text:
Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.
Wednesday, January 31, 2007
It's Complicated: part one
One of the hardest things about being a surgeon is the inevitability of complications. It's true for any doctor; but with surgery, it's as if they are lit in neon and given a soundtrack. At least to me. Aiming for perfection (as do we all) and beating myself up (more than healthier people) when I miss the mark, I found bad outcomes of nearly any magnitude deeply disturbing. The big ones are there for lots of people to see: nurses on the surgical floor or ICU, operating room personnel when you have to re-operate. And of course, the patient. The family. My family, for that matter. Smaller problems might just be between me and the patient; but they still are painful. Carrying the responsibility for having done harm to people who gave me their trust can be nearly too much to bear. Thankfully rare, it's never been easy. Nor should it be.
I don't know the extent that I speak for other surgeons in this matter. I actually believe I took it too hard, and too personally; so what I say (which I'm sort of anxious to find out myself) may be fairly singular. But I got a specific request to tackle the subject, and I think it's an excellent one. So here goes.
There are two cardinal sins, in my estimation, for the general surgeon. The first, the sine qua non of a surgical screw-up, is injuring the common bile duct. Nailing the bowel with a suture while closing an abdominal incision is the other. Each tends to bespeak carelessness, and I'm sorry to say I've done both. Only once each, thank God, in what I'd conservatively estimate to have been around ten thousand operations (not all, of course, subject to those particular errors.) Actually the cardinal error -- more like the pope error -- of bile duct injury is to do it and not recognize it at the time. THAT, I've never done. Unrecognized bile duct injury can lead to a tragedy for the patient. If you're gonna ding it, at least see it at the time and fix it. That usually works out ok.
In the community of my first job as a surgeon, each newbie was subjected to a monitoring process in which every other surgeon in town was to scrub with him/her at least once at to render some sort of judgment. So the first time I was able to do a case unmonitored, I had the referring doc assisting me on a very routine gallbladder removal. It was the classic situation for injury: the easy case -- when the going is tough, you tend to have all the feelers out for problems. (I'd add, apropos a comment I received on my mini-gallbladder post implying it was the worst of all possible worlds, this was in the days of the big incision, and well before laparoscopic surgery.) My patient was a tiny woman, with tiny ducts. Her gallbladder had practically no length of duct connecting it to the main bile duct, so I thought I was dissecting the cystic duct (normally much longer, it's the tube that connects the gallbladder to the common duct), when in fact I was working my way down the common duct. Somewhere along the line, I discovered I'd cut it clean in half. As my heart sank and my hands got clammy with the realization, my forehead and armpits drenched themselves with sweat and I told the referring doc I'd be wanting to get my partner in to help at that point. He was only too happy to vacate. I repaired the duct -- among the smallest I've ever seen -- over a baby-sized T-tube, drained it, and closed up. And for the first time as a real doctor, I had to face my patient and tell her what happened.
It's excruciating. I hate everything about it. There is a very real temptation -- to which, even in this age of attorneys under every rock, some people still succumb-- to fudge it, not to tell it like it was, to protect oneself. In my case, I think, the urge is motivated less by fear of lawsuit than of confronting my own inadequacy. And the acute awareness that I'm telling a person things will not be as she expected; that her life could be very unpleasant for awhile. It's not what she signed up for, and it's my fault. Face to face. You're screwed. My fault.
I doubt I could successfully bullshit a person if I tried. My car got stolen when I was in med school. In the glove box was a small amount of what might be called an herbiferous stimulant (that it was small and had been in my glove box for months bespeaks the extremely limited use to which it was put.) For what may be the only time in the history of the local police, they found my car, and called me to pick it up at the station. Finding the glovebox contents strewn about the car, I noted it was all there; except for the one item. To the query if anything was missing, I said no. Couple of days later, there were two cops at my door, holding badges at eye level (narcotics boys) and asking for me. Had they just graduated from cop school, had they never seen a guilty person in their lives, they'd have known I was as guilt-ridden as if I were holding a bloody dagger. They displayed (holding it by a string: no fingerprints) the Alka-Seltzer bottle which held the offending material, and asked if I knew what it was. "Well," I said. "You guys being here and all, I suppose it's some sort of drug...." Fortunately, they also knew that the car had been stolen and there was no way to pin the contents on me. A stern warning was what I got, as my future career and my father's wrath passed before my forebrain: the one waning, the other waxing. I'm a lousy liar. (And since then [well, not too long after] a confirmed non-user.)
I told my patient truthfully what had happened, but I was not above trying to put it in the best light. Her anatomy was unusual, I explained, with her gallbladder so close to the bile duct that removing it left the duct damaged. True. But passively stated. To my retrospective regret (because it was less than entirely forthcoming), I glossed over the fact that I hadn't recognized the anatomy until I'd done the damage. I didn't lie. Yet I didn't resist the urge to sugar coat it. She was disturbed, but not beside herself: ultimately she had to put up with a capped-off tube with no drainage for three of months, after which it was gone and she had no further problems. (Being just out of training, I wrote to my professor to ask his advice about how long to leave the tube. In doing so, I said "I was recently called upon to repair a bile duct...." It was not untrue. I hoped he'd assume it was someone else's injury. He never said otherwise, but he was a very wise man.) It could have been much worse. As to the conversation I'd had with my patient, it's weighed on me ever since, and it was a long time ago. So many issues are at play in such a situation, it's hard to enumerate them, let alone fully understand them. I'll try.
The suture thing was quite different: the whole spectrum of terribleness, way worse for everyone. It had been a routine colon operation, and she'd gone home quickly, doing fine, only to come to the emergency a few days later, sick. My clamminess didn't take over right away, because my first instinct was to try to fool myself, to convince myself it wasn't what it was....
41 comments:
- james gaulte said...
I have bloged lately about what I fear to be a major tendency to push individual responsiblity in medical training to the very back burners and replace it with team play,systems muddling,and signing out.I know the docs of your surgical generation and my internist cohort had individual responsibility branded for ever on the limbic cortex-or somewhere.Your current post really exemplifies that.
I have never seen the truth about an incident be as harmful as "almost" the truth. A couple of observations. The truth is easy to remember;and truth is a good defense. The "almost" truth leads to questions which almost always make the defendent look like what they are --a liar. I also applaud your position of "it was my error".
- SeaSpray said...
I appreciate this post but from the perspective of probably looking at a 4 hour open ABD surgery. It unnerves me when I read about all the potential complications but helps me to know there are surgeons who care so much about their patients. I admire everything surgeons do. You've all paid your dues to practice your profession and I think it takes guts (no pun intended) to be a surgeon. I am grateful for the surgeon I have had this past year. Because I am high risk I have to go to a larger hospital and even tho I've heard good things about the new surgeon, it is really difficult to leave the one that has worked with me all year. Oh well- one has to do what they have to do.
Your "Taking Trust" from back in Oct. is still my favorite post followed by The Independent Urologist's post called "Letter to the Editor". :)
P.S. I will be finishing Part III soon - maybe tonight. :) - 1/31/2007 3:32 PM
- Bo... said...
I think it probably takes a massive amount of heart, dedication, and courage to be a surgeon. I hope you don't beat yourself up about those incidents anymore...
- Unknown said...
It's true for every surgeon who is any good at all: you never forget the screwups. I've been retired for nearly a decade, and I still lie awake some nights reviewing one or another unhappy such circumstance; mostly they were relatively few and minor with no long-term consequences but, fortunately rarely, sometimes not.
- Lizzie said...
As a patient who's had a few complications.... sometimes it's easier to hear the glossed over version. Things happen.
- Bongi said...
interesting coincidence that you blog about the dreaded complications just as i blogged about the dreaded m and m where the complications are displayed for all to see. as far as coming clean about your mistakes, one of my colleagues once really wrecked the rectum of a patient because of total stupidity. his prof advised him not to present the case on the m and m because it was totally indefensable. he took the advice and remained mum. the stories of his blunder are still doing the rounds, but always behind his back. when i once (the first and i trust the last time) cut the common hepatic duct (i noticed my mistake and repaired it. the patient did well) my prof also advised me not to present it on the m and m. i thanked him for the advice and presented it anyway, owning up to what i'd done. that m and m was not fun. i felt terrible and even questioned what i'm doing in surgery if i screw up so severely. but it passed and there were no stories afterwards.
i realise this is seeing mistakes from our side as the surgeons and not addressing the patient's side of things, but this is because to most of us these blunders are very difficult to live with. i'm in no way disreguarding the patient. i'm just looking at it from my view for the moment.
my point is honesty is the best policy, even if it is not the easiest policy. i agree with james that the final responsibility must lie with me as the surgeon. there is a team, but it's my patient and i must take responsibility completely. - 2/01/2007 4:51 AM
- Sid Schwab said...
