes in my journal. I kept a personal blog for over ten years on golfism.org. I am working on a novel -have been for a decade but not making much progress. I read mostly nonfiction but will listen to audiobooks of science fiction -currently marching through all the Dune prequels written by Brian Herbert, the son of Frank Herbert, the author of Dune and its original sequels. I am working on a grand unifying theory of circulation.
Procedures
As a vascular surgeon, I perform operations in the traditional open fashion, and endovascular procedures which are a done with imaging from x-ray. Occasionally, I do laparoscopic surgery. The open surgical procedures include operations on the aorta and its branches, and on arteries in the legs, arms, and neck. I also work on veins throughout the body. The patient arrives with a set of conditions, a prior history, and an examination, and given a problem, you evaluate it with various tests which can be blood tests, vascular tests, imaging studies like X-ray, Ultrasound, Vascular Lab Studies, CT scans and MRI’s. This is called the workup -getting data to plan a procedure. Knowledge of anatomy and physiology and biomechanics of flow are crucial to put together a plan that will be successful in treating the disease with low complication rate and good durability. The procedures require a great deal of planning and often I include my colleagues within my department and those in other specialties to get their insights for making a plan that accounts for the reason for operation, plan for operation, contingency plans, and recovery in the hospital, and healing outside the hospital. You can see some of these cases on my blog, vascsurg.me.
The image above shows a common femoral artery aneurysm presenting as a pulsatile mass in the right groin. The first image on left is an arteriogram (a sketch of one) that I would get prior to surgery. The patient is also suffering from pain in the right leg due to a lack of blood flow because his superficial femoral artery (SFA) is occluded and his profunda femoral artery (PFA) is open but has a blockage at its origin where the aneurysm ends. I plan the surgery and execute it. During surgery, things may pop up -good things like finding an otherwise pristine SFA filled with plaque. Removing the plaque, it becomes a great conduit for replacing the aneurysm and avoids using an expensive graft which can become infected -your own tissues fight off infection better than graft.
In the F1 Movie, Brad Pitt’s character describes a sense of pure driving, being in the flow, being completely at peace on the road. The best moments in surgery, I reach a flow state where actions follow one after the other. It’s a form of spiritual ecstasy, to be completely focused and present. Even better is having the patient do well -to be able to walk without pain and the fear of possibly losing a leg or dying.
Who should not do vascular surgery. By definition, anyone not trained in vascular surgery. Successful vascular surgeons come in all shapes and sizes, but they share common traits -grit, focus, some intelligence, and hand-eye coordination. That would mean those who give up easily, have trouble with focus, are unintelligent, and have poor dexterity should not go into vascular surgery. The saddest cases are when the desire to be something does not match up with the reality. It is possible for non-vascular surgeonsto make a living doing a focused practice around varicose veins for example, but a good vascular surgeon is hard to create. Also, you should not do this for money or prestige, there are easier ways to get money or prestige.
Who should go into vascular surgery. Anyone who thinks they might like it should certainly look into it. The best way is to directly observe a vascular surgeon at work. That is the whole purpose of the rotations in medical school. Sadly, many medical schools do not offer much time in a surgery rotation and vascular surgery exposure is inconsistent. Our society has been working hard for over a decade to improve this and we are seeing it in the excellent applicants to our training programs. The best candidates are driven people with a track record of academic excellence, but the qualities that make a good surgeon are harder to define. Desire alone is insufficient and sadly academic excellence, while it will get you into the door, doesn’t predict who will be a great surgeon. There has to be grit -an ability to persist despite hardship. There has to be a nimble mind that can solve problems quickly. And there has to be the physical hand skills that define surgery but somehow have been dropped from the initial evaluation of candidates for surgery.
Who should not go into surgery. Based on my answers above, those quick to give up, are unintelligent, and poorly coordinated should not go into surgery. I would add to this lazy, dishonest, and sociopathic. No criminals please.
There is no perfect answer to this. I knew a fellow who did not score well on tests and was rejected from medical school five years in a row, but eventually got in and completed a residency in a surgical subspecialty and has a very successful practice. While he was being rejected from medical school, he spent five years in the lab, and he could do open heart surgery on dogs very well, was coauthor on numerous papers, and his surgical skill was excellent -like if you were stuck taking tennis lessons from a professional for five years but never playing an actual game. There are also many examples of people who were told too late that they were no good for surgery.
