Progress Note on Hawaiian Lobster Quilt

I started this quilt at the suggestion of my blog friend, Dr Theresa Chan (rural doctoring).  The post on it’s origins can be read here.  As I explained there, I enlarged the lobster pattern I found here (link removed 3/2017) and then “blended” it into the “Hoya” Hawaiian appliqué block.   The Hoya block I found in a book I have called Hawaiian Quilting by Elizabeth Root.  For the border, I again used the Hoya block and added the leaves from the Anthurium block for the center area of each border.  The corners are the Angel’s Trumpet block.  All three blocks can be found in the Elizabeth Root book.

The quilt top is now basted to the batting and backing.  I used the “fusible” Warm and Natural batting.

Here is a close view of the lobster with his antennae.

The machine quilting will be both outline and echo.  Here I have taped around the center in preparation to do the first echo.

So Theresa put on your thinking cap.  When it’s finished how are we going to auction it to raise the proposed money for Zippy and children’s brain cancer research?

Marking and Markers

Updated 3/2017 -- photos (except my own) and all links (except to my own posts) removed as many no longer active and it was easier than checking each one.

This past weekend, Kevin MD, told us about Sharpie’s actually being anti-bacterial.

Surgeons use markers to identify the right body part for procedures. Unfortunately, they care become contaminated with bacteria which can lead to surgical site infections.
Enter the Sharpie: "As it turns out, the ink used in a Sharpie pen has an alcohol base, making it an unexpected germ fighter." ….

That’s nice to know, but mostly what I got from the report was the reminder to clean the tips of the reusable markers with an alcohol based wipe between patients.  For me the marker helps me in my planning, not in my germ control.  Here is my post on marking/markers from last December.

Marking is very important in both my quilting and my surgery work. I don't mean the kind of marking that gives you "yellow snow" (nod to Frank Zappa) or the kind that leaves you a trail of crumbs to find your way home (Hansel and Gretel).

In plastic surgery, a lot of time can be spent in the preop area marking your patient. So you want a marker that won't wash off so easily that it is gone with the scrub. For breast and body "work", I use (and the nurses tell me so do most of the others) a black Sharpie.

It is marketed as a permanent marker, but I still find that I have to remind the person prepping the patient to not "scrub too hard" or "that's enough". When you have marked the patient standing or bending in different ways to be sure you get the most skin removed, these positions and maneuvers can't be duplicated in the operating room. During the procedure, I use whatever marker the hospital has, usually the Accu-line products. Those are also what I use when I need a really fine line (ie eyelid) when marking.

The skin marker should be nontoxic and non-allergenic. If used during the procedure, then it must be sterilizable. The ink must have a visible color and must be non-reactant  with other chemicals used on the skin (e.g., povidone iodine). The ink must be resistant to mechanical cleaning but removable in time.  The information immediately below is from the first reference article.

The photo to the right is from the first article referenced below. Note how the ink "disappears" with the scrub. Their skin marking ink (1) and frequently used skin markers (2, methylene blue dye; 3, Securline, a surgical skin marker; 4, red permanent marker; 5, black permanent marker; and 6, Viscot, a surgical skin marker). (Center) Skin prepared with povidone iodine solution and scrubbed five times. (Below) Skin prepared with Betadine and scrubbed five times. Their marking ink --The formula consists of basic fuchsin (1.3 g of dye material), 5.6 ml of acetone (resolvent), 11 ml of alcohol (dissolvent), and 100 ml of distilled water. This formula may be diluted by adding alcohol.

In quilting, you want a marker that will stay long enough to see the pattern you are quilting. You want to be able to either "brush" it off gently later (as with chalk pencils) or to wash it out. The different colors of fabrics used can sometimes make this more challenging. For the quilt I am preparing for hand quilting, I used the blue washable marker on the "mustard" (light fabric) and a silver chalk pen on the brown (dark fabric). Here are some links to tips by experts like Ami Simms (blue washable marker), and Sharon Darling (Quilter's Choice Marking Pencil, Miracle Chalk).

REFERENCES

Skin Marking in Plastic Surgery; Plastic & Reconstructive Surgery, 115(5):1450-1451, April 15, 2005; Ayhan, Meltem M.D.; Silistreli, Ozlem M.D.; Aytug, Zeynep M.D.; Gorgu, Metin M.D.; Yakut, Macide M.D.

