SurgeXperiences is a biweekly round-up of the latest happenings in the surgical blogosphere. Each edition is written by a different website, and this time we have the privilege of playing host. So please, sit back, enjoy, and don’t forget to tip your server on the way out. Let’s get to it.

The boss had a particular interest in everything anal, including flatus.

Or so says Bongi, as he recounts a hilarious episode of who-dun-it that occurred during rounds. You can read the rest over at Other Things Amanzi; we just couldn’t let Bongi get away with having the only website to use the above phrase.

Okay, on to more serious matters.

Although a cholecystectomy should be a straight-forward procedure, as it was for the now gallbladder-free author of At Your Cervix, it is still a procedure, and plenty of things can go wrong. For example, although you would probably expect to come out of it with your legs still attached, Dr. Val describes a patient who did not. And no, it was not a horrifying clerical error or mixed-up chart, a situation that one could at least begin to address.

No, this was a case of a surgeon who wanted to get home as soon as possible and declared before the procedure, with no apparent understanding of how divine retribution works, that he would “set a new record for speed of gallbladder removal.” He might have done it, too, until he stabbed the aorta with a hastily-inserted trocar. He then proceeded to handle the emergency with the same hubris that caused it, and the patient ended up trading jaundice for gangrene.

In another botched case last week that got lots of coverage in the mainstream press, things are a little bit fuzzier. The case was an eighteen year old girl who went under the knife at an outpatient center for the correction of breast asymmetry and nipple inversion. About two hours into the procedure, she developed what is now believed to be malignant hyperthermia and died after transfer to a nearby hospital.

It’s not clear who, if anyone, is to blame here — was the center stocked with non-expired Dantrolene? did she have any indications to warrant a caffeine-halothane contracture test? But since this was an elective plastics procedure, most people have, of course, decided to blame the patient.

Over at Nunoftheabove, for example, there is certainly no shortage of moral outrage. “More and more young people are turning to elective surgeries to give them what nature did not,” writes the blog author, while one commenter laments “she had to turn to surgery for self-esteem.”

Fortunately, Dr. Coleman Brown offers a more rational take on the issue, reminding us that “this was an unfortunate incident that could have happened under any sort of routine non-cosmetic surgery.” Also, as one his commenters points out, details are still sketchy, and for all we know her left breast was a D cup and her right an A cup.

Or maybe they weren’t. In either case, do we really have any right to judge the worthiness of someone else’s insecurities? Meanwhile, over at Suture for a Living, Dr. Bates offers another case of someone else seeking to improve their appearance with plastic surgery. This, however, was not your usual case of nip and tuck; rather, she writes of a French man afflicted with neurofibromatosis who has received the first-ever total face transplant. A year has passed since Dr. Laurent Lantieri and his team performed the revolutionary sixteen-hour procedure, and reports indicate the patient is doing just fine. It is, however, still unclear if Brad Pitt consented to being the donor.

Not willing to be outdone by the French, of course, American surgeons at University of Miami last week performed some surgical wizardry of their own, temporarily removing a patient’s stomach, liver, pancreas, spleen, small intestine, and ascending/transverse colon in order to excise a tumor that had involved the celiac and superior mesenteric vessels. (If, by the way, you’d like to see what it looks like when the guts come out, check out these two amazing videos from The Sterile Eye: left hemicolectomy, and low anterior resection.)

Dr. Sid Schwab, over at surgeonsblog, was impressed with the procedure from a technical perspective but questioned whether such “spectacles” are really justified, especially when they consume limited resources from which other patients would derive greater benefit. In the comments section, the discussion about rationing care intensifies, with Dr. Bates noting her frustration upon hearing “that a liver transplant patient was getting a THIRD liver after rejecting the first two. When does the next person in line get the liver treatment?” ArkieRN writes “I had this exact thought when pouring blood products into a well ventilated patient who had progressed into DIC resulting in using up nearly the entire hospital supply … blood was spilling out of the patient faster than we could replace it.” 

