Opening the Medical Mind

“Health care’s political economy exists only for the disease. To the system, the person with the disease remains in obscurity.” —Justin Mutter, Center for Biomedical Ethics, UVA

Every profession has its sacred cows. These are ideas, policies, practices, procedures and so on that have been anointed as the Gold Standard and thereafter can’t be questioned. Most of them probably were a best practice when first adopted, but once they could no longer be questioned they simply continued to exist as-is, even though anyone outside the profession would find the so-called Gold Standard laughably obsolete.

In most professions the sacred cows tend to be fairly harmless. At worst they slow things down, make processes inefficient, add a certain fustiness to the field. In medicine, though, sacred cows kill people.

Let’s take the example of coronary artery bypass grafting, or CABG (pronounced, believe it or not, “cabbage”). As my longer-suffering readers know, I underwent a CABG procedure exactly five years ago this month, which is perhaps why it’s on my mind.

As far as we know, the first CABG procedure was performed in 1962—the patient died. But later in the 1960s the procedure was pioneered at the Cleveland Clinic, and by the mid-1970s, CABG had reached the stage where it remains to this day.

It’s true that incremental improvements have occurred. These advances have reduced death rates gradually from the downright-scary level to the there’s-a-reasonable-chance-I’ll-survive-but-probably-not-for-very-long level.

When she was in high school, my wife thought she might want to be a surgeon, like her father. So she wangled an internship at the Miami Heart Institute in 1977 and was able to observe CABG procedures being performed. When I had my CABG, four decades later, it was still the same old procedure she’d witnessed way back then.

If any other profession was still doing things today the way they were doing them four decades ago, that profession would be extinct. But surgeons are not only still doing CABGs more-or-less exactly as they did them back then, they’re doing them ever more frequently. In fact, the United States has the highest rates of CABG of all 16 OECD countries, and the rate at which the procedure is performed in the U.S. is twice as high as in many developed economies.

If CABGs were minor procedures, none of this might matter. But in fact it is one of the most barbaric surgeries ever devised by the mad mind of man.

What happens is…

Wait. If you’re in the middle of your Cheerios, you might skip the rest of this post.

What happens in a CABG procedure is, first, you are placed under general anesthesia. That in itself is no small thing, and the longer you are under, the larger the thing gets. In a multiple bypass procedure, you can be under for many hours—eight, in my case—and many bad, and a few permanently bad, misfortunes can befall you during those long hours.

Next, a breathing tube is shoved down your throat and is connected on the other end to a ventilator, which breathes for you for eight hours. Ouch, for many days afterward.

After that the surgeon makes an 8-to-10-inch incision down the center of your chest, exposing the chest bone. That incision will heal completely in, oh, 20 years or so.

The doc then takes a power saw (!) and cuts your rib cage open, spreading the ribs and clamping them open wide so he can reach in and pull your heart out of your body. Your chest muscles will protest for many months.

A procedure called hypothermic cardioplegia is then performed—that’s a fancy way of saying they stop your heart cold by bathing it in a solution containing potassium. But you don’t die…at least not immediately. That’s because you’ve been hooked up to a terrifying-looking, many-tentacled monster called a cardiopulmonary bypass machine, which sends oxygen into your blood stream.

(This terrifying machine is a perfusion pump, invented by the Nobel Prize winner, Alexis Carrel. Carrel was a Frenchman who was, you will not be surprised to learn, a Nazi collaborator.)

The surgeon next takes an artery or vein from your body to use to bypass closed or narrowed places in your cardiac arteries. If you’re lucky, you will only need one bypass, and the doc will use the left internal mammary artery as the bypass graft. If you’re unlucky like me and need six bypasses, the doc will have to use both the mammary artery and also the saphenous vein, a long vein that runs down the inside of the calf.

There are a couple of serious problems here. The first is that, while the mammary artery isn’t a cardiac artery, it’s at least an artery. If the graft is done well, the mammary artery should last a long time. The saphenous vein, however, isn’t an artery at all, it’s a vein. You’ll be lucky if it lasts five years.

The other problem is that your leg now no longer has a saphenous vein and legs are supposed to have them. Your surgeon will assure you that it will grow back, but what he means is that it would have grown back if you’d of happened to be 20 years old.

Eventually, eight hours later, all this gets reversed. You’re unhooked from the heart-lung machine and blood flow is restored to your heart. Sometimes the heart starts beating on its own, but sometimes they have to apply electric shocks to get the thing started up again.

Tubes are then inserted into your chest to drain fluid. These will be sticking out of you when you finally regain consciousness, and they hurt so bad you wish you were still unconscious. But you only thought that hurt. When they pull the damn things out by the roots, that’s when it really hurts.

The surgeon then sews up the chest he sawed open earlier, using wire. That wire stays inside you forever.

Finally, they stitch up the incision on your chest, remove the breathing tube, and send you the intensive care unit. You will be in unbearable pain and you will learn that docs are so terrified of opioids, they give you Tylenol.

My mind wasn’t working at that point, but when it began working a few days later, I invented a neat gismo that would always handle patient pain properly. This gismo is a button, and when you push it the attending doc and nurse immediately feel exactly the pain you’re feeling. Problem solved as they race for the morphine drip.

On that happy note, we’ll pause until next week, when we will try to understand why the medical profession would still be torturing people like this.

Next up: Opening the Medical Mind, Part II