73 - Seadragon

This is Adam Rodman, and you are listening to Bedside Rounds, a bi-monthly podcast on the weird, wonderful, and intensely human stories that have shaped modern medicine, brought to you in partnership with the American College of Physicians.

This episode is called Sea Dragon, part of my series on the history of diagnosis. Modern surgical techniques have turned appendicitis from a life-threatening disease into something routine, even boring. But what do we do in isolated areas, say... a base in the Antarctic, a nuclear submarine in the middle of the Arctic Ocean, or even an understaffed hospital in a low-income country where no surgeon is immediately available.

In this episode, we're going to talk about the birth of what we today call clinical decision support and how its creators grappled with what it means for computers to think alongside doctors. Along the way, we're going to talk about Soviet-American cooperation in the Antarctic, an underwater appendectomy during the Second World War, the influence of HAL 9000 and R2-D2 on building diagnostic machines, and grappling with a fundamental question.

What do we do when a computer makes better decisions than a human? This is going to be a, well, three-part episode. So before we start to grapple too deeply with this existential angst, we're going to start in the trenches. Before we get started, this is part of my continuing series on the history of diagnosis.

You don't actually have to have listened to any of the previous episodes, but the development of clinical decision support is intertwined with many mid-century ideas about diagnosis that I've talked about for like, I don't know, the last eight hours, especially the two-parter with Kaprik Dhaliwal.

on the first attempts to understand the diagnostic mind and program a computer that could think like a doctor. That's episode 68 and 69 of the history and the database, as well as episode 63 and 64 with Shani Herzig on the legacy of Jakob Yerl-Shar. and the merging of biostatistics and uncertainty into the concept of diagnosis.

Caveat number two, I'm going to be talking a lot about surgery today, which is pretty problematic for those of you who know, because, well, I'm a general internist who works at... as both a hospitalist and in the clinic. So my personal experience is, you know, pretty limited. Since, you know, I see a surgical problem, I tell people to either go to the emergency room or I call surgery.

So caveat emptor, if I make any egregious mistakes about abdominal surgery, you know how to find me and correct me. The acute, or as it was often called in the pre-CT scan days, a surgical abdomen is a very common presentation. It's familiar to all paramedics, ER doctors, and surgeons, despite there still being considerable disagreement about what an acute abdomen is. actually entails. Generally, patients present with relatively sudden onset of severe abdominal pain and an almost rigid abdomen.

the abdominal muscles contract to inflammation of the inner lining of the abdominal cavity, the perineum. As you can imagine, it's generally caused by something quote-unquote bad happening inside the belly, and the most common cause is usually appendicitis.

The appendix is a blind tube that comes off the cecum in the large bowel. And despite traditional teaching that it's somehow vestigial, it plays a part in both immune function and maintaining our gut microbiome. Sometimes collections of stool called fecaliths and... yes, that's literally just a fancy way of saying poopstone, will get stuck at the end of the blind sack, leading to increased pressure, inflammation, and eventually a bacterial infection. This is what we call acute appendicitis.

Nothing quite speaks to the success of modern medicine and surgery quite like our success with appendicitis. It's incredibly common. The lifetime incidence is about 1 in 15. We know appendicitis was deadly prior to modern surgery, but you know.

We naturally don't have great numbers because we've been doing surgery for a while. By looking at low resource settings, we can guess that mortality of untreated appendicitis is almost 50%. With modern surgical techniques though, antisepsis and antibiotics, The mortality rate in high-income countries is 0.1%, though perforated appendicitis still carries a mortality of roughly 5%. Even in severely resource-constrained settings, such as a case series in Malawi, the mortality rate was only 5%.

And these deaths were largely driven in delays in getting to a surgical center, meaning that we can do a remarkable amount for patients with a trained surgeon and some basic drugs. Fortunately, there are increasingly few places in the world where there's not some access to surgical services, but those places do still exist. So what happens if we find ourselves in that situation?

