I am up to my knees . . . .

. . . In appendices. 

The long-awaited Appendectomy Rant.

During my third year of Residency, I travelled to Ft. Bragg, NC for a three-month rotation. This was a splendid time in the life of a young, developing surgeon. After completing two grueling years of subordination, it was a chance to develop my own "style" if you will.  During those three months, I was one of two residents working in busy community-style hospital. We did all kinds of standard General Surgery procedures which would be considered "Bread and Butter" cases as well as a smattering of more involved surgery. While down there, I split call with the other Resident - Blundy*. We basically alternated taking call every other night during the week and every other weekend.

As the Surgeon on call, we were the first to be notified of any potential surgical case. Very few call nights passed without a trip to the hospital. At the time, it seemed that an inordinate number of these trips were for acute appendicitis. I remember thinking that I was taking out a lot of appendices while I was there. To be honest, I don't really remember how many young soldiers' appendices fell prey to my knife, but in retrospect it was probably on par with what one would expect taking care of a population that size. In the remaining 3yrs of my residency, I probably took out an equal number to what I did at Ft. Bragg. I thought appy hunting couldn't get much better than the fertile grounds around Fayetteville.

Then, I got to Camp Bucca. I have now been here just over two months. In that time, I have removed 15 appendices. Fifteen. While this number may not sound shocking to anyone, consider this:

The average annual rate of appendicitis is reported to range from 84-230 per 100,000 population.

The approximate detainee population at Camp Bucca is 15,000.

Some simple math places the expected ANNUAL incidence of acute appendicitis in a population of that size to be between 12.6 and 34.5.  

One might ask, "Why such a large range?" One answer would be that the higher number is adjusted for age and represents the highest incidence that I have found reported. It is the 10-19yr age group. Not knowing the average age of Bucca (though I'm pretty certain it is significantly higher than 19), I use it as the upper limit of reasonably reported data. The only prospectively gathered data I could find put the incidence at the lower end.

Okay, enough scientific blabber. I have taken out 15 appendices in 2 months. At this rate, one might reasonably predict that I should remove a total of 45 before I leave, and that in the span of one year, it would be expected that 90 appendectomies would be performed. Ninety is a much larger number than 12.6 or 34.5. 

The next logical question would be, "Gee, Steve, that's pretty high. Why do you suppose that is?" I do not have the answer to this question. It could have something to do with age, although even when you consider the age group at the highest risk, it's still far less than the rate we're seeing here. It could have something to do with diet; there is a reported correlation between low fiber and appendicitis (apparently fiber prevents any and all diseases related to the colon and rectum. If every one simply had enough dietary fiber intake, Colo-Rectal Surgeons would be out of a job). While the food contains an adequate amount of fiber, I'm not sure anyone can really say how much of that is being ingested. 

While I do not have an answer, I do have plenty of animosity. I cringe when I see the ER docs. Any sentence containing the phrase, "...right lower quadrant pain..." causes an extremely distasteful visceral reaction. I thought that no sound could elicit such a Pavlovian response other than the maddening chirp of my pager. I was wrong. The complex interplay of phonemes which make up the above phrase is exponentially more powerful than the simplistic beep of a pager.

Another thing which I do not understand is why I hate appendicitis so much. It really isn't that much of an inconvenience for me. It's usually a pretty short (30min) case. There is no laparoscopic equipment at Bucca - they are all done the old fashioned way. This should be a great opportunity to do a case that's rarely done back home. After all, prior to arriving here, I hadn't done an open appy in several years! Nevertheless, appendicitis carries an excessively frustrating connotation for me. I don't know if this was cultivated during my time at Ft. Bragg and simply lives on to today, or if there is some more deeply seeded hatred for this worm-shaped organ with no known physiologic purpose. Whatever the reason, I find myself here, in this most miserable of places, taking out an unprecedented number of these most miserable organs.

* - Names have been changed to protect the innocent. But they know who they are. Yes. They do.