Saturday, August 24, 2013
Friday, August 23, 2013
The boy, a teenager most likely, lies naked on Bed 2 in a trauma bay at Harbor-UCLA Medical Center. His brown skin, slick with sweat, is ashen.
"What's your name?" a resident asks as half a dozen doctors and nurses circle him.
The boy can't answer.
"Ohhh," he moans.
"How old are you, sir?"
The boy's hipbones delicately protrude from his narrow waist. He has a woman's name tattooed down his right arm from elbow to wrist and the bullet hole is to the right of his navel.
Putnam, chief of trauma, stands back and watches and listens. He is puzzled that the wound is hardly bleeding.
"Sit up for me."
There is no sign of an exit wound.
"Hey. Wake up."
A resident slaps the boy. They need him conscious.
Putnam knows the surge of adrenaline that brought the boy this far is nearly spent. If his blood pressurecrashes, his heart will stop. Putnam wonders if it is too late.
"Let's go to the OR," he says, loud enough to get everyone's attention.
The season of shootings has begun on time. Last year, from July through September, this Torrance hospital treated 107 gunshot victims, the highest number in the county.
This year, four GSWs — medical shorthand for gunshot wounds — arrived on the first day of summer. One was a suicide and three were assaults. Three died and one would probably be discharged in a few days.
Now, on June 23, two more have come in, both teenagers, both assaults. They walked through the front door at 2:25 a.m., no EMTs, no police. The hospital staff calls it the homeboy ambulance service: patients brought in with injuries often from gang shootings.
Putnam can see that one of the boys will be OK. He has a clean wound through the shoulder.
The boy with the nickel-sized bullet hole is far worse, and they know nothing about him. No name, no age, no family. For now, they call him Zinc, one of the pseudonyms the hospital uses for its John Does.
Emergency departments in hospitals throughout America have physicians like Putnam, doctors who specialize in saving the lives of shooting victims.
Other traumas, like concussions and automobile accidents, can be subtle and require imaging to see what's hidden. Gun injuries don't hide their tracks, but they are just as much a mystery, a puzzle put together by the surgeon as seconds race by.
No matter the clarity of the injury, the damage can extend like concentric rings beyond the trajectory of the bullet. There is the blast effect, the sometimes fatal bruising that can occur to organs in the vicinity of a wound. There is the so-called triad of death, the interplay between body temperature, blood acidity and coagulation.
There is ancillary debris — shards of glass, pieces of clothing, even upholstery if the bullet has passed through furniture — and there are always infections from bacteria carried into the wound.
Putnam, 44, estimates that he has treated about 5,000 GSWs and consulted on nearly 2,000 more over the last 20 years, 10 of them at Harbor-UCLA. The victims he remembers the most are the children and women, the bystanders hit by stray fire, the wounded who spoke to him in the ER but died in the operating room.
Whenever he loses a patient, he hears his mother asking him what he could have done differently. And whenever he saves a life, he knows that success is often just a matter of luck.
Medicine and technology have come far in recent years in balancing the odds, but when it comes to gun violence, the numbers are overwhelming.
"Why guns?" Putnam asks. "Why so many guns? It once was fistfights. It once was stabbings. Now it's a whole new world out there, and with guns, it's just too much."
The emergency room team washes the boy with an antiseptic. He has been intubated and anesthetized. Blood transfusions have begun.
"Sticky blues," Putnam calls out. No time to wait for the antiseptic to dry. Nurses drape blue cloths around the boy until he disappears, with only a torso remaining.
Putnam, dressed in surgical scrubs, gloves, cap and headlamp, makes the initial incision from sternum to pubic bone, bowing around the navel.
Chief resident Carrie Luu follows the scalpel with a "Bovie," a pen-shaped tool that cauterizes the open blood vessels with electrical current. The air smells of singed flesh; tendrils of smoke rise into the lights.
Putnam sets a clock running in his mind. Two hours is optimum. Three is the limit. Anything longer compounds the trauma with a phenomena known as physiologic exhaustion, when the body has worn itself out trying to compensate for the injury.
Putnam and Luu begin by separating the small intestine and colon from their ligaments. They notice a few holes in the bowel, but those repairs can come later.