There's much I could say about the comment I just deleted, including the fact that it seems to be from the same person who has slithered over here before.
I realized in venturing into this area I could stir up feelings in people who've had problems with their doctors. (This fellow's comments cover a far broader swath, however.) I'm trying to write honestly and personally about it, revealing my errors both of commission and omission, and -- as it is with writing -- to discover things about it myself. Were I perfect, there'd be no need for the series. As I've said before: I invite and welcome contrary comments. I expect to learn from them as well. I do not invite or tolerate degenerate personal attacks; most especially from people who (I can only assume) have no idea what I am really about. - 2/01/2007 12:32 PM
In all honesty, I have to say this is a very emotional issue for me and my response may not be appropriate for this place - if you decide to delete it, I understand.
I had a life altering experience with a surgeon - which traumatized me both physically and emotionally. My poor outcome is a direct result of the surgeon not facing a situation that could have made her lose face with her colleagues (and herself, most likely). To this day, she will not admit that she grossly mishandled my situation.
I think the worst part of my experience is how it destroyed my self-esteem. The first few months of my recovery my inner voice just cried "why me?" "why did she hate me so much that she left me to die?" "I must not deserve to live?" "why bother?" I do not believe that she did anything wrong surgically, but she lacked a post-op follow-up policy which directly led to a severe case of inra-abdominal infection - a mess of SBO, sepsis, peritonitis, pneumonia, blood transfusions, acute pancreatitis - not my best days.
That is what I blame her for...for putting me through that experience only because she couldn't be bothered with post-op clinics. This abandonment destroyed my self esteem; not the fact that I had the infection but the fact that she refused to see me in follow-up and literally told me to deal with it however I saw fit - because, a "technically perfect" procedure didn't need ambulatory care (once discharged from the ward, she belived no follow-up care was needed).
This is why I am so touchy about the subject of surgeons not having long term relationships with their patients. My PCP just today mentioned that the problem with surgeons is that they do not have to treat their mistakes; that we just get pushed into primary care to deal with.....That is why I cannot help but think if a surgeon followed his patients after the surgery and longer than just a couple of months post-op (espcially with ICU patients) that a sense of responsibility and understanding of consequences may be heightened.
My philosophy with medicine is that I do not expect my surgeons and physicians to be perfect; but I do expect them to be up-front with me and to do whatever it takes to correct or minimize the effects of human error. I know no one is perfect; but how a person faces his / her mistakes and takes responsibility and is a true test of character.
I share my story in order to give you physicians and surgeons out there an understanding of how a short-time, routine encounter in your life, ends up being the turning point in another person's life journey. At the risk of hyperbole, my life ended at 40 - as a direct result of a deliberate act; not a minute goes by that I am not affected by her actions;and to her? as far as she is concerned, I don't even exist; I pass her in the hall and she is clueless to what she destroyed.
Ironically, Dr S was the first and only surgeon who has alluded that this was not a normal situation; that has actually eased my emotional turmoil. In my opinion, facing your mistakes as a care giver not only builds character in the one who erred but can be a powerful healing tool for the patient "wronged". - 2/01/2007 1:28 PM
- Sid Schwab said...
Anonymous: I'd never delete a post like yours. And I agree with everything you said. Especially the part about continuing to see patients for however long it takes. Frankly, the behavior of the surgeon you describe sounds WAY out of bounds and, I'd hope, very far from typical. I'm sorry you had to suffer so much.
Kudos to you, again - partly for the excellent post and the way you bring the human side out. But mostly for your willingness to admit an 'oops.' I think it's the single best approach in medicine - I find far more accepting patients and family members when I apologize for missing an IV than when I hear co-workers blame "rolling veins" or some such thing, or when I sheepishly apologize and admit I completely forgot to bring that cup of ice chips instead of making excuses...that kind of thing. I don't think there's anything wrong with being fallible or humble and a surgeon - it's the ones with the God-complex that scare me.
a great post, and fun to read. thanks for being genuine about the inhaling. none of us is perfect, and carelessness or random error run through us all the way down to our DNA. Unless errors are in spite, i think we all need to be forgiving of each other. lawyers probably wouldn't like that.
Medicine is the only profession where perfection (or at the very least,the absence of notable error) is the norm. It is inhuman, inhumanE, and unnatural. It defies the 2nd law of thermodynamics, and Mother Nature doesn't like her laws broken.
That said, I think you were on the "coming clean" methodology of damage control long before a JAMA or NEJM study proved its effectiveness quantitatively.
It's called respect and decency. Would that more people had them. - 2/07/2007 7:44 PM
Sometimes even with the best of intentions Physicians and surgeons have things that go wrong. Why then do they try to cover it up instead of just explaining to you what went wrong so you can understand it.You know and they know you do and so do other medical personnel but it is all a deep dark secret sometimes to be discovered many years later after much uneeded suffering.
I have to say that I have experienced common bile duct injury and it has changed my life forever. My children suffered my husband and my mother passed only 2 months after my corrective surgery which I face in 10-15 years to do all ove again. The surgeon I had cut out two inches of common bile duct and he didn't catch it so let's just say I went through 3 hospitals no exaggeration.My surgeon acted all concerned until I got sent to another hospital then I was never his problem anymore. I commend you on your honesty but it is sad that my family and I have to suffer for years to come because of his mistake.
Wow. I'm late to the table as I just found Dr. Shwab's website. I find his take on surgery and the surgeon performing it fascintaing. So many complications riddled my husband's surgeries that I was convinced he would at some point demand to go to some place other than Duke. A teaching hospital. He never did. We always had confidence in our surgeons, but we always had frank discussions with them as well. We voiced our fears and concerns. No doubt having 12 fresh-faced kids in short coats peering over your bedside was a nuissance.....but we never considered leaving our doctor's care. How else do you make doctors other than letting them watch other doctors?
- Sid Schwab said...
kelly: thanks for your comments, and for finding the blog. Come back any time!
One of the comments said that you may have 10-15 years before your "replacement" bile duct has to be replaced. Is that a decent estimate? My surgeon was so cagey about it. He said he really couldn't say how long it would last. Also, how do you know when the replacement duct has closed up or is in the process of collapsing or something?
- Sid Schwab said...
It's not something that always occurs. It depends in part on what sort of "replacement" was done. Things can scar down, making the opening narrow. If it happens, depending on the actual surgical anatomy, it might be solved by dilating it without an open operation; something done, depending on various things, by a radiologist or a gastroenterologist. As to signs, there could be some changes in lab work (liver tests), there could be jaundice, possibly infection. Ultrasound could see dilated ducts in the liver. But again, it may well never happen.
I too believe surgeons should bare the responsability of following up with patients, especially when they have made a mistake. My fiance's surgeon was all too quick to get rid of him after he made a mistake damaging his common bile duct during a "routine" laproscopic gall bladder surgery. He saw him twice. The second time he almost refused to see him because the insurance only covered 2 months of follow up care. (He was in ICU for 3.5 weeks after surgery then bed ridden for another month with a home nurse)
The day of the surgery we waited 7 hours to speak to the surgeon after the surgery, eventually my fiance emerged the surgeon did not. In fact we, the family, did not hear from the surgeon until 2 days later after myfiance was rushed into ICU. The surgeon told us that a cat scan showed an awful lot of fluid in his abdomen and that he could have possibally damaged the bile duct during the surgery however he does not believen this to be the case and it is probabally the fluid he used to clean up the surgery. My fiance was raveged with infection, developed pneumonia, bed sores, extreme weight and muscle loss, lost alot of hair, and while in the hospital had tubes down his nose, and out his side draining bile. We suffered alot, we both lost our jobs due to this, and are struggling to et back on track. My credit ha plmmeted from 700 to I can only imagine what and we had to move in with family. He was unable to work for a substantial amount of time it took me 4 months to find a new job when I lost that one to having to take time off to care for him. One of his sutures had to be reopened and packed to drain infection. When he could finally see the surgeon he had 1 follow up a his office, the second one he was turned away saying he was passed the post op care period allotted-which he was past due to the mistake this surgeon caused- it was only when the surgeon realised he never had told my fiance to get the stent removed-that they inserted into the bile duct- that he had hid receptionists track him down through calling me and getting his cell # and telling him to turn around and come back to the office so he could tell him to get the stent removed. Then trying to get a surgeon involved to take out the stent was a nightmare no one wanted to get involved for fear of being dragged into a lawsuit. Finally the original surgeon got a doctor to remove it as a favor to him but the doctor wanted nothing more to do with it and wouldnt discuss anythung but the removal,and would not preform any catscans etc. to make sure the complications didnt still exist. We are still struggling to find a doctor to help us. He has returned to work even though he is still in daily pain. With shooting pains in his abdomen. This has been goin on since march and many tell us t will be at least a year before he gets the help he really needs due to peoples fears. All we really want is for him to get better and feel as best as e possibally can. We just want the truth as to his condition and what could be done to make it somewhat better. I applaud you Dr. S for being honest. It took my fiance becoming lethargic before the hospital realised something was wrong, they ignored his cries of pain and the fact that he was still there a day past expected release date-ultimately 24 days past when all was said and done. - 11/12/2009 8:20 PM
- Sid Schwab said...
anonymous: your experience is exemplifies our health care system at its worst. You have my sympathy.