What you should not do is listen to just a single person who has a poor opinion of you. You should examine the situation and decide if there is some truth to the issue, but you need at least three opinions. For example, I would like to be a professional golfer. I can get at least three people to tell me honestly that this is a bad idea. I would like to be a writer. I can get at least three people to tell me honestly this is a good idea. You get the picture. In medical school you will rotate and work with many people and you will have grades and feedback. You need to get honest opinions as you move forward. You need to study hard and get great grades because no matter what you do, your patients will be depending on you.
In George Orwell’s Animal Farm, under the dictatorship of the alpha pig, Napoleon, the pigs who represented the nomenklatura of the farm chant the slogan “four legs good, two legs better,” after initially declaring “four legs good, two legs bad” during their revolution. They clearly understood the luxury afforded by a bipedal lifestyle, because in rising on two legs, you get arms and hands which can do many things like caress a baby or wield a cudgel. What the pigs in the parable weren’t realizing were the consequences of a bipedal lifestyle.
When Lucy, the Australopithecine, bipedal hominid ran about on two legs, she did have the use of two arms and hands. Possibly an adaptation to living in tall grasslands with few trees, the ability to stand tall like meerkats, allowed the biped to see far into the horizon for big cats who probably loved the big brained hominid for the high calorie meal inside the hard skull -many fossils from this time show puncture marks from the incisors of medium to large cats.
The walking and running put heat stress on the brain, and the tool use which happened incredibly early and is observed in the chimpanzee, likely drove the selection for a larger brain (more neurons will allow for one to lose some neurons to heat stress but stay in the game), but it created likely the first problem for our ancestors -discharging a cantaloupe sized head through a pelvis that was small to begin with but now also reshaped for bipedalism. We still suffer from a childbirth process that no other mammal faces -birthing a less than fully cooked baby -a tradeoff for that giant head.
Standing also meant the load bearing was shifted 90 degrees with long term consequences. For our ancestors who only lived about 20-40 years if the chimps are correct, this wasn’t a big deal as arthritis and tendinitis didn’t preclude eating and breeding and didn’t affect them until they were old. But with modern sanitation and social structures, we are reaching 100 years and the majority of the problems of the integument -the bones and ligament, the low back pain, the sore knees, the ratchety hips, can all be explained by our bipedal lifestyle. Your arm is 30-50 pounds of meat and bone and supported only by muscles off your spine, and your blood vessels and nerves traverse a narrow passage through these muscles and your first rib. Your diaphragm with 5-10 pounds of heart, lungs, and blood sits on first branch artery off of your aorta. Your veins, designed to drain blood from your organs, have to do so with over a meter of static water pressure and your sump pumps only work when you are walking. Muscles and their tendons are stretched tight in the odd way that upright walking and running demands, compressing blood vessels and nerves. All of this weight is put on your feet which have to deal with up to a ton of pressure with running…
I’ve talked about this concept many times before but never had a chance to put it together like this talk. I may write an article. Looking back, I did this blog post (Link).
I am grateful to Ms. Mei Nortley and Mr. John Raphael for the invitation to give this talk.
Recently, an AI was fed the world literature on AAA repair and asked about guidelines and superiority of open versus endo repair. It concluded that the past twenty year, endografting has only benefitted the physicians and the device companies (this was present at VEITH). I recommend open to patients likely to benefit from it. I recommend EVAR same way. They are not equivalent especially when patients end up getting insurance denials. I hope it isn’t too late to turn this boat around and train surgeons on open techniques that seem to have been abandoned in many parts of the world.
I will touch on vascular compression disorders like median arcuate ligament syndrome, thoracic outlet syndrome, nutcracker syndrome, pelvic congestion syndrome, popliteal entrapment syndrome, varicose vein disease. Presentation given to the Oxford University vascular unit. Will be streamed on Oxford Vascular Collaterals.
