Retracted

 Updated 3/2017-- all links (except to my own posts) removed as many no longer are active.

One of the scrub techs that I worked with this past week, asked me "Dr Bates, what causes a nipple to be inverted?"

So I begin to launch into the different grades of inverted nipples and how they can be treated, but I reined myself in. "Usually the problem is the ducts are too short. Why?"

"I have a friend who has an inverted nipple. She called and asked me. Why do they do that -- I'm just a scrub tech."

"How long has hers been inverted? And how old is she?" I ask.
"Only a little over a month. She's 35 yo."

Not an inverted nipple, but a retracted one. One of the changes you look for during a breast exam. "She needs to go see her doctor and get a mammogram. She will most likely need a biopsy of the nipple. She very likely will have breast cancer."

"I think that's what she was afraid of. Me, I'd want to know, but she's afraid to find out."
"Please, tell your friend not to put it off. I know she is afraid, but the sooner it's diagnosed the better."

There are benign and malignant reasons for a retracted nipple, but all require a history and physical and a diagnostic mammogram. There is a very nice set of algorithms for evaluation of breasts here, including a larger version of this one.

Even though this article is over one hundred years old, it is still relevant. It helps keep it all in perspective.

On the Diagnostic Value of the Retracted Nipple as a Symptom of Disease of the Breast; Br Med J. 1866 December 8; 2(310): 635–637; Thomas Bryant (PDF file)

SurgeXperiences -- Call for Submissions

Updated 3/2017-- all links removed as many no longer are active.

The 2nd season of SurgeXperiences will be kicked off by Jeffrey, Monash Medical Student, on the 6th of July. The following is a request from him:

It will have a loose theme of “Doing better”.

Why? I am currently reading Atul Gawande’s 2nd book called “Better: a surgeon’s notes on performance“.

So get that literary genius in you start typing. How you have gone that extra mile for a patient to “do better”, or what have you done to ensure others, e.g. the OR staff, to do a little more to ensure better patient outcome, etc. All submissions outside of this theme are still welcome. Please submit your posts to me via this form.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. The deadline for submissions will be midnight on July 4th. Please submit your posts here.

Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Fireworks Safety

 Updated 3/2017-- all links removed as many no longer are active.

This is a repeat of the post I did last July 2. I wish you all a safe and happy July 4th.

I love watching fireworks explode and light up the night sky. I do not like to take care of the injuries that they can cause. So please use the following tips to keep yourself and your children safe this July 4th (or consider leaving the fireworks to the experts and just enjoy the show):

• Never allow children to play with or ignite fireworks.
• Read and follow all warnings and instructions.
• Fireworks should be unpacked from any paper packing out-of-doors and away from any open flames.
• Be sure other people are out-of-range before lighting fireworks. Small children should be kept a safe distance from the fireworks; older children that use fireworks need to be carefully supervised.
• Do not smoke when handling any type of "live" firecracker, rocket, or aerial display.
• Keep all fireworks away from any flammable liquids, dry grassy areas, or open bonfires.
• Keep a bucket of water or working garden hose nearby in case of a malfunction or fire.
• Take note of any sudden wind change that could cause sparks or debris to fall on a car, house, or person.
• Never attempt to pick up and relight a "fizzled" firework device that has failed to light or "go off"
• Do not use any aluminum or metal soda/beer can or glass bottle to stage or hold fireworks before lighting.
• Do not use any tightly closed container for these lighted devices to add to the exploding effect or to increase noise.
• Never attempt to make your own exploding device from raw gunpowder or similar flammable substance. The results are too unpredictable.
• Never use mail-order fireworks kits. These do-it-yourself kits are simply unsafe.

If you need more information on the injuries that can occur, check out these sites:
Indian Hand Center
Reflections by Dr. Bruce Campbell---5th of July
Fireworks Related Injuries by the CDC
Prevent Blindness America

Memory Quilt 3

Here is the third quilt made from the shirts. It is also 50 in X 70 in. It is machine pieced and quilted. I recently finished it or thought I had, but I have since been given more patches from old hats that I am suppose to put on the quilts.

Here is a close up photo. You can the first two memory quilts here and here. This one has the same Route 66 fabric for the backing as I used for the second quilt.

Extensor Tendon Repair

 Updated 3/2017-- photos and all links (other than to my own posts) removed as many no longer are active and it was easier than checking each one.

Because there is little to protect the extensor tendons (thin skin, minimal subcutaneous tissue), they can be easily injured by knives, saws, teeth (hitting someone), etc. The extensor tendon anatomy can be reviewed here online, or in more depth offline using a good anatomy or hand surgery text.

These injuries will often include fractures or soft tissue injuries (lacerations, crush, loss of skin, etc). This post is only a brief overview of the repair of "isolated" extensor tendon laceration at the time of injury, not reconstructively later. This post will in no way make the reader an expert on extensor tendon injury/repair, but will give you a general understanding (maybe).

Injuries of the extensor tendon are defined by zones. The tendon injuries in finger Zones II-IV and VII tend to fare worse than injuries in the other zones.

Zone I --

• DIP joint of the fingers
• IP joint of the thumb

Zone II--

• Middle Phalanx of the fingers
• Proximal Phalanx of the thumb

Zone III--

• PIP joint of the fingers
• MP joint of the thumb

Zone IV--

• Proximal phalanx of the fingers
• Metacarpal of the thumb

Zone V--

• MP joint of the fingers
• CMC joint/radial styloid of the thumb

Zone VI -- Dorsum of the hand
Zone VII -- Dorsal retinaculum
Zone VIII -- Distal forearm

Primary suture of extensor tendon lacerations in all zones is the accepted standard. Indications for the need to repair include:

• Tendon laceration greater than 50%
• Tendon laceration less than 50% with significantly decreased strength compared with contralateral finger (the finger next to the one injured)
• Tendon laceration associated with significant overlying skin loss, joint space penetration, or bony fracture

Reasons not to do a primary repair include:

• Skilled physician unavailable in which case simple closure of the skin to aid in prevention of infection until the patient can be seen by a hand surgeon, sooner rather than later in a perfect world.
• Contaminated injury, particularly open zone 5 "fight bite" injury. The injury due to hitting someone in the mouth.
• Presence of bony fracture, open joint space, or significant overlying skin loss (requires an orthopedist or hand surgeon for repair) See the injury posted by Shadowfax last week.

Treatment by zone of injury
Zone I -- Mallet Finger, see my post from last year

• Management ranges from simple immobilization to aggressive open reduction and internal fixation.
• Extension splinting of just the DIP joint has become
  the standard of care for most mallet injuries. Splinting is continuous for a period of 6 to 8 weeks and may be continued longer.
• Indications for operative treatment are controversial. The three most often indications include (1) open injuries, (2) those individuals who are noncompliant or unable to tolerate
  a splint, and (3) in cases where there exists a large dorsal fragment with palmar subluxation of the distal phalanx.

Zone II -- Injuries are typically seen with sharp lacerations, saw injuries, and crush injuries.

• Acute lacerations with extensor lag present on examination need to be explored and repaired.
• If there is active extension with some weakness against resistance, it can be treated with splinting for 3 to 4 weeks.
• A running core suture oversewn with a epitendinous stitch is recommended for the repair.

