Tuesday, January 7, 2020

"Time goes on crutches"

       A Man on Crutches (1878) by Edouard Manet
                    Metropolitan Museum of Art
    After a lifetime of using crutches only metaphorically, to dismiss unseemly forms of support, it was odd to suddenly lean upon a crutch in a very real and literal sense.
     Not being a very rambunctious child, I never broke my leg, so never before last week had to wrap my hands around crutches, a pair of which I was assigned when leaving Northwestern Memorial Hospital with my new metal hip.
     The education started before I was rolled out the door, crutches held firmly before me, like a battle standard. I was not to support my weight on my armpits. 
    "There are a lot of nerves in your armpits and you can damage them that way," the physical therapist said. Rather I was to brace myself with my hands. Otherwise I faced woes  common enough to earn their own names: crutch paralysis and crutch palsy. (The standard crutch is called an "axillary crutch," axilla being the technical name for your armpit. Good Scrabble word).
     Forearm crutches, considered more ergonomically sound, are more popular in Europe than here, where they've never caught on. 
Terracotta amphora, 480–460 B.C. (Metropolitan Museum)
     I found crutches easy to get around with, even on our many flights of stairs, when I transfer them to my free hand: one hand on the rail, the other holding the crutches as a kind of double-staff.
     Then yesterday, time on my hands, I considered the word "crutch," and played the game where I try to guess its derivation. Old, obviously, related to "crotch," no doubt, denoting the Y shape. Close. A thousand years old, spread through Old- and Middle-English, plus other Germanic languages—in Dutch it's kruk—the word is closer to "crook," as in shepherd's crook, and denotes bentness.  Through most of history a crutch was a Y-shaped stick.
      The first definition in my 1970s Oxford English Dictionary would never fly today: "1. A staff for a lame or infirm person to lean upon in walking." Setting aside the odd "in walking" usage—wouldn't "when walking" be better?—I figure "lame" must have gone by the wayside. And indeed, the online Webster's elevates crutch users to "the disabled." (Nothing like the definite article to denote official societal pity: "the disabled." "The homeless." I guess I should be grateful we aren't at "The journalists.")
     The OED has crutch as a verb, a form I never considered. "Up and down ... the various steps ... do we delight to crutch it," reads an 1828 reference. 
Crutches were used in Ancient Egypt
      The symbolic crutch starts cooking about 400 years ago. Crutch as code for age is all over Shakespeare. When old Capulet, in his dressing gown, comes upon a disturbance in the streets of Verona in the first scene of "Romeo and Juliet," he calls for his long sword, but his wife immediately shuts that down, saying, "A crutch, a crutch! why call you for a sword?" Thanks dear. 
    Although, to be fair, "crutch" is not always a negative in Shakespeare.
    "Lay hold upon him Priam, hold him fast," Cassandra urges in "Troilus and Cressida." "He is thy crutch, now if thou loose thy stay." 
    Crutch can also be a metaphorical verb, as in Dryden:  "Two fools that crutch their feeble sense on verse."
     I've leaned on "crutch" a few times myself.   In 2008, when John McCain was running for president, and brushed aside questions about how many homes he owns with a lofty reference to his North Vietnamese captivity, I wrote:
     "To say that, as a hero, he can put his heroism to work any way he pleases misses a crucial point: McCain is not the only hero. What about all the other men and women who served and suffered, proud individuals who face their daily challenges and do not whip out their heroism as a Get-Out-of-Jail-Free card to blow off whatever mess they've created? Who don't cite their service when getting a traffic ticket? Doesn't McCain owe a duty to THEM, to wear his record with the grace and honor it deserves, and not transform it into a cheap political tool, already being mocked as 'a crutch' and 'the POW card.'

         Le Grand Opéra(1821) by Eugène Delacroix
     Crutches are one of those interesting devices that are blandly accepted in actuality—nobody snickers at you for using crutches—but distinctly negative as metaphor, a situation not found in other dual purpose words like "bandage" or "medicine." Using a crutch is never a good thing unless there's something wrong with your leg.
    The handsome aluminum pair I received were McKesson crutches, by the way, and if the name means nothing to you, don't feel bad, it meant nothing to me either. A sure sign of just how under-the-radar the enormous medical establishment really is.  With revenues of $208 billion, McKesson is No. 7 on the Fortune 500, down from No. 6 last year. Four of the top 10 companies on the Forbes list are in the healthcare industry, a reminder of exactly why Americans don't have national health care and probably never will: because it is very, very profitable that we don't.

