Sunday, October 22, 2006

Reviews and Reader Comments About the Book (If gushing praise annoys you, skip to the exerpts, which follow below)

"...Buy this book.

More accessible than Oliver Sacks, funnier by far than Atul Gawande, totally devoid of snarky ego, and a fascinating insight into how surgeons are made and how they evolve. Buy this book. Read it. If you work with surgeons, read it again. Stick little bits of torn-up paper in between the pages you find particularly interesting, as I did. Keep it by the bedside.

I once reviewed a book here and had hellish trouble finding anything nice to say about it. I am now having hellish trouble not fawning over Cutting Remarks. Sid neither suggested I review this book, neither did he send me boxes full of cheese curds and poutine gravy. I'm doing it on my own.

Verdict: Buy the damned book already. If we're lucky, he'll write another one." Head Nurse Blog

"Great book! You made me laugh out loud about a dozen times. And when you left the County for the last time, you made me cry. Most importantly, you really, really, really let me know what being a surgeon is all about. I think the book is unique, probably a classic" R.S., Superior Court Judge, Sacramento, CA

"I like the terseness of your writing style and the humor that seeps out inunexpected places. I like the pace you set throughout the book - never going overly long on any subject but always saying enough to paint each section vividly. I like the way you speak to readers as equals - not "dumbing down" medical procedures or terms to the level of some television series. If I needed more info, I think you assumed I'd pull out a relevant reference and find it. I like that. I also liked the fact that when I was finished, I wished there was more to read. Lord, how I hate trudging through some novel all while constantly checking how many more pages there are to go before I can put the thing away. In yours, I kept noting with regret the diminishing thickness of the pages remaining as I got closer to the end." L.S., Newspaper Columnist, Edmunds, WA

"I enjoyed it so much. It has taken me almost 30 years of nursing to understand and appreciate what a doctor must go through to become a physician and how it affects all aspects of their life.... Your book was a "don't -put-it-down-until-you've-finished" type of read." K.M., RN

The Rough Road to Surgical Excellence, June 23, 2006
Reviewer: John N. Baldwin MD "John N. Baldwin, MD" (Twain Harte, CA)
For most surgeons, residency training is long, arduous, often brutally exhausting and requires great nerves and stamina. Dr. Schwab takes the reader from the timidity of the first day as a "real Doctor" just out of medical school to a time, six years later, when he emerges competent, brave and able to handle almost any surgical situation. Framed in the world-class University of California San Francisco program, these years are spent in cardiac, transplant, vascular and trauma surgery, to name but a few of the "rotations". Fabulous stories from those days bring the reader right out of his chair, as when the "jumpers" (off the Bridge) come into the SF General Hospital Emergency Room in full cardiac arrest. This is a "can't put it down" book, which reminded me of the way I felt in 1970 when I first read M*A*S*H, which up until then was the only surgical "novel" which had both pulse-quickening operating room drama and out of the hospital humor. This book does much the same, but all of the stories are true! Although surgeons will see themselves in it's 221 pages and delight in the memories, laymen with any curiosity or interest in just how tough it is to get to the top of the surgical pile will also find it a fascinating read, and at the end, will probably resolve to pick it up in a few months to read it again. Great work, Dr. Schwab. John N. Baldwin, MD FACS (General, Vascular and Chest Surgery)

Accurate depiction of the medical field, October 8, 2006
Reviewer: John Washburn
As a family physician, I have been disappointed with a good deal of the mainstream media portrayals of doctors. Rarely does a book, article or TV show come along that paints an accurate picture of what doctors are and what we go through to become what we are. Cutting Remarks defies that trend.
There is nothing more unique than residency training and, in many cases,nothing more challenging. It's one of those rare things that, once you go through it, you swear you'd never do it again, but wouldn't trade the experience for anything. Dr. Schwab captures the essence of that feeling in his reflections.
I like surgeons, mainly because they tend to have a sense of humor and more resemble humans than their internist counterparts. Dr. Schwab does a phenomenal job of portraying surgeons in such a light. As I read, I found myself immersed in nostalgia from my days of residency, whether it was 120 hour work weeks or cornering the market on "cutting sutures".
He takes us on a journey through the dreadful intern year, where a once triumphant fourth year medical student has to, yet again, work from the bottom of the totem pole. From trauma surgery to orthopedics to his time spent as a surgeon in Vietnam, his memories of becoming a surgeon are filled with rich descriptions of fellow residents, staff surgeons and, of course, patients. Every doctor has memories of certain patients from residency, whether they were particularly challenging or simply had a unique personality, and Dr. Schwab's memories truly make for good reading.
Schwab's writing style is also quite impressive. A common trap in memoir-writing is to get bogged down in the personal detail that fails to capture the reader's attention, while missing the main punch of the memory. Schwab avoids this trap well. His sharp descriptions mimick the very blade he has become so adept at using.
This book should be on the list of "must reads" for anyone in the medical field, especially medical students or those in pre-med and certainly for anyone considering a surgery career. But, even if you're not in the medical field, it's a great alternative to the usual doctor characterizations that you'll find on ER or House. Dr. Schwab has removed the usual mainstream physician stereotype like an inflammed appendix. This is real life. This is how doctors live, and what we have gone through to achieve our career. Bravo Dr. Schwab, you've done our profession quite a service.