Zone III --

• The treatment of acute injuries is designed to prevent the boutonniere deformity.
• Injury in this zone often involves a laceration to the central slip. Reapproximation of the central slip should be undertaken.
• Closed injuries should be treated with splinting alone.

Zone IV --

• Partial lacerations encompassing greater than 50 percent and complete lacerations are repaired with a modified Kessler technique or modified Bunnell suture using a 5-0 non-absorbable suture.
• Postoperatively, the patient is placed in a volar positioning splint.
• For the first 3 weeks, passive extension is allowed in the splint.
• At week 4, gentle active extension is monitored.
• No passive flexion is allowed at any time for the first 4 weeks. After 4 weeks active flexion is initiated and graded resistive exercises are added to the regimen.

Zone V --

• The injuries here may divide the sagittal band allowing the tendon to shift laterally. If this is not repaired, the patient may have difficulty with extension of the the proximal phalanx.
• Use of the modified Kessler or modified Bunnell is a good choice.
• The patient is placed in a dynamic extension splint for early mobilization. During the initial 4 weeks, the patient is allowed to perform active flexion to 30 degrees of MCP joint motion with passive extension by means of rubber band traction.
• The range of motion is increased gradually over the ensuing several weeks to full by the 5th week.
• After 5 weeks, the dynamic extension splint can be discontinued, provided there is no extensor lag or other complications present to interfere with motion.
• Once the splint is discontinued, the patient may begin active extension and flexion.
• Eventually, graded resistive exercises are begun to augment strength and mobility.

Zone VI --

• Injuries through or just distal to the juncturae tendinum may be difficult to diagnose because of the minimal extensor lag associated with these injuries.
• Injuries occurring proximal to the juncturae may result in retraction of the proximal tendon stump. This makes repair technically more challenging.
• Here the tendons are very superficial, covered only with thin paratenon and scant subcutaneous tissue. Degloving injuries are not uncommon and may require grafting, or local versus distant flap coverage.
• Modified Bunnell using 4-0 nonabsorbable suture is a good way to repair the tendons in this zone.
• Postoperative dynamic splinting and therapy is similar to Zone V.

Zone VII --

• Injuries in this zone may have the worst prognosis as the injuries may produce mass healing of tendons to the underlying joint capsule and surrounding retinaculum. All of that may impair tendon excursion (sliding/movement) after healing and frequently results in a tenodesis of the tendons at the wrist.
• Injuries in the wrist will often require releasing the retinaculum for visualization and repair. As much of the extensor retinaculum should be preserved as possible to prevent bowstringing of the tendons.
• Modified Bunnell or modified Kessler using a 4-0 nonabsorbable suture
• Early dynamic splinting may prevent or minimize postoperative adhesions. Often the same postop regimen as for Zone 4 is used.

Zone VIII --

• Injuries in the forearm may involve extensor muscle bellies, tendons, or the musculotendinous junctions.
• Actual muscle injuries should be repaired with liberal figure-of-8 stitches.
• Static mobilization for 5 to 6 weeks with the wrist extended to approximately 45 degrees is recommended.

Thumb Zones I - III

• Repair is similar to that of the fingers.
• A thumb spica splint is used initially. During the first 3 weeks, the wrist is positioned to 30 degrees of extension. The thumb, CMC, MCP, and IP joints are all held in an extended
  manner.
• At week 3, gentle active extension of those joints is initiated.
• At weeks 4 to 5, there is continued gentle active extension with the addition of gentle active flexion of the same joints.
• At week 6 and beyond, graded resistive exercises are initiated.

You may want to read Doc Shazam's post on Extensor Tendon Repair in Honduras --Part 3, or start with Part I and Part II and get the entire story.

REFERENCES

Extensor Tendon Repair; eMedicine Article, July 22, 2007; Adam J Rosh, MD, MS and Nancy S Kwon, MD,MPA

Mallet Fracture; eMedicine Article, June 17, 2008; Michael E Robinson, MD

Boutonniere Deformity; eMedicine Article, Jan 11, 2008; Randle L Likes, DO and Sean D Ghidella, MD

Extensor Mechanism of Fingers; Duke Orthopaedics Wheeless' Textbook of Orthopaedics Online

Extensor Mechanism Anatomy, Biomechanics and Closed Rupture of Digital Extensor Tendons; E-Hand.com; Charles Eaton, MD

Doyle, J. R. Extensor tendons: Acute injuries. In D. P. Green (Ed.), Green's Operative Hand Surgery, 5th Ed. Philadelphia: Elsevier Churchill Livingstone, 2005.

Extensor Tendon Injuries: Acute Management and Secondary Reconstruction; Plastic and Reconstructive Surgery:Volume 121(3)March 2008pp 109e-120e; Kevin R. Hanz, M.D.; Michel Saint-Cyr, M.D.; Maynard J. Semmler, O.T.R.; Rod J. Rohrich, M.D.

New Nerve Reseach

This information is from the Lahey Magazine Summer 2008 Edition, pp 6-7. Only part of it is reprinted here. The entire article can be read here (pdf file).

Led by David J. Bryan, MD—an MIT-Harvard lecturer and specialist in hand surgery and microsurgery in Lahey’s Department of Plastic and Reconstructive Surgery—the team recently presented results from original research on the use of tissue-engineered conduits in peripheral nerve (sciatic nerve) models. The study, funded by a grant from longtime Lahey benefactor Leisa V. Clayton, demonstrated that artificially engineered nerve tissue can perform as well as, and possibly better than, standard live-tissue nerve grafts in restoring lost peripheral nerve function.

The current standard of care calls for using live nerve tissue taken from other parts of the body. According to Bryan, autologous (self-donated) nerve grafts have limitations in terms of availability, side effects—mainly loss of sensation in the donor site—and clinical effectiveness. To overcome these challenges, the Lahey team collaborated with an outside engineering group to create a custom-made, bioengineered blend of synthetic polymers and proteins using sophisticated spinning equipment.

Electrospinning—an application of the emerging field of nanotechnology—allows researchers to create minute quantities of a desired cellular fiber for use in peripheral nerve tissue grafts. The artificial material created at Lahey has all the desired qualities needed for the ideal nerve graft: biocompatibility, porosity, biodegradability and the ability to promote growth of new blood vessels in damaged nerve tissue. Bryan reports that nanotechnology has allowed his research team to make great strides in understanding how nerve cells communicate, grow and regain function. Proteins—organic compounds that play a vital role in all basic cell processes—are the key to understanding the inner working of nerve tissue, he explains. Looking to the future, Bryan is extremely excited about the emerging field of proteomics, the study of proteins in living cell tissue.

Grand Rounds, the iPhone Edition

Updated 3/2017-- all links removed as many no longer are active.

You don't have to stand in line for this iPhone 3G edition of Grand Rounds. Just head on over to MyThreeShrinks (Shrink Rap) and settle in.

Welcome to Grand Rounds, Volume 4, #40 (see future GR schedule). If you missed our first Grand Rounds last year, with our amazing Clicky Brain, then feel free to pause and enjoy. This year, since the anticipated release of the Apple iPhone 3G is just around the corner (July 11), we asked for submissions to have some connection to the iPhone, no matter how twisted the logic is to make the connection. The bloggers obliged. So we are including, free of charge, our Clicky iPhone, which will let you visually navigate this week's Grand Rounds submissions. Of course, below that is the regular text for you old-schoolers. And if you have low vision or prefer to LISTEN to your Grand Rounds, you can get our PODCAST of it HERE.

