The radiologist has access to special techniques for visualizing the inside of the body, and among these are computerized axial tomography, the CAT scan, and the magnetic resonance imaging, the MRI scan. This complex machinery can reproduce images of your body on a computer screen showing almost every part of your anatomy, and sometimes do it in an almost three-dimensional way. They can see pathology, such as tiny lung, brain or abdominal cancers, abscesses, bowel obstructions, and many other abnormalities. They can also tell when there isn't anything wrong, and that's important for the surgeon also. You may have all the signs and symptoms of appendicitis but, with negative radiological studies, the surgeon may decide to hold off on surgery, and the diagnosis actually may be as simple as food poisoning or gastroenteritis.
Another modality is nuclear medicine. In this field the patient is given radioisotope material, though not radioactive enough to cause any damage, which frequently localizes in a special organ or special tissue, and radiologists are thereby able to make specific diagnoses. Examples are special scans for pulmonary embolism, for thyroid and parathyroid disease, brain tumors, and infections, to name a few. These are painless studies which give the surgeon a lot of information. For example, when I first started in surgery, we often had to spend hours in surgery exploring the neck for a 3 millimeter parathyroid gland tumor. Now the parathyroid scan can often localize the tumor so that the surgeon can find it rapidly, saving the patient extra time under anesthesia and saving the surgeon from getting ulcers looking for a tumor, like a “needle in a haystack.”
Ultrasound is another modality used by the radiologist, where sound waves create an image on a screen. The trained technicians and radiologists can diagnose cysts in breasts, liver, pancreas, or anywhere else in the body, gallstones in the gallbladder and common bile duct (see Gallbladder), and hematomas, seromas, and abscesses. The radiologist can also insert tubes and drains in these cysts, if indicated, using ultrasound, CAT scan, or MRI scan. On numerous occasions, radiologists have inserted drains in intra-abdominal abscesses, saving the patient a complex and difficult operation.
The radiologists have been working hand in hand with the surgeons since the end of the nineteenth century, when Wilhelm Roentgen first discovered the x-ray, and each year new procedures evolve that will continue to aid in diagnosis and, hopefully, simplify procedures for the patient.
Chapter 27
ALCOHOLISM, DRUG, AND OTHER ADDICTIONS AND SURGERY
Yo mamma, would you like a hit?
You won't have to worry the least little bit.
A little vodka, some “bennies” or a “toot,”
'Cause the doc will fix ya up, room and board to boot!
We have a wonderful system, health care for the addicted
Even if your complications aren't fully predicted,
No matter how sick you get, just another refrain,
You can just go right out and do it again.
It's always remarkable for me to know that upwards of 40% of all hospital admissions are related directly or indirectly to drug, alcohol, tobacco, and other addictions. It is a subject rarely well dealt with by the medical schools, residencies, and hospitals. It is a serious problem, and yet it is apparent that less attention is paid to this topic even in the medical texts than to relatively obscure diseases, such as Myasthenia gravis and lupus erythematosus.
With international programs such as Alcoholics Anonymous, Narcotics Anonymous, Smokers Anonymous, and many support groups, and with the individual, nursing, physician, and hospital discharge facilities, we are still sorely lacking in appropriate management of this tremendous problem. Smoking alone is responsible for many thousands of deaths each year from lung cancer.
I mention this topic in a surgical text because so many of my patients have this addiction problem to one degree or another. The availability of treatment programs is far below our needs, and the HMO and insurance companies shy away from the diagnosis and treatment because it is so expensive and the success rate is so poor.
Let us just run down a few of the problems associated with addictive disease:
1. Smoking can cause bronchitis, pneumonia, emphysema, cancer of the throat, mouth, lungs, stomach, esophagus and pancreas leading to extensive surgeries and morbidity, vascular disease leading to bypass surgery and amputations, and heart disease, which may lead to open heart surgery.
2. Alcohol can cause esophagus and stomach cancers, or severe liver disease with liver failure, ascites or fluid in the abdomen, which may require surgery, heart disease, and severe neurological disorders. There are a host of directly related problems due to excess drinking, including auto accidents, spousal abuse and injury, knife and gun wounds, and kidney failure.
3. Drug abuse can lead to sudden death, abscesses, liver failure, and bizarre behavior leading to trauma and death to oneself and to others.
Many of these problems require surgical intervention, and yet the addiction is so strong that the patients keep returning and returning, sicker each time, until the problems compound and they die. It's a massive public health problem, yet the public all but turns its back on it. It has taken over a hundred years to make a dent in the tobacco industry in the last few years and, unfortunately, it may take many years to impact the drug and alcohol problem.
If you or a loved one has an addictive disease, you will understand that these are diseases of denial, unlike cancer of the breast or colon. In spite of a deteriorating life in all areas—professional, social, and economic—these diseases destroy the body, often in a slow progressive fashion.
Wake up America! Get yourself or your family member the help needed; don't just treat the sequelae and symptoms of the disease. Too often the patient will gladly undergo surgery, but balks at taking care of the problem that has resulted in the need for the surgery.
Chapter 28
CONTRIBUTIONS FROM THE SUBSPECIALISTS
It seems in most predicaments,
Someone puts in his two cents,
But if you get enough of tuppence,
Soon you'll have a pound of uppance.
As a surgeon I'll accept,
As much good help as I can get,
So I will get a complete list,
Of every well known specialist.
I want to acknowledge that, as a surgeon, I am continually reliant upon the expertise of a number of subspecialists who have helped me in the diagnosis and treatment of patients over the years. We no longer stand as the independent physicians of the nineteenth century. They were the horse and buggy doctors who visited homes and accomplished their remarkable feats of diagnosis and treatment with only a skeletal outline of what we have today. They often failed, and yet they usually did the best they could with the support and tools they had.
With the twentieth century, we saw the emergence of specialties and then subspecialties of medicine because of the complexity of diagnostics and the vast increase in information and interventional procedures. This gave rise to the surgical subspecialties, as we will see in Part II, and also gave rise to the medical subspecialties, among which are the gastroenterologists, pulmonologists, intensivists specializing in caring for patients in the intensive care unit, oncologists, hematologists, cardiologists, infectious disease specialists, radiation therapists, pain management experts, psychosocial support teams, and many others. I will mention a few of the ways these experts help the surgeon and let your own imagination lead you to understand how invaluable all these physicians are to the surgeon and thereby to the patient.
The gastroenterologist, in addition to his medical diagnostic expertise, uses several types of endoscopes; these are lighted tubes that can be inserted into the intestinal tract through the mouth or rectum. They can examine the stomach and duodenum and the entire