On 11-12-09 I had a Lap Choley and went home. Over the next 24 hours, I got violently ill you know, nausea, vomitting along with severe pain. Upon returning to the ER, it was discovered that my liver enzymes and bilirubin were critically high. I was transferred to a larger hospital where the surgeon whom which done the procedure works. It took 2 days to discover that My common bile duct had been clipped. Initially, the surgeon was apologetic, and openly admitting what had happened. I even chose him to correct it. After finishing he had told my family that he removed the clips, (showed them photos of the clipped duct) and was able to spare my common bile duct without having to do the hepatojejectomy, forgive my spelling. three days later, they decided to place a stent, which took both a PTCA and an ERCP, which I had already gone through previously in attempt to diagnose the problem. I am a RN and work with this physician occasionally at a smaller hospital in a rural community where he comes in and performs these day surgeries once a week. Saying this, we had a working relationship in which he admitted that this made it even harder for him. I know he was devastated, I can tell by the looks on his face everytime he walked into my room. However upon my latest follow up visit he has now revoked the idea that it was clipped and says that he actually just kinked it and there was no damage to the duct. The Gastroenterologist as well as the radiologist and the surgeon himself specifically stated that he placed a surgical clip directly on the common bile duct throughout my hospital stay. he is also saying now that my cystic duct was "not anatomically correct" and it had a short neck. To me now I feel and know that he is starting to smooze over the truth to justify his error and this saddens me. I am starting to lose respect for this surgeon that I once thought highly of. The story has completely changed. In my opinion, honesty is the best policy and is usually the best route to go in hopes to avoid a nasty lawsuit. I just keep thinking of what I tell my daughter, "you don't get into as much trouble if you tell the truth." I do not have any ill intentions, however, from a patient's point of view, it makes it easier to think about a lawsuit when one knows there is dishonesty involved, not that those are my intentions, but after all, I am human and do think about it sometimes. I would like to commend you as a surgeon for your point of view of screw ups, it humanizes you as well as other doctors that follow suit. Doctors, especially surgeons, are placed far above on a pedalstool (rightly deserved by most)and people forget not only are they human, but they have emotions too. So thanks for this article. I see some of you in this surgeon, however I'm afraid he's turning direction, he must have taked to his legal department or maybe his insurance company, who knows? I was way more accepting of this and the "complication" before our last office visit. Now I don't know what to think. Thanks again for your perspective!
- Sid Schwab said...
I don't know what to think either, Charlie. I have the same impression of your surgeon that has evolved with you. Were you to take action, I'd assume there is documentation of what the original status was: in his op notes, in the radiology reports, and those of the GI doc.
On the other hand, it sounds like the major issue with you is the sense of disappointment and, for lack of a better work, betrayal. So maybe you could tell him that and see how he responds. Or not.
In any case, as with the commenters above, I'm sorry for what you've had to go through, and for the extent to which a fellow surgeon may not be living up to his responsibilities. - 12/15/2009 10:06 PM
On December 7/06 I had an open cholecysectomy, because of "extensive adhesions" from previous emergency surgery to remove a ruptured spleen. I was told that my bile duct, gall bladder and liver were all "gummed" up together with scar tissue. During the process of separating the gallbladder and cystic duct my common bile duct was severed (not nicked, but cut in half). The surgeon quickly reattached it somewhere on my duodenum. I was plagued with upper right quadrant radiating to the middle back pain on and off until I was hospitalized5 months later, because there was a bile duct stricure and bile was backup up into my liver, to the point where I could not eat anything. A cholangiogram was performed and a tube was inserted through the ducts in my liver to all bile to flow properly. After 3+ weeks it was removed and I was advised that I might get sick again, or I might not, but if I got the same pain, accompanied by fever to go back to the hospital for pain meds and antibiotics. Jump ahead to Dec. 2008 - during the course of 5-6 weeks I started getting sick again, extreme fatigue, pain that would come and go and then I got the fever. Not a high fever, but one that spiked about 38.5, then down to normal, then back up again. Ultrasound showed dilated bile duct, so back into the hospital again, where an ERCP and Sphincterotomy (sp?) was performed. Infection and pain finally went away and I was referred to a GI specialist. Two more scope procedures, but no answer - just that I might be a "sludge" former. Sounds funny - even to me - who has to deal with this crap every day. Jump forward to July 2009, started getting extreme fatigue and the pain. Tests shows my elevated liver enzymes were even more elevated. I had another bought of infection and pain, but GI specialist was too booked up to see me, and I didn't have the energy to explain the whole thing to an emerg. doctor. Fortunately I fought the infection off myself. For over three years I have had elevated liver enzymes - GGT and Alk Phos, and when I get an infection ALT/AST and sometimes bilirubin go up. I have suffered from extreme fatigue since the 2006 surgery and building a quality of life has been difficult because I never know when I will get sick again. I only know I will. I have now seen one of the top surgeons in my province (cancer and transplant surgeon). He told me that he knew what the problem was, and he could fix it, AND he questioned why I had not been referred to him sooner. I'm not sure what type of surgery he will be doing, but it it major open surgery involving reconstruction of my bile duct. Oh yeah and did I mention that the surgical report is kind of vague as to exactly where the injury is. In fact by GI Specialist asked me recently if the surgeon told me exactly where the injury was because she didn't know based on the original surgical report, and couldn't tell from the ERCP, as dye would not go into certain parts of the bile duct! So this has been my life for over three years. Some people go on vacation, I have medical procedures. Personally I'd rather go one a tropical vacation. I've spent alot of time trying to research my medical problem and it is difficult to find information on the internet. I think the surgery might be called a choledochoduodenostomy. Do you know if this is correct.
- Sid Schwab said...
You've had a hell of a bad ride, anonymous. It's a nightmare. The good news is that it sounds as if you have a surgeon who knows what he's doing.
Hard to know exactly what happened and what was done the first time around, but it seems pretty certain the problem is stricturing at the area of injury/repair. It was probably inevitable that, once that occurred, surgery of some sort would be needed, ultimately.
There are various surgical solutions to the problem, depending on the exact anatomy. Choledochoduodenostomy is among them, although that might be what was done the first time around, from your description. Another is Roux-en-Y choledochojejunostomy; and there's Roux-en-Y hepaticojeunostomy. The difference is mainly where the hook up is done, ie how close to the liver.
Here's a decent image of the anatomy. You can see how the intestine is divided, and reattached leaving a free end. That construction is done for many hookups. - 12/20/2009 8:51 PM
Thank you Dr. Schwab for your prompt response. I've now obtained a copy of the surgeon's report from my GP and the procedure will be a choledochoduodenostomy. This will be the second time this procedure will have been done on my body, but this time by a surgeon with much more expertise with these types of injuries. Apparently I like have contaiminated static bile and stricturing of the anastamosis, and am at high risk for sepsis, because I don't have a spleen. Your response was greatly appreciated. The surgeon has strongly recommended that next time I get sick, I head immediately for Emerg. and he will perform the surgery as an emergency procedure (given that the wait list is 1-2 years). Have a great Christmas!
- diane-j-m said...
Hi My mom had a common bile duct injury. It has been 4 years now since the injury. She has had a tube that goes from the outside of her side through the reconstructed bile duct. it has to be changed every 8 weeks. Some months she has to return to the hospital several times a month, because it leaks out on her skin. A couple of weeks ago, she had to go to the hospital six times because of this matter. Do you know of any surgeon that specializes in this repair. She tired of these problems, that have taken her life away. She lives in Iowa, and goes to Iowa City University Hospital every 8 weeks or sooner.