Their Clicky iPhone is wonderful! You really need to head on over there and try it out.

Now, a request from me. I am trying to decide whether I am tech savvy enough to use the iPhone (and all it's features). I am not an Apple user. Will I be able to get it to work easily with my Windows PC to "sync" my calendar, addresses, etc? I have gotten some input from a few friends (Vijay, Symtym, Laura), but any other would be appreciated. I really want one, just want to be able to do everything without too much frustration. I don't think I am very tech savvy. Thanks for your input.

Don't you just love.......

Updated 3/2017-- video and all links removed as many no longer active.

Grunt Doc posted yesterday about having a run-in with a skunk. It left his car with a not so funny smell. My husband tells a story about a time when he and his friend Dave went to a car show. They had been sitting in the car with the doors closed, checking out all the features. Finished with their inspection, they exited. One of them farted just as they stepped out of the car. [My husband always says it was his friend, but knowing my husband it could easily have been him.]

Simultaneously, an exhibitor opened the door on the opposite side for a couple to enter the car and check it out. His words, "Don't you just love that new car smell."

Medical Tourists

Updated 3/2017-- all links removed as many no longer are active. 

The first or second year I was in practice I received a call from Dr Gaspar Anastasi. He had been the head of my plastic surgery residency while I was at Boston University Hospital. He was calling to ask me to do follow up for him on an otoplasty patient who lived in Arkansas. I readily agreed. In fact, I was honored that he would ask.

These days we think of the medical tourist as someone who goes to another country (ie. from the USA to Singapore for an operation), but in some ways the same issues may arise when the patient simply goes out-of-state to have a procedure done. They are not always ready, willing, or able to go back for follow up. This is especially true if a complication arises, be it small (missed stitch) or large (wound infection). They may have used up all their vacation time and not want to take the days off for travel.

I have had patients come to me from Nevada, Arizona, Texas, Louisiana, Tennessee, and Mississippi. Usually because they have family that lives here. They plan on staying with them while they recover. Still, I ask the ones who are more than 3 hours away if they are willing to stay around 10-14 days after surgery before agreeing to do the procedure. I ask them if they are willing to return if the need arises or if they have a local physician who is willing to help out. I try to make them think about what could happen. Even the ones who live closer I try to outline the follow up that will be expected.

There is a nice article in this month's Contemporary Surgery Journal discussing the ethics of caring for/refusing to care for a patient who comes to you with a complication after having their surgery elsewhere. You can read it here (may have to register).

A former patient presents with general malaise and reports having had low-grade fever. The examination is unremarkable, but laboratory tests indicate an infection not isolated to an organ system. Groin and blood cultures are positive for MRSA.

A while ago you diagnosed an abdominal aortic aneurysm in this patient, but she went to India for aortic endograft placement. You are considered an authority on graft infection. What should you do?

A. Tell her to return from whence she cometh.
B. Alert the media to the problem of cheap international medical care.
C. Advise the patient to sue in International Court.
D. Care for her as you would any patient.
E. Tell her that once a patient leaves your care, she leaves permanently.

My answer is D. Though I wish the patient would come to me for the entire "package", I would do what needed to be done. I would prefer to meet them before the initial surgery, but we don't always have that luxury. I would prefer that I could try to get them to do their care (if it is available, though specialized care is not always) closer to home or at least at a distance they are more willing to travel as needed. I would prefer that the surgeon call me and let me know that he would like me involved in the postop care.

Is it possible that this concept of international travel for surgery is here to stay? Most likely. So maybe the patient should find a "local" surgeon who would be willing to do the postoperative care when they return. The patient could then give their "international" surgeon the name, address, phone number, and e-mail address of the "local" surgeon so that information could be communicated and care coordinated.

What would your choice be?
Article:

The Medical Tourist Whose Outcome Went South; Contemporary Surgery, Vol 64, No 6, pp 290-291; James W Jones, MD PhD, MHA (This article was condensed from: Jones JW, McCullough LB. What to do when a patient’s international medical care goes south. J Vasc Surg. 2007;46;1077-1079.)

SurgeXperiences 124 is up!

 Updated 3/2017-- photos and all links (other than to my own posts) removed as many no longer are active and it was easier than checking each one.

The FINALE edition (124) of the FIRST season of SurgeXperiences is up! Dr T, Notes of an Anesthesioboist, is our host. (photo credit)

The loose theme for the collection was "Secrets and Surprises" - what season finale would be complete without a few of those?

Yet there's another ingredient that no real season finale would be complete without. It's The Unanswered Question. The Unsolved Mystery. Unfinished Business. Arguably it's why any of us keeps returning to any realm of inquiry or learning.

The world of medicine abounds with unanswered questions. While they might not show up here in the form of a conventional "cliffhanger ending," they're here all right...lurking behind the answers to other questions, the often-untidy "resolutions" to stories, and in situations that remain unresolved altogether and that keep us wondering about doctors, nurses, patients, the O.R., the characters in the vast series of episodes that comprise life in medicine today.

Very nice edition! I hope you will go over and enjoy reading.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. The 1st edition of the second season will be be hosted by person who started it all --Jeffrey Leow, Monash Medstudent, on July 6th. The deadline for submissions will be July 4th. Please submit your posts here.

Here is the catalog of past surgeXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Memory Quilt II

I posted about the first memory quilt made back at the end of May. Here is the second one I have finished. It is from the strips and has three pockets (all working pockets). This one is 50 in X 70 in. It is machine pieced and quilted. I used the Baptist Fan pattern for the quilting.

Here you can see some of the shirt labels and one of the pockets.

The fabric used for the back of this one features Route 66. The man who is being remembered with these quilts had planned to drive Route 66. He never got to take that trip.

Ring Finger Avulsion

 Updated 3/2017-- all links removed as many no longer are active.

Dr Smak:

Mr. Zink was the coolest teacher in my middle school. Everyone liked him: nerd, jock, cheerleader alike. He taught science, and if you were lucky you got him two years in a row. In those few minutes after the lesson finished, but before the bell rang, he would tell us the grossest stories that he knew.
I still remember them. The one about the kid playing basketball with his class ring on, who left his ring and its attached finger on the rim after a dunk, connected by all the tendons from his finger to his shoulder. (Can that really happen?)

Yes, that can happen. Well, not the "to his shoulder" part as the tendons to the fingers don't originate that high in the arm, but the avulsion of the ring finger can and does. (III type injury) A typical story may be

She had avulsed the skin off her ring finger of her right (dominant) hand whilst attempting to jump over a spiked fence, catching her ring on the spike.

The physics/mechanics of the injury is explained well here.

The first 1998 study conducted under Dr. David M. Kupfer, Department of Plastic and Orthopaedic Surgery, University of San Diego in California, involved dropping a 30-pound weight attached to a ring bearing finger hanging from a hook, from a 9-inch height.