Quilt Tips From Quilters Around The World--Marking Tips
Appalachian Mountain Quilters Marking Techniques by Kimberly Wulfert

Soft-Tissue Injuries of the Fingertip

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

As we get closer to Halloween and in light of my post on preventing injuries when carving those pumpkins, I thought I would review injuries to the fingertip.  This post is a reworking of the post a did on fingertip injuries/amputations more than a year ago.  In this post, I’m going to stick to injuries of the fingertip.  (photo credit)

Fingertip (or pad) injuries are very common. They range from simple lacerations to partial amputations. Simple lacerations are repaired by suture or Dermabond (I have even told family members to use super glue. The bleeding must be stopped. The finger must be cleaned with soap and water. There must not be any tension pulling the edges apart. The glue is used on the surface, never within the cut.)

If Dermabond is used, it is best to avoid use of antibiotic ointments as these can “dissolve” the bond before the cut is healed sufficiently. 

The question is much more complicated when there is loss of tissue. The main treatment objectives are:

1) closure of the wound

2) maximize sensory return

3) preserve length

4) maintain joint function

5) achieve a satisfactory cosmetic appearance.

How these goals are achieved will depend on the amount of tissue lost, whether there is bone exposed, and which finger is involved.   It may also depend on the patient’s profession or hobbies (ie professional musician who may not tolerate decreased sensitivity to his long finger whereas a truck driver might not notice it). 

 

Injuries may also be classified according to where the amputation has occurred or whether the injury primarily involves the pulp (soft tissue) or nail bed.  These classification systems refer to the zone (photo credit) and the plane of injury.

Zone I is distal to the phalanx (bone)–There is no exposed bone and most of the nail bed is intact which will allow normal nail contours following healing. Treatment of these injuries is usually conservative, especially if the tissue loss is superficial and less than 1 cm square. The wound should then be left open to heal by secondary intention. Meticulous wound care and conservative debridement of these injuries are essential. A dressing of topical antibiotic ointments and non-adherent gauze left alone for several days will facilitate healing. Daily dressing changes can be done after the 4-5th day. As the scar contract, it will give an excellent aesthetic and functional result.

Zone II is distal to the lunula (growth matrix of the nail)–These are complicated by the bony exposure of the distal phalanx. The decision-making process begins with whether length should be preserved (necessitating coverage of the site) or whether sacrifice of length is justifiable in the given situation. The primary aim is to restore function to the individual, and many of these injuries can be converted to wounds with no bone exposed by rongeuring and then closure. If there is no possibility of direct closure, then cover can be accomplished by means of a local flap. The plane (slant of the injury) of zone II injuries helps determine what type of repair technique should be used.

Zone III is proximal to the lunula. –These involve the nail matrix and result in the entire loss of the nail bed. These injuries are most often treated by amputation (revising the end of the traumatic amputation and closing the stump). Replantations distal to the DIP are often not successful.

Methods of ClosureSplit

Thickness Skin Grafts (STSG)–are useful in Zone I injuries that are larger than 1 cm square. It’s advantage over FTSG is that it contracts as it heals and therefore keeps the resultant insensitive area as small as possible. Split-thickness skin from the hypothenar eminence or instep of the foot closely matches the native fingertip skin and is a good choice for the donor skin.

Full Thickness Skin Grafts (FTSG) can be taken from the hypothenar eminence, the lateral groin, the volar wrist crease, or the anti-cubital fossa (inner elbow crease). Some feel that this leaves a less conspicuous donor scar than the STSG.

Flaps are necessary when the loss of fingertip pulp is more than one-third the length of the phalanx. There need to be soft-tissue replacement to support the distal nail. Local flaps include:

Atosoy-Kleinert Flap (photo)
was first described in 1970. It is a triangular volar V-Y flap advancement for reconstruction of the distal pad. It help preserve length when the bone is exposed. It is not indicated in injuries where an oblique flap with more palmar skin loss than dorsal is present.


Kutler Lateral V-Y Flap (photo)
was first described in 1944. It employs two triangular flaps developed from lateral positions and reflected to cover the tip of the digit. This is most applicable to oblique palmar and traverse tip amputations. As the V-shaped skin flap is advanced, an incision line is created which resembles a “Y” when sutured.