- Sid Schwab said...
diane j-m: I'd agree it's worth considering a surgeon with lots of experience with biliary surgery. An operation is theoretically possible, depending on the anatomy, and it could rid her of the tube and its problems.
I'd suggest searching the term "biliary pancreatic surgeon." I know of a couple: in San Francisco, at UCSF, Lawrence Way. He might or might not still be doing surgery but he'd be a very knowledgeable source of info. Also, in Boston, Andrew Warshaw. Another, in Portland Oregon, is Karen Deveney. Any of them might at least be able to suggest people nearer to you. Karen is a friend. I guess dropping my name would get her attention, although she'd likely help without it... - 7/01/2010 6:07 PM
My mother had a lap. chole 5 1/2 years ago with the end result of a common bile duct injury. To date, my mom has had numerous hospital stays. She has had the hepatojejunostomy reapir by a wrold known surgeon who was unforteuneately anable to save her right hepatic duct due to its extent of injury sustained. The right lobe of her liver has since atrophied because of this. She has had numerous drains placed and removed and then placed again....(over and over like a broken record), several dilitations, scans etc. She is weak and suffers from fatigue. She is very depressed and has lost any hope in chances that someday she MAY feel any normalcy again or will this kill her....there is a small percentage that given everything her now Dr's and Surgeons are doing for her to repair the damage and stricturing in her left hepatic duct, that it may not work and eventually she may be diagnosed with liver failure. This is all becuase the initial surgeon who completed the cholecystectomy was uncertain of her anantomy, proceeded anyway through the transcection without another thought as to convert or obtain an intraoperative cholangiogram. Furthermore, after transection, did not take steps to make sure structures that shouldnt be cut, were intact. Emergency care was not given to my mother until almost 4 days post op when she was sent to another facility for extensive treatment. The surgeon and facility involved in the initial operation, ignored my mothers cries of pain, telling her to just take her pain medicine. I am very disgusted with the initial surgeon who WILL NOT admit his mistake and expalins it all away. I hope that he NOW proceeds with caution in doing surgery and utilizes tools (scans, etc.) that are at his disposal thanks to technology, to ensure future patients safety and quality of life. Thanks to him, my moms quality of life is next to nothing!And thank goodness my mother has her family who loves her very much and stands beside her win or lose! We love you mom!!!
- johnie65 said...
This a true doctor.Far and few in between.A doctor who can admit mistakes and actually communicate with a patient is old school.Why are there not many more like this doctor.We truly need them now.Amazing!
Goodness this sounds like my life except my bile duct was severed during gallbladder removal in 1993 and i went through reconstructive surgery and now i have episodes of extreme abdomanol pain, vomitting,fatigue all the time. These episodes started in 2007. I am tired. I have applied for SSDI because of this. I was 26 when i originally had the first surgery. I wont have anymore surgerys. I think i am affraid .
I made a comment regarding my situation on 03/13/2013 and havent been responded to. What happened to me years ago was horrific i dont have no physical ability to work a steady job and have many other issues that i had to apply for SSDI and it would be nice to hear some response on what my chances are due to the fact i have the episodes spiratically.. all of my mysery was at the hands of a dr and would like something to finally go right. Life isnt fair and i lived the life of the hand that was dealt me.
- Sid Schwab said...
Anonymous: there's a comment above from 3/16, but not 3/13. Assuming you are the same anonymous, but just miswrote the date, your previous comment didn't seem to be asking for a response, so I didn't write one. It's a terrible situation, and I hate hearing such things. I'm sorry to hear of your struggle. You said you weren't intending to have more surgery, so it's hard to know what other options there are.
The only advice I can give, since situations like yours are so complicated that it's impossible to make recommendations without knowing all the details, is to seek help at a major medical center if that's feasible. Search for "biliary-pancreatic surgeons" in your area, or contact the surgery department of the closest center associated with a surgery training program. - 3/20/2013 7:34 PM
Telling the truth, even if a little sugar coated, would have made me feel better when my surgeon clipped a duct. Instead, I heard it's gas, constipation, pain is caused by the gas used. Then the question "Have you ever had surgery, if you had you would know that this is normal". (yes, I've had 3 csections) The whole time with this look of you are really bothering me for no reason. It took a week of excruciating pain, 3 hospital discharges, hundreds of tests, and time away from my family before we knew the problem. His new answers or comments for what happened are what I like the most. I've only had this happen to 1 other patient out of probably 3000, but she wasn't as badly sick as you. He repeated this several times, but then his numbers would change! Maybe he thought I was doped up on pain meds & not really listening. If he handled the situation appropriately, as you did, I would probably still be upset that it happened to me. Instead, I'm wishing that he could experience EXACTLY what I did for a total of 5 months. I'd even tell him he's just constipated, but I wouldn't give him med to help the problem (yes, he did that to me too). We need more physicians like you!
- Sid Schwab said...
Really sorry to hear of your struggles. Not a great testament to my colleagues, either.
My sister has just had a gallbladder op go wrong. She was left screaming in agony for days before they investigated and found out the extent of the issue. Her surgeon lied to her face, saying it was just a nick and nothing serious then went on leave. It was left to another doctor to tell her it had been completely cut.....we're still not clear on whether a section was removed. She's now had a repair op done to bypass and connect to the intestine (again, we think, because info is given sparingly) We've been given no info on possible long term effects despite several doctors making off the cuff remarks to my sister that lead her to believe long term health and QOL is compromised. Can anyone shed any light on what these might be?
- Sid Schwab said...
I'd say she's certainly entitled to a full explanation to her satisfaction. The surgeon who did the reconstruction ought to do so. There are a couple of different ways to hook things back up, but the exact method probably doesn't matter much as long as bile is draining back into the intestine.
I'd guess the surgeon won't be able to make any sort of specific predictions about quality of life. The main risk is that the area of hookup could eventually scar down and cause a partial blockage of bile flow.
This may well never happen, in which case her quality of life would be expected to be normal. If it were to happen, then, depending on the anatomy of the hookup, the scarred area could be dilated, either endoscopically or via a catheter passed through the liver. Both relatively simple, not requiring surgery.
The surgeon ought to be able to say what approach might be used if it were necessary. Hopefully, it never will. - 10/24/2013 8:57 AM
I went through having my common bile duct cut and ended up having biliary bypass, now a year and half later it is closing up. I am unable to eat now for about a month except bland food. I'm starving. I am afraid to go under the knife again, but have no choice. My surgeon was happy to blame it on my anatomy, play like he was unsure if he cut it, I wake up from surgery with a straw in my mouth and people telling me to drink while a machine surrounded me ---that evening. I did get shipped off for multiple surgeries and a 2 week stay. Huge scars, many miles away from my young child, alone. I can't tell you how much $ I had to pay out, now same thing the following year. I can't afford it. I'm not one to believe in lawsuits, so I am torn, but feel my life may end up cut short. I'm always worried about it. I cannot leave my job, although we planned to relocate prior to this. I have no choice but to stay. I'm really hurt by it. I am considering talking to a lawyer in light of the new surgery required. Not being able to eat is pure he**.
- Sid Schwab said...
I hate hearing stories like that. I'm sorry you're suffering so.
- Unknown said...
So my 89 year old father, very healthy for his age,(only takes Zantac for heartburn), needed his gallbladder out as it became infected. Long story, inadvertently clamped his CBD. Two days afterward, found bile in drain, and did ERCP to stent; followed up with MRCP, realized CBD clamped. Surgeon claims inflammation caused his error. When asked if he should have gone in to better visualize my dad's anatomy at the time, he claimed that "he never likes to second guess himself". That, to me is a frightening statement. My dad is being sent home with a drain for the next three weeks, and will return for surgical repair. Again, he's 89. Should I look for an alternative surgeon? I just don't have the confidence. Any advice? Thanks
- Sid Schwab said...
Mr Bertone,
That's a really unfortunate situation, all right. I agree that when a complication occurs, second guessing is what's called for; i.e, if a surgeon -- or anyone else, for that matter -- causes a problem it seems imperative to think about how things might have been handled differently, and whether they should have been.
If the response was a little clumsy, it doesn't necessarily he shouldn't be trusted; that's something you and your father have to decide, based on your feelings, I guess. It's certainly not the first time such a thing has happened with laparoscopic gallbladder surgery, even to excellent surgeons.