Results showed that in more than 90% of cases, the injuries caused by rings and wedding bands are Class II (29%) and Class IV (61%). On the tested sample (41 fingers), Class I injuries (10%) occurred at less than 80 N and the first ring avulsions at 111 N. Maximum finger resistance is 346 N with average resistance at 154 N. Film records also show that the skin is the finger’s strongest part. Once the skin tears, the remaining finger degloves or quickly avulses. Accordingly, although thin and narrow or tight rings are less resistant to traction and cause the skin to shear under traction, they are more dangerous than wide, thick rings.

Classification of Injury (Urbaniak)
Class I

• Circulation adequate.
• Standard bone and soft tissue treatment is sufficient.

Class II

• Circulation inadequate.
• Vessel repair preserves viability permitting immediate or delayed repair of other tissues

Class III

• Complete degloving or completed amputation.

• Judgement is essential because, although a complete amputation can be revascularised and viability restored, the potential for function is limited.
• In degloving injuries, the potential for useful function exists, but revascularisation is not easy or may not be possible.

These injuries are best avoided.

Be careful if you are in the building/construction, logistics and transportation industries. Consider not wearing your wedding ring while at work (that's exactly what I have told my husband).

Remove any rings or wedding bands during activities where the risk of injury is especially high. This includes many DIY activities, gardening, and handling heavy objects.

Your thumb, index, and middle fingers are most crucial for hand function. Consider wearing rings only on the ring or pinkie.

REFERENCES

Ring Avulsion Injury: The Do's and Don'ts of Initial Management; The Internet Journal of Orthopedic Surgery ISSN: 1531-2968; A Atrey, MRCS, P Landham, MRSC, T Lasoye, FRCS

Recommendation on the Risk of Wearing Rings and Wedding Bands; THE CONSUMER SAFETY COMMISSION (15th December 2005)

Finger Avulsion Injuries: A Report of Four Cases; Indian Journal of Orthopaedics, Vol 42(s), pp 208-211, 2008; Fejjal N, Belmir R, El Mazouz S, Gharib NE, Abbassi A, Belmahi AM

Microvascular management of ring avulsion injuries; J Hand Surg Am 1981;6:25-30; Urbaniak JR, Evans JP, Bright DS. [Pubmed]

Some Shout Outs

Updated 3/2017-- photos and all links removed as many no longer are active and it was easier than checking every one. 

Grand Rounds 4:39 comes to us from the South Pacific this week. It is hosted by David Khorram at his blog, Marianas Eye. David is an eye surgeon and author. You can check out the book here. Back to grand rounds, here's what David has to say:

I’ve always wanted to be a newspaper editor, not because I want to edit, but because I want to write headlines. And not for a respectable paper like the New York Times. Maybe for a newspaper, like the Enquirer -- you know, where an editor can have some creative freedom with the facts. So, finally, I get my chance with this week's Grand Rounds. Sometimes the headlines I’ve written relate to the post, sometimes, they are just a whacked out free associations. Like all headlines, their purpose is to get you to read the posts. I hope I can entice you. There are some really great writers out there. Great job everyone.

I say he did a great job! Hope you will check it out.

Dr David Loeb will be the guest this week on the Dr Anonymous Blog Talk Radio Show. Dr David is a pediatric oncologist at John Hopkins. It should be a very interesting interview. I hope you will join us in the chat room.

Tips for first time Blog Talk Radio listeners (from Dr A):

For first time Blog Talk Radio listeners:
*Although it is not required to listen to the show, I encourage you to register on the BlogTalkRadio site prior to the show. I think it will make the process easier.
*To get to my show site, click here. As show time gets closer, keep hitting "refresh" on your browser until you see the "Click to Listen" button. Then, of course, press the "Click to Listen" button.
*You can also participate in the live chat room before, during, and after the show. Look for the "Chat Available" button in the upper right hand corner of the page. If you are registered with the BTR site, your registered name and picture will appear in the chat room.
*You can also call into the show. The number is on my show site. I'll be taking calls beginning at around the bottom of the hour. There is also a "Click To Talk" feature where you do not need a phone to call into the show - only a microphone headset. Hope these tips are helpful!

And a reminder to get those posts in for the FINALE edition of the FIRST season of SurgeXperiences! The host will be anaesthesist Dr. T at her blog Notes of an Anesthesioboist on Sunday June 22, 2008. Deadline for submission is midnight Friday June 20th. T's request:

Tonight I was honored once again to be invited to host the SurgExperiences blog carnival for its final edition of the season, SurgExperiences 124, to be posted on June 22. I am considering the theme "Secrets and Surprises," but the last time I thought I might have a theme, the collected works morphed into something else - so again, the "theme" isn't written in stone!

Please submit your posts here or email her directly at anesthesioboist@gmail.com with a link to your post.
Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Strokes

"Beep*Beep*Beep"

I tried to drag myself from the deep slumber I was in. It was 1:30 am, Sunday night or Monday morning depending on how you look at it. No quite what Buckeye called the "witching hour" but close and my brain was acting as if it were.

I turned on the kitchen light so I could read the number and to help jump start my brain. It read 555-3028, Debra Peel. My brain--"who the heck is Debra Peel".

I punched in the number 555-3028. "Hello, this is Dr Bates. Someone had me paged."
"No one here paged any doctor."
"I'm sorry. This is the number I was given."
"This number is 555-0328."
"I'm sorry."

I hang up and try again, being very careful to punch the correct numbers. "Hello, this is Dr Bates. Someone had me page."

"Dr Bates, this is Mr Debra Peel. You operated on my wife three days ago." Now my brain fires with the memory of his wife and her surgery. It had been an easy surgery in a 61 yo healthy female. The surgery had take one hour and there had been no problems during or after (until now).

"Yes, Mr Peel. How can I help you?"

"My wife is complaining of a funny feeling in her right face and arm. Would her pain medication do that to her?"

"Mr Peel, will you tell me more about that funny feeling?"
"Dr Bates, here's my wife. I'll let her tell you."

Debra Peel, "Dr Bates, I had a bit of a right-sided headache with a tingling/numbness of my right face around nine. I took some Tylenol and went to bed. I thought it would just go away, but now it's worse and my right arm feels funny. Do you think my pain medication could be causing this?"

My brain is trying to access the input--no slurred speech, no audible breathing problems. "Anything else? Any chest pain?"

"No, I can breath fine. My chest doesn't hurt. Could my pain medicine be causing this?"

"Ms Peel, you need to go to the emergency room and let them access you for a problem in your head or heart. You need to hang up the phone and go to the emergency room now." My brain is thinking TIA or stroke.

"You don't think it could just be my pain medication?"

"No, Ms Peel. Your pain medication would effect both your arms, not just one. Please, go to the emergency room and let them check you out."

"Okay, we'll go to **Hospital"

I put the pager up, turned off the kitchen light, and went back to bed. My brain did not return to it's nice slumber. The next morning -- I mean later that morning--around 10 am, I called the Peel home to see if I could find out what had happened at the hospital.

"Hello, Ms Peel, this is Dr Bates. How are you doing? Did they find anything?"

"Dr. Bates, they did an EKG and a brain scan. I had an episode while I was there so they got to see it. They didn't find anything wrong though."

An hour later, my phone at the office rings and it's Ms Peel. "Dr Bates, the hospital called me back. The radiologist read the brain scan and found a blocked artery in my head. I'm suppose to go see my family doctor. I have an appointment tomorrow with him, so can we change my appointment with you to another time."