Lifting the intestine out of the torso, they find a pool of blood the size of a football flooding the back of the abdomen. This explains why the entry wound was dry. The boy is losing more blood than they can give him. Putnam wonders again if they are too late.
He orders more transfusions. A resident begins suctioning the abdomen.
"Minus 8," a nurse calls out. It's a measure of the blood's acidity, a reminder of the triad of death. A normal reading — zero — means blood clots can form naturally.
As patients lose blood, lactic acid accumulates in the cells, and the enzyme that helps coagulation doesn't function. The more acid, the more bleeding, and patients' temperatures drop until there's no stopping the loss.
Trauma teams try to interrupt this cycle. Transfusions and warming blankets help. The OR's thermostat is set as high as it will go: 85 degrees. The boy lies on a pad that's heated to 100 degrees, but still his temperature has fallen to 93.
Unable to see beyond the blood collecting in the abdomen, Putnam reaches in, and his fingers find the inferior vena cava — a vein nearly an inch in diameter — that channels blood from the lower half of the body back into the heart.
He pushes down on it, and the bleeding slows. When he eases up, he can hear a whoosh. The vena cava has been punctured.
Fired from a handgun, a .45-caliber bullet averages 900 feet per second, and unless it hits a bone, it usually follows a straight line.
This bullet's journey passed through the skin and the colon, the intestine and then the vena cava. It stopped just behind the pancreas, with its point boring nearly two inches into the spine at an angle, just missing the spinal cord.
Putnam probes the vertebra. He feels sharp fragments of bone and a hole in the L-3 vertebra no larger than his little finger. If the bullet posed a risk for pain or infection, he would remove it, but experience tells him it is safe to leave behind.
With the blood drained, he can see the damage to the vena cava: two holes in the vein, most of the tissue shredded. There will be no repairing it. Each end will have to be tied off permanently, and the other veins will have to adjust by carrying blood back to the heart.
But ligating the vena cava is tricky. Unlike arteries with their thick muscular walls, veins are as fragile as tissue paper.
Putnam puts a clamp with long pincers on the vein, which swells like a garden hose. Even in the best of circumstances, fewer than half of patients with similar injuries survive.
The boy jerks, a sudden reflex.
"Can you paralyze him so he'll stop bucking?" Putnam asks. More paralytics are added to the cocktail of intravenous drugs.
Putnam guides Luu, the chief resident, as she starts to tie off the vein. The stitch reverses direction with each pass and looks like the threads on a baseball.
"Minus 11," a nurse calls out. They have been working for almost 90 minutes.
"Come on," Putnam says, encouraging Luu. "This is where all these things really matter."
She is having trouble. Sideways torque in the needle tears out the suture. Luu is still learning — and Harbor-UCLA is a teaching hospital — but now Putnam has to take over.
"Big pledgets," he calls out, asking for the felt-like material, nearly a inch in diameter, that will act like gaskets to support each suture against the tissue. "Hurry, please."
His hands rise and fall quickly, deftly, with the grace of a pianist. His stitches, though, aren't perfect. He learned long ago that there was no call for elegance in surgeries like this. A perfect stitch could mean a dead patient.
With a little more than 12 passes, the lower portion of the vein is closed. They are almost two hours in. Putnam is sweating and splattered with blood. The room is stifling.
"Watch your eyes," Putnam announces as he removes the clamps and tests the sutures. Given the pressure in the vein, blood could spray across the room if the sutures don't hold.
"Still very oozy," he says. The body's normal coagulants haven't begun to stop the other sources of bleeding.
He and Luu staple the top portion of the vena cava and turn to the intestine. They draw the long, serpentine tube through their hands inch by inch, stapling and stitching any tear.
A cloth is tossed on the floor to mop the blood at Putnam's feet. By now, almost 80% of the boy's blood has been replaced.
Loosely positioning the intestine inside the abdomen, Putnam begins bandaging. He won't close the incision because he plans to open the boy again in two days to reassess the work and to see how the body is healing.
"OK, we're moving," the scrub tech announces as soon as Putnam steps back and begins to strip out of his surgical gown.