The bigger question relates to what's planned as a way of surgical repair. There are at least a couple of options, and it might not be possible to choose with certainty until the operation is under way. But I'd think he should be able to say what he thinks the options are, where the clip appears to be (the closer to the liver the more difficult the operation), and how experienced he is in this sort of reoperative repair or reconstruction.
I'd bet you'd have a better handle on how you feel about it after such a conversation. OTOH, to decide now that you want another opinion/explanation is perfectly reasonable. The key, in my view, is to have a surgeon reasonably experienced in this sort of reoperative surgery.
Good luck. If you feel like it, when it's all resolved, I'd love to know what was done. - 12/23/2014 5:02 PM
Moving this post to the head of the list, I present a recently expanded sampling of what this blog has been about. Occasional rant aside, i...
In no way is it false modesty to say that physicians are not healers. At best, what we do is to grease the way, to make conditions as favora...
Finally I'm getting around to writing about the gallbladder. Don't know what took me so long, seeing as how, next to hernias it'...
I finished the previous post with the sad story of my patient, illustrating diagnostic difficulties at the fringes of biliary disease. An...


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"We grew up knowing that nothing comes for free. You must fight for your dreams, and this environment makes you prepared for all of life's battles." - Godofredo Pepey
Rio de Janeiro and Curitiba are often the first two locations that come to mind when the topic of producing world-class mixed martial artists in Brazil is brought up, but over the years, Fortaleza has been the birthplace of several UFC fighters, including Thiago Alves, Wilson Gouveia, Jorge Gurgel, Hermes Franca, Marcus Aurelio, Diego Brandao, marking it as an MMA hotbed. The latest native of the city to make his way to the Octagon, featherweight Godofredo Pepey, isn't about to dispute that distinction.
"We are brave, with strong wills," said Pepey, through manager / translator Julio Heller, when asked what is it about Fortaleza that has seen it produce such talented fighters. "We have value for everything that we have in our life, and we grew up knowing that nothing comes for free. You must fight for your dreams, and this environment makes you prepared for all of life's battles."
It also doesn't hurt to have a little guidance, and while many fighters looked to the standouts that came before them, both locally and throughout Brazil, Pepey didn't need to look any further than his older brother Godofredo Claudio.
"I was hooked on the sport since the beginning," he said. "My older brother started to train jiu-jitsu and always invited me to go with him. I loved the sport and saw that my career and my future would be in the sport. So I have a lot to thank my brother for."
Since those early days, Pepey has proved to have a special talent for the sport, winning all eight of his pro fights (finishing each of his foes) before earning a spot on the first season of The Ultimate Fighter Brazil in 2012. From there, it was business as usual, as he defeated Johnny Goncalves, Wagner Campos, and Marcos Vinicius to stamp his ticket for the featherweight final against Rony Jason. But there, the string of success snapped, as Jason won a three round unanimous decision at UFC 147 last June and a UFC contract.
Now 9-1, the 25-year-old said that he got over his first defeat "Very quickly, very quickly," and what helped in that process was the decision to leave his Fortaleza gym in the hands of his brother for three months and move 3000 kilometers from his home to a new training camp and team in Curitiba. He believes that it's a decision that has already paid dividends.
"A game plan, and a team behind me thinking about alternative plans during the fight is something that I have now," he said. "It's amazing the difference from that time to now. I have a head coach, a jiu-jitsu coach, a great team of sparring partners, a manager, and so many professionals working with me and helping me to be a better fighter."
Included is a coach he met on TUF Brazil, the renowned Andre Dida, and for the last three months, Pepey hasn't just worked with his new squad of teammates, including another UFC on FX competitor in Francisco Trinaldo, but with two legends of the sport in Wanderlei Silva and Mauricio "Shogun" Rua.
"It was amazing," said Pepey. "'Massaranduba' (Trinaldo) and me are lucky guys; we had the privilege to train with both legends Wanderlei Silva and Mauricio Shogun. Our camp was fantastic. Just a few days training with these guys and you start to understand the "feeling" of the sport, that it's not only about money. These guys have been on the road for more than 10 years and they are still loving what they do. They accomplished so many things - belts, fame, money - but they still train harder than anyone. It is an honor and a privilege to share their experience, and they motivate me to keep pushing hard in my career. They are examples of lives dedicated to the sport, and this is an experience that I will take with me forever and I hope to have more opportunities to share more time with them."
It's always nice to hear the younger fighters in the game respecting and being in awe of the greats, and while Pepey is just beginning to follow in the footsteps of "The Axe Murderer" and "Shogun," he already has a good start in developing the finishing instincts that they've mastered.
"Jiu-Jitsu is my background and where I have more experience," said the BJJ black belt. "When I decided to move to Curitiba, I knew that my standup game would improve a lot, and that is something that I needed, because I know that the fans want to watch exciting fights and you must be prepared to face any situation in a fight, so I hope to keep winning and finishing my fights."
This Saturday in Sao Paulo, he gets a second chance at winning his first UFC fight when he takes on grappling specialist Milton Vieira. Vieira debuted on the same UFC 147 card as Pepey did, and after a draw with Felipe Arantes, he's looking to hit the Octagon win column for the first time as well. Yet despite his opponent's edge in experience, Pepey is hungry to get his hand raised.
"He is an experienced fighter with fights in PRIDE and Strikeforce, and with his great jiu-jitsu he has my respect, but now is my moment," he said. "I need this victory to prove that I can be in the UFC and I'm counting the days before the UFC in Sao Paulo. I came to the UFC to stay there. It is the best MMA event in the world, and I didn't reach the TUF final by accident. I'm sure about that and now is the time to prove it."
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Pair of carved wingback armchairs with hair-on-hide seats and linen surrounds; 205-606
- 31x32x44 each
This special online auction will be filled with a variety of fine furniture, antiques, artwork, accessories and more! Check back at auction start time for the full catalog, photos and online bidding!
Items from the Estate of William A. Heatley are listed as item numbers 550 thru 599 and 775 thru 823.
Tuesday, July 2; Wednesday, July 3 & Friday, July 5 from 8:00am - 4:00pm *We will be closed Thursday, July 4th
New auction items come in immediately following the close of this auction! All items must be removed to make room for all of the new pieces! We do not have room to store items past the designated pick-up times!
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Research in Motion, the company behind the BlackBerry smart phone, has made some spectacularly wrongheaded moves in the six years since Apple announced its first iPhone. It said the iPhone wasn't a game changer and claimed that apps don't matter. It's grafted new features like touch input onto its aging operating system in ways that didn't please anyone. It's wasted time it didn't really have to spare on a misbegotten tablet.
But in April 2010, RIM did something deeply sensible: it acquired QNX, the maker of a highly regarded, industrial-strength operating system used for applications such as car electronics and medical devices. It then set out to build all-new BlackBerry phones built on top of QNX's plumbing — a project so ambitious that it wasn't the least bit startling that it took years and involved multiple delays.
And now, at long last, that 2010 decision has a shot at paying off.
Last week, RIM began its press event in New York City by announcing news that was simultaneously shocking and logical: it was changing its name to BlackBerry, bringing its corporate branding in line with its much more famous product. Then it unveiled the first two phones running BlackBerry 10, its new QNX-based platform. The BlackBerry Z10 is a full-touch model that goes on sale in some countries this month; it'll show up in the U.S. on AT&T, T-Mobile and Verizon in March. (Only Verizon has announced a price so far: $199 with a two-year contract.) The BlackBerry Q10, which sports the iconic BlackBerry physical QWERTY keyboard, will arrive later this year.
I've spent the past few days with a Z10 review unit provided by BlackBerry. The phone isn't the sort of reality-defying, epoch-shifting landmark BlackBerry would have needed to silence its critics and lure teeming masses of skeptical iPhone and Android fans. It needs more high-profile apps, additional features to set it apart from other smart phones and fewer gnarly bugs.
But you know what? In multiple ways, it's already better than I expected it to be. Behind the scenes, BlackBerry has been building a mobile operating system that's fresh, fun and functional. It's put the software on a handset that's recognizable both as a current smart phone and as a BlackBerry — just the sort of thing it desperately needed to keep remaining BlackBerry loyalists from defecting.