"Thank you, Ms Peel, for letting me know. Sure, would you like to come in today for me to remove your sutures?"

The symptoms of stroke are distinct because they happen quickly:

• Sudden numbness or weakness of the face, arm, or leg (especially on one side of the body)
• Sudden confusion, trouble speaking or understanding speech
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance or coordination
• Sudden severe headache with no known cause

Patients' Fears and Dreams

Patients will sometime have dreams (nightmares?) before their surgery similar to the "got up to give my book report and I had no clothes on" ones from our younger school days. Some of them are understandable -- you can "see" a thread that connects the procedure and the anxiety and the dream. A good example of this is the 4th Season episode of Roseanne "Less is More" which dealt (very nicely) with her breast reduction surgery. In the episode she had a dream where she woke up after surgery and actually had larger breasts. She was dressed as Madonna in the "cone bra". I've had breast reduction patients tell me versions of this one.

Recently an abdominoplasty patient was talking to me before surgery. I was trying to answer any last minute questions or concerns. She needed to tell me about the dream she had the night before.

Patient-- I remember hearing you say as I went to sleep in the operating room, "I can't make a straight cut with the patient on this water bed."

Me -- A water bed?

Patient -- Yes. I know it makes no sense, but I was on a water bed. And my brother-in-law was assisting you and he was wearing a clown outfit.

Me -- Well, are you okay with going ahead this morning. We don't have any waterbeds here.

Patient -- Yes. I'm just a little nervous, but I really want the surgery.

Everything went well. The incisions were straight as I didn't have to fight the waves of a water bed. I was thankful for that (smiling to myself here).

SurgeXperiences 124 -- Call for Submissions

Updated 3/2017-- all links removed as many no longer are active. 

It time for the FINALE edition of the FIRST season of SurgeXperiences! This edition will be hosted by anaesthesist Dr. T at her blog Notes of an Anesthesioboist on Sunday June 22, 2008. T's request:

Tonight I was honored once again to be invited to host the SurgExperiences blog carnival for its final edition of the season, SurgExperiences 124, to be posted on June 22. I am considering the theme "Secrets and Surprises," but the last time I thought I might have a theme, the collected works morphed into something else - so again, the "theme" isn't written in stone!

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. The deadline for submissions will be midnight on June 20th. Please submit your posts here or email her directly at anesthesioboist@gmail.com with a link to your post.

Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Please, help make this a truly great finale and submit a post. Thanks Jeffrey for getting this surgery carnival started.

Adventures with Zippy

 Updated 3/2017-- all links removed as many no longer are active.

Zippy the Lobster is making the rounds of Dr Rob's blog friends. He is trying to raise awareness and money for pediatric brain tumors. He was recently here in Arkansas to spend time with Rusty and me. He arrived in Arkansas after visiting the Calhoun's in Louisiana (Charming BB). We all had a great time. You can check out his pictures of his Arkansas visit here. You can visit Zippy's blog that chronicles all his adventures here. You can make a donation to his nonprofit (Childhood Brain Tumor Foundation - MD) here.

Before leaving Arkansas to visit PK in Oklahoma, Zippy helped me make a fruit basket to take to the Father's Day picnic.

Happy Father's Day to all you fathers out there!

Raising Money for Childhood Cancer Research

Updated 3/2017-- all links (other than to my own posts) removed as many no longer are active and it was easier than checking each one.

Many of you know that Dr Smak's son Henry was diagnosed with brain cancer last fall. His sister Anna will be hosting a lemonade stand July 4th. You can help. Here's how:

The Scheck house will be hosting our very own Alex's Lemonade Stand on the 4th of July.

Alex's Lemonade Stand Foundation is a unique foundation that evolved from a young cancer patient's front yard lemonade stand to a nationwide fundraising movement to find a cure for pediatric cancer. What makes the foundation different is that it's model inspires people who would not be likely to donate to childhood cancer to make donations with the reassurance that "no donation is too small".

The fourth of July is traditionally in our neighborhood an insanely huge community yard sale. Since it falls on a Friday this year we expect big crowds. Our garage is packed full of yard sale fodder, proceeds which also will be donated to the foundation.

In addition to raising money from the lemonade sales, Anna is soliciting friends and family to pledge an amount of money for each cup of lemonade sold. This obviously greatly accelerates the earnings, and will hopefully motivate our "customers" to buy plenty of lemonade! If you're interested in sponsoring Anna, please email Bryan at mailto:bryanscheck@gmail.com so we can sign you up. We have donations ranging from 25 cents to a dollar a cup (!), and we have set an ambitious goal of raising $1000. Additionally, some people have felt more comfortable giving a flat donation, which we are also very grateful to receive.

There is a website designed to take the donated money here (link no longer active, 3/2017). Once the big day is over, we will call or email you to let you know what your donation is based on cups sold. You can then donate over the website.
Thank you for joining us in the fight against childhood cancer... one cup at a time!

I hope you will help them surpass their goal. I have sent my e-mail to Bryan already.

I Received My Quilt

Updated 3/2017-- photos and all links (other than to my own posts) removed as many no longer are active and it was easier than checking each one.

Back in April I was invited to participate in "Another Little Quilt Swap". I finished my little quilt (laced ribbons quilt) in May and mailed it to ____. Wednesday I got home to find I had received my quilt. Paula Dennee, otherwise known as Paula the quilter, is the maker of mine. She named it "One of These Things is Not Like the Others" and you can see it posted on her site here. I absolutely love it! She sent a note along with the quilt to explain her inspiration. She gave me permission to share it. It makes me love it even more.

I wanted to include a note about your little quilt. The first time I went to your blog was April 18. That picture stayed in my mind and this little quilt was the result.

In an email she shared this regarding the quilting which you can appreciated in the picture of the back.

O. And did you notice that I quilted it in the swirly type motion used for breast self exam? I certainly had fun making this. So glad you liked it.

Paula, I am thrilled with this quilt. Thank you so very much.

A Lot of Hot Air?

There is an article in the Cosmetic Surgery Times Vol 11 No 5 2008 on the subcutaneous injection of carbon dioxide (CO2). The treatment is called carboxytherapy.

Subcutaneous injections of carbon dioxide (CO₂) can safely and successfully treat cosmetic concerns such as skin laxity and fatty deposits that may remain following liposuction, as well as psoriasis and hair loss, says an expert based here. Additional uses for this treatment — called carboxytherapy — include stretch marks, scars and cellulite, he says.

This is the first time I have ever read or heard of carboxytherapy. So I did a search using carboxytherapy on Medscape -- no articles. I searched the database of the Journal of Plastic and Reconstructive Surgery -- no articles. I changed the search to carbon dioxide/ subcutaneous injections and got this one relevant hit:

• Carbon dioxide therapy in the treatment of localized adiposities: clinical study and histopathological correlations. Aesthetic Plast Surg, May 2001

I didn't do any better with a google search. At least not for scientific information. So back to the CST article, here is a description of carboxytherapy:

I've been using this technique for more than a year, and getting fantastic results," says Raphael Nach, M.D., a head and neck surgeon in private practice. He estimates that he has treated at least 40 patients for post-liposuction problems such as persistent islands of fatty tissue, skin irregularities and skin laxity. Dr. Nach explains that by adding CO₂ gas to the subcutaneous tissues, localized post-operative accumulations of fat can be reduced or eliminated." Alternative forms of treatment have been advised to assist the general recuperate process," he says, "but none have been as successful in eliminating these localized fatty deposits."