Monday, January 6, 2020

No shortage of Iranian cultural sites for Trump to blow up

Nasir al-Mulk Mosque
    When President Trump said Saturday that the United States had targeted 52 important Iranian cultural sites—52 being the number of American diplomats taken hostage when the American embassy was seized in 1979—the sheer callous brutality of the threat cut through the recuperatory fog and caught my attention.
     If Iran reacts to our assassinating Maj. Gen. Qasem Soleimani Friday, they can expect national treasures at “a very high level & important to Iran & the Iranian culture” will be destroyed, Trump tweeted. “Those targets, and Iran itself, WILL BE HIT VERY FAST AND VERY HARD. The USA wants no more threats!”
     Threats like the one Trump was at that moment delivering, hypocrisy being one of our president's superpowers. Another being a constant ability to amaze. Really, you think you must be in the basement now, and an entire necropolis of baseness and loathsomeness opens up beneath your feet.
     It isn't that the United States is incapable of taking vengeance on cultural gems. The medieval Saxon city of Dresden, which survived most of World War II generally intact, was fire-bombed by the Allies in February, 1945, three months before the end of the European war, with a loss of 100,000 lives, not for any particular military purpose—though there were factories and rail hubs—but, it was believed, as a blow to German morale and as general payback for starting the war.
     But such acts are considered war crimes now, exactly because they were done in the past. Trump of course is utterly ignorant of such things, and stuck by his threats, using Iranian brutality as America's new moral compass.
     “They’re allowed to kill our people," Trump told reporters Sunday. "They’re allowed to torture and maim our people. They’re allowed to use roadside bombs and blow up our people. And we’re not allowed to touch their cultural sites? It doesn’t work that way.”

     The whine is a perfect example of what I call "terrorism envy:" "Awww, c'mon! They get to cut people's heads off! Why can't I? It's not fairrrrrrrr!" 
     Perhaps because the assumption that such threats are Trump's typical empty bluster and lies, I didn't notice anybody in the media pause to wonder precisely which cultural sites are in the crosshairs should Trump break precedent and actually follow through on something he insists he will do.  And what's the actual process for this? Did he assign some colonel to come up with 52 candidates?  And did that cringing underling then start pawing through old Rick Steves guides to Iran, looking for cultural destinations to demolish?

     If so, it wasn't a very difficult assignment. There are quite a lot to choose from.
   The ruins of the 2500-year-old city of Persepolis come immediately to mind. The ceremonial capital of the Achaemenid Empire is one of 24 UNESCO World Heritage sites in Iran, and a reminder that it has hosted civilization back nearly 10,000 years, to the Assyrian and Mesopotamian empires. It wouldn't take too many cruise missiles to level those old stones. 

     Iran has dozens of museums, including museums focusing on electricity, music, and carpet. It also has a peace museum, whose eradication would be one of those gaslighty touches that Trump sometimes revels in.
     My guess is that Trump isn't thinking—to stretch the term—about blowing up ruins, or museums, but in his ganglional clump of a mind, "cultural" is a code word for "religious." There are hundreds of significant mosques in Iran, some of surpassing beauty, such as the Nasir al-Mulk Mosque in Shiraz, shown at the top of today's post. I picked it for its sheer loveliness, rather than any deep history. It was built in 1876, at the height of that country's embrace of the West, and it would be ironic if it got one of Trump's missiles, which is another form of Western influence, I suppose.  
      There are also many shrines, like the 1100-year-old shrine of Imam Reza in Mashhad, conveniently close to the border with Afghanistan. 
     A man of Trump's intellect should not be underestimated. There is no reason why destruction of Iranian cultural sites need be limited to Iran, whose legacy has spread across the globe. 
     The University of Chicago's Oriental Institute, for example, has a gorgeous human-headed winged bull from the court of Sargon II.  No need for a difficult air attack launching expensive ordinance: Trump could dispatch a few federalized Illinois National Guardsmen with sledge hammers to break the thing up, or use dynamite, like the Taliban blowing up the Bamyan buddhas. The destruction could also be a blow against another perennial enemy, the City of Chicago. Extreme? Sure. But if terrorists get to do it, why not us? 

Sunday, January 5, 2020

Surgical Notes #5—2010: Loyola anatomy lab illustrates shortage of medical cadavers

Torso of a Male Cadaver, by Eugène Delacroix
(Metropolitan Museum of Art)
     Six days post-surgery, and I'm doing ... fine. Not too much pain, getting around the house on crutches, haven't gotten the okay to go outside yet. The physical therapist has been here twice, to stretch the new hip. I'm doing my exercises, sort of. I've mused on starting up writing on current topics—the Trump administration seems to have started a war with Iran, for instance, and is now threatening to attack Iranian "cultural," aka religious, sites. 
     But you don't need me to trill "Woe!" over that, or whip out a felt board and laboriously explain Why This is Bad. You get it.
    The bottom line is, I'm in an odd, rare, twilight, I-don't-feel-like-writing-anything-right-now-thank-you state. Must be the meds, which I've already begun to dial back, though I understand their connection with the thing not hurting too much. The bandage covering the incision—and this I did not expect—is nine and a half inches long. Check a ruler if you have trouble envisioning just how long that is. The bandage comes off Monday, and I can't say I'm eager to see what's underneath. But this is all about moving forward, gingerly. Anyway, I might try a stab at something new Monday. So one final day of the end of my visit to Stritch, which started yesterday. Thank you for your patience. If your comment did not get posted last evening, I may have accidentally deleted one that I meant to post, so please re-submit. It wasn't a conscious rejection. 

