**Bumped to top from 5/21/07 2300
There's a saying, in medicine, that "all bleeding stops." It's black humor in that, if, as the surgeon, you don't take the initiative and stop it, the patient's death will eventually stop the bloodloss. It's a way of emphasizing the importance of controlling the bleeding, and the principle can be applied in many, many areas.
In surgery, an operation has steps. It is, at times, possible to accomplish the goals of the surgery without following all of the steps, but a surgeon who does so leaves his patient open to a much higher risk of complications, of adverse outcomes and unintended consequences. If the surgeon fail to do each step in its proper place, taking care to perform the step well and thinking carefully about the next step before moving on, that higher risk of complications, orthopaedically speaking, can lead to infection, bleeding, hematoma, failure of fixation, nerve injury. And always one of those steps is to control the bleeding, or potential areas of bleeding.
I hate to phrase it this way, but one of the features of residency training in surgery is that you often get to see staff surgeons do it wrong. Some are simply rough with the tissues, or they try to take shortcuts, or they ignore bleeding that shouldn't be ignored. Then, later, perhaps you'll get to see the same operation performed correctly, and observe the stark contrast - and the improved results - when attention is given to each detail in addition to the final goal. While many residents think that the chance to cut, to use their own hands, is what trains them for their own surgical practice, I found equal or greater training was possible by simply observing this simple dichotomy. Often the thought that, "Wow, I can see the anatomy much better when assisting him" was enough to trigger that realization.
I can recall a case that I was doing as a senior resident, plating and bone grafting a midshaft humerus fracture nonunion. The attending physician was a trauma and fracture specialist, but, ahem, not known for his delicate handling of tissues. I had carefully exposed and cleared the nonunion, and was getting ready to plate the bone when the attending stuck his hands in, and with a "Well, let's see what we've got here," used his hands to tear away some vessels and muscle that I had been carefully trying to preserve. "Looks good," he said, as I moved quickly to control the large amount of fresh bleeding he had just caused.
This is going to be a bizarre segue, but probably the biggest problem I, and I suspect many others, have with the omnibus immigration bill that Congress plans to send up for Mr. Bush's signature is that it seems to be an operation that is being done wrong. The second, third, fourth, fifth steps are being given the attention, and the first, and most important step, the step without which this operation will ultimately fail, is being given insufficient attention. Set up the guest worker program - check. Have all the illegals register - check. Pay a fine - check (maybe). Set priorities on family members vs. job skills - check. Create a path to citizenship - check. Oh, wait, what are we forgetting...
The first thing to do is to stop the bleeding. Any bill needs to mandate, first and foremost, control of the flow of illegal immigrants across the border, if at minimum for security from terrorists, drug cartels, and other ne'er-do-wells. This bill is far too much about how to accomodate those who have already arrived here illegally than about stopping, or even slowing, the flow of illegal immigrants.
The issues involving the illegal immigration issue are certainly complex, but too much of the debate surrounding those issues are colored by craven political calculation rather than what's best for the citizens and legal residents of this nation. One thing that we should all be able to agree on is that the bleeding has to be stopped. All bleeding stops, but we don't want it to stop because the patient has died, through astronomical costs or otherwise. Better to control the bleeding ourselves, then assess the situation and deal with a stable patient.
5/24/07 0640: For an example of an unanticipated problem caused by failure to stop the bleeding, check out this post from Captain Ed. And thanks, Jay Tea, for reading.
5/30/07 1215: It looks like about 84% of America is with me on this. We have a new slogan "Hemostasis first!." Former Senator Bill Frist of Sen. Tom Coburn can explain it to the rest of Congress