TECHNIQUE IN BRIEF The technique requires no anesthesia. First, one sterilizes the skin with Hibiclens (chlorhexidine topical antiseptic; Mölnlycke Health Care U.S., Norcross, Ga.) or its equivalent, he details. "Then a 30-gauge needle connected to the carboxytherapy machine is used to infiltrate the tissues with different volumes of carbon dioxide gas, depending on the condition that's being treated," Dr. Nach explains. A typical treatment site requires about 50 cc to 200 cc of gas, injected either once or twice a week, he says. Each session lasts 15 to 20 minutes. Depending on the treatment area, he says, four to six puncture sites with the 30-gauge needle may be necessary.

I found some references that state that this procedure is FDA approved (including Dr Nach), but according to the ASPRS website (2008) it isn't.

Carboxytherapy
Injection of carbon dioxide for cosmetic purposes, namely to treat cellulite. Not U.S. FDA approved.

I then tried a search of the FDA website and got no hits on carboxytherapy or carbon dioxide/ cellulite.

So for now I would suggest being very skeptical of any claims that carboxytherapy would improve anything. Dr Oliver or anyone else have any information on this? Preferably scientific information.

Grand Rounds 4:38 is Up

Updated 3/2017-- all links removed as many no longer are active.

Grand Rounds is up across the pond at NHS Blog Doctor. Dr. Crippen begins this edition with

Dr Crippen was particularly addicted to ER as are a lot of British doctors. What would Mark do? we always asked when there was an emergency. Sadly, suddenly Mark was no longer with us. Medical life has not been the same since.

My favorite character of that show ER was always Dr Peter Benton. The show lost it's appeal for me when he left the show.

Ian Furst, Wait Time and Delayed Care, feels that Dr Crippen left out his (Dr. Crippen's) own post on Dr. John Briffen. Ian feels it is a must read. It is an interesting post.

Thanks to Dr. Crippen for putting all these "good reads" together for us.

And don't forget to listen to the Dr Anonymous Show tomorrow night at 8 pm CST/ 9 pm EST. His guests this week will be David Best, MD and Michael Banks, MD from The Doctors Channel. Come join us in the Chat Room which is always fun.

My Friend Lisette

Late Friday night, June 6, 2008, my friend Elizabeth "Lisette" Marie Columbo Johnson lost her fight with ovarian cancer. She was only 56 yo. I meet her in the OR where she was a surgical nurse. I loved working with her. She was good -- as a person, at her job, to the patients, to her colleagues. She was beautiful. She was so full of life and shared her passions with us in stories.

She loved that I had named my dog Columbo. "That's my maiden name." She would often ask about him and my other dogs. She had a black Labrador when we first met so we shared many dog stories. At some point a roadrunner took up residency near her home. The bird would visit her deck. She brought in pictures of the roadrunner just sitting on a deck chair for us.

She loved to travel (India, Russia, Africa). I loved her travel stories and pictures. I would have loved to have been a team member with her on "Amazing Race". She would have made me more adventurous.

From her obituary:

Lisette was born in Darby, PA and graduated from the University of Pennsylvania. She spent most of her career as a surgical nurse in Dallas and Little Rock. In Dallas she was active in charity work and was a past Chairman of the Multiple Sclerosis Society’s Yellow Rose Gala.

She was an avid outdoors enthusiast, animal advocate, sporting clay shooter, traveler and mah-jongg player.

She touched the lives of many and was an inspiration to us all. She will be dearly missed. In lieu of flowers, please make a donation to the Ovarian Cancer Research Fund or the ASPCA.

For more information on ovarian cancer:
National Cancer Institute -- Ovarian Cancer Page
Center for Disease Control -- Ovarian Cancer
Ovarian Cancer Awareness Organization
Ovarian Cancer Symptoms --TBTAM

Hi!

Updated 3/2017-- video and all links (other than to my own posts) removed as many no longer are active and it was easier than checking each one.

Dr Rob's recent post, Hi Doc! got me musing about my encounters with patients outside of the office. Very often the reactions to a plastic surgeon aren't the same as the reactions to the family physician.

I get some who readily want to acknowledge that they know me. This can be in the "groupie/fan" kind of way or "friend (want-to-be)" kind of way.

The "fan" is happy to tell anyone who is present "This is the doctor who did my breasts. They are just perfect. Dr Bates' is the one I've been telling you to go see." This one I sometimes enjoy, even though I often am embarrassed by their gushing. I have had to stop a few of these from showing off their scars in the store. One even offered to show my husband "my work" (which I did not allow).

The "friend" -- "Hi Ramona. JB, this is my plastic surgeon. The one who did my scar. She's the one we need to go see for our BOTOX." In the back of my mind, I can't help wondering if this one is "fishing" for a discount for bringing me business.

Then there are the ones who don't want to acknowledge they know me professionally. "Didn't I meet you at that charity event?" "I remember meeting you at C and D's." I try to play along without resorting to bald-faced lies. They don't want whoever is with them to know they have seen a plastic surgeon. They might have to explain why.

There are some who don't even want to acknowledge they have met me in any capacity. You can see the fear in their eyes begging "don't know me, don't know me". These I will just smile at and once again taking their lead take the "friendly stranger" interaction. They really don't want anyone to know they have seen a plastic surgeon. They can't think of any other reason they should know me to give to their friends/colleagues. The one I remember the most was a young reporter years ago. I had done a breast reduction for her and happened to see her in a store where she was setting up to broadcast a report.

For this last patient, it helps that I don't really look like most peoples idea of a plastic surgeon. In fact, if I was to be on the game show, Identity, I would probably be a stumbling block for most. When you run into me at Wal-Mart of Kroger, I will often be in jeans or shorts and look like I could use Stacy and Clint's help with my wardrobe.

I'm happy to acknowledge you if we meet in the public eye, but if you don't want to acknowledge me that's okay too.   If you do want to talk to me, let's try to keep it social.  Remember I'm "off work".  As Lynyrd Skynyrd puts it "if you want to talk fishin, I guess that'd be okay"  or in my case dogs or quilting.

SurgeXperiences 123

Updated 3/2017-- all links removed as many are no longer active.

SurgeXperiences 123 is up over at The Sand Man. QuietusLeo has done a great job. You can read it here.  It represents the fact that he is a Leo and puts people to sleep (anesthesiologist) for a living.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. The 24th edition will be be hosted by , (host still needed), on June 22nd. The deadline for submissions will be June 20th. Please submit your posts here.

Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Dog Bite Prevention

Once again I missed National Dog Bite Prevention Week. It's the third full week of May and it's already the end of the first week of June. I don't think it ever hurts to review this information as more than 4.7 million people a year receive bites from man/woman’s best friend and I dearly love my dogs -- deceased ones (Columbo, Ladybug (photo), and Girlfriend) and the living one, Rusty.

Many cities and towns across America are beginning to restrict by out-right ban or by registration of certain breeds. In Little Rock, a new city ordinance requiring all pit bulls in the city to be registered, sterilized, and microchipped took effect. This ordinance was passed because of an increase in attacks which are said to be unprovoked.