Topic: “Vascular Compression Syndromes: The Consequences of a Bipedal Lifestyle” – Dr Woosup Michael Park, MD
Time: Sep 13, 2024 12:45 PM London, 0700 Central Daylight Time
Join Zoom Meeting
https://us02web.zoom.us/j/88625730033?pwd=sky6SPZYyaWwkT8YwRT1oWm15rWnxG.1
Meeting ID: 886 2573 0033
Passcode: 147871
One of the conclusions of the BEST-CLI trial (ref 1) was that of equivalency between alternate bypass conduits and interventions when a single saphenous vein is not available. I recently contacted Dr. Matt Menard to see if there had been subgroup analysis of these bypasses which represents a heterogeneous group of conduits including PTFE, PTFE with vein patch, spliced vein, composite vein, and even possibly allograft. The results from the abstract were intriguing -“83 of 194 patients (42.8%) in the surgical group and in 95 of 199 patients (47.7%) in the endovascular group (hazard ratio, 0.79; 95% CI, 0.58 to 1.06; P = 0.12) after a median follow-up of 1.6 years” with the primary MALE endpoint. If this was a football game, there would be a video review of the call. And they are looking at this, I was assured by Matt, but we would all have to wait for this year’s SVS VAM. Dr. Matt Menard is coming to speak at our 12th Annual Vascular Disease Update (link) which I highly encourage you to register and attend (addendum).
The Cohort 1 from BEST-CLI is an illustration of the vascular surgeons’ LIMA to LAD. It’s something we already knew from years of experience, but laid out in level 1 data (below).
The BEST-CLI paper is short on detail about cohort 2. This is where a lot of clinical decisions get made, and I suspect the vast majority of patients are getting interventions because fewer surgeons are facile with leg bypasses and vein patches.
Why the vein patch? While not a panacea for the lack of vein, from its inception, it has proved a worthy adjunct in limb salvage. Decades before endovascular therapies showed good limb salvage with modest to poor patency rates, Dr. Frank Veith showed that infrageniculate PTFE bypasses showed good limb salvage with poor patency (reference 2). Vein patches, such as the Taylor patch illustrated at the top, showed good patencies (reference 3) in an era where DOACS, DAPT, and statins were not available.
Why a patch works is debated. Some feel it is the modification of the end to side anastomosis that creates an optimal shape for containing turbulence which leads to intimal hyperplasia. This was the concept behind the Distaflo graft which I tried but have abandoned for not improving patency in my personal experience.
The best explanation of why vein cuffs work is from an animal study from Vienna. Intimal hyperplasia is best explained as a foreign body reaction and the reaction is worse with a true foreign body than with autologous materials. A simple anastomosis with PTFE to tibial artery creates a ring of hyperplasia. Vein patching moves this severe foreign body reaction off of the artery, leaving a gentler vein to artery reaction to occur on the outflow (reference 4).
My final point is that these surgical papers used to be the mainstay of podium presentation in the 90’s and ’00’s, but are now infrequent as the bulk of the time at these meetings is devoted to gadgets which almost always involves purchasing a box and contracting for disposables (the printer and ink business model). I am going to review our institutional results of these PTFE bypasses, and hope to see more from other groups. I look forward to the BEST-CLI papers to come, and other trials.
References
Addendum
The Annual Vascular Update at University Hospital has something for everyone, including a presentation on IRAD by Dr. Santi Trimarchi, and BEST-CLI by Dr. Matthew Menard. Local faculty from Cleveland are also featured in a broad review of vascular medicine and surgery chaired by Drs. Mehdi Shishehbor, Heather Gornik, and our chair in vascular surgery, Dr. Jae Sung Cho. Link. I will be presenting on neurovascular compression syndromes and renal failure/heart failure.
Reading this article on Vascular Specialist, the vascular surgeons’s Daily Prophet, “Likes, dislikes and reposts: The new age of the vascular surgery influencer” by Drs. Jean Bismuth (@jeanbismuth) and Jonathan Cardella (@yalevascular), they rightly point the spotlight on the trend of some vascular surgeons posting cases on social media for the purposes of self-promotion, virtue signaling, and influencing.
I can agree with their point that many of these posts are made by mediocre practitioners who display only the best and curated images, but I felt uncomfortable with the feeling that I may be one of those people being castigated for over-exposure on social media. They warn the readers of the dangers of misinformation fed to an uninformed public, but overlook the potential of social media for education and community. Being a vascular surgeon who has been on social media for over a 15 years, there are reasons why I am here which are not explained by this article, and I am compelled to elaborate on them.
