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 colon, identifying lesions, taking biopsies, removing some tumors, checking for recurrence of malignancy and even using special devices to stop bleeding that, in the past, required operative intervention. They give the surgeon more information and thereby help us do our work in a more prepared and educated manner. They can visualize bile ducts and remove stones, obviating the need for most common bile duct surgery. They can place tubes in the stomach through the abdominal wall for tube feedings and are trained in giving total parenteral nutrition (TPN) to support the pre- and post-opera-tive patient who cannot take food by mouth.
The pulmonologists use bronchoscopes to examine the lungs and take biopsies, as well as managing peri and postoperative lung problems from pneumonia, to mucus plugs (mucus that gets stuck in the bronchi or tubes in the lungs, which prevents a patient from breathing adequately), and managing respirators and all pulmonary problems with the latest medications.
We have discussed infectious disease doctors and hematologists in prior chapters. Their contributions to the support team are invaluable. The oncologists manage the cancer patients. Many years ago the surgeons would manage all aspects of cancer therapy, but this is rarely the case today.
So the surgical care of a patient is a comprehensive one, and the surgeon who uses all the help at hand will be doing his patient a great service.
Chapter 29
CHEMOTHERAPY AND RADIATION THERAPY FOR CANCER
It's important that we say enough,
That cancer treatment's sometimes rough.
In this chapter I'll be brief:
It ain't all roses, but it's not all grief!
Let me make it clear at the outset: This is not a book about cancer and cancer therapy. It is about surgery. But many times the patient undergoing a surgery for cancer will have preoperative or postoperative chemotherapy or radiation therapy. I want to give you at least an introduction to what you can expect in terms of side effects and treatment of these side effects.
Their effects and complications