The following is a re-posting of my Dog Bite Prevention post from last June. Maybe next year I'll get one published on during the third week of May.

Each year, nearly 1 million Americans seek medical attention for dog bites; half of these are children. Most dog bite-related injuries occur in children 5-9 years of age. Almost two thirds of injuries among children 4 yrs or younger are to the head or neck region. Dog bites are a largely preventable public health problem, and adults and children can learn to reduce their chances of being bitten.

Basic safety around dogs:
• Do not approach an unfamiliar dog.
• Do not run from a dog and scream.
• Remain motionless (“be still like a tree”) when approached by an unfamiliar dog.
• If knocked over by a dog, roll into a ball and lie still (“be still like a log”).
• A child should not play with a dog unless supervised by an adult.
• A child should immediately report stray dogs or dogs displaying unusual behavior to an adult.
• Avoid direct eye contact with a dog.
• Do not disturb a dog who is sleeping, eating, or caring for puppies.
• Do not a pet a dog without asking permission from its owner first.
• Do not pet a dog without allowing it to see and sniff you first.
Things to consider before adding a dog to your household:
• Learn about suitable breeds of dogs for your household.
• Dogs with histories of aggression are inappropriate in households with children.

• If your child is fearful or apprehensive around dogs, then don’t get one. it will not make the child less fearful.

• Spend time with a dog before buying or adopting it. Use caution when bringing a dog into the home of an infant or toddler.

• Spay/neuter virtually all dogs (this frequently reduces aggressive tendencies).
• Never leave infants or young children alone with any dog.
• Do not play aggressive games with your dog (e.g. wrestling).

• Properly socialize and train any dog entering the household. Teach the dog submissive behaviors (e.g. rolling over to expose abdomen and relinquishing food without growling.

• Immediately seek professional advice (e.g. from veterinarians or animal trainers) if the dog develops aggressive or undesirable behaviors.

Snail's Trail Quilt

This quilt pattern is different from the previous snail's trail quilt I made. This quilt is for a friend. I picked out the colors with "I like earth colors" in mind. So in my mind the browns are obviously for the earth. The green for the grasses and trees of the earth. The blues for the rivers, lakes, and oceans. The reds/pink for the sunrises and sunsets.I debated with myself on which layout I liked best. Each block is 5 in square (finished, 5.5 in with seam allowances).

Here is the finished quilt. It is 40 in X 50 in. Each of the arc pieces are machine pieced and then hand appliqued to a square. The squares were then machine pieced. The machine quilting is overlapping circles in a variegated brown.

Here is a closer shot. I mailed the quilt earlier this week.

High Pressure Injection Hand Injuries

Updated 3/2017-- photos and all links (other than to my own posts) removed as many no longer are active and it was easier than checking each one.

Thankfully high-pressure injection injuries to the hand are uncommon because they have the potential to cause devastating consequences. To complicate things, these injuries often look innocuous with their initial presentation. Despite this innocuous looking injury, these accidents should be treated as limb-threatening injuries and immediately referred to a hand surgeon.

The three most common devices responsible for these injuries are:

1) grease guns -- A force of 100 to 200 psi (pounds per square inch) is generated by air compressors to propel the grease through the lubricating mechanism. The actual force is amplified by a pump and a reducing nozzle, so that a pressure of 5000 to 10,000 psi is generated.

2) spray guns -- A hydraulic pump forces paint through the spray gun at pressures up to 5000 psi.

3) diesel fuel injectors -- Pressures from 2000 to 6000 psi

The most commonly injected substances are automotive grease, diesel oil, paint, and varnish. Other substances reported include paint thinners, oil, molding plastic, cement, wax, air with rust, water with sand, and sealers (ref 6). There are reported injuries due to the solvents (ref 4) in the garment dry cleaning industry (isoparaffinic hydrocarbons, methoxypropanol, and dichlorofluoroethane) and also with Freon. Typically, paint and paint thinner injuries have much worse outcomes than grease gun injuries.

Injuries occur most often in men. The left hand (usually the non-dominant) is involved in nearly 2/3's of the cases. The most commonly injured site is the index finger, followed by the palm and the long finger. Direct contact with the skin is not necessary for injury. The jet may penetrate through gloves and other protective garments.

Mason and Queen in 1941 divided the clinical findings into three states:
Acute --

• The immediate symptoms result from the injection of the foreign material are swelling, numbness, and vascular insufficiency.
• This distention of the tissues may cause a pressure buildup that exceeds hydrostatic pressure, limiting tissue perfusion similar to that in compartment syndrome.
• The chemical injury caused by the substance itself may result in tissue destruction and an inflammatory reaction (which leads to more swelling, which may further compromise the tissue perfusion)
• Infection may occur in the necrotic tissue or from contamination from the substance injected.
• Initially, the patient may complain only of mild pain and may even continue working, leading to a delay of care. The injured area may at first seem inconspicuous, presenting as a small pinprick, and caregivers who may not be familiar with this injury may regard it as insignificant. The finger eventually becomes painful, numb, bloated, edematous, tense, pale, and cold.
• Radiographs may help assess the extent of the spread of the injected material, which may present as air in the soft tissue, or as radiopaque material in other cases.

Intermediate

• Oleomas often develop following the acute phase. These are nodular "tumors" that develop as a result of a foreign body reaction to the injected material.
• Oleomas may remain unchanged for years, but fibrosis often occurs with them, leading to loss of function. Because of this, oleomas should be excised completely along with any fibrosis associated with them.

Late

• Skin overlying the untreated oleoma may breakdown. This may lead to ulcer and draining sinus formation.
• The skin becomes thick and pitted.
• The ulcers and draining sinuses may become infected.
• Development of squamous epithelioma in the sinuses have been reported.

The following guidelines are suggested for optimal treatment:
1. Early medical evaluation, including radiographic studies.

2. Prompt surgical consultation. Patients treated properly within 10 hours of injury had much better outcomes than those treated in a delayed fashion.

3. Administration of tetanus prophylaxis and intravenous antibiotics.

4. Elevation and splinting before and after surgical exploration. Do not use cooling packs to control edema because their use may further compromise tissue perfusion.

5. Surgical exploration using general anesthesia or axillary block. Digital and local blocks may contribute to tissue edema and are associated with worse outcomes.

6. Use of an extremity tourniquet to establish a bloodless operative field after exsanguinating the arm by elevation. Esmarch bandage exsanguination may cause further spread of the injected toxins into tissue planes or compartments.

7. Wide surgical exploration, including decompression of tissue compartments, debridement of nonviable tissue, and high-volume saline irrigation. Particular attention should be directed toward fluid tracking around neurovascular bundles. Flexor tendon sheaths are less likely to be involved.

8. Wound cultures when appropriate to direct antibiotic therapy.

9. Consider leaving the wound open, with a planned second look operative irrigation and debridement.

10. Consider early amputation of a cool or poorly perfused digit.

11. If edema is significant, consider administering 100 mg of hydrocortisone intravenously every 6 hours until improvement is observed. Change to 25 mg of oral prednisone daily and taper over 3 to 5 days. Restart hydrocortisone if edema, erythema, or pain worsens. [Controversial.]

12. Frequent postoperative reassessment and return to the operating room if indicated.
13. Early postoperative hand therapy to maximize functional outcome.
Prevention of these injuries is the best.