Volar Flap Advancement (photo)
is credited to Moberg for coverage of thumb tip amputations. It may also be used for fingertip amputations where length is to be maintained. It provides a sensible covering (has feeling) by advancing volar skin on its neurovascular pedicle. Advancement is limited to 1 cm.


Cross-Finger Pedicle Flap (photo)
was first described by Gurdin and Pangman in 1950. It is useful in distal amputation of the index finger or thumb and in situations where multiple digits are injured and maintenance of length in the remaining injured tips is considered to be of critical importance. Cross finger flap uses skin and subcutaneous tissue from the dorsum of an adjacent finger to cover the fingertip injury. The defect created by “lifting” the flap is covered with a STSG. The pedicle is left attached for 12-14 days and then divided and “tailored” into place.


Thenar Pedicle Flap (photo)

was described in 1926 by Gatewood for coverage of injuries with exposed bone. It was modified by Smith and Albin in 1957 with a technique described as a thenar “H-flap”. The indications are similar to that for a cross-finger pedicle flap (preservation of length, exposed bone). The potential for joint stiffness with a permanent flexion contracture and /or unsightly scar in the donor area must be kept in mind. It is apllicable to injuries in the tips of the index and long fingers, but not the ring or small as the flexion required is not comfortable.Contraindications for use of the cross-finger or thenar flaps would be any general condition that might lead to stiffness (rheumatoid arthritis, Dupuytren’s contracture, etc). There is increased risk of joint stiffness with either flap in someone over 30 years of age.

Replantation of Severed Tip
Replanted single fingers can be stiff and impede the opposition of other fingers to the thumb and overall hand function. Replanted single-finger amputations can achieve better range of motion when the level is distal to the insertion of the flexor digitorum superficialis. Single-finger replantation can be considered when patients have injuries to other fingers of the same hand. All of these injuries require splint immobilization and rehabilitation that impedes immediate return to work. Single-finger replantation can be considered in special circumstances. The surgeon must not become absorbed in the technical challenge of the replantation and neglect the other associated injuries because poorer outcomes and greater financial cost (due to lost wages and cost of hospitalization and therapy) can result.




REFERENCES
Information & Pictures from Operative Hand Surgery, 2nd Edition, David Green MD, Churchhill Livingstone
Fingertip and Nailbed Injuries by Joseph Donnelly, MD

The V-Y Plasty Technique in Fingertip Amputations by Edward Jackson, MD--American Family Physicians

Fingertip Injuries--Eaton Hand Center
Fingertip Injuries/Amputations—AAOS
Fingertip Injuries by Glen Vaughn--eMedicine article
Assessment & Initial Management of Hand Injuries--Zoltan Hrabovszky

Cohen, B. E., and Cronin, E. D. An innervated cross-finger flap for fingertip reconstruction. Plast. Reconstr. Surg. 72: 688, 1983

Soft-Tissue Injuries of the Fingertip: Methods of Evaluation and Treatment. An Algorithmic Approach; Plast. Reconstr. Surg. 122: 105e, 2008; Lemmon, J. A.,  Janis, J. E., Rohrich, R. J.

Nail Lengthening and Fingertip Amputations;  Plast. Reconstr. Surg. 112: 1287, 2003; Adani, R., Marcoccio, I., and Tarallo, L.

Shout Outs

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

Kim, Emergiblog, is this week's host of Grand Rounds. Nice edition! You can read it here (photo credit).

Welcome to the Emergiblog Speedway, where the Grand Rounds 500 is about to get underway! No chance of a rain delay - our bloggers are ready to roll!

Thirty-nine bloggers have shown up for the event. All entries have qualified; no posts were sent back to the garage.

And ladies, don’t worry, you’re welcome on the track, I just wanted to use the classic starting phrase!

Life is so fragile.  Please, lend your support to Dr. Smak as her son’s brain cancer has returned.  You can go here or here to donate money towards pediatric brain cancer research.

JeffreyLeow, Monash Med Student, will be taking part in the adventure race, Anaconda Lorne,  in Dec 2008 after his exams. The organizers have helped set up a fund-raising website through which anyone can donate. Please consider donating through this link.   The donated money will go to the Burnet Institute.

any additional fundraising that can be achieved helps the Burnet Institute fight some of the world’s most deadly infectious diseases through medical research and public health education, both here in Australia and overseas. To find out more about the Burnet Institute and their work, click here.