     The rope is a surprise.
     In the hour that Dr. Frederick Wezeman spent preparing first-year students at Loyola University's Stritch School of Medicine for what to expect in gross anatomy when they cut into their first patient—a medical cadaver—many issues were covered, from the importance of not wearing open-toed shoes (scalpels can fall) to the need to wear latex gloves (embalming fluid can irritate the skin) to the value of working as a team.
     He didn't mention the rough brown rope tied tightly around each corpse's chest.
     "Let's lift him up a bit," says a first year, feeling along the rope. "It's a sailor's knot."
     At each of the 20 stations, students introduce themselves to one another and cope with the ropes used to move the cadavers. The rope leaves a deep impression in skin already flattened from the bodies lying on their backs, as tissues lose pliability after death.
     "That's crazy," says Steve Zuniga. "I didn't know they get flat like that."
     Today's task for 150 students is to expose the trapezius—a large muscle in the back, named for its trapezoidal shape. The reason students start there, as opposed to any of the other 640 muscles in a human body, is that it is large and thus hard to miss or ruin.
     They position the bodies using sections of wood beam—worn, blackened blocks that seem at odds with the medical setting.

The 1885 Illinois Cadaver Act allows it

     David Neubauer consults a big red Gray's anatomy atlas, then returns to the body.
     "This is the sacrum," he says, cutting along the spine from the nape of the neck to the small of the back, exposing a layer of yellow fat under the skin.
     How did the group pick him to go first?
     "I had the scalpel first," he says.
     I wanted to be here under the assumption that students dissecting for the first time would find it difficult. But while some admitted to nerves in Wednesday's column, there was no sign of emotion in the room. I never saw a student so much as wince.
     "We jumped in," said Anthony Rutkowski.
     Dr. Wezeman, the course director and professor who has been teaching at Loyola for 30 years, says students today are far less squeamish than students in the past.
     "They're ready for it," he says. "They're exposed to blood and guts much more than when I was growing up. When you watch TV you see a lot of medical things that are pretty graphic, so they're not as shocked when they come into a cadaver room."
     Though TV can't explain it all, as students leap to tasks not seen on prime time.
     Issra Rashed, 21, wordlessly takes a paper towel and removes some waste left behind when a cadaver was inadequately washed.
     "Didn't want us all looking at it," she says.
     The cadavers cost $1,500 and come from the Anatomical Gift Association of Illinois.
     Loyola students must crowd eight to a body, in two teams of four, as they work because cadaver donations have been falling.
     "Quite a bit," says Paul Dudek, executive vice president of the association. "Twenty-five years ago we had 700 to 800 donations. So far this year, we've had about 330."
     Dudek blames the growing popularity of cremation and pre-need funeral packages. Driver's licenses also once had a box allowing you to donate your body to science
     "That for some reason was dropped," says Dudek, adding that he could easily place twice as many cadavers as he receives — he gets requests from as far away as England and the Caribbean — but that the supply bottleneck might finally be dissolving.
     "The 1885 Illinois Cadaver Act allows medical schools to request individuals buried at public expense," he says. The association has recently worked out an agreement with the Cook County medical examiner's office and the County Board so that some of the county's 500 yearly unclaimed bodies of indigents can be sent to them. Prisons might be another source.
     "We're pretty excited about it," he says, using an adjective that might sound odd, until you realize the joy of learning involved.
     Watching the first-year students work is Oma Lawrence, 26, a fourth-year from Hawaii.
     "They'll all go home today and reflect," she says. "I remember my first cadaver — a lady. I can actually still picture her nerves. You can't help but be a little queasy."
     Or maybe not. A few days later, I speak with Emily Zepeda — a doctor's daughter from St. Charles who had enthused, "I can't believe I get to learn this!"
     "Today was amazing," she says, describing how midweek the students took turns using a bone saw to expose the spinal cord.
     "I was a little scared, at first," she says, of handling the Stryker saw. "But it truly was like getting to see a treasure."