Putnam remembers all the bad news he's ever delivered. He won't have to remember this one.
At 5:25 a.m., three hours after arrival, he pronounces the boy in critical condition, expected to live.
A little before 6 a.m., Putnam goes looking for the family. He still doesn't have any information about the boy.
Sleeping families fill the waiting rooms, and in the ER, Putnam speaks with the other victim, who says he doesn't know his friend's name.
Then a call comes in. A woman is asking if the hospital has seen a young man with the name Connie tattooed on the underside of his right arm.
Within an hour, Connie Greene and her husband meet Putnam in the ICU. She is the boy's mother, and his name is Leandrus Benton. He is 16.
"He's OK," Putnam tells the parents. "He lost a lot of blood, and we almost lost him."
Connie starts to cry. In the last five years, two of her nephews have been killed in street shootings.
Leandrus — or Lee, as he's known to his family and friends — had been walking home from a party in Wilmington that night. As he would later explain, he and his friend thought it would be safer to take the alley than the street. Lee had heard the gun but didn't see the shooter. The bullet, he said, burned through his gut.
Putnam walks the couple into the ICU, and as they wash their hands, he pulls out gowns, gloves and masks for them. He then takes them to Lee, waits a minute and draws the curtain around them so they can be alone with their son.
The call came Sunday morning, just after I had returned from a bike ride on one of those rare, glorious, sunny Cleveland days.
"It's your doctor," my wife said, as she handed me the phone. Never a good sign, your doctor calling on a weekend.
I had recently seen him for my routine physical, where I had been found to have high blood pressure. I tried to explain it away, blaming the morning traffic as I dropped off my children at camp, drinking a tall cup of coffee and running to my appointment. But my wise doctor ignored my attempts to minimize it and had referred me for a stress echo, an ultrasound of the heart, followed by a run on the treadmill, followed by another ultrasound of the heart. I had completed the test just two days earlier.
"Your resting echo images" — the ones before I exercised — "showed wall motion abnormalities in the left circumflex distribution," he said. "You need to see a cardiologist." Translation: Your heart muscle isn't moving in a region fed by one of the three main blood supplies to the heart. You've had a silent heart attack sometime in the past.
I sat down in the living room, the only sounds being those of the wood clock on the mantelpiece, and the distant murmur of my wife and children chattering away in the other room. Time passing, and family.
"I'll e-mail him and copy you right now, to get you in," my doctor concluded. I thanked him, my brain too jolted to generate any clarifying questions.
A heart attack. It was official. My dad, his father and my great-grandfather did not bother to pass down to me their good looks, but they had managed to secure in their patrilineage coronary artery disease: All three had died suddenly, of cardiac arrest. I was on deck.
True to my doctor's word, the e-mail came across my iPhone within the hour. And then I waited for a "reply to all" from the cardiologist.
And checked my e-mail more times than I'm comfortable admitting publicly.
I revisited past illnesses, trying to identify the one concealing a heart attack: the upper respiratory tract infection that left me short of breath; the chest pain a couple of days after a vigorous upper body workout at the gym.
That afternoon I called a friend who is a cardiologist, and she kindly reviewed my echo report.
"It's probably just an error – this doesn't make any sense at all. Don't worry," she said.
That helped for a few hours, until it didn't. I later talked to a friend who specializes in cardiac imaging, who was much more blunt.
"You're being an idiot," he told me. "This has to be a bad test. Why are you letting this bother you?"
Because the men in my family die from heart attacks. And while I can modify my lifestyle to avoid eating gribnitz — fried chicken fat — spread on rye bread like my grandfather, and can exercise regularly unlike my father, I can't escape their genes.
A couple of days passed without an e-mail from the cardiologist. I called his office and left a message. My wife noticed I was distracted.
"You're not letting this bother you, are you?" she asked.
I told her I was.
She reminded me that when one of my patients calls, concerned that they have leukemia because of a low platelet count, that I always reassure them that the test was probably wrong and that they should get it rechecked. "You've had two doctors tell you the same thing. Why can't you follow your own advice?"
Because this is emotional, not logical.
