The foreign body blog

It’s been over five years since I wrote a blog about foreign bodies. That’s remarkable enough (considering how fun* and interesting** and sometimes outright terrifying*** foreign bodies can be), but what I find really surprising is that no one has ever dedicated a blog to foreign bodies. Think of it: doctors around the world could submit photos and stories to the blog’s manager, who would after a year or two write a large format / coffee table book on foreign bodies, make oodles of money, then get his medical license revoked for violating patient confidentiality, and then lose oodles of money when he is sued by umpteen patients whose clinical photos showed up in the book (Damn you, I just know that was MY colonic can of Budweiser you included on page 135!), and then recoup all of his lost wealth and respectability when Quentin Tarantino directs a movie about his travails featuring Johnny Depp as the doctor-turned-coffee-table-book-author.

The pause that refreshes!

In med school, a well worn photocopy of an article from the Journal of Gastroenterology made the rounds among us budding surgeons. The article detailed a number of case histories of colonic foreign bodies, but the most memorable one concerned a gay couple who were celebrating the New York Yankees’ victory in the 1978 World Series by putting to good use a baseball signed by Catfish Hunter****. If I remember correctly, the non-incapacitated half of this couple was insistent that the baseball be removed unscathed. (Which brings to mind the apocryphal story of the ER patient with an electric vibrator located just past the reach of his fingers. The surgeon, so the story goes, asked him whether he wanted the vibrator removed, “or do you want me to change the batteries.”)

Most foreign body stories are not as much fun as these, particularly at my end of the body. It’s hard to laugh at a toddler’s misfortune, after all. And betting on the date of a swallowed penny has limited entertainment value.

Not many blogs on foreign body extraction, I’m afraid. Here’s one from rural Nepal, and here’s another from a blog oddly entitled, “Dr Ko Ko Gyi’s Blog /
Autobiography of Dr Abdul Rahman Zafrudin.” Dr. Gyi/Zafrudin has a number of disturbing images on that site, but here’s the money quote:

Rectal foreign bodies are typically inserted and the majority of cases are the result of erotic activity. Typically found objects are vibrators, dildoes, light bulbs, candles, shot glasses, and bottles. Patients may be very embarrassed to disclose the circumstances regarding the foreign body insertion and there may have been multiple attempts at removal. The image shown demonstrates a vibrator in the rectum along with a pair of salad tongs that became lodged after attempts at self-removal.

He also includes a nasal foreign body story from House, and it’s anyone’s guess why he included a fictional story amongst a number of true ones.

The author of the Sermo Blog solicited “most interesting foreign body” stories from a number of physicians. My favorite quote:

Response from a Urologist: “At our hospital recently the general surgeons removed from the stomach a bound and gagged barbie doll that the patient had swallowed.”

All this talk of rectal foreign bodies has made me hungry. Time to make dinner.

D.

* My favorite: beads. The trick is to hook the hole. Close runner-up: any nasal foreign body that can be extracted by tricking the patient into sneezing it out (I have my ways!)

** Most interesting: the piedrito, which I blogged back in 2005.

*** Most terrifying: half of a pigeon skull wedged between the vocal cords of a two-year-old. Terrifying because this easily could have turned into a lethal situation.

**** Details made up by yours truly. Except I’m pretty sure the cause of celebration was, indeed, the Yankees’ victory.

A public service announcement

On an intellectual level, I’ve been aware of an increased rate of oropharyngeal cancers in nonsmokers in the last ten years or so, but I only really woke up to it after having two such patients fall into my lap within the last several weeks. Seems I can no longer say, “If you’ve never been a big smoker or drinker, you have extremely little chance of getting throat cancer.” I’ll have to modify it to say, “If you’ve never been a big smoker or drinker, and if you’ve never had sex, you have extremely little chance of getting throat cancer.”

Yeah, you heard me. This is the bugger:

That’s the human papillomavirus, or at least it’s a fetchingly colored depiction of HPV. And for today’s public service announcement, the key facts are these:

1. HPV is an important cause of cervical cancer. Apparently, and not surprisingly (since mucosa is mucosa, after all), it’s also associated with many oropharyngeal squamous cell carcinomas.

