Seadragon

Bedside Rounds

This episode of Bedside Rounds, the first in a series of three episodes, is on the development of clinical decision support (CDS) systems, the role they play in medical decision making, and how this will change in the future with artificial intelligence. This first episode, Seadragon, goes over the history of high stakes abdominal surgeries, which led to the development of the "model" CDS, AAPHELP, also known as the Leeds Abdominal Pain Scale. You’re invited to join Dr. Rodman as he explores the assumptions that underlie much of decision support, the implications for how doctors think, and why both are incredibly important in taking care of patients.

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Bedside Rounds

This is Adam Rodman, and you are listening to Bedside Rounds, a 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 “Seadragon,” 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 Antarctica, 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 on during the second World War, the influence of HAL9000 and R2D2 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 a two-part episode, so before we start to grapple too deeply with 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 by many mid-century ideas about diagnosis that I’ve talked about for the past few episodes, especially from the two-parter with Gurpreet Dhaliwal on the first attempts to understand the diagnostic mind and program a computer that could think like a doctor – episode 68-69, the History and the Database, as well episodes 63 and 64 with Shani Herzig on the legacy of Yakob Yerushalmy and the merging of biostatistics and uncertainty into diagnosis.

I’m going to be talking a lot about surgery today – which is problematic, because I’m a general internist who works as a hospitalist and in the clinic, so my personal experience is (fortunately) limited, since my usual reaction is “go to the ER” or “call surgery now.” So caveat emptor – if I make any egregious mistakes about abdominal surgery, you know how to find me!

The acute – or as it was often called in the pre-CT scan days a “surgical” – abdomen is a very common presentation, familiar to all paramedics, emergency room doctors, and surgeons, despite there still being considerable disagreement about what it actually entails. Patients present with relatively sudden onset of severe abdominal pain, and an almost rigid abdomen – the abdominal muscles contracting to inflammation of the inner lining of the abdominal cavity, the peritoneum. As you can imagine, it’s generally caused by something “bad” happening inside the abdomen – and the most common cause by far is 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 – yes, literally just a fancy way of saying “poop stone” – will get stuck at the end of the blind sack, leading to increased pressure, inflammation, and finally a bacterial infection – acute appendicitis. Nothing quite speaks to the success of modern medicine and surgery quite like our success with appendicitis. It’s incredibly common, with a lifetime incidence of about 1 in 15. We know appendicitis was deadly prior to modern surgery, but we naturally don’t have great numbers. By looking at low resource settings we can guess that the mortality of untreated appendicitis is almost 50%. With modern surgical techniques, antisepsis, and antibiotics, the mortality rate in high income countries is 0.1%, though perforated appendicitis still carries a mortality of about 5%. Even in severely resource constrained settings, such as a case series in Malawi, the mortality rate was 5%, largely driven by delays in getting to a surgical center – meaning that we can still do a remarkable amount with a trained surgeon and some basic drugs (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897218/)

Fortunately, there are increasingly few places in the world where there’s not some access to surgical services. But those places still do exist. So what do we do then?

First stop, some of the remotest places that 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 it would be this way. Immediately after WW2, the United States sent an armada, consisting of 13 ships and 4700 men, to train for the possibility of a war with the Soviet Union (assuming that, at some point, the US and Soviet Union would 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 Sates. But apparently seeing little of value – and realizing that it would needlessly antagonize the Soviet Union – the US 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 twelve 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 Leonod Rogozov set off for the Antarctic in November 1960, as part of the sixth Soviet Antarctic expedition onboard the research vessel Ob. Rogozov was the expedition doctor, a 27 years old from Leningrad, who had interrupted his advanced studies – effectively a modern surgical residency – to join the expedition. The team was successful in setting up the base at an Antarctic oasis, called Novolazarevskaya. The base is still there today, supporting up to 70 people. After setting up the base, the Ob returned to Russia, leaving Rogozov and 11 other men behind to staff the base through the Antarctic winter.

What was life actually like at Novolazarevskaya? I found an article from 1972 by Gregg Vane, an American research scientist who took part in a Soviet-American research exchange after the signing of the Antarctic Treaty. He wintered at Novolazarevskaya just a few years after Rogozov and company helped set up the base. Vane 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 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 wintering – got along very well together “except for a few minor personality conflicts held in check by the people involved.” The author had a few warm memories in particular – the Russians held a “rousing” Fourth of July celebration with a banquet and fireworks and their celebration of “harvest day” they when had their first fresh cucumbers – they ended up producing 50 kg of tomatoes, cucumbers, onions, chives, and flowers from their unofficial greenhouse. He concludes that “wintering with the Soviets was a personally rewarding, once-in-a-lifetime opportunity.”