Be the Lede
My journey started with hacking Google searches. My first job out of fellowship was a faculty position at my medical alma mater, Columbia P&S. The PR department asked everyone to compose a blurb for a web page and after searching on Google on how to rise in a Google search, I wrote out a paragraph full of the right verbiage to maximize my relevance on search. It wasn’t very difficult in 2002 to do this. Searching “vascular surgeon in New York” on Google after posting that info page consistently brought me up to the top five links, ahead of whole departments and many big names. I did over 400 cases my first year out, and I really felt if I could make it there, I could make it anywhere.
Bury the Lede
Unfortunately, like many vascular surgeons in New York, I got named in a lawsuit, and like many young surgeons with limited means and large loans to pay off, I couldn’t fight it and took the advice of hospital lawyers and settled. After that lawsuit, a Google search would return an article by the law industry PR around 2007, and I was at that point very busy in private practice in Iowa. It was so discouraging seeing that as the only thing speaking for me. I decided that I had to take an active part in shaping the message around me, to not let my Google search profile be defined by that article.
I decided to write and figured a few articles every week over a year would bury that article behind many better articles. I began to blog about something I am both horrible at but aspire to greatness in –golf (www.golfism.org). Writing about myself and my struggles in golf and being a young father and husband was how I found my voice. It was during this period that I found my best pieces were when I gave something of myself.
After finding my author legs, I began writing about vascular surgery, something I’m pretty good at but aspire to greatness in, on a personal blog (docparkblog, on Apple’s defunct cloud service). After a year, the blog got only 30-50 hits a day, at most 100. By internet standards, that’s low, and I kept my day job. After giving a talk at Midwest Vascular to an audience of about 50 mildly interested surgeons, that 30-50 engaged readers on my blog a day felt pretty good. A hundred was amazing. Medscape eventually tapped me for blogging on their site. My blog there, “The Pipes Are Calling,” was rated among the top 5 most read medical blogs in the world when I shut it down in 2011.
The Influencer
This social media presence generated influence -I was asked to participate in prominent research trials like PIVOTAL, CVRx, and CREST and others despite being in private practice. This is common now, but rare 15 years ago. The blogging did bury the lede. It eventually generated misunderstanding in the hospital administration at that time in 2011 and I was asked to stop blogging, at least until they could figure out what this internet thing was about. In 2012, I joined the Cleveland Clinic, I huddled with their social media department and came up with ironclad rules:
After launching www.vascsurg.me in 2013, I chose to focus on technique and opinion. I used my Linked-In and Twitter accounts to promote my articles. I always communicate in my authentic voice, although over the years, I’ve toned down the irony which is frequently misunderstood. In moving to my current hospital, University Hospitals, the first thing I did was arrange for a social media release and confirm what I was doing was okay. In reading the article by Drs. Bismuth and Cardella, in 2023, misunderstanding is still at the core of arguments against the use of social media.
The Worst
I have seen egregious examples of bad behavior on social media by physicians, as mentioned in the article. On my Twitter stream, I’ve seen people put stents in subclavian veins for thoracic outlet compression and wait for praise, which they get from similarly ill informed people who don’t realize I see patients like this several times a year with swollen arms and faces. While I was in Abu Dhabi, someone put stents in a patient from the common femoral to popliteal artery, and receive accolades for “minimally invasive skills” from all corners of the globe, only for me to remove the stents a month later and perform fasciotomies on the same patient -a middle-aged claudicator! There, I couldn’t post a rebuttal to the original case presentation because of local social media laws. Despite the word getting out, the surgeon only doubled down on his minimally-invasive fantasies. About the same time, I witnessed a relatively famous person self-implode on Twitter while accusing vascular surgeons of butchery (his words) by supporting open surgery over head to toe interventions. He got crushed by the general disapproval of his misrepresentation and personal bullying of a vascular surgeon, and then disappeared from social media. Evaporated. Good. We all have to do better.