Paul Auerbach, MD, Medicine for the Outdoors, has a nice post on the field management for a penetrating ("sucking") chest wound. 

The usual teaching for improvisational management of chest wounds is that all open wounds (particularly those in which air is bubbling) should be rapidly covered, to avoid “sucking” chest wounds that could allow more air to enter the pleural space and thus continue to worsen a collapsed lung. For a dressing, a Vaseline-impregnated gauze, heavy cloth, or adhesive tape can be used. The dressing should be sealed to the chest on at least three sides…….

Tim Sturgill MD JD, Symtym, will be the guest on the Dr Anonymous' Blog Talk Radio show this week. He describes himself this way

a board certified emergency physician, at mid–career, with interests in:

• Emergency Medicine
• Emergency Medical Services
• Health 2.0
• Health Informatics
• Health Law
• Health Technologies
• Medicine 2.0
• Web 2.0, semantic web

Late Day Addendum:

Alvaro Fernandez, The Brain Fitness Authority, hosts the first edition the first edition of MetaCarnival:  a Carnival of Carnivals.  Check it out here.

Welcome to the first edition of MetaCarnival: a Carnival of Carnivals (announced here), the new, monthly, and interdisciplinary gathering of blogs and blog carnivals.

Let's picture all participants in the shadow of an expansive sycamore tree, conducting a lively Q&A lunch discussion.

Article Review Highlights: Breast Cancer, 2008

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

This post is a review of several articles from Medscape on the 2008 Breast Cancer Symposium.  It will just give you some of what I thought were the highlights from the articles.  I have listed the articles with links for those of you who wish to read the full articles.

From New Concepts and Therapeutic Approaches for Early-Stage Breast Cancer by Michaela Higgins MD and Antonio Wolff MD

Risk, Screening, and Prevention

• These include not only those related to BRCA1 and BRCA2 mutations, but also other genes whose roles have yet to be fully defined.
• CDH1 mutations are associated with a lifetime breast cancer risk of about 40%, as well as with diffuse gastric carcinomas, and CDH1-related carcinomas are usually of lobular histology.
• The lifetime risk of breast cancer for individuals affected with Peutz-Jeghers syndrome is 45%.
• Patients with Li-Fraumeni syndrome have a higher incidence of radiation-induced cancers, and consideration should be given to mastectomy rather than breast-conserving therapy and radiation for the treatment of early breast cancers in carriers of this mutation.
• The American Cancer Society recommends the use of annual magnetic resonance imaging (MRI) screening in addition to standard annual mammography in women with a lifetime risk greater than 20% of developing cancer or in those with a history of chest irradiation.
• Type 2 diabetes mellitus is an independent risk factor for breast cancer, and patients treated with metformin have a reduced incidence of breast and liver cancers.

Triple-Negative Breast Cancer

• There is considerable heterogeneity among triple-negative breast cancers. Indeed, these cancers can include, if rarely, disease metastatic to the breast, medullary carcinoma, pure apocrine carcinoma, and some metaplastic breast cancers as well as tumors defined by gene expression profiling as "basal-like" breast cancers.
• It is hypothesized that in the absence of the normal BRCA1 DNA-repair mechanism, BRCA-deficient cells are more likely to use the polyADP-ribose polymerase (PARP1) DNA-repair pathway.

From  Advances in the Treatment of Metastatic Breast Cancer by Andrew Seidman MD

Locoregional Therapy of the Primary Tumor in Patients With Distant Metastases

• Preclinical experimental evidence and hypotheses of self-seeding raise the notion that perhaps we should be more aggressive about the local control issue in more patients with simultaneous distant metastases.

ER, PR, and HER2 Status in the Primary Tumor and Distant Metastasis: A Moving Target?

• When patients are suspected of developing metachronous distant metastases, the dictum most oncologists are taught is "settle this issue and get some tissue." Biopsy confirmation of metastatic disease is the rule rather than the exception.
• At Memorial Sloan-Kettering Cancer Center, we have a unique set of matched breast primary tumors and brain metastases from patients who underwent medically indicated craniotomy; we have observed very high concordance in HER2, ER, and PR status between the breast primary and brain metastases (Brogi E and Seidman AD, unpublished data).