First stop, one of the remotest places you could be in the world, Antarctica in the 1960s. In the year 2023, it's generally accepted that no country owns Antarctica, but it wasn't always clear that it'd be this way. Immediately after World War II, the United States sent an armada consisting of 13 ships and 4,700 men to train for the possibility of a war with the Soviet Union, assuming that, of course, at some point, the U.S. and the Soviet Union would actually fight in the Arctic.

But they had an ulterior, and at the time classified, motive securing a large portion of the Antarctic for the United States. But apparently seeing little of value and realizing that it would needlessly antagonize the Soviet Union, the U.S. never pushed the issue.

Over the next decade, there was considerable squabbling among neighboring nations, and after a decade of negotiations and argument, the Antarctic Treaty was signed in 1959 by 12 countries, which made it clear that human presence in Antarctica was for scientific cooperation and research with the military only involved insofar as they were necessary to resupply research bases.

It was with this context that Leonid Rogozov set off to the Antarctic in November of 1960 as part of the 6th Soviet Antarctic Expedition on board the research vessel Ab. Rogozov was the expedition doctor, a 27-year-old man from Leningrad who had interrupted his advanced studies, basically in a modern surgical residency, to join the expedition. The team was successful in setting up a base at an Antarctic oasis called Novolovraskaya. The base is still there today, supporting up to 70 people.

After setting up the base, the ob returned to Russia, leaving Rogozob and 11 other men behind to staff the base through the long Antarctic winter. What was life actually like at Novola Rebskaya? I find... I found an article from 1972 by Greg Vane, an American research scientist who took part in a Soviet-American resource exchange after the signing of the Antarctic Treaty. He wintered at Novolorovskaya just a few years after Rogozov and company helped set up the base.

Bain was an experienced Antarctic researcher and had already spent a number of winters in American bases. He was especially struck by the fact that his Russian colleagues were all civilians with no military presence except a single political officer.

The day-to-day activities were centered around, well, science. Launching weather balloons, taking various measurements of the Earth's atmosphere, mapping the stars with telescopes at night, journeying to local lakes to take samples. Most of the station crew... For his visit, there were 18 in total wintering, got along very well, quote, except for a few minor personality conflicts held in check by the people involved, end quote. I can only imagine being stuck in a winter with that many people.

The author had a few warm memories in particular. The Russians held a rousing 4th of July celebration with a banquet and fireworks and their celebration of harvest day when they had their first fresh cucumbers. They ended up producing 50 kilograms of tomatoes, cucumbers, onions, chives, and flowers from their unofficial greenhouse.

He concludes that, quote, wintering with the Soviets was a personally rewarding once-in-a-lifetime opportunity. I think it's fair to say that Rogozov probably passed his time in a similar way at Novolovitskaya. conducting research, maintaining the base. But after a few weeks, Rogozov's help took an ominous turn. A few weeks into their isolation, he awoke feeling weak and nauseated.

And he soon developed pains starting from his epigastrum and radiating to his right lower quadrant. He immediately recognized this as the telltale sign of appendicitis. classically pain at McBurney's point, named after the 19th century American surgeon who described the spot, quote, very exactly between an inch and a half and two inches from the anterior spinous process of the ilium on a straight line drawn from that process to the umbilicus, you know.

case you were wondering. I'm going to be quoting from two primary sources here. Rogozov wrote an account of his surgery published in English in 1962, and then half a century later, Rogozov's son published excerpts from his journal translated into English, which was published in the British Medical Journal. Both of these links are in the show notes.

2009 account in particular is riveting reading. In his journal he wrote, It seems that I have appendicitis. I am keeping quiet about it, even smiling. Why frighten my friends? Who could be of help? A polar explorer's only encounter with medicine is likely to have been in a dentist's chair.