Both Dr. Schwab and the commenters note, however, that one’s opinions on rationing tend to change when the patient is a loved one. Somehow, large and expensive procedures that yield just two more years of life become a lot more worthwhile when they’re being planned for mom or dad. But to an outsider, it’s still selfish, and a waste: as gay CME guy writes in the comments, “I watched my cousins [utilize heroic measures for] their father with stage 4 esophageal cancer. The last few months of his existence were miserable… They weren’t doing it for him. They were doing it for themselves.”

Indeed, it’s hard to make objective decisions for a family member. For that reason, many physicians and professional societies recommend that doctors not treat members of their own family. In another post, however, Dr. Schwab unravels the logic of this argument and finds it wanting. He writes:

if it’s acceptable — laudable, even … — for doctors to establish and to have a connected relationship with their patients, then doesn’t it follow that the idea of professional distance is a flawed one? Doesn’t it imply I’d make better decisions when caring for a patient I don’t like than for one I do? If not, then at best the idea of caring for a relative or close friends differs from caring for ‘regulars’ only in degree; and a smaller degree, at that, than convention would suggest

Dr. Schwab is probably right that physicians can be just as effective as strangers, and perhaps even more so, when it comes to treating loved ones. But, as one commenter argues, the relationship can still be unfair to the patient. Annie writes:

The other side of the coin is the ability of your relative/friend/colleague/staff/patient to express concerns, complaints, fears, etc. Those people know you outside your surgeon role. Would they feel free to express a disagreement with your recommendations? How do you manage noncompliance? What happens if there are undisclosed “secrets” which affect the treatment or outcome? 

Ultimately, it is concluded, the appropriateness of treating a family member or friend depends on lots of factors — the type of procedure, the ability of the surgeon to compartmentalize, the nature of the relationship, and so on.

Elsewhere, however, we see that family members can also be the worst possible ministers of health, and that sometimes their misguided good intentions lead to significant harm. Over at Urostream, for example, Dr. Keagirl writes about patient-controlled analgesia and notes that sometimes “the family will keep a vigil over the patient’s every single facial expression, and if there is a suspicion of an involuntary grimace, or a little moan that escapes during the nap, they will press the button. Certainly well-meaning, but probably not the wisest course of action especially when the patient goes into respiratory depression…”

At the Atlantic, meanwhile, Megan McArdle writes about parents who deny their children proper vaccinations and notes that their agenda is self-defeating, since it undermines the herd immunity on which it depends, and that it has led to new outbreaks of diseases like mumps and measles. McArdle even calls such parents sociopaths and writes, “People who are unvaccinated, unless they have a legitimate medical reason for same, should not be allowed to use public roads, public sidewalks, or public services. They have a right not to vaccinate their children. But they do not have a right to risk my health.”

In the rather extensive comments section, Palmrita responds to McArdle and ignites a firestorm, writing, “After careful reading and research, I have refused vaccines on my kids… I build good health through nutrition, love, and exercise. True good health is not found in a shot. Am I a sociopath?” The resounding answer, as expected, is yes. TW Andrews writes, “And additionally, an idiot.”

On his blog, Dr. David Loeb finds yet another piece of dangerous medical misinformation in an ad placed by the Indoor Tanning Association in the New York Times, in which it is claimed that “there is no compelling evidence that tanning causes melanoma.” Given the extensive and unequivocal evidence that, in fact, it does, Dr. Loeb argues that such ads are “irresponsible and dangerous.”

Yes, there is a misguided and illogical world out there, and as Joey M.D. points out, the internet sometimes facilitates patient ignorance. But new technology can also do lots of good, so let’s end with a little bit of futuristic medical escapism, courtesy of Microsoft. In this video, the company illustrates what they believe the future of medicine and patient care will look like. And, with the exception of the far-too-easy-looking fundus exam two minutes in, it’s all pretty believable.

We hope you’ve enjoyed this latest edition of surgeXperiences, and we look forward to reading your comments. The host for the next edition is still in the works, but you can already submit posts for consideration at this site. Also, if you have a surgery blog and are interested in hosting, please contact the coordinator, Jeffrey Leow. Until next time.