The Z10 feels modern in part because it's the first BlackBerry in years that isn't based on outdated hardware. Its 4.2-in. screen is midsize by 2013 standards; the 1280-by-768 resolution gives it an eyeball-pleasing density of 356 pixels per inch, a skosh better than the iPhone 5. It's got an 8-megapixel camera on the back and a 2-megapixel one on the front for video calls, a zippy dual-core processor, LTE 4G wireless broadband and 16GB of storage with a MicroSD slot for expansion.
The industrial design, while not exceptional, is nice. The phone is .35-in. thick, but the bedimpled plastic back pops off so you can replace the battery. (Which you may well want to do: after a day of use, I found that the battery gauge was usually dangerously close to empty.)
Modern phones, of course, aren't defined by their hardware. All that plastic, metal and silicon is just a container for software and services. And while BlackBerry 10 isn't really the 10th version of the BlackBerry operating system — it won't run programs written for any previous version — it works hard to update some of the concepts that once made BlackBerrys so successful.
Back in the 1990s, the very first RIM devices weren't smart phones — they were smart pagers, and their defining application was the first really powerful e-mail service you could put in your pocket. E-mail and other methods of textual communications have remained core to the BlackBerry experience ever since, an emphasis that doesn't change in BlackBerry 10.
You do much of your communicating in the BlackBerry Hub, an überapp that stitches together e-mail, phone calls, updates from social services such as Facebook and Twitter, text messaging and BlackBerry Messenger, which now does video calls and screen sharing as well as instant messaging. The BlackBerry folks envision the Hub as a timesaver that will reduce the need to bounce around from separate app to separate app; in fact, they don't even provide a dedicated home button to get you to BlackBerry 10's home-screen grid of app icons. (You reach it by swiping up and to the right, a gesture that's easy enough once you remember it.)
The BlackBerry Hub is well done, but the Z10 wouldn't be nearly so slick a communicator if it weren't for its on-screen keyboard. It's the best stock keyboard I've ever seen on a touch-screen smart phone — a smart successor to the clicky little physical keys on most BlackBerrys of yore.
As with an iPhone or Android handset, you can tap to type, a process that benefits from such niceties as number keys that sit in a row atop the alphanumeric ones and gestures like the ability to swipe the backspace key to delete an entire word. But the BlackBerry 10 keyboard uses predictive technology to let you type without tapping. As you type, the operating system displays its best guess for the word you're planning to enter on the spacebar, letting you complete it with one touch. It also wedges other word possibilities in between the letters on the on-screen keyboard. You can select any of them by flicking a word upward — whereupon the software may show its guesses about the next word you intend to type.
I found that mastering all this wasn't a cakewalk: the word suggestions are displayed in tiny, low-contrast type that's tough to read, and I'm used to typing as fast as my thumbs can muster, which tends to cover the suggestions. But with a little squinting and adjustment to my habits, the keyboard let me get text into e-mail and other applications at a remarkably speedy clip.
A feature called BlackBerry Balance, also available on the PlayBook tablet, caters to a traditional BlackBerry fan base: corporate IT people. Using BlackBerry's server software, they can divvy the operating system into two separate-but-equal environments — one for personal stuff and one for work stuff. Each can have its own set of e-mail accounts, apps and other items, and a company can enforce security measures such as preventing an employee from cutting and pasting corporate data into a personal e-mail account.
Beyond all these classically BlackBerryesque touches, the company has packed BlackBerry 10 with other apps. It's built camera software with a mind-bending feature — somewhat similar to one in some Samsung phones — that lets you snap a group portrait, then move individual faces backward and forward through two seconds' worth of time until everyone is smiling and has open eyes. There's a little tool for composing multimedia shows, a note-taker called Remember and a voice-powered assistant akin to Apple's Siri and Google's Google Now. The company has also put together decent on-phone storefronts for music, movies, TV shows and magazines.
It's easy to find spots where these offerings are shallower than their iPhone and Android counterparts — the map app and voice assistant are both minimalist compared with the competition. But there are also plenty of instances of the bundled apps going beyond the basics; the Web browser, for instance, has a streamlined reader review that's comparable to the one in Apple's Safari.
And then there are third-party apps and games — an impressive-sounding 70,000 of them at launch, the company says. Plenty of high-profile contenders are already in the BlackBerry World store or on their way: Documents to Go, Dropbox, Facebook, Foursquare, Fruit Ninja, Jetpack Joyride, Kindle, LinkedIn, Rdio, Skype, Twitter, Where's My Water and others.
Appwise, it's probably the most impressive haul ever for an operating-system debutante. And yet, there's no way for a brand-new platform to come anywhere close to rivaling Apple's iOS or Google's Android, both of which boast hundreds of thousands of programs. Among the high-profile apps and games that aren't (yet) on BlackBerry 10: Bejeweled, Flipboard, Hipstagram, Hulu Plus, Instagram, Netflix, Temple Run and YouTube. Evernote is also missing, although BlackBerry's own Remember app is similar and provides access to Evernote notebooks.
The more I dug around in BlackBerry World, the less giddy I was over the count of 70,000 apps. Some of the lesser known wares I sampled were crude conversions of PlayBook or Android apps that weren't so hot in the first place. Quantity is fine, but what BlackBerry World needs most of all is quality.
Other than the app situation, the biggest telltale signs that BlackBerry is rushing to play catch-up with iPhone and Android are the bugs and other raw edges that remain. It's no shocker that they're there — even Apple's iOS, the most polished mobile operating system, still gets a tad erratic when it undergoes a major upgrade — but they're irritating evidence that BlackBerry could have used even more time to wrap up BlackBerry 10.
Some of the glitches I ran into:
- At one point, almost all the features in the browser — like the ability to share pages — refused to recognize my gestures. (They started paying attention again once I rebooted the phone.)
- The operating system periodically froze altogether for a few seconds, and back buttons didn't always function.
- Remember, the Evernote-like note-taker, is a mess — it referred to calendar items by cryptic monikers like "appointment_19343" and kept redownloading the same photos from Dropbox every time I opened the app.
- When I tried to use PayPal to pay for apps and movies, the phone not only wouldn't accept it but also spit up cryptic error messages that didn't seem to be designed for consumption by human beings at all.
Major operating systems may get all the attention, but minor ones can matter at least as much. If a thoroughly debugged BlackBerry 10.1 comes along soon, it would make the Z10 much easier to recommend.
Even then, the new, improved BlackBerry could turn out to be a noble failure. It's not clear that the mobile market has room for a another solidly successful operating system beyond iOS and Android: Palm's Palm Pre was bursting with promise but never went anywhere, and Microsoft's Windows Phone is admirable but not yet popular.
So if you still think BlackBerry is toast, that's your prerogative, and you could be right. We'll see.
Still, the company that's releasing the Z10 can no longer be dismissed as an embarrassingly out-of-touch outfit hobbled by an obsolete operating system. It's not going to trounce the iPhone and Android, but it has a shot at re-establishing itself as a scrappy underdog with a viable platform. Even that would count as a surprise comeback for a company that so many have written off for so long.


text:
I, too, was dismayed to find that isset($foo) returns false if ($foo == null). Here's an (awkward) way around it.
if (compact('foo') != array()) {
Of course, that is very non-intuitive, long, hard-to-understand, and kludgy. Better to design your code so you don't depend on the difference between an unset variable and a variable with the value null. But "better" only because PHP has made this weird development choice.
In my thinking this was a mistake in the development of PHP. The name ("isset") should describe the function and not have the desciption be "is set AND is not null". If it was done properly a programmer could very easily do (isset($var) || is_null($var)) if they wanted to check for this!
A variable set to null is a different state than a variable not set - there should be some easy way to differentiate. Just my (pointless) $0.02.


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Title: Branded
Author: Abi Ketner & Missy Kalicicki
Release Date: June 28, 2013
Genre: Young Adult/New Adult, Dystopian
Reveal Host: Lady Amber's Tours
Twenty years ago the Commander came into power and murdered all who opposed him. In his warped mind, the seven deadly sins were the downfall of society. He created the Hole where sinners are branded according to their sins and might survive a few years. At best.
Now LUST wraps around my neck like blue fingers strangling me. I've been accused of a crime I didn't commit and now the Hole is my new home.
Darkness. Death. Violence. Pain.
Now every day is a fight for survival. But I won't die. I won't let them win.
The Hole can't keep me. The Hole can't break me.
I am more than my brand. I'm a fighter.
My name is Lexi Hamilton, and this is my story.