And he knew evacuation was impossible. The nearest other doctor was in Mirny, 800 kilometers away. They were closer bases from other countries, of course, but quote, though there are foreign nearer, none of them has an airplane and a blizzard ruled out a flight. He didn't want to frighten his colleagues, and he tried to keep his situation a secret. He tried putting cool towels on his abdomen and gave himself a little bit of the station's precious supply of penicillin. But he continued to worsen.

I'll let Rogozof himself say what happened next. Quote, I did not sleep at all last night. It hurts like the devil. A snowstorm whipping through my soul, wailing like a hundred jackals. Still no obvious symptoms that perforation is imminent, but an oppressive feeling of foreboding hangs over me. This is it. I have to think through the only possible way out to operate on myself. It's almost impossible, but I can't just fold my arms and give up.

And then a little bit later, I've never felt so awful in my entire life. The building is shaking like a small toy in the storm. The guys have found out. They keep coming by to calm me down. And I'm upset with myself. I've spoiled everyone's holiday. And then the final journal entry before his surgery, quote, I'm getting worse, I've told the guys. Now they'll start taking everything we don't need out of the room.

Rogozov planned out the entire operation with his colleagues as if he were a general going to war. After all, there was a real risk that he'd lose consciousness after he had opened his abdomen. If that were the case, they were instructed to spray penicillin over the inside of his abdominal cavalry and provide artificial respiration until he woke up. I guess that's a good backup plan.

The base meteorologist and driver were his surgical assistants, holding a mirror to aid Rogasov in visualizing his abdomen and retracting his open abdominal cavity. Rogozov scrubbed and gowned, then entered a reclining condition, injecting a Novocaine solution into his abdominal wall and made a 10 to 12 centimeter incision. Because of his angle he sometimes had difficulty seeing the bottom of his wound. For some parts of his surgery he operated purely by the physical feel of his hands.

After 30 minutes, weaves of nausea and vertigo started to wash over him, and he started to take rest breaks, though fortunately he never lost consciousness. After two hours, he resected his vermiform appendix. As he expected, there was a perforation at the base. throughout his abdominal cavity and close the wound.

And yes, there are actually photographs of the entire surgery, which you can see in the BMJ article. I'll also share them on Twitter. The team had plenty of scientific equipment and the meteorologist was in charge of photographically documenting the entire surgery.

The photographer actually wrote in his journal, quote, when Rogazov had made the incision and was manipulating his own innards as he removed the appendix, his intestine gurgled, which was highly unpleasant for us. It made one want to turn away, flee, not look, but I kept... my head and stayed. Artemov and Teplinsky, that is two of his surgical assistants, also held their places, although it later turned out they both had gone quite dizzy and were close to fainting.

Rogozov himself was calm and focused on his work, but sweat was running down his face and he frequently asked Toplinski to wipe his forehead. The operation ended at 4 a.m. local time. By the end, Rogozov was pale and obviously tired, but he finished everything off. Rogozov retired to his bunk, still buffeted by fevers. However, by day five, they had completely resolved. On post-op day seven, he removed his sutures, and by post-op day 14, two weeks after the surgery, he had returned to full duty.

Rogozov and his colleagues remained at the base for over a year. On May 29, 1962, he sailed back to Russia. He returned to his surgical training and successfully defended his dissertation, and he spent the rest of his life working and teaching at the first Leningrad Medical Institute, never returning to Antarctica. When he would be asked in the future about his auto appendectomy, he would always respond, quote, a job like any other, a life like any other.

Showing how even the best laid plans can fail, the Soviet Union had made contingencies for a possible medical emergency. Every expedition had a doctor who could also perform basic surgeries, of course. But even then, their doctor ended up getting appendicitis.

The solution that the Soviet Union came up with, as recounted by the American vein almost a decade later, was to ensure that every Soviet research station had two doctors. I guess thinking that the chance that two doctors would get appendicitis was quite low.

