* Letter from Steve Doak, M.D. to my doctors
I have had conversations with Lucille and find her to be a delightful person with no evidence of hypochondriasis or hysteria.
Having had lots of experience with surgeons in three years as a surgery intern and resident and as a practicing radiologist I will attest to Lucille’s assertion that many doctors, particularly surgeons and especially plastic surgeons have an automatic reflex to begin blaming the patient upon the occurrence of any bad result. This may represent either a response learned during training or an underlying narcissistic tendency, so commonly found in lawyers.
It is amazing to me that even though plastic surgeons are all board-eligible or board-certified general surgeons before beginning plastic surgery training, that in this particular case they seem to have forgotten the first tenet in treating trauma, whether it be the trauma of plastic surgery or otherwise, which is that one must guarantee the adequacy of the airway. Just because they are exalted plastic surgeons at MGH does not mean they should stop being doctors.
Lucille relates to me that the plastic surgery journals are full of articles each month relating to new and untested surgical procedures, almost the new operation of the month sort of thing. She describes the plastic surgical residents at MGH as using clinic patients, under the tutelage of the attendings, perhaps so they can generate even more articles about innovative procedures, as guinea pigs. “Using patients as experimental animals” is the expression that is used in my circles and I could give you plenty of examples in a one on one but this is not the time or place.
I view the explanation of Lucille’s problems as quite simple. She had a neck lift and the surgeon obviously tied his repair directly or indirectly into the tissues related to the base of the tongue and the first person to recognize this was the speech pathologist who did her first MBS and described the base of the tongue as appearing obviously anchored or fixated. This is what Lucille had figured out for herself a long time before but she had no way to prove it until I suggested she try pulling out on her tongue using a cloth for traction and this led to immediate and dramatic relief of her trouble breathing, as it pulled the base of her tongue out of her oropharynx. This, to me, would constitute good evidence to get on with the program and try to find a competent, experienced problem-solving surgeon used to operating in this area to explore the operative site and presumably take down at least part of the previous surgical procedure. Her ENT, however, wants more dramatic and direct demonstration of the problem and I can agree with this, considering today’s medico-legal climate.
The problem as I see it is that so many people involved in her case have been caught up in overly-conventional thinking. Her second MBS resulted in almost a repeat of her first one since she was not able to move her mandible around much with the forceps and her fingers got in the way of visualization of her airway. Single frames of her second MBS posted on her website did not reveal adequate collimation or composition to cut out the air space in front of the neck and concentrate on the oropharynx. The whole thing was over so fast that that there was not time to get the study focused on the base of the tongue, let alone the tongue traction maneuvers.
Her ENT said he wanted an airway fluoroscopy and everybody sort of goes blank instead of asking what, exactly, they want to see and the answer would be to prove that the tongue in the neutral non-swallowing position is way back in throat, pops forward with traction and this forward displacement is associated with marked improvement in breathing, as related to inspiration.
She had a pulmonary function test and the fact that the numbers were normal was used as evidence against her having a problem. Lucille relates to me now that the mandible is forced open when breathing into the mouthpiece which altered the position of her tongue and made breathing easier. I am not sure if she told them about it or if they would have listened to her if she had. In any event, this serves to prove the old adage that sampling the data or a test involving any degree of invasiveness often alters the data.
She relates to me that her oxygen sats are normal when she walks into the office so I responded that she should get them to walk her around until she gets short of breath and check this again.
As one can tell, I am trying to instill more of a problem-solving mentality into her condition.
At this point in time I think she has real problems which may be treatable by taking down the previous surgical repair. As a temporizing measure, she might try a plastic airway, to the extent that she can tolerate it.
As for justification for further intervention I would try to prove oxygen desaturation with exercise and take some good collimated pictures at fluoroscopy using spot films and cine, to show the tongue popping in and out of the oropharynx with traction and correlate that with symptoms. Remember, we are supposed to act like doctors and not robots, right?
I wish her good luck.
Steve Doak, M.D.
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