My review:
As a fan of dystopian fiction I was really psyched to read this book. In a new twist on the psychology of mob mentality, Lexi Hamilton lives in a society that "brands" people in accordance with the seven deadly sin they are accused of committing. Being from New England, it reminded me of the early Puritanical society of the Mass. Bay Colony. The story flowed easily and I never had trouble keeping up. I loved Lexi's strength and the humor that runs rampant through the entire book. The spark between Lexi and Cole, her guard in the Hole, is fantastic. Each character that shows up are fantastic and very well written, they pop off the page. I highly recommend you read this book, especially if you are a huge fan like me this new brand of dystopian fiction. Great read, i can't wait for the next book!
Read Chapter 1 of Branded:
Chapter One
I'm buried six feet under, and no one hears my screams.
The rope chafes as I loop it around my neck. I pull down, making sure the knot is secure. It seems sturdy enough. My legs shake. My heart beats heavy in my throat. Sweat pours down my back.
Death and I glare at each other through my tears.
I take one last look at the crystal chandelier, the foyer outlined with mirrors, and the flawless decorations. No photographs adorn the walls. No happy memories here.
I'm ready to go. On the count of three.
I inhale, preparing myself for the finality of it all. Dropping my hands, a glimmer catches my eye. It's my ring, the last precious gift my father gave me. I twist it around to read the inscription. Picturing his face forces me to reconsider my choice. He'd be heartbroken if he could see me now.
A door slams in the hallway, almost causing me to lose my balance. My thoughts already muddled, I stand waiting with the rope hanging around my neck. Voices I don't recognize creep through the walls.
Curiosity overshadows my current thoughts. It's late at night, and this is a secure building in High Society. No one disturbs the peace here—ever. I tug on the noose and pull it back over my head.
Peering through the eyehole in our doorway, I see a large group of armed guards banging on my neighbors' door. A heated conversation ensues, and my neighbors point toward my family's home.
It hits me. I've been accused and they're here to arrest me.
My father would want me to run, and in that split second, I decide to listen to his voice within me. Flinging myself forward in fear, I scramble up the marble staircase and into my brother's old bedroom. The door is partially covered, but it exists. Pushing his dresser aside, my fingers claw at the opening. Breathing hard, I lodge myself against it. Nothing. I step back and kick it with all my strength. The wood splinters open, and my foot gets caught. I wrench it backward, scraping my calf, but adrenaline pushes me forward. The voices at the front door shout my name.
On hands and knees, I squeeze through the jagged opening. My brother left through this passage, and now it's my escape too. Cobwebs entangle my face, hands, and hair. At the end, I feel for the knob, twisting it clockwise. It swings open, creaking from disuse. I sprint into the hallway and smash through the large fire escape doors at the end. A burst of cool air strikes me in the face as I jump down the ladder.
Reaching the fifth floor, I knock on a friend's window. The lights flicker on, and I see the curtains move, but no one answers. I bang on the window harder.
"Let me in! Please!" I say, but the lights darken. They know I've been accused and refuse to help me. Fear and adrenaline rush through my veins as I keep running, knocking on more windows along the way. No one has mercy. They all know what happens to sinners.
Another flight of stairs passes in a blur when I hear the guards' heavy footfalls from above. I can't hide, but I don't want to go without trying.
Help me, Daddy. I need your strength now.
My previous desolation evolves into a will to survive. I have to keep running, but I tremble and gasp for air. I steel my nerves and force my body to keep moving. In a matter of minutes, my legs cramp and my chest burns. I plunge to the ground, scraping my knee and elbow. A moan escapes from my chest.
Gotta keep going.
"Stop!" Their voices bounce off the buildings. "Lexi Hamilton, surrender yourself," they command. They're gaining on me.
I resist the urge to glance back, running into what I assume is an alley. I'm far from our high-rise in High Society as I plunge into a poorer section of the city where the streets all look the same and the darkness prevents me from recognizing anything. I'm lost.
My first instinct is to leap into a dumpster, but I retain enough sense to stay still. I crouch and peek around it, watching them dash by. The abhorrent smell leaves me vomiting until nothing remains in my stomach. Desperation overtakes me, as I know my retching was anything but silent. My last few seconds tick away before they find me. Everyone knows about their special means of tracking sinners.
I push myself to my feet and look left, right, and left again. Their batons click against their black leather belts, and their boots stomp the cement on both sides of me. I shrink into myself. Their heavy steps mock my fear, growing closer and closer until I know I'm trapped.
Never did I imagine they'd come for me. Never did I imagine all those nights I heard them dragging someone else away that I'd join them.
"You're a sinner," they say. "Time to leave our society."
I stand defiant. I refuse to bend or break before them, even as I shiver with fear.
"There's no reason to make this difficult. The more you cooperate, the smoother this will be for everyone," a guard says.
I cringe into the blackness along the wall. I'm innocent, but they won't believe me or care.
The next instant, my face slams into the pavement as one guard plants a knee in my back and another handcuffs me. A warm liquid trails into my mouth. Blood. Their fingers grip my arms like steel traps as they peel me off the cement. The tops of my shoes scrape along the ground as I'm dragged behind them until they discard me into the back of a black vehicle. The doors slam in unison with one guard stationed on each side of me, my shoulders digging into their arms.
Swallowing hard, I stare ahead to avoid their eyes. My dignity is all I have left. The handcuffs dig into my wrists, so I clasp them together hard behind me and press my back into the seat, unwilling to admit how much it hurts.
Did they need so many guards to capture me?
I'm not carrying any weapons, nor do I own any. I don't even know self-defense. High Society frowns on activities like that.
The driver jerks the vehicle around and I try to keep my bearings, but it's dark and the scenery changes too fast. Hours pass, and the air grows warmer, more humid the farther we drive. The landscape mutates from city to rolling hills. They don't bother blindfolding me because they escort all the sinners to the same place—the Hole. Twenty-foot cement walls encase the chaos within. There's no way out and no way in unless they transport you. They say the Hole is a prison with no rules. We learned about it last year in twelfth grade.
To the outside, I'm filth now. I'll never be allowed to return to the life I knew. No one ever does.
"All sinners go through a transformation," one of the guards says to me. His smirk infuriates me. "I'm sure you've heard all kinds of stories." I don't respond. I don't want to think about the things I've been told.
"You won't last too long, though. Young girls like you get eaten alive." He pulls a strand of my hair up to his face.
Get your hands off me, you pig. I want to lash out, but resist. The punishment for disobeying authority is severe, and I'm not positioned to defy him.
They're the Guards of the Commander. They're chosen from a young age and trained in combat. They keep the order of society by using violent methods of intimidation. No one befriends a guard. Relationships with them are forbidden inside the Hole.
Few have seen the commander. His identity stays under lock and key. His own paranoia and desire to stay pure drove him to live this way. He controls our depraved society and believes sinners make the human race unforgivable. His power is a crushing fist, rendering all beneath him helpless. So much so, even family members turn on each other when an accusation surfaces. Just an accusation. No trial, no evidence, nothing but an accusation.
I lose myself in thoughts of my father.
"Never show fear, Lexi," my father said to me before he was taken. "They'll use it against you." His compassionate eyes filled with warning as he commanded me to be strong. That was many years ago, but I remember it clearly. My father. My rock. The one person in my life who provided unconditional love.
"Get out," the guard says while pulling me to my feet. The vehicle stops, and I'm jerked back to reality. The doors slide open and the two guards lift me up and out into the night. A windowless cement building looms in front of us, looking barren in the darkness.
The coolness of the air sends a shiver up my spine. This is really happening. I've been labeled a sinner. My lip starts to quiver, but I bite it before anyone sees. They shove me in line, and I realize I'm not alone. Women and men stand with faces frozen white with fear. A guard grabs my finger, pricks it, and dabs my blood on a tiny microchip.
I follow the man in front of me into the next room where we're lined up facing the wall. Glancing right, I see one of the men crying.
"Spread your legs," one of the guards says.
They remove my outer layers and their hands roam up and down my body.
What do they think I can possibly be hiding? I press my head into the wall, trying to block out what they're doing to me.
"MOVE!" a guard commands. So I shuffle across the room, trying to cover up.
Five of us sit in the holding room. One by one, they pull people into the next room, forcing the rest of us to wonder what torture we'll endure. An agonizing amount of time passes. I lean my head back and try to imagine a place far away. The door opens.
"Lexi Hamilton."
A guard escorts me out of the room, and I don't have time to look back. As soon as the door closes, they pick me up and place me on a table. It's cold and my skin sticks to it slightly, like wet fingers on an ice cube. Then they exit in procession, and I lie on the table with a doctor standing over me. His hands are busy as he speaks.