     —Originally published in the Sun-Times, October 22, 2010 

Saturday, January 4, 2020

Surgical notes #4—2010: Anatomy students meet their first patient

De humani corporis fabrica (Of the Structure of the Human Body) by Andreas Vesalius
   (Metropolitan Museum of Art)
     You don't always come into a story at the beginning. When I first visited gross pathology lab at Loyola University's Stritch School of Medicine, it was December, 2009—the end of term. I was pleased with the column, posted here last yearbut wanted to see students at the beginning of the semester, when they first met their cadavers. So I returned the following October and produced today's and tomorrow's columns. 
     I give myself credit for going back, because seeing the flayed apart heads—think onion blooms—mentioned in that first column, lingered with me, and not in a good way. I remember, one night shortly after doing the research, in bed, staring up into the darkness thinking, "It's bad enough to have trouble sleeping, but do I also have to be awake and see the FACES OF THE DEAD?!?"
     Not to complain. These columns were my idea. Part of being a professional is, you gird your loins and do the task in front of you. Which has been helpful, post-surgery, such as every morning when I have to inject myself in the stomach with a hypodermic of anti-coagulant, to ward off blood clots and strokes. Do I like it? No. But I do it, before breakfast, to make sure I get it out of the way. 
    Anyway, I hope you enjoy these columns from a decade ago, and appreciate your patience while I convalesce. 

      It isn't as if Emily Zepeda, Hannah Johnson and Lisa Moore have never seen a dead body before. They have.
     "When I interviewed here, they took me around," says Moore, 23, as the others nod.
      Still, the women are nervous. "First-day jitters all over again," Moore says.
     "You do hear stories," says Johnson, 22, "about people who have to step out of the room to avoid fainting."
     "The room" is gross anatomy lab at Loyola University's Stritch School of Medicine. Every October, each first-year medical student goes from being someone who wants to become a doctor, who may have volunteered at a hospital or gone overseas on a medical mission, to someone who can take a scalpel and peel back the skin on a corpse.
     "This is unlike anything we've ever done before," said Johnson. "Some of us have taken some form of anatomy class in undergrad. But this is completely different."
     "This is anatomy," said Zepeda. "This is what every medical student has been doing since the beginning."
    But first, a steeply sloped lecture hall, lights dimmed, a setting straight out of a Dutch engraving, where students sit in 11 tiers. On the screen: "Human Gross Anatomy, Structures of the Human Body."
     "Good morning and welcome," says Dr. Frederick Wezeman, professor of orthopedic surgery and the classic grey-haired, white-coated image of what a doctor should look like. "We have a very full day for you."
     He crosses his arms, gazing at the room.
     "So what are we going to do?" says Dr. Wezeman. "We're going to be doing a lot of identification, of locations and relationships. You have to know your anatomy. What you learn might seem tedious and detailed to the point of 'Why do I have to know that?' Yes, you do have to know that."
     Almost every student has a laptop, some are already studying charts of skeletal and nerve systems. One is on Facebook.
     "We're going to teach you to speak a new language here," Dr. Wezeman says. "You're going to be talking anatomy. Obviously, dissection is very, very important. Lectures are important, you are paying $42,000 in tuition and you want to be able to learn in different modalities."
     He leads the students through the practical considerations of cutting up a body: wear gloves, no cameras, no souvenirs.
     "You can't take anything out to scare someone at Halloween," he says.
     Students must keep their cadavers moist.
     "If it dries out, you'll have to tag dried-out structures," he says.
     The cadavers are not idealized human bodies, but unique, real individuals.
     "Not all cadavers are normal," he says. "We will encounter a lot of surgical intervention, you will encounter pathologies, you'll encounter situations that you're going to scratch your head about. But they're wonderful learning tools. . . . All the things that normally occur in populations. They're going to be downstairs.
     "Some of them are obese. That's going to create an additional challenge. Be aware. Turning a cadaver over is a team effort. We don't want cadavers falling on the ground."
     Dr. Wezeman reviews the muscle system in the back where the students will first cut.
     There is a brief ceremony—three students come to the front of the lecture hall and speak eloquently to the former owners of the bodies waiting for them downstairs, describing the hands that caressed new babies, the lips that smiled and kissed.
     "These are not merely bodies, they have become our teachers," one student says.
     Then the students head downstairs, to change into scrubs, and enter a very bright white room where 22 body-sized white plastic bags are waiting on tables. There is another ceremony—the students bow their heads, fold their purple-gloved hands in front of themselves, praying.
     If Loyola seems to go overboard thanking the cadavers and stressing respect, remember there is a long, ghoulish history to gross anatomy that includes both grave-robbing and comic photographs of cadavers taken by medical students in the first half of the 20th century. That mind-set is long gone, and Loyola intends to keep it that way.
     The prayers done, the room shifts into commotion as students collect forceps and hemostats from large white buckets that once held Schwartz's premium pickles and take their positions around their cadavers.
     Emily Zepeda happens to be by the zipper, open to reveal a curled foot of indescribable color—a deathly greenish white with yellow toenails, arched at an unnatural angle. She reaches for the zipper and pulls.