The next day I called the cardiologist's office again, and he scheduled a more detailed ultrasound. I underwent the test and saw him the following day.
"Your repeat echo was stone-cold normal," he told me. "The first one was probably just a technical error, involving where the probe was held." He brought up the images on the computer to show me the differences, and was very apologetic.
It happens. Medicine is not an exact science, and even routine tests have variability.
That night, back home, we had a celebratory dinner, butter and cheese be damned. The phone rang during the meal, and I let it go to voice mail. I listened to the message as we cleaned up, from a distant cousin.
"I got some news today, from my doctor," he said, sounding nervous. "I have prostate cancer, and I'd love to get some advice on what to do next."
I called him right back. I didn't want him to have to wait to hear from me one second longer than necessary.
Thursday, August 22, 2013
Monday, August 19, 2013
You're feeling fine when you go for your annual physical. But your mammogram looks a little funny, or your PSA test is a little high, or you get a CT lung scan and a nodule shows up. You get a biopsy, and the doctor delivers the bad news: You have cancer. Because you don't want to die, you agree to be sliced up and irradiated. Then, fortunately, you're pronounced a "cancer survivor." You're glad they caught it early.
But maybe you went through all that pain for nothing.
For decades, the reigning theory has been that the earlier a cancer is spotted and treated, the less likely it is to be lethal, because it won't have time to grow and spread. Yet this theory infers causality from correlation. It implicitly assumes that cancer is cancer is cancer, even though we now know that even in the same part of the body, cancer is many different diseases -- some aggressive, some not. Perhaps people survive early-stage cancers not because they're treated in time, but because their disease never would have become life-threatening at all.
This isn't just logical nit-picking. Thanks to widespread screening, the number of early-stage cancers identified has skyrocketed. In many instances -- including types of breast, prostate, thyroid and lung cancers -- more early diagnoses haven't led to proportionate decreases in mortality. (New drugs, not early detection, account for at least two-thirds of the reduction in breast-cancer mortality.) The cancers the tests pick up aren't necessarily life-threatening. They're just really common. So more sensitive tests and more frequent screening mean more cancer, more cancer treatment and more cancer survivors.
"We'll all be cancer survivors if we keep going at the rate that we're going," saysPeter Carroll, the chairman of the department of urology at the University of California at San Francisco and a specialist in prostate cancer.
In a well-intended effort to save lives, the emphasis on early detection is essentially looking under the lamp post: Putting many patients who don't have life-threatening diseases through traumatic treatments while distracting doctors from the bigger challenge of developing ways to identify and treat the really dangerous fast-growing cancers.
"Physicians, patients, and the general public must recognize that overdiagnosis is common and occurs more frequently with cancer screening," argues a recent JAMAarticle by the oncologists Laura J. Esserman (a surgeon and breast-cancer specialist), Ian M. Thompson Jr. (a urologist) and Brian Reid (a specialist in esophageal cancer). They argue for limiting the term "cancer" to conditions likely to be life-threatening if left untreated.
That's going to be a tough change for a lot of people to swallow. For patients and the rest of the public, getting tested offers a sense of control, encouraging an almost superstitious belief that frequent screening will ward off death. (A few years ago, when the actress Christina Applegate was making the talk-show rounds urging young women to get breast MRIs, my own oncologist told me he was getting calls from women who thought the tests would not merely detect but preventbreast cancer.)
Early detection of non-life-threatening cancers also produces a steady supply of "cancer survivors," who work to support cancer charities and make their efforts look successful. There's an entire industry devoted to celebrating "breast cancer survivors" in particular, and many women are heavily invested in that identity. It offers a heroic honorific as a reward for enduring horrible treatments. A term originally coined to remind cancer patients that their disease need not be fatal has become a badge of personal achievement.
Physicians, meanwhile, fear making a mistake. It seems safer to treat someone who doesn't really need it than to miss something potentially fatal. But, warnsEsserman, director of the Carol Franc Buck Breast Care Center at UCSF, "the cancers that grow and spread very quickly are not the ones that you can catch in time with screening." If anything, emphasizing early detection misdirects research and funding. "We have to come up with better treatments, we have to figure out who's really at risk for those and figure out how to prevent them," she says. "We're not going to fix it with screening."