September 8, 2006
Reviewer: A. Cooley "misscooley" (Bainbridge Island, WA)

Being the type of person to permanently remove the surgery channel from my TV, I didn't expect to like this book. Truthfully I didn't like it, I LOVED IT! Dr. Schwab is hilarious, brilliant, touching, and extremely insightful. It is not often we get inside such a talented and humble man's mind. This book made me laugh out loud and darned if I didn't learn a lot! I am eagerly awaiting the sequel.

A unique voice in medical non-fiction , July 28, 2006
Reviewer: gensparkie (California)
This gritty and sometimes laugh-out-loud funny memoir of a surgeon's years of training in San Francisco from 1970 to 1977 caught my attention from the intro, which is headed Reality Check:

"Someone said writing is easy: you just sit down at a typewriter and open a vein. As I've been in the business of preventing bleeding, this may not work out well. You wouldn't want John Updike taking out your gallbladder."

This dry and self-deprecating humor is found through the entire book and helps relieve the tension of some of the more difficult surgical moments. His riffs on the surgeons who trained him are hilarious: "Lester Weisman looked like Death. Bony, stooped, hook-nosed, and spider-fingered, he spoke in a voice that was chronically hoarse, a wheezing gust from Hades... Raising a hand toward you if he addressed you, he let the fingers droop and motioned vaguely, as if it were too much effort to point. When he smiled, it looked like he smelled something putrid. He should have carried a scythe, but it would have been unseemly for a former chairman of the department." And then Schwab deadpans, "I liked him a lot."

Then, his descriptions of the patients he and his colleagues worked with had me rocking with laughter. There was one story about a man with a pocket in his esophagus (a diverticulum) "who used to carry around a jar of pickled oysters. Before eating, he'd swallow one, which exactly filled the diverticulum without pushing too much on the esophagus. So he could eat, after which he'd push on the side of his neck and regurgitate the oyster into the jar. Probably didn't get invited out much."

Another thing I loved was the feeling of poetry or artistic enjoyment that he shares about how surgery works. In one passage, he talks about stitching up a bowel after surgery: "As you watch the edges disappear inward, and see a row of evenly spaced sutures complete a perfect circle, no mucosa showing; as you observe the tiny nearby arteries dancing their proof that you haven't disrupted the blood supply to the edges, you know you can safely drop it back inside, a secret gift to the patient."

The clarity and density of Schwab's writing allows him to pack in an enormous amount of information and insight. With most books that I am enjoying, I will read 100 pages or more in one sitting, but with this one, I wanted and needed to slow down and really savor every word, because there were so many excellent stories and well-explained surgical adventures in each chapter. His writing style, of making every word really count, really imparted the feel of a surgical internship perfectly in the sense that the pace of surgical action, emotional conundrums, and medical information (presented in a manageable way for the layman) never slowed.

I'd absolutely recommend this to anyone who enjoys medical non-fiction. Schwab has a really unique voice in this field, and even after having read about twenty medical narrative non-fiction books in the last two years, I found this to be a fresh and enjoyable addition to the genre.