      Postscript: Dr. Emily Zepeda is a pediatric ophthalmologist in Oklahoma City. Dr. Lisa Moore is in family practice in Glenview. I couldn't find any information on Hannah Johnson. 
    Part one of two parts.  To read Part 2, click here.

              —Originally published in the Sun-Times Oct. 20, 2010

Friday, January 3, 2020

Surgical notes #3: 2001—Chicago surgeon tries to do his part

     This is the sidebar to the piece on orthopedic surgery in Lithuania posted yesterday: what happened after Dr. Lubicky finished operating. For some odd reason, I didn't mention the goal of our late-night outing: a bust of Frank Zappa, incongruously situated in Vilnius, that Dr. Lubicky wanted to see.  Dr. Lubicky still practices, as a pediatric orthopedic surgeon in West Virginia. 

Dr. John Lubicky
     VILNIUS, Lithuania After three hours of difficult surgery, Dr. John Lubicky strips off his latex gloves and leaves the operating room as if it were on fire.
      "What a job!" someone says. 
     But the Chicago surgeon is already gone. In a moment, he has washed up, changed into coat and tie and is striding down the dim halls of Children's Hospital here in that rapid gait particular to Olympic speed-walkers and great surgeons. Doctors scramble after Lubicky. Those who hesitate are left behind as he sweeps into an examination area. 
     Children already are waiting for him—they have been for hours, in wheelchairs, in braces, wearing their church clothes, their parents hovering grimly behind them. Ten minutes after surgery, Lubicky is shuttling between two small examining rooms. He sees a frightened, cross-eyed girl in pigtails and a boy in a wheelchair, his eyes rimmed in red. As soon as he finishes in one room, he heads to the other. 
     He flexes a leg, tilts an ankle, then gives the news, which is often grim. He urges an interpreting doctor not to sugar-coat his translation to a worried mother of a 14-year-old who broke his neck. "She has to know it's unlikely anything will improve," he says. The mother of a 9-year-old with acute meningitis wants to know if he might ever walk. Lubicky shakes his head. "No."
     The exchanges seem brusque. But Lubicky has found truth is often in short supply in the Lithuanian medical system. "Their doctors don't always tell them," he says. "They need to know the situation so they can come to terms with it." He finishes with the last child of the day. "Is that it?" Lubicky asks, and he's off again. Lubicky is handed some pictures done in amber, gifts from a grateful patient, one of many. "Do you know how many books on Lithuania I have?" he asks, in an aside, stashing them. 
Frank Zappa bust, Vilnius
      Lubicky doesn't do what he does here for the gratitude. He's not doing it out of cultural pride, either—he isn't Lithuanian. Foreign travel holds no appeal—he rarely goes to see the local sights, other than a ritual late-evening quick-step through the dark streets of Vilnius, his colleagues traipsing after him. So why does he do it? 
     "He feels it's a privilege to care for people, not a privilege for them to come to you," says Liana Chotikul, a surgical nurse from Baltimore who is working with him. But why so dedicated? Even his closest associates can only guess. "I think he's very religious," says Norene Jamieson. 
     While he speaks of wanting to scale back, to think more of himself and his own family, Lubicky can't ignore the needs here in Lithuania. The trips will continue, he says, as long as there's a need, the sort of need he saw on his first visit, in 1993. "A continuous line of children," he remembers. "They didn't even have a place for people to sit. They just stood there all day, lining up on the sidewalk, waiting to get in."
     —Originally published in the Sun-Times, March 20, 2001

Thursday, January 2, 2020

Surgical notes #2—2001: Devoted doctors making a difference

Watching orthopedic surgery, Vilnius, Lithuania, 2001 (Photo by Robert A. Davis)

      I'm home and on the mend after my hip replacement Monday. But I'm giving myself a few days to get settled before I have to scrape together a coherent thought. In the meantime, I'm running some surgical stories from the past. I appreciate your indulgence.