The Best
I have also seen patients with rare diseases such as median arcuate ligament syndrome reach out and connect with each other and with physicians about diseases that aren’t taught in medical school or residency training on social media. There are Facebook groups, Twitter hashtags, and sub-Reddits, a rich communities of people who have to make serious decisions about their lives, many with limited access to specialists in their far-flung burgs and precincts. I think the fear is that bad decisions will be made based on bad information, but even in the highest, most rarified medical institutions, patients may get misguidance, have a complication, a poor outcome, in-person which can be worse than a social media interaction. If we value patient autonomy, access to the best information needs to be available. Social media lowers the barriers to access, for bad or good. Yes, it can do a whole lot of bad, but also an immense amount of good.
Keeping it Real
The authors are correct in that people will prefer to promote themselves rather than air complications and bad outcomes. The American surgical M&M process is an amazing and cherished tradition and protected process. It has no place in social media. Most surgeons also take the view that social media presence doesn’t lengthen your CV, it doesn’t bill. The many cheap suits of medical social media, the hawkers, the hucksters, the fragile egos will always be there on Twitter and Linked-In.
But other functions such as access and broad dissemination of information, experience, and opinion, are legitimate and critical. Comparatively few people get the message from a closed academic conferences and traditional modes of dissemination are slow. Most of the best social media posts are, as the authors mention, case reports. They fail to mention case reports under “open access” cost about 500USD to publish.
The peer review process, which I participate in, results in sometimes glacial turnaround times with papers landing often a year or more after presentation at a conference. I also learned from my time in private practice that these barriers block the voices of many legitimately great surgeons whose remarkable talents are only shared locally. I also learn from my time in academic practice that too many departments are not multiplicities of talents (Avengers Assemble!), but shops built around single personalities, who may declare that having never seen something, it cannot exist -to the detriment of those with unseen problems. Social media is the great leveler. Young surgeons can raise their profile, and non-academic surgeons can have a broader platform to share their expertise. If legitimately good people are dissuaded from participating, only the cheap suits will remain. As always, caveat emptor, et primum non nocere.
https://www.jvscit.org/article/S2468-4287(23)00014-X/fulltext
Innovation was a needed to avoid the coagulopathy that comes so frequently at the end of thoracoabdominal aortic aneurysm repair in a low volume but fully resourced environment such as we had in Abu Dhabi. In this demanding disease, there are no shortcuts to success but every little bit of advantage helps.
There was an OpMed article on Doximity (https://www.doximity.com/newsfeed/1946e8dd-eddc-4eb4-aad6-46fe59c86da5/public) which reports that 69% of 58,000 physicians surveyed said they would provide emergency care. That number is depressingly low at first view but can be answered by asking how many of us are ATLS, ACLS, or BLS certified? A quick search fails to give a result, although various pro CPR groups have on their websites that all caregivers should be trained in BLS. The darker question is how often do fully trained and certified physicians choose to withhold care and hide their identities?
I can give you a quick answer. Most doctors will sit on their hands when the PA announces “is there a doctor on the plane?” hoping that someone else will raise their hand. Back when I was a second year surgical resident, I took a vacation with my wife to London and Paris. On the flight, over the Atlantic, the cabin crew asked for any medical assistance. Before I had a chance to contemplate the question my wife jumped up and pointed at me and shouted “He’s a Doctor!”
I was in shorts and hoodie, with a baseball cap. Back then in my late twenties, I looked about 15 years old. The British Airways stewardess looked at me dubiously, then looked around behind me to see if any other hands were raised. <sound of crickets>
She escorted me up the stairs to first class and in one of the giant chair-and-a-half recliners was a pale fellow in a nice suit, diaphoretic, dyspneic, and maybe a little drunk. He couldn’t speak well but was awake and maintaining his airway. His radial pulse was thready and weak. I pressed the button that fully reclined him into a bed, not a little jealous.
“Are you having chest pain?” <head shake>
“Do you have pain anywhere?” <head shake>
“Are you diabetic?” <¯\_(ツ)_/¯>
Cold, clammy, dehydrated, drunk -hypoglycemia was my diagnosis. I asked the stewardess if they had any tubing, a funnel, and orange juice -because that is how you deliver sugar to someone who can’t protect their airway. I was an enthusiastic PGY2 and the orange juice enema was one I was eager to roll out. She looked at me funny and handed me a large black leather suitcase -the kind you see sniper rifles disassembled and packed. In it was a pretty thorough crash cart with defibrillator, airways, Mac blades and handles, bag mask, IV’s, bags of saline, and boxed syringes of code meds including D50. Oxygen was available. It was British Airways first class after all.