"Don't move. This will only take a few minutes. It's time for you to be branded."
A wet cloth that smells like rubbing alcohol is used to clean my skin. Then he places a metal collar around my neck.
Click. Click. Click.
The collar locks into place, and I struggle to breathe. The doctor loosens it some as I focus on the painted black words above me.
The Seven Deadly Sins:
Lust Blue
Gluttony Orange
Greed Yellow
Sloth Black
Wrath Red
Envy Green
Pride Purple
"Memorize it. Might keep you alive longer if you know who to stay away from." He opens my mouth, placing a bit inside. "Bite this."
Within seconds, the collar heats from hot to scorching. The smell of flesh sizzling makes my head spin. I bite down so hard a tooth cracks.
"GRRRRRRRRR," escapes from deep within my chest. Just when I'm about to pass out, the temperature drops, and the doctor loosens the collar.
He removes it and sits me up. Excruciating pain rips through me, and I'm on the verge of a mental and physical breakdown. Focus. Don't pass out.
Stainless steel counters and boring white walls press in on me. A guard laughs at me from an observation room above and yells, "Blue. It's a great color for a pretty young thing like yourself." His eyes dance with suggestion. The others meander around like it's business as usual.
I finally find my voice and turn to the doctor.
"Are you going to give me clothes?" A burning pain spreads like fire up from my neck to my jaw, making me wince.
He points to a set of folded grey scrubs on a chair. I cover myself as much as I can and scurry sideways. Grabbing my clothes and pulling the shirt over my head, I try to avoid the raw meat around my throat. I quickly knot the cord of my pants around my waist and slide my feet into the hospital-issue slippers as the doctor observes. He hands me a bag labeled with my name.
"Nothing is allowed through the door but what we've given you," he says.
I hide my right hand behind me, hoping no one notices. A guard scans my body and opens his hand.
"Give it to me," he says. "Don't make me rip off your finger." He crouches down and I turn to stone. I don't know what to do, so I beg.
"My father gave this to me. Please, let me keep it." I smash my eyes shut and think of the moment my father handed the golden ring to me.
"It was my mother's ring," he'd said. "She's the strongest woman I ever knew." With tears in his eyes, he reached for my hand and said, "Lexi, you're exactly like her. She'd want you to wear this. No matter how this world changes, you can survive." I turned the gold band over in my palm and read the engraving.
You can overcome anything… short of death.
"You're going to take the one thing that matters the most to me?" I say, glaring into the guard's emotionless eyes. "Isn't it enough taking my life, dignity, and respect?"
A hard blow falls upon my back. As I fall, my hands shoot out to stop me from smashing into the wall in front of me. The guard bends down and grabs my chin with his meaty fist.
"Look at me," he commands. I look up and he smiles with arrogance.
"What the hell?" He staggers a step backward. "What's wrong with you? What's wrong with your eyes?"
"Nothing," I respond, confused.
"What color are they?"
"Turquoise." I glower at him.
"Interesting," he says, regaining his composure. "Now those'll get you in trouble."
Reality slaps me across the face. I have my father's eyes. They can't take them from me. I twist the ring off my finger and drop it in his hand.
"Take the damn ring," I say. I walk to the door. He swipes a card and the massive door slides open to the outside.
"You have to wear your hair back at all times, so everyone knows what you are." He hands me a tie, so I pull my frizzy hair away from my face and secure it into a ponytail. My neck burns and itches as my hand traces the scabs that have already begun to form. Squinting ahead in the darkness, I almost run into a guard standing on the sidewalk.
"Watch where you're going," he says, shoving me backward. His stiff figure stands tall and I cringe at the sharpness of his voice.
"Cole, this is your new assignment, Lexi Hamilton. See to it she feels welcome in her new home." The guard departs with a salute.
"Let's move," Cole says.
I take two steps and collapse, my knees giving out. The unforgiving pavement reopens the scrapes from earlier and I struggle to stand. A powerful arm snatches me up, and I see his face for the first time.
Author Bios:
Abi Ketner Is a registered nurse with a passion for novels, the beaches of St. John, and her Philadelphia Phillies. A talented singer, Abi loves to go running and spend lots of time with her family. She currently resides in Lancaster, Pennsylvania with her husband, triplet daughters and two very spoiled dogs.
Melissa Kalicicki received her bachelor's degree from Millersville University in 2003. She married, had two boys and currently lives in Lancaster, Pennsylvania. Aside from reading and writing, her interests include running and mixed martial arts. She also remains an avid Cleveland sports fan.
Abi and Missy met in the summer of 1999 at college orientation and have been best friends ever since. After college, they added jobs, husbands and kids to their lives, but they still found time for their friendship. Instead of hanging out on weekends, they went to dinner once a month and reviewed books. What started out as an enjoyable hobby has now become an incredible adventure.
Follow the Authors:
twitter @abiandmiss.com
website and blog www.abiandmissy.com
Facebook https://www.facebook.com/AbiandMissy
goodreads http://www.goodreads.com/book/show/17402117-branded
Book Trailer: http://video214.com/play/PlssJogkXB4H85hKKomnOA/s/dark


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SRD:Magic Circle against Evil
This material is published under the OGL |
Abjuration [Good] | |
Level: | Cleric 3, Good 3, Paladin 3, Sorcerer/Wizard 3 |
Components: | V, S, M/DF |
Casting time: | 1 standard action |
Range: | Touch |
Area: | 10-ft.-radius emanation from touched creature |
Duration: | 10 min./level |
Saving Throw: | Will negates (harmless) |
Spell Resistance: | No; see text |
All creatures within the area gain the effects of a protection from evil spell, and no nongood summoned creatures can enter the area either. You must overcome a creature's spell resistance in order to keep it at bay (as in the third function of protection from evil), but the deflection and resistance bonuses and the protection from mental control apply regardless of enemies' spell resistance.
This spell has an alternative version that you may choose when casting it. A magic circle against evil can be focused inward rather than outward. When focused inward, the spell binds a nongood called creature (such as those called by the lesser planar binding, planar binding, and greater planar binding spells) for a maximum of 24 hours per caster level, provided that you cast the spell that calls the creature within 1 round of casting the magic circle. The creature cannot cross the circle's boundaries. If a creature too large to fit into the spell's area is the subject of the spell, the spell acts as a normal protection from evil spell for that creature only.
A magic circle leaves much to be desired as a trap. If the circle of powdered silver laid down in the process of spellcasting is broken, the effect immediately ends. The trapped creature can do nothing that disturbs the circle, directly or indirectly, but other creatures can. If the called creature has spell resistance, it can test the trap once a day. If you fail to overcome its spell resistance, the creature breaks free, destroying the circle. A creature capable of any form of dimensional travel (astral projection, blink, dimension door, etherealness, gate, plane shift, shadow walk, teleport, and similar abilities) can simply leave the circle through that means. You can prevent the creature's extradimensional escape by casting a dimensional anchor spell on it, but you must cast the spell before the creature acts. If you are successful, the anchor effect lasts as long as the magic circle does. The creature cannot reach across the magic circle, but its ranged attacks (ranged weapons, spells, magical abilities, and the like) can. The creature can attack any target it can reach with its ranged attacks except for the circle itself.
You can add a special diagram (a two-dimensional bounded figure with no gaps along its circumference, augmented with various magical sigils) to make the magic circle more secure. Drawing the diagram by hand takes 10 minutes and requires a DC 20 Spellcraft check. You do not know the result of this check. If the check fails, the diagram is ineffective. You can take 10 when drawing the diagram if you are under no particular time pressure to complete the task. This task also takes 10 full minutes. If time is no factor at all, and you devote 3 hours and 20 minutes to the task, you can take 20.
A successful diagram allows you to cast a dimensional anchor spell on the magic circle during the round before casting any summoning spell. The anchor holds any called creatures in the magic circle for 24 hours per caster level. A creature cannot use its spell resistance against a magic circle prepared with a diagram, and none of its abilities or attacks can cross the diagram. If the creature tries a Charisma check to break free of the trap (see the lesser planar binding spell), the DC increases by 5. The creature is immediately released if anything disturbs the diagram—even a straw laid across it. However, the creature itself cannot disturb the diagram either directly or indirectly, as noted above.
This spell is not cumulative with protection from evil and vice versa.
Arcane Material Component: A little powdered silver with which you trace a 3-foot diameter circle on the floor (or ground) around the creature to be warded.
Back to Main Page → System Reference Document → Spells


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