REFERENCES

1. High-Pressure Injection Injuries of the Hand; Plastic & Reconstructive Surgery. 45(3):221-226, March 1970; Ramos, Hernando M.D.; Posch, Joseph L. M.D.; Lie, Kim K. M.D.

2. Conservative management of a high pressure injection injury to the hand; Plastic & Reconstructive Surgery. 72(5):742, November 1983; Kelleher, John C.; Kendrick, R. W; Colville, J.

3. UPPER EXTREMITY: Emergency management of high pressure injection injuries of the hand; Plastic & Reconstructive Surgery. 83(2):403, February 1989; El, Helaly M.; Beheri, Gamal E.

4. High-Pressure Hand Injection Injuries Caused by Dry Cleaning Solvents: Case Reports, Review of the Literature, and Treatment Guidelines; Plastic & Reconstructive Surgery. 111(1):174-177, January 2003; Gutowski, Karol A. M.D.; Chu, Jason M.D.; Choi, Mihye M.D.; Friedman, David W. M.D.

5. Long-Term Follow-Up of High-Pressure Injection Injuries to the Hand; Plastic & Reconstructive Surgery. 117(1):186-189, January 2006; Wieder, Anat M.D.; Lapid, Oren M.D.; Plakht, Ygal M.Med.Sc.; Sagi, Amiram M.D.

6. High Pressure Injection Injuries; Hand Clinics 2 (3), 1986: pp 547-552; B Thomas Harter Jr MD and Kathleen C Harter MD

7. Grease gun injuries to the hand: Pathology and Treatment of Injuries (oleomas) following the injection of grease under high pressure.; Quarterly Bulleting of Northwestern Medical School, 15:122, 1941; Mason, M. L. and Queen, F. B.

8. High-Pressure Injection Injuries; eMedicine, Feb 19, 2008; Jugpal S Arneja MD and others

Some Shout Outs

Updated 3/2017 -- all links removed as many no longer active and it was easier than checking each one.

Just wanted to link to some posts and information I found interesting.

First off Happy Hospitalist did a grand job using the Six Degrees method linking the posts of Grand Rounds 4:37 to himself. Check it out.

Second If you don't know about the SixDegrees.org, the charity charitable initiative that Kevin Bacon started in partnership with Network for Good, you may want to check it out. Either make your own charity badge (see mine on the left side-bar, bottom) as I raise money for the Arkansas Food Bank. Or add your charity to the Network for Good list.

Third Paul Levy posted "Terrorism Near and Far"

A riveting presentation today to our Board of Overseers. First was Diane Covert, freelance photographer and creator of "Inside Terrorism: The X-Ray Project". This is an exhibit which uses actual X-rays and CT scans from two large hospitals in Israel to explore the effects of terrorism on a civilian population.

Fourth Did you see this post at MedGadget on the New Luke Arm? Wow, I wish I could have helped develop this (wish I was smart enough). I always wondered if we would get to this point during my life since watching the Six Million Dollar Man as a kid. Wow!!!

Fifth Check out the x-rays of the Appendicolith over at Scalpel. I don't recall ever seeing one as large or as clear as this one. Impressive!

Sixth Dr Rob Oliver, Plastic Surgery 101, has a nice post on Malignant Hyperthermia and the recent patient death in Florida.

Seventh Fat Doctor's son had to have eye surgery this week. She shares the video of the surgery with us here.

Eighth Did you catch this "My Bloodsucking Visit to a Leech Clinic" posted May 23, 2008 by Canadian Medicine? [via Kevin,MD] Let me refer you back to my post on Leeches.

Ninth Don't forget that tomorrow night, Dr Anonymous will be hosting Dr Gwenn O'Keeffe on his Blog Talk Radio show.

Tenth And the "Peace Globe Movement" in the blogosphere. This is a simple idea brought forth by Mimi Lenox back in the fall of 2006. Mimi was even a guest on The Doctor Anonymous Show Number Eleven back on October 25, 2007.

Tick Prevention

I wanted to share a tip with you on getting rid of the tick you find crawling on yourself. My husband taught me this. When you see the tick or have pulled it off, get a piece of Scotch tape and apply it to the tick. You can then place the tick into the trash without fear of dropping it onto your floor. It will also get rid of the need to flush the tick down the toilet, and thus save water.

Now here is the post on ticks I did almost a year ago with a small addition.

Having been outside more lately, as the weather has gotten so much nicer I have also noticed more ticks. I believe that prevention in medicine is to the act of doing something (change diet, not smoke, use condoms, etc) to avoid the need for treatment of a disease (heart disease, emphysema, HIV). So I would encourage all or you to take the proper steps to prevent Lyme's Disease and avoid the need for treatment. The "preventive" steps to take are to either avoided the tick-invested area or used a DEET or permethrin-based tick repellent and then doing a body check for ticks that same evening.

• According to the Center for Disease Control it takes 36-48 hrs for transmission of B.burgdorferi or B. microti to occur from an attached tick and not all ticks are infected. Therefore, a tick bite does not necessarily mean a person will get infected. Prompt removal of the attached tick will reduce the chance of infection.
• Tick paralysis is rare. One reason the condition is so unusual is that the tick must be attached for five days before symptoms develop. So do a daily tick check of yourself and your children if you live or visit an area that has ticks. (reference below) [This section added as well as the references.]

I walk my dogs daily in the woods nearby. My dogs are protected with Frontline. I use Deep-Woods Off and often wish I could use Frontline. That would be so much simpler, apply once monthly. Don't forget the sunscreen and wide-brimmed hat.

Protect yourself, then get outside and enjoy life!

REFERENCE

Six Case Studies in Potentially Life-Threatening Weakness; Emergency Medicine, May 2008, pp 25-30; Scott C Sherman MD

Eye Patches

Recently one of my blog friends mentioned the need for a Latex free eye patch. She has double vision from her myasthenia gravis. She has a Latex allergy. My local stores don't care any latex free eye patches. The elastic has latex, so the readily available ones won't work for her. I bought one of the eye patches (less than $2) to use as a pattern. I don't know her size, but using myself I tried it on and trimmed it until it was "comfortable". This then became my pattern.

I had some Ultrasuede scraps that I used for the patches which I stiffen with a heavy-weight iron-on backing. To protect her from the elastic, I covered the 1/8 in elastic with 1/4 in double folded bias tape.

I am going to mail her the "pattern" and some extra supplies along with the two finished eye patches. She has mentioned a friend near her that sews. So if she wants more, maybe that friend can make them for her. Especially, if these two don't fit properly.

I tried to get Rusty to model the patch, but he didn't like having it over his eye. Bless him, he did allow this photo.

If you don't want to make your own, but would like something other than the basic patch found in most stores try the links found here on the message board of the American Foundation for the Blind.

SurgeXperiences 123 Call for Submissions

Updated 3/2017 -- all links removed as many no longer active and it was easier than checking each one.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. The 23rd edition will be be hosted by QuietusLeo, The Sand Man, on June 8th. He is an anesthesiologist in Israel.

In case you were wondering - "QuietusLeo" is latin for "sleeping lion" (I think). Obviously, I was born a leo. The connection seems to make sense.

The deadline for submissions will be June 6th. Please submit your posts here. Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.