So this example is pretty remote, but remember, there was a trained surgeon present. The plan just didn't, it just didn't go as planned. But we can get to more remote places for a surgical emergency, say... a submarine in wartime. So take, for example, the case of Daryl Dean Rector, a 19-year-old seaman aboard the USS Sea Dragon patrolling the Pacific Ocean on September 11th, 1942, who, just like Rogozov, awoke with a classic...

presentation of appendicitis. Submarines did not have doctors stationed aboard, and the only medical provider was Johnny Leipz, a pharmacist's mate. That being said, by his own admission, Leipz did have experience assisting with surgery after his first ship,

Sea Dragon's sister submarine, the Sea Lion, had been sunk in Manila's harbor. Decades later, Leipzig would participate in an oral history, and I'm just going to quote directly from that. The link is in the show notes if you want to read the entire thing. I had been up on the watch, and when I came down to the after battery section of the submarine, the crew's compartment, I found Daryl Rector. It was his 19th birthday. He said to me,

Hey doc, I don't feel very good. I told him to get into his bunk and rest a bit and kept him under observation. His temperature was rising. He had the classic symptoms of appendicitis. The abdominal muscles were getting that washboard rigidity. He then began to flex his right leg up on his abdomen to get some relief.

He worsened and I went to the CO to report his condition. The skipper went back and talked to Rector, explaining that there were no doctors aboard. Rector then said, whatever Leipz want to do is okay with me. The CO and I had a long talk and he asked me what I was going to do.

Nothing, I replied. He lectured me about the fact that we were there to do the best we could. I fire torpedoes every day and some of them miss, he reminded me. I told him that I could not fire this torpedo and miss. He asked me if I could do the surgery and I said yes. He then ordered me to do it. When I got to the appendix, it wasn't there. I thought, oh my God, is this guy reversed? There are people like that with their organs opposite of where they should be.

I slipped my finger down under the cecum, the blind gut, and felt it there. Suddenly, I understood why it hadn't popped up where I could see it. I turned the cecum over. The appendix, which was five inches long, was adhered, buried at the distal tip, and looked gangrenous two-thirds of the way.

What luck, I thought. My first one couldn't be easy. I detached the appendix, tied it off in two places, and then removed it, after which I cauterized the stump with phenol. I then neutralized the phenol with torpedo alcohol. There was no penicillin in those days. When you think of what we have in the armamentarium today to prevent infection, I marvel. The sea dragon was even less prepared for surgery than Novolorevskaya.

The entire surgery was performed in the wardroom. The ether mask was an inverted T-strainer covered in gauze. Their sterile gowns, they were reverse pajama coats. The scalpel had no handle and was attached to a hemostat. The retractors were bent spoons from the galley.

To sterilize them, the sailors boiled the spoons in water and covered them in alcohol that they milked from the torpedo launching mechanism. But Leipz was successful. Rector fully recovered from the surgery and was back on duty 13 days later. Leib stayed in the Medical Service Corps until 1962, then became a hospital CEO. He would not be formally recognized by the Navy for surgery until 63 years later when he was 84. A rector, unfortunately, died on board the submarine Tang just two years later.

So I hope that I have convinced you, though I doubt that you need convincing, that the decision to perform abdominal surgery is fraught and high risk in situations where medical care is scarce. Both of these situations turned out well, but just perusing a database of casualties and World War II suggests that there were plenty of appendicitis cases that went far more poorly. What does this all have to do with computers and diagnostic machines, you should be asking?

Situations like these, where a doctor might not be immediately available, or on a Navy ship far off to sea where a medical emergency might mean aborting their mission, were part of the impetus to operationalize the first effective and practical diagnostic machine. But because I... created a monster of an episode, I'm going to end here. Don't worry, I will be back along with Shani Herzig to finish this story in just a couple of weeks. But before that, it's time for a hashtag Adam answers.