I looked around and saw no great place to hang an IV, so I grabbed the D50, horse needle and all, and found his cephalic vein and injected the whole vial. The change was instantaneous -the eyes which were spinning beachballs, stopped wobbling and focused. All that was missing was that Apple Macintosh “bongggg” sound. I gave the fellow a gauze and instructed the stewardess to give him orange juice spiked with sugar.
“Shall we land?” asked the stewardess. The neighboring passengers, all dressed as if for a fancy cocktail party, looked at me with eyes that said, “We really need to get to London.”
“Where are we?” I asked.
“Over Reykjavik. The captain needs to know now.”
I look at my patient, and he had unreclined himself in his fancy leather loveseat, and shook his head. “Thanks. I’ve got to get to London for a meeting.” He was going to be fine. I recommended he see someone for his diabetes (which he confessed to neglecting), and I walked downstairs and back to my seat in steerage.
A older couple (I’m sure they were middle-aged like I am now) was next to us and the lady smiled, and the man leaned over and asked, “how did it go?”
“Hypoglycemia. Are you a doctor?” I says.
“Why yes, a cardiologist. We’re going to London for a conference!” he chirped. I think he caught that I was giving him an accusing look, and added, “you’re wife volunteered you so well, so enthusiastically, I figured you had it well in hand. Good job.”
I sat down and my wife immediately asked, “did you ask them to upgrade us?”
“No.” That is the advantage of a wife when she isn’t volunteering you for missions, she’s looking out for your interests. I was going to make some grand statement of my purpose in life, but was interrupted. The stewardess came up with a brown bag full of tiny bottles of liquors, spirits, and whiskeys, which made me very happy, but my wife just rolled her eyes.
“You would have been happy with a cookie,” she hissed. “Why didn’t you ask for an upgrade? What’s wrong with these people?” And I thought the same, for a different reason. Seated all around me were likely cardiologists headed to London for that conference. Just counting bald heads, there were at least twenty.
Now, nearly thirty years on, I don’t blame those fine folk for not being quick on the draw. I am sure one of them would have stood up eventually, but the last thing you want to do on vacation is work, and what I did upstairs in first class was not much different from the work I was doing every other night on call (this was 1995).
Now, in the middle of my career, there isn’t much that gets my blood running, so I empathize with the festive, sanguine attitudes of the many physicians probably on the plane with me, headed for a nice holiday and conference in London. Some happy fellow jumps up and takes care of the problem, so no need.
Also, I’m not shy in crowds or stressful situations. Everyone in first class was watching me get venipuncture with the D50 syringe and the horse needle which was easy because the fellow was so thin. At that point in my life, screaming HIV positive crack addicts fighting you while getting central lines and spinal taps were the norm. I suppose I couldn’t fault someone more bookish and scholarly for not standing up right away. I assume 69% would have.
I’ve been called about a half dozen other times on planes. It used to be my wife volunteering me, but over the years, even she has taken on a bit of a glazed attitude. The last one a few years ago was a poor fellow whose wedding ring was causing an ischemic finger, made worse by traumatic attempts at removing the ring. Soap and rubber bands fixed him. It barely elicited an eye roll from the spouse who did not volunteer me that time. It was one of those cheap airlines in the American Southwest and I got nary a thanks.
I have never contemplated the medical malpractice ramifications of rescuing someone, saving a life. I assume something like sea-law prevails up in the air, where the captain can marry folks and push them off gang planks, where decency, need, and common sense prevails over tort law. Unfortunately, I have never seen another black suitcase since that first time on British Airways, and the pre-9/11 days of carrying a pocket knife are long gone, making emergency surgeries and fashioning of MacGyvered medical devices impossible. The idea of embarking on supporting the life of someone when the last time you ran a code was in medical school may be too much to ask someone, and doing the wrong thing may be worse than doing the right thing badly.
Did you know you can fix a tension pneumothorax with a pen, a rubber band, and a condom, with the appropriate knife and fortitude, and maybe a tiny bottle of vodka.
But isn’t that why we went into medicine? To save a life is to save the world, the Talmud tells us, and we can be heroes, if just for one day.
A Surgeon's Notes 