     VILNIUS, Lithuania—The walls of the main operating room at the National University Children's Hospital here are covered with pale green bathroom tile—the same tile, it turns out, found in prisoners' showers in the old KGB prison not far away.
     The tile is old and cracked in places. Inside the walls, the heating pipes can't be regulated, so the operating room is warm, uncomfortably so. Sweating doctors flee from time to time to the coolness of the bleak corridors.
     A hot operating room isn't the only telltale sign you're not in an American hospital. Medical waste is tossed out with the trash. There is little disposable equipment. Food for patients is scooped out of chipped enamel pots trundled on a cart down the hall. The air in the operating room isn't filtered. Instead, the exhaust pipe from the anesthesia machine is merely jammed in a nearby air intake, and whatever is in the patient's lungs is pumped directly into the hospital's ventilation system.
     On the operating table is a 13-year-old Lithuanian girl. Her eyes are taped shut, and she has two red clips in her hair.
     She has a vertical talus—a congenital deformity of her left foot that would have been corrected when she was an infant if she had been born in the United States. But, living in Lithuania, the problem was never fixed, leaving her foot drawn back, toes tightly clenched, nearly touching her shin.
     She can't walk and can't wear a shoe on that foot. After the operation, she should be able to do both.
     The surgeon's hands move with balletic grace, manipulating bones this way and that. He inserts long pins to hold the bones in place and fuses useless joints into useful positions.
     Two hours into the operation, the question arises of how to close the incision because, with the patient's toes properly aligned, there isn't enough skin. The doctor attempts a new procedure—cutting skin from the lower leg, freeing it from the tissue beneath and letting it stretch more easily. The technique is so new it was only just described in the January Journal of Pediatric Orthopedic Surgery, in an article by a noted Chicago surgeon, Dr. John P. Lubicky, chief of staff at Shriners Hospitals for Children.
     Trying it might be reckless for the average doctor in Lithuania. But, in this case, the man holding the scalpel is Dr. John Lubicky.
     "He's the best surgeon I've ever worked with," says Dr. Greg Brebach, an orthopedic surgeon at Rush-Presbyterian-St. Luke's Medical Center.
      Brebach is one of a dozen doctors, residents and nurses Lubicky has brought to Lithuania on this, his 10th, visit as part of an extraordinary humanitarian effort that aims to do no less than help a nation's medical system leap 50 years into the future—or, more aptly, leap 50 years into the present.
     Lubicky made the first trip by himself, in 1993.
     "The Russians were still there, and they left their medical system," says Lubicky. "The hospital was dirty and smelly. Everything was broken and in bad shape. Every case was a failure, practically. There were lots of conditions we don't see here—poor neonatal care, lots of bone and joint infections in newborn and young children, and probably some effect from Chernobyl in terms of congenital defects."
     Norene Jamieson, the nurse manager of surgery at Shriners, is on her ninth trip with Lubicky. She remembers the first trip well. Jamieson brought lots of equipment, but not the special brushes and antibacterial soap used in the United States. She figured they would wash in whatever the Lithuanian manner was, not realizing just how backward the system was.
     "You had to scrub with lye soap for four minutes, then dip your arms in formic acid for three minutes," she says. "They sterilized the formic acid each morning by setting it on fire. My arms were all welted and blistered."
     Jamieson never left the antibacterial soap behind again. She organizes the yearly trips, in addition to her own trips to Colombia with a team of plastic surgeons. It is a major logistical challenge.
     "I solicit people all year long for donations for trips we sponsor," she says.
     This year, the team brought 39 cases of medical equipment, worth $300,000, and left it all behind for the Lithuanians to keep. Included was an $80,000 set of state-of-the-art Moss-Miami tools for spinal surgery.
     "A drop for American medicine," marveled Dr. Jurgita Januskyte, a Lithuanian surgeon. "But, for us, it's expensive."
     The American doctors and nurses flew in the previous Saturday, dropped their bags at the hotel, then went to the hospital. Before the week was out, they would examine 176 children and perform 19 surgeries. That might not seem like a lot, until you realize that the procedure to correct a scoliotic spine—one of the operations they performed—can take 12 hours.
      This is the last surgery of the week. The next day will be spent giving seminars on things such as how those new Moss-Miami tools should be used. Fifty doctors come from all parts of Lithuania to hear Lubicky speak.
     "We never thought our role was to come over here and do a lot of cases," says Lubicky. "Our role was to make them self-sufficient, and I believe that has happened, to a certain extent. They know what to do."
     Some of the Lithuanian doctors use their annual vacation to observe the Americans. They give credit to Lubicky—who last year was decorated by Lithuanian President Valdas Adamkus for his work here—for playing a key role.
     "Dr. Lubicky has changed children's orthopedic surgery in Lithuania," says Dr. Kastutus Saneukas, head of children's orthopedics at the hospital. "We get new techniques, new experience, news, the latest books, journals, education. He changes minds every time he comes."
     The medical personnel on Lubicky's team also speak of the experience in glowing, reverent terms, particularly the residents. "This is what we went to medical school for," says Brebach, who is on his first trip.
     "It gives them an idea how orthopedics are practiced in another country," says Jamieson. "It also opens their eyes to the needs of people in other countries. Maybe when they're finished with their residency and out on their own, they will devote time to helping in other countries. There's a tremendous need."