2. The HPV2 and HPV4 vaccines protect against most of the HPV serotypes causing cervical cancer and genital warts. Safety data is quite favorable:

Serious adverse events and deaths were evaluated in a pooled safety analysis that included 29,953 females aged 10 through 72 years (16,142 received HPV2). Proportions of persons reporting a serious adverse event were similar in vaccine and control groups (5.3% and 5.9%, respectively), as were the types of serious adverse events reported. In the pooled safety analysis, including 12,533 women who received HPV2 and over 10,730 in the control groups, incidence of potential new autoimmune disorders did not differ (0.8% in both groups).

3. HPV-related oropharyngeal cancers are on the rise. Unlike the typical throat cancers, which are associated with heavy alcohol and tobacco use and poor oral hygiene, HPV-related oropharyngeal cancers are associated with having multiple sexual partners. (But all it takes is one bad apple, you know?)

4. It does not seem like such a great stretch to argue that boys as well as girls should receive the HPV vaccine, particularly since HPV is also associated with anal and penile cancers. It’s safe and effective, so why not do it? Seems logical to me, but there are people who take the other side. (For the “pro” side of the vaccinate-boys argument, click here.) As best I can tell, the arguments against vaccinating boys comes down to: it’s too much trouble, it’s too expensive, boys will benefit anyway if enough girls get vaccinated, and HPV-related cancers really aren’t that big of a deal.

5. On that last point: while it is true that the HPV-associated throat cancers are more sensitive to radiation therapy and have a better prognosis than the smoking-and-drinking throat cancers, people can still die from HPV throat cancer.

So I think it boils down to “what is the worth of a life.” Cost effectiveness arguments make a lot more sense when there are two edges to the sword*. For example, should all men above a certain age be tested for PSA, the tumor marker for prostate cancer? It’s a little controversial, and it’s more than the cost of the test that is debated. The issue is whether an elevated PSA leads to unnecessary tests or treatments, all with potential for harm. (The LA Times has a good piece on this issue.)

I don’t see the double-edge to this sword. These are safe, effective vaccines.

I know what I’m recommending to my son.

D.

*In which case the cost, as a matter of public health policy, is still only one small part of the overall debate.

Not all cylinders firing

One thing about age: you can’t function as well with a cold or with too little sleep. So while my cold may be in its last gasp, I still need my sleep. Oh yeah do I need it.

I had an emergency case last night. The case didn’t run late, but it was one of those situations where despite my best efforts, things could still turn bad. When my pager went off at 11:30, my heart started pounding because of course I thought the worst. In fact, the ER doc from the local hospital was calling me out of desperation because none of the other Bako ENTs would answer his call. I couldn’t help him, and he was grateful to me for returning his call (probably frustrated as hell that the only person to return his call was the one person who contractually couldn’t help him), but my heart was still pounding.

I managed to get to sleep by 12:30, but it was a fitful sleep filled with fantasies of things going wrong. I’d wake up hoping it was morning, that many hours had passed, because the more time that passed, the more likely it was that my patient had gotten past that interval of risk. That he had, in fact, been discharged, sent home, hopefully sleeping more comfortably in his bed than I was in mine. Eventually I settled into something resembling a more restful sleep, only to be roused at 5:45 by some officious little dweeb of a nurse who needed a verbal order to extend my patient to 23-hour observation status. He couldn’t have waited another hour to call? Apparently not.

There’s no sleeping after a call like that. I contemplated getting up early (main advantage being, I could take myself out to breakfast) but I was just too tired. So I lay there exhausted, half dead, too tired to get up, too wired to sleep.

All day, I kept forgetting to finish things. No patient “quality issues” of course, just some sloppiness . . . blanks not filled in, messages not sent. I remembered, sometimes hours later, to pick up the threads. Things never quite flew apart.

Take out food was made for days like this.

D.