CNS Metastases in HER2-Positive Metastatic Breast Cancer: The RegistHER Study

• Brufsky and colleagues reported on a prospective, observational study of 1023 patients with newly diagnosed HER2-positive metastatic breast cancer.
• Of the 1009 patients included in the analysis, 337 (33.2%) experienced CNS metastases at a median time of 12.8 months from metastatic diagnosis.

New Concepts and Therapeutic Approaches for Early-Stage Breast Cancer by Michaela Higgins MD and Antonio Wolff MD; Medscape Article, Oct 15, 2008
Advances in the Treatment of Metastatic Breast Cancer by Andrew Seidman MD; Medscape Article, Oct 15, 2008

SurgeXperiences 209 is Up!

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

Resident Anesthesiology Guy, "The Choloform RAG" (photo credit), is our host for this edition of SurgeXperiences.  He did a very nice job which you can read here.   

Thanks for the submissions. I think this will be another great edition and will be my very first, both in submitting as well as in hosting. I know that some hosts like themes or stories before they get to the submissions. I will, instead, just let the authors do the talking for this edition with some distinction between the specialties so you can go where you're most likely to read as well as peruse the minds of those around you.

The next edition (210) will be hosted by From Dupont to Abdoun on November 9, 2008.

This site is a product of my experiences as a Georgetown medical student (near the famous Dupont Circle) on academic sabbatical living in Amman, Jordan (near the not so famous Abdoun Circle).  I plan to return to the U.S. in 2009 to complete a residency in emergency medicine.  It is my hope to tell the stories of the many wonderful patients and diseases I have encountered, to describe health care in Jordan, and to elaborate (or maybe just ramble) on some of my thoughts about practicing medicine in a developing country.  Thanks for reading!

The deadline for submissions is midnight on Friday, November 7th.  Be sure to submit your post 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.

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.

Humane Society Calendar Debute

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

Our local humane society (Pulaski County Humane Society) began publishing a Day Planner in 2005. It has turned into a very good fund raiser for them. This past Thursday night was the debute of the 2009 seen here. I ordered several that first year to give as Christmas presents. They were such a big hit the first year, I've had to keep doing it.  You can read my post from last year on these day planners here.

As per the Humane Society’s website:

The planner makes an excellent holiday or birthday gift and will be available at outlets soon to be listed below for ONLY $25.00! This year there are over 200 heartwarming photos of pets and their owners in a highly stylized, sturdily bound planning calendar. Help the Humane Society of Pulaski County and get yours in time for Christmas and stay up to date in 2009!
But why wait? You can place your order now to receive your books in November, using this MAIL ORDER FORM. (Depending on your browser, you may need to right-click on ORDER FORM and select 'download' or 'save'). Please print the form, complete it, and mail it to the address included in it.

This year Rusty has his picture in the day planner.

“For a New York Beauty” Quilt

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

TBTAM sent me a quilt block (bear claw pattern) she found while antiquing.  I have long admired the New York Beauty quilt block.  Her small gift gave me a reason to “tackle” the block and make a small quilt using it.  I did okay, but even using paper piecing some of my points and connections aren’t as nice as I would like.  When I critique my quilts, I sometimes feel as if it’s my own form of M&M.  Despite the imperfections, here it is.

I machine pieced it using the paper piecing method.   The small quilt is 24.5 in X 24.5 in.  The suggested colors (by TBTAM) were red, yellow, blue, and black.  They are all here, though just a small amount of blue.  The quilt is both hand and machine quilted.

This detail photo actually shows the colors better.

Resources for patterns and inspiration:
Quilter’s Corner Club – free New York Beauty block patterns
Mona’s Creativity – My New York Beauty
Donna Duquette – New York Beauty Blocks
Mostly About Quilts – New York Beauty for a Minnesota Beauty
New York Beauty Meets the Orient Quilt (stunning)
New York Beauty Quilt (beautiful)
Peggy Martin Workshop – New York Beauty (several beautiful quilts)

I Hope You Will Vote

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

My husband and I are going to vote today. We plan to take advantage of the “early voting”. I find it much easier than trying to get out and vote on the first Tuesday of November. It is less crowded and I don’t have to worry about going to the “correct” location. You are allowed to go to any of the available locations in your county during the “early voting” period.

I will not tell you who to vote for, nor will I tell you whom I plan to vote for. I would like to encourage you to VOTE.

If you live in Arkansas and wish to vote early:

To check for a polling site in your area, visit the Secretary of State's website (click here) to contact your county clerk.