A Few Passages From My Book

Ordinary thyroid surgery is very tidy. The thyroid is like the trinket in a surprise package; you open one layer after another, each prettier than the last. Once there, if you get your finger in exactly the right place, not a filament too deep or shallow, you can sweep in front and behind each lobe of the gland, popping it forward and partly out of the neck. Because there’s critical anatomy behind the gland, you have to contain your excitement. But the dissection is nevertheless a classic exercise in anatomy.
Except now. Besides being huge and stony, Gary’s gland was stuck to everything, even the skin over it. It became obvious there was no way it was coming out. All that was possible was a biopsy to find out what type of cancer it was and, because his trachea was already distorted by the tumor, a tracheostomy to prevent future airway obstruction (placing a breathing tube directly into the trachea). “Trach,” pronounced “trake,” is the abbreviated term.
Placing a trach tube is usually not difficult, especially with the neck wide open and absent a respiratory emergency. The normal thyroid drapes over the trachea but doesn’t obscure it. In this case, however, it was necessary to chisel through rock to get there, and having finally exposed the trachea, no available tube was long enough or shaped appropriately to pass through this huge gland and angle comfortably into the trachea. .......

It was a cheap horror movie, switching from black and white to color at the scariest moment. I opened the shower door to see Gary wilting, collapsing slowly like a leaking balloon, melting onto the floor as pint after pint of blood sprayed from his neck with each cough, the white tile walls by now splashed fatally red. Momentarily paralyzed, I felt as if blood were draining from me as well. Somehow, I acted, and as we dragged Gary across the hall to his bed, I called for an IV set-up and managed to get a needle into a big vein. The blood bank was two floors below. Using the handrails like parallel bars, I swung over several stairs at a time, knocked open the lab door, demanded ten units of O-negative
blood, STAT!!

** ** *** ***

San Francisco General Hospital, “the County,” was the essence of our surgical training, the crucible and the soul. More dignified and in some way predictable, the UCSF hospital—Moffit Hospital— was the medical center, the research hospital, where I’d started. The County was drama, fear, chaos, and excitement, the prism through which you saw yourself and your readiness to be a surgeon. A classic county hospital, decades old, it was made of solid brick, with incongruous fancy filigree—artsy details along the roof line, marble in the entryway—overlooked and no longer relevant to the seething survival-struggle that the place had come to embody. Slung low, with long hallways, too few and too slowelevators, SFGH housed patients in open wards, dank and underlit warehouses, except for the rare private room used for people with dangerous infections, or for the occasional muckamuck waiting to get well enough to transfer the hell out of there. The County was, in a word, alive.
It also had a dark side, buried deep. Connecting the main building to the psych ward across the alley were long and claustrophobic tunnels—dangerous at any time for a lone woman, eerie even for me when I made the rare trip over there. Not sated by its diet of damaged people, the County sometimes coughed up its own cud from down there; assaults on employees, though uncommon, were not rare. But from a physician in training, and most especially from a surgeon, San Francisco General Hospital demanded love and got it easily, unconditionally. It’s where I always wanted to be.

* * * *

Lester Weisman looked like Death. Bony, stooped, hook-nosed, and spider-fingered, he spoke in a voice that was chronically hoarse, a wheezing gust from Hades. He walked slowly, head down, peering above his glasses. Raising a hand toward you if he addressed you, he let the fingers droop and motioned vaguely, as if it were too much effort to point. When he smiled, it looked like he smelled something putrid. He should have carried a scythe, but it would have been unseemly for a former chairman of the department.
I liked him a lot. At this point in his career he had only a few patients, but he gave the occasional lecture. “The parathyroid . . . [grimace] . . . was first described . . . [sigh] . . . in the African water buffaloooh . . . [lengthy exhale]. . . .” Weisman even still did the occasional thyroid or parathyroid operation, and I wondered what his patients thought when they met him: hoarseness is the main complication of such operations, and he was the anthropomorphism of the word.

* * * *

We spent time on the wards and in the operating room, but the intensive care unit was the center of the vortex for the junior residents. If critical illness were heat, you’d melt in there. Jumping out a sixth-story window does things to a body. So does getting run over by a bus or taking a shotgun to the belly. Having five or six such victims at all times, along with a few lesser recoverees— couple of stab wounds, a bullet or two, ruptured appendix, perforated stomach or colon—produced a broad if wobbly workbench on which to learn to care for the sickest of humanity. Hearts and lungs, kidneys and livers failed alone or in concert, while we dialed in drugs, adjusted the ventilators, calculated fluid and caloric requirements, cleaned wounds, checked drains. With the help of surgical and anesthesia attendings, we became comfortable juggling disparate needs of multiple patients, street performers in white coats. Cirque du malaise......