So it’s likely that Rogozov similarly passed his time in Novolazarevskaya in a similar fashion, conducting research and maintaining the base. But after a few weeks, Rogozov’s health took an ominous turn. A few weeks into their isolation, he awoke feeling weak and nauseated, but he soon developed pain, starting from his epigastrum then radiating to this 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 “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”.)

I’m going to be quoting from two primary sources here – Rogozov wrote an account of his surgery, published in English in 1962, and half a century later, Rogozov’s son published excerpts from his journal translated into English, published in the BMJ. Both of these are in the shownotes – the 2009 account in particular in 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.”

Evacuation was impossible; the nearest other physician was in Mirny, 800 km away. There were closer bases from other countries, but “Though there are foreign nearer, none of them has an airplane, and a blizzard ruled out a flight in any case.”

He did not want to frighten his colleagues, and tried to keep his situation a secret, utilizing conservative management – local cooling along with the station’s precious supply of penicillin. But he continued to worsen. I’ll let Rogozov himself say what happened next:

“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 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. Tomorrow is May Day. And now everyone’s running around, preparing the autoclave. We have to sterilise the bedding, because we’re going to operate. “

And then the final journal entry before his surgery: “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 would 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 cavity and provide artificial respiration until he woke up).

The base meteorologist and driver were his surgical assistants, holding a mirror to aid Rogozov in visualizing his abdomen and retracting his open abdominal cavity. Rogozov scrubbed and gowned, then entered a reclining condition, injected a Novocain solution into his abdominal wall and made a 10-12 cm incision. Because of his angle, he sometimes had difficulty seeing the bottom of his wound. For some parts of the surgery, he operated purely by the physical feel of his hands. After 30 minutes, waves 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, that was a perforation at the base. He sprayed penicillin throughout his abdominal cavity and closed his wound.

And yes, there are photographs of the entire surgery, which you can see in the BMJ article (and I will also share on Twitter). The team had plenty of scientific equipment, and the meteorologist was in charge of photographically documenting the procedure. He wrote in his journal:

“When Rogozov 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. Artemev and Teplinsky [that is, his two surgical assistants] also held their places, although it later turned out they had both 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 Teplinsky to wipe his forehead . . . The operation ended at 4 am local time. By the end, Rogozov was very pale and obviously tired, but he finished everything off.”

Rogozov retired to his bunk, still buffeted by fevers. However, by day 5 they had completely resolved. On POD7, he removed his sutures, and by POD14 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. He spent the rest of his life working and teaching at the First Leningrad Medical Institute and never returned to Antarctica. When he would be asked in the future about his auto-appendectomy, he would respond: “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 – and even then, appendicitis had proven incredibly dangerous because they couldn’t protect against their only DOCTOR getting sick. The solution, as recounted by the American Vane almost a decade later, was to ensure that every Soviet research station had two doctors.

So this example is pretty remote – but there was actually a trained surgeon present. But of course, we can get to more remote places for a surgical emergency – say, a submarine in wartime. Take, for example, the case of Darrell Dean Rector, a 19-year old seaman onboard the USS Seadragon, patrolling the Pacific Ocean on September 11, 1942, who, just like Rogozov, awoke with a classic presentation of appendicitis. Submarines did not have doctors stationed on board, and the only medical provider was Johnny Lipes, a pharmacist’s mate. That being said, by his own admission, Lipes did have experience assisting with surgery after his first ship, the Seadragon’s sister submarine, the Sealion, had been sunk in Manila’s harbor.

Decades later, Lipes would participate in an oral history, and I’m going to just quote directly from that. The link is in the shownotes 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 Darrell 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 [Commanding Officer] to report his condition. The skipper went back and talked to Rector explaining that there were no doctors around. Rector then said, "Whatever Lipes wants to do is OK 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 organs opposite 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 5 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 Seadragon was even less prepared for a surgery than Novolazarevskaya. The entire surgery was performed in the wardroom; the ether mask was an inverted tea strainer covered in gauze. Their sterile gowns were reversed 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 then covered them in alcohol that they milked from the torpedo launching mechanism.

But Lipes was successful. Rector fully recovered from the surgery and was back on duty 13 days later. Lipes stayed in the Medical Service Corps until 1962, then became a hospital CEO. He would not be formally recognized by the Nay for his surgery until 63 years later, when he was 84. Rector, unfortunately, died on board the submarine Tang two years later.

I hope I’ve convinced you – though I doubt you needed 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 in WW2 suggests that there were plenty of appendicitis cases that went far more poorly.

What does all this have to do with computers and diagnostic machines? Situations like these – where a doctor might not be immediately available, or on a Navy ship far out to sea where a medical emergency might mean aborting their mission – were part of the impetus to operationalize the first effective and practical diagnostic machines. But because I’ve created a monster of an episode, I’m going to end here and get to something I haven’t done in a long time: #AdamAnswers. Don’t worry – I’ll be back, along with Shani Herzig, to finish this story in a couple weeks!

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