There are plenty of scientific unknowns. Take the commonly diagnosed breast cancer called ductal carcinoma in situ, which accounts for about a third of new U.S. diagnoses, 60,000 a year. In these cases, the cells lining the walls of milk ducts look like cancer, but they haven't invaded the surrounding breast tissue. DCIS was a rare diagnosis before the introduction of mammograms, which are highly sensitive to milk-duct calcifications, and the JAMA article labels it a "premalignant condition" that shouldn't even be called cancer. Arguably, a lot of women who think of themselves as "breast cancer survivors" have survived treatment, not cancer.
Yet oncologists who identify DCIS have been surgically removing it (and in many cases the entire surrounding breast) for 40 years, so it's hard to know how dangerous it actually is. "Since we really don't know the true natural history of DCIS we do not know if DCIS always progresses to invasive cancer or not," says Colin Wells, a radiologist at the University of California at Los Angelesspecializing in breast imaging. "There are some reasons to think not, but this needs to be worked out" with further research. If DCIS does spread to invade breast tissue, the question remains whether that cancer threatens to go beyond the breast, becoming lethal if untreated.
By contrast, we do know that a lot of prostate cancer isn't dangerous. Autopsy studies show it's quite common in older men who die from unrelated causes. "Out there in the street, if you remove the prostates in men over the age of 50, 30 to 40 percent would have some kind of cancer," Carroll says, "most likely, low grade and low volume."
Thanks to more sensitive tests, he notes, the prostate "cancers we're detecting today are totally different than the cancers we saw two decades ago. And our ability to distinguish these tumors is much better. We have the wherewithal now to be able to tell a patient that your cancer is highly likely confined to your prostate, of small volume, slow growing, and something that may not need immediate treatment at all."
Carroll has more than 1,000 patients under "active surveillance," getting regular PSA tests, imaging and biopsies. Only about one in three turns out to need treatment within five to 10 years. (An additional 10 percent opt for surgery simply because they get tired of all the tests or can't take the anxiety.) The program is also working, Carroll says, to "decrease the burden of testing," ideally by eliminating the need for repeated biopsies.
Prostate cancer illustrates the cultural barriers to abandoning what Esserman calls today's "scorched earth policy." Despite the widespread awareness that many prostate cancers aren't life-threatening, many physicians are determined to find and treat it any time a PSA score comes in a little high. "I saw a gentleman this week who had had 12 biopsies, no cancer, and they said there must be cancer in there and they did 24," says Ian Thompson of the University of Texas Health Science Center at San Antonio, who is one of the JAMA authors.
A prostate-cancer diagnosis is still terrifying to patients and their families. Thompson describes many of his conversations with patients -- and especially with their wives -- as "talking them off the ledge." When he tells patients they're likely to be fine without immediate treatment, they often worry how they'll explain the good news to their children or neighbors. People expect a cancer diagnosis to entail trauma.
Although Carroll thinks calling slow-growing prostate tumors "cancer" is important to encourage vigilance, Thompson wants to change the nomenclature, using the term IDLE (indolent lesions of epithelial origin) to describe low-risk cases where waiting isn't likely to make a difference. Just using the word "cancer," he argues, creates unnecessary suffering.
"The number of people that will die from those slow-growing prostate cancers is really low," he says, but the unacknowledged costs of giving them a cancer diagnosis are huge: "the person who can't sleep for two weeks before his next test results, and all the follow-up biopsies and all the lost wages, and the people who can't get life insurancebecause they now have a new cancer diagnosis, the person whose firm says, 'Well, we're concerned you have cancer and therefore you can't be promoted to this job.'"
It's a compelling case, but changing the vocabulary finesses the fundamental cultural issue: the widespread and incorrect belief that "cancer" is a single condition, defined only by site in the body, rather than a broad category like "infectious disease." Someone doesn't develop "cancer" but, rather, "a cancer." How frightening that diagnosis should be depends on which one.http://mobile.bloomberg.com/news/2013-08-18/what-if-what-you-survived-wasn-t-cancer-.html