We have an excellent question from Tony Brew. I think Tony probably has the record for most questions submitted. Someone recently asked how slash when the term Scut emerged. Did you cover this already? No, Dr. Brew, don't worry, I have not. So let's start with the term scut itself because my non-American and non-medical listeners might not be familiar with it. Scut, the way we use it today, is a shortened form of the word scut work.

which means routine and often menial labor. Merriam-Webster marks the first citation to be 1962. quote, scut work, menial or clerk work that should be done by assistants or subordinates, common among medical interns as, quote, this internship has too much scut work, i.e. marking bins, typing reports, cleaning up the lab, etc. The word is actually a lot older. The oldest reference I found...

was in the Trained Nurse and Hospital Review in 1928, which is a medical periodical published in New York City in the early 20th century, in a piece called The Hospital and the Intern. And I just want to point out that's intern with two E's, so I-N-T-E-R-N-E.

because it's still using the French spelling from whence it came. And this is actually reprinted from The Medical Record, which is a defunct periodical, it's not related to today's medical record, from 1920. That was a weekly medical journal.

The author writes, Quote, the medical record thinks the hospital intern is generally conceded to have a hard lot, responsible to attendants, to superintendents, to patients, to relatives, often perhaps deservedly abused by all, working if he be at all conscientious. many hours a day with blame for mistakes and often with scant praise for work well done.

one may well wonder what that the breed persists. Many months of the intern's career can be spent in doing what he himself is prone to call scut work, i.e. urinalysis, blood counts, and all the rest of clinical pathology. or addressing the uninteresting surgical cases given anesthetics, and all too often, quote, riding the bus. Okay.

I have no idea what riding the bus means in this context, like circa 1920, so if you're up to date with your old tiny slang, please let me know. A couple of things here. From the context of the article, it's actually pretty clear that scout work was a commonly known term by American interns. at the very least by 1920. It also makes me pretty suspicious of Merriam-Webster's assertion that Scutt originally referred to an intern. All of these early references only talk about the Scutt work itself.

And the word scut by itself only really appears at the end of the 20th century as a shortened version of this phrase. And finally, quite interestingly, scutwork pretty much has the modern definition as early as 1920. Where does it come from to actually try to answer Tony's question? Scut's an old word, and it refers to a rabbit's tail. I think we can rule that one out as a source. Scut is also a 19th century slang term, meaning a contemptible person.

That seems maybe a little bit more likely. I think that's where the idea of Scott being an intern comes from. But like most slang or argot, no one knows, though it's pretty clear that it originated in the American hospital setting.

By the post-World War II period, scut work was used outside of medicine, which is probably what got it referenced to Merriam-Webster in the 1960s. And after the popularity of House of God, the phrase scut work went mainstream. You can actually see this spike on Google Ngrams.

coinciding shortly after the publication of the book in 1978. So that is where the word scut or scutwork comes from. But let's deal with the more, or at least what I think is the more interesting question here. What exactly...

is scut work. After all, in the 1920s, interns apparently considered uninteresting quote-unquote surgical cases and giving anesthesia, you know, the kind of essential medical procedures for patients in the bread and butter of an operating room, scut. In 1991, a training program in Alberta sought to answer this question by having residents keep diaries overnight of what they actually did, and then constructed surveys asking both residents and faculty to find the educational content of each.

and the SCUD content of each for the 20 most commonly performed activities. These range from drawing blood, inserting IV cannulas, working on discharge paperwork, calling for test results, receiving outside records, taking samples to the laboratory, performing H&Ps on short-stay patients that a resident would not follow after, and obtaining informed

consent for procedures that the resident would not perform. First of all, all of the residents, or well, 98% of them, agreed on a common understanding of scut work. quote, non-urgent of little educational value within the competence of non-physicians peripheral to the resident's role in patient care and generated by persons who do not appreciate the resident's workload or who take for granted the resident's availability, end quote.

But the study found considerable variation based not on the activity, but by the clinical scenario, by the context. For example, the ward staff calling residents to start IVs was considered scutt. However, if a nurse had already tried and failed, most residents felt it was appropriate.

And while bureaucratic hassles like radiology requisitions and literally carrying things to the lab were considered scut, the paperwork of filling out an autopsy form, which required a detailed conversation with the deceased's family, was not. And perhaps...