Tending the wards, out of the ICU, was like being some sort of deviant gardener. Working our way up and down rows of beds lined along the edges of narrow, cavernous rooms, separated by curtains which hung like under-watered foliage— drooping, dirty, shredded—we cultivated patients who were in various states of mute acceptance or vocal defiance. “This pain medicine you’re givin’ me ain’t fer shit” was the most common salutation. (Until, after a day or two of complaining, they’d be pleasantly compliant on morning rounds, having made the connection; the night shift orderlies had a side business going. Drugs flowed when the lights went out.) The open wards, while highly efficient, by definition prevented intimacy, exacerbating an already precarious relationship. No one was happy to be there; most had fallen victim to their own or someone else’s stupidity or violence. Some were in withdrawal from alcohol or drugs; many weren’t anxious to return to their home life, while we were trying to get them well and out of there. Gratitude was not in the air. But I loved it. This was a real county hospital, the ferment of its wards connecting back to the earliest days of hospitals in this country, and across the seas to Europe. I felt it every time I entered.

** ** ** **

There aren’t a lot of kids with kidney failure. Katy Dawkins was beautiful, very sick, and very scared, admitted to a service that could be cold and hurried. When she arrived, I was smitten and never entertained for a moment maintaining professional distance from this speed-talking, pig-tailed ten-year-old, freckled like a crumpet. Having had some unusual problems with matching, she was getting a kidney from her dad—and even he was much less than an ideal match. Such “living related” transplants were uncommon then, and she and her dad were admitted a few days early for preparations. That meant I had time to get to know Katy and her family. Dad was a big guy and seemed perfectly comfortable with the plan; he’d apparently already donated a bunch of his freckles. I liked to visit Katy at night, when no one else was around, and when I could usually spare a few minutes.

* * * * *

When you’re still an embryo, your intestines are floating out in front of you, and your belly is wide open. As development proceeds, the intestines corkscrew their way inside, and the colon lays itself down around the inner periphery of your abdomen, in the shape of an inverted horseshoe. The right (“ascending”) colon is the first part, beginning where the small intestine joins it, in the lower right part of your belly. It heads up the right side to the liver, takes a left turn and crosses under your stomach (becoming the “transverse colon”), heads up toward the spleen (the “splenic flexure”), makes a hairpin turn down to the left side (the left, or “descending” colon), and finally takes an S-shaped (“sigmoid” colon) spin into the rectum. The blood vessels to the colon head outward from the middle of your belly, like hands on a clock. All of that derives from the embryological corkscrew, and it meansthat if you cut it loose from its outside attachments to the abdominal wall, you can deliver the colon up into your hands where you can work on it quite easily (unless it’s stuck and swollen from infection or a large tumor, or has perforated and retracted inward, or any of a number of other things that can make it anything but easy). Doing that—separating the colon from the sides of the abdominal wall—has always struck me as one of the neatest things a surgeon does. It’s like knowing one of the body’s deepest secrets: this big long fat bloody tube, which seems tightly stuck in there, can in fact, with the most delicate of maneuvers, be made to lift right out while still connected to its blood vessels. The trick is inserting your hand in just the right place laterally and doing a “c’mere” motion with your first two or three fingers, then cutting the thinned-out layer you’ve made. It’s nearly bloodless up the right side and down the left (it does get harder in between).

* * * * *

I believe I mentioned that Dr. Williams was a lunatic. He was a good operator but certifiably crazy in the OR, regularly losing control, yelling, berating people, throwing instruments. He might accuse someone of sabotage if something went wrong. That kind of crap was tolerated back then. Shaking his head like a bad imitation of Richard Nixon, he’d tighten his lips into a sort of cephalic anus and suck air in with a hiss at anything he didn’t like, which was nearly everything.

* * * * *

An artfully made bowel anastomosis is a thing of beauty. There’s an inner row of dissolving suture, in a running fashion, from the back side to the front, done in such a way as to make it all turn inward, and an outer row of individual (interrupted) stitches, requiring turning the tip of the needle holder in a perfectly circular motion, digging the exact depth to penetrate the outer surface and muscle, but not the inner layer (mucosa). As you watch the edges disappear inward, and see a row of evenly spaced sutures complete a perfect circle, no mucosa showing; as you observe the tiny nearby arteries dancing their proof that you haven’t disrupted the blood supply to the edges, you know you can safely drop it back inside, a secret gift to the patient.

Reviews and Reader Comments About the Book (If gushing praise annoys you, skip to the exerpts, which follow below)

"...Buy this book. More accessible than Oliver Sacks, funnier by far than Atul Gawande, totally devoid of snarky ego, and a fascinating...