      —Originally published in the Sun-Times, March 20, 2001

Wednesday, January 1, 2020

Surgical notes #1—1988: A new heart beats the odds

Saint Catherine of Siena Exchanging Her Heart with Christ
by Giovanni di Paolo (Metropolitan Museum of Art)

     Happy New Year! 
     One rule of mine is not to dwell too long on any topic. So having written four columns on spine surgery in July, and a big sleep apnea piece earlier this month, the prudent strategy would be to avoid first person accounts of medical procedures for a while. 
      But the spine surgery series did really well—Apple News picked it up—and my boss barked, "Steinberg! Can't you get your hip replaced or something?" 
     Well, okay chief, if you insist...
     Kidding.  He didn't say that. What happened is, my professional discretion might have said one thing, but my body had other ideas. The right hip has been deteriorating for years; some days it felt like somebody has jammed a pine cone in there. I've been using a cane for three months. Lately it has been getting even worse. So I went under the knife at Northwestern Monday. Nothing as complicated as the summertime laminoplasty. Just a quick hip replacement, which I'm told is a very simple, routine procedure nowadays. I should be home Tuesday afternoon.
     I will write about it, eventually. Over 300,000 Americans had hip replacement surgeries last year, so it's not as if this is some esoteric topic.
     Still, I want to give myself a few days to let the drugs wear off, the cobwebs clear and to learn how to sit again. I've written about a good many surgeries over the years, and thought I would share a few while waiting for Mother Nature to sign off on my recovery. How long? We'll see. This story was a favorite of mine. I can still see myself flipping through two notebooks, seeing the scribbled words "baby chick" and wondering: why did I write that?