You know, honestly, unsurprisingly, faculty consistently thought that tasks the residents felt were SCUT were more educational. The conclusion of the study was that residents draw a distinct line between SCUT and service, the same task if done to advance patient care with service. If pushed on the resident because they were just available, you know, forced labor, especially if it could be done by non-physician personnel, that was scut. And the conclusion of the article, quote,

Scud work is an important part of resident's duties that exerts a strong influence on resident satisfaction. It comprises various duties that have little educational value and that could be delegated to non-physicians. Scud may also be associated with more complex clinical... But other means may also...

lend educational value to the services that residents provide. Even if Scutwork appeared to have a well-understood definition in the study, I think it's still an insufficient answer, honestly, and it doesn't get... to the heart of why Scut work resonates and why we're talking about it right now. By way of example, I asked in a honestly very unscientific Twitter poll specifically to attendings if they ever had to do Scut, and 80% of them said yes.

But how is that possible if scut work is something that distracts from educational activities? After all, we're attendings.

Even in 1991, the phenomenology of Scott had a wonderful retort by one Michael Smith, a private practice physician in Virginia, and I'm just going to read the entire letter. Quote, just as it is naive to think that education stops after residency and fellowship, it is naive to expect that scut work stops too. Perhaps the only physicians to escape scut work are those who stay in academia.

In the private practice of medicine, I routinely draw blood when my staff or the hospital staff are unable to get the sample. The same is true for IV cannula. I fill out most of the requisitions for tests ordered from my office and often for patients in the hospital, especially if I want the information on them to be accurate. I usually search for patients' films in the x-ray department because I am not satisfied with just looking at a report.

I schedule most of my own procedures. I can do it faster than my staff can. If I want laboratory results before the type report is available, I call the lab myself or ask my staff to do it. I even run an occasional sample to lab myself if I want it done quickly. I speak to a lot of insurance companies, more every day for pre-certifications and to justify continued hospital stays. It is too easy for insurance companies to tell my staff that they won't approve beds.

I frequently take a history from and do physical examination on patients for whom I may not end up being the primary physician. I may even have to do the discharge summary. It might be easier than arguing with a colleague. In conclusion, it is well to point out that medicine does not have a corner on scutwork. Try being a parent.

Well, I am an academic physician. I'm also a parent. And 31 years later, this rings completely true to me, especially his complaint about what we now call peer-to-peers with insurance companies seeking to deny care for my patients. This gets to what Lakshmi Krishnan, Mike Noyce, and I spoke about way back in episode 70, way back, a couple months ago.

Our self-conception of our job and the stories we tell about it tend to be considerably different than what we actually do at work. The ubiquity of the word scut and the fact that pretty much all of human activity has moments of drudgery. Even editing this podcast attests to this contradiction. So Dr. Brew, that was a very long-winded way of saying, Scutt has been with us for a long while, and it will almost certainly stay with us for quite a while longer.

Now that's really it for the show. This was the first of a three-parter, so expect the next two parts with Shani Herzig about the birth of clinical decision support and diagnostic artificial intelligence over the summer. CME is available for this episode if you're a member of the American College of Physicians at acponline.org slash bedside rounds.

All of the episodes are online at www.bedsiderounds.org or on Apple Podcasts, Spotify, Google Podcasts, any, anywhere, anywhere you get podcasts. The Facebook page is slash bedside rounds. The show's Twitter account is at Bedside Rounds. If you want amazing swag designed by Sukriti Vanthea, The merchandise store is at tpublic.com slash store slash bedside rounds. And I'm personally at Adam Rodman MD on Twitter for as long as it continues to exist.

All of these sources are in the show notes and a transcript is available on the website. And finally, while I am actually a doctor and I don't just play one on the internet, this podcast is intended to be purely for entertainment and informational purposes and should not be construed as medical advice. If you have any medical concerns... please see your primary care provider.