     Dr. Bryan Foy gently scoops up the human heart and holds it, as he would a newborn chick, with one hand cupped underneath, one hand over the top.
     It is 1:24 a.m. at Illinois Masonic Medical Center, 836 W. Wellington. Foy turns, takes a step, and places the heart in a metal bowl of frozen slush. Taking a pair of long tweezers, he peers into the various orifices of the heart. It looks good.
     Meanwhile, at Loyola University Medical Center in Maywood, other surgeons are waiting to remove the Jarvik-7 artificial heart that has kept Peter Reali, a 55-year-old machinery repairman from Brookfield, alive for the past 34 days.
     Loyola receives a phone call from the operating room at Illinois Masonic. The donor heart is out. Foy and the transplant team are heading for the helicopter and the seven-minute trip back to Loyola.
     Heart transplants, once rare and experimental, are becoming more common. When Loyola began transplanting hearts in the spring of 1984, there were 14 transplant centers in the country. Now there are more than 100, including seven in Illinois. Loyola has given hearts to more than 120 people—100 of whom are still alive.
     One of them is Peter Reali, who had never been in a hospital when he had his heart attack last April. Two weeks later, his heart stopped four times, to be restarted by electric shock. Doctors decided his heart was about to give out, and placed him on the Jarvik until a donor heart could be found.
     During tense weeks of waiting, the irony that his life could only be saved by someone else's accidental death was not lost on Reali.
     "It don't seem right, waiting for somebody to die," he said, the Jarvik ticking loudly at the foot of his bed. "But you still want to live. There's no other way to do it. You can't go to a used heart store."
     Hopes were high around Memorial Day. Most heart donors come from trauma victims; motorcycle accidents are so frequently a source of donated hearts that doctors dub them "donorcycles."
     On May 31, an ex-con was shot in the head and taken to Illinois Masonic, where he was pronounced brain dead. His family agreed to donate his organs.
     Two other heart patients in the state besides Reali had blood types and body sizes that made them eligible for the heart. Their doctors conferred, and Dr. Roque Pifarre, the chairman of the department of cardiovascular surgery at Loyola, convinced them the heart should go to Reali.
     An hour before the transplant is to begin, the Loyola surgical team assembles at Loyola: surgeon Foy; Ravi Kamath, his assistant; Kathleen Siebold, procurement coordinator, and Hazem Tillawi, a profusionist (person who floods the donor heart with cold fluids to keep it viable). Together, they wait for a helicopter to take them to Illinois Masonic to pick up the heart.
     To cover their apprehension, the team members joke among them selves. Foy speculates on the possible effect that the heart of a felon might have on Reali.
     "If Mr. Reali wakes up and has an irresistible desire to steal objects and carry a baseball bat, we'll know why," he says.
     At 11:39 p.m., a Long Ranger II helicopter looms from the east, a cluster of multicolored lights against a black sky. The group moves quickly to the chopper and climbs in for the quick ride to a landing zone near the hospital.
     At precisely midnight, they enter a large surgical theater, brimming with shining instruments. In the center, stretched out on a table, is the gunshot victim, both arms straight out. His chest heaves up and down as the respirator breathes for him. Someone covers his face with a towel.
     His chest is scrubbed with a yellow antiseptic and a thin plastic film placed over it. At 12:18 a.m., Foy takes a small electric saw and cuts into the chest. The air is filled with the smell of burning flesh.
     While another team digs into the glistening intestines, isolating the kidneys, Foy carefully cuts the connective tissue around the heart, until it is isolated, a beige and purplish muscle the size of a fist, beating furiously.
     The pace picks up as both teams prepare to remove the heart and kidneys. At one point, eight pairs of hands are frantically working inside the chest.
     At 1:20, the heart is stopped, the aorta clamps off and Foy makes the final cuts to remove the heart. The kidneys are close behind.
     After checking the heart, Foy places it in the freezing saline solution and seals it in a round Tupperware container. The container is placed in a red and white Igloo Playmate cooler, and the team hurries back to the helicopter.
     Tillawi carries the heart, never losing contact with it. When changing his scrub suit, he keeps his foot pressed against the cooler side, like a baseball player leading off from a base. There is no joking now, just silent concentration of the unfinished business ahead.
     By the time the team returns to Loyola, the head of the cardiac unit, Pifarre, assisted by Dr. Henry Sullivan and cardiologist Dr. Mark Zucker, have removed the Jarvik. It sits on a table, looking very much like the tail light assembly from an old Buick. Reali is kept alive on a heart-lung machine, which circulates and oxygenates his blood.
     By 2:17 a.m., the donor heart is placed in Reali. Sullivan and Pifarre settle down to the task of hooking it up.
     Using pink thread and a tiny, curved needle, Sullivan attaches the loose arteries, a task that requires amazing dexterity because he holds the needle and thread with long tongs.
     "That's a nice fit," he says.
     At 2:24 a.m., more icy saline slush is poured over the heart, using a tool resembling a turkey baster. Ten minutes later, Sullivan looks up, gives a half-sigh, half-groan, and returns to work. It is the greatest display of fatigue or emotion any of the five surgeons display throughout the six-hour operation.
     Fourteen people hurry about the crowded operating room. A medical photographer snaps pictures. The blood suctioned out of Reali is "cleaned," impurities removed using a centerfuge, then put back into Reali. About 40 percent of his blood can be recovered this way.
     A sign of just how routine heart transplants are comes shortly after 3 a.m., when Sullivan jolts the new heart with a pair of small electric paddles.
     There is no commotion, no cheering. Just a pause as everyone in the room looks up at the crazy jumping of purple and green lines on the heart monitor hanging from the ceiling. The heart is alive and beating, after a fashion. The heart machine still continues to do most of the work, to reduce the strain on the heart. The work of the lungs is still done by a device resembling an oversized blender.
     For the next two hours, Pifarre stands over the heart, watching it, changing the level of fluids to alter blood pressure, reducing the work done by the heart machine, occasionally poking an inquisitive finger against the heart.
     "The heart is starting to take over on its own a bit," says Michael Wallock, a profusionist. "There's some nice ejection now."
     Ten minutes later there is trouble: irregular heartbeats. Pifarre looks for bleeding in the new sutures, and Zucker stares into the open chest, his hands on his hips, like a golfer considering a putt.
     At 4:05 a.m. the heart machine is shut down. The heart is beating on its own. At 4:16, nurse Elissa Bailey leans on a table and momentarily dozes, then snaps her attention back on the operation. A little before 5 a.m., Pifarre goes to tell Reali's wife, Dorothy, how the operation is going. Orderlies begin cleaning up the operating room. Three large hampers are filled with garbage—wrappers, towels, empty supply packages, gauze.
     At 5:10, the geared chest spreader is taken off. "Do you have a sterile peanut butter and jelly sandwich back there?" Foy asks, as he scrapes the chest bone in preparation for closing the chest.
     Heavy steel wires are threaded into the sides of the chest. Pifarre and Foy pull hard on the thick wire to draw both sides of the rib cage together.
     "He seems to tolerate it well," Pifarre says.
     "There was a little drop," Foy says, looking at the blood pressure monitor. "But nothing sustained or dramatic."
     The wire is bent and twisted along a 12-inch incision, then snipped off with wire cutters. The skin is closed, using surgical staples. Just after 6 a.m., the blue paper coverings are torn away from Reali, and he becomes a person again instead of just a draped chest.
     "Well, here's Peter," Pifarre announces, pulling open Reali's eyelid.
     "OK buddy, don't give up," Foy says. "Whatever you do. Not now."
     Reali is rolled to his room at 6:20 a.m., the surgeons accompanying him, supervising the tangle of tubes and wires.
     The next morning he is brought out of the anesthesia; his first thoughts are that he doesn't hear the Jarvik ticking, which he interprets to mean that either the transplant worked or he is in heaven.
     "I looked down there, and there was no machine powering me," he says, recalling the moment. "It was nice."
     Two weeks later, Peter Reali walks out of the hospital, with his wife and family. He returns weekly, to check for signs of rejection - the body's immune system battling the foreign heart tissue—a major obstacle in heart transplants. But, for now, Reali is doing well and is optimistic.
     "I feel good," he says. "Being home feels good. I go for walks; it's beautiful. My knees are a little mushy, but I go just a little bit farther every day. In a way, I'm glad it happened. It's something I won't forget."

      —Originally published in the Sun-Times, July 17, 1988