If you live in Pulaski County, Arkansas, then here are the locations and hours:

Pulaski County Regional Building 501 W. Markham Street, Little Rock
Mon-Fri Oct. 20-24
8:00 am – 6:00 pm
Sat. Oct. 25
10:00 am – 4:00 pm
Mon-Fri Oct. 27-31
8:00 am – 6:00 pm
Sat. Nov. 1
10:00 am – 4:00 pm
Mon. Nov. 3 Last day
8:00 am - 5:00 pm

Other Early Voting Locations:
Early voting will be available at the following locations on the dates and times indicated:

Sue Cowan Williams Library
1800 S. Chester, Little Rock
Dee Brown Library
6325 Baseline Road, Little Rock
Roosevelt Thompson Library
38 Rahling Circle, Little Rock
William F. Laman Library
2801 Orange Street , North Little Rock
Jacksonville City Hall
#1 Industrial Drive, Jacksonville
Jess Odom Community Center
1100 Edgewood Drive, Maumelle
Jack Evans Senior Citizen Ctr
2301 Thornhill Dr, Sherwood
McMath Branch Library
2100 John Barrow Road, Little Rock
Mon-Fri Oct. 20-24
10:00 am – 6:00 pm
Sat. Oct. 25
10:00 am – 4:00 pm
Mon-Fri Oct. 27-31
10:00 am – 6:00 pm
Sat. Nov. 1 Last day :
10:00 am - 4:00 pm

Organ Donation

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

Last week my friend and fellow blogger Vijay (Scan Man) asked me for information regarding organ donation in the United States.  He was preparing a talk for a local Rotary Club to try to increase organ donation in his country.  My Oct 13th issue of the AMA News arrived a couple of days later and had an article on the same issue here – trying to increase the number of organ donations in our own country.  The article is “Other Nations, Other Answers”.  I think it is a free, open link, but in case it doesn’t here are the highlights.

The highlights:

• In late September, 99,728 people were on the United Network for Organ Sharing waiting list.
• One waiting patient dies every 73 minutes.  Three in four waiting patients need kidneys.
• Iran has the world’s only legal, regulated system of kidney donor compensation.  They claim to have nearly eliminated their country’s waiting list.
• Iran implemented its unique kidney donor compensation system in 1988, and by 1999, the wait for kidneys was eliminated, according to a study in the Nov. 1, 2006, Clinical Journal of the American Society of Nephrology. By the end of 2005, nearly 20,000 kidney transplants had been performed in Iran, with more than three-quarters of the supplied kidneys coming from unrelated living donors who were paid.
• Iran's regulated, legal system of compensating living kidney donors aims to eliminate black market organ brokers and transplant tourists, encourage cadaveric organ donation, and give both rich and poor a chance to get a kidney. Once a potential kidney recipient -- who must be an Iranian citizen -- is identified, a screening process occurs. (reference article below explains the system)
• Spain, by law, presumes organ donation after death unless the individual said otherwise while alive.  Their cadaveric organ procurement rate is 35% higher than ours. If the U.S. could do what Spain does with its presumed-consent law, the U.S. would net nearly 14,000 more organs a year.
• Extreme poverty, endemic corruption and a growing demand for transplants, especially of kidneys, have allowed black market trafficking to flourish in countries such as the India, Philippines, Pakistan and South Africa. This unregulated trade is universally condemned, as there is no assurance that donors are treated well or that recipients get healthy, matching organs.
• On the black market, donors are often paid as little as $1,000 for kidneys, which sell for nearly $40,000.
• The American Medical Association is examining solutions to the organ shortage. The AMA favors studying presumed consent as well as compensation for families of cadaveric organ donors. The Association will lobby Congress to change the 1984 National Organ Transplant Act, which bans "valuable consideration" in exchange for donation, to allow for ethically designed trials of financial incentives.

This referenced article gives the Iran system.  Organ Sales and Moral Travails: Lessons from the Living Kidney Vendor Program in Iran, Policy Analysis No. 614, Cato Institute, March 20;  Benjamin E. Hippen, MD

Other References
"A Gift of Life Deserves Compensation: How to Increase Living Kidney Donation with Realistic Incentives," Cato Institute, Nov. 7, 2007
Do Presumed Consent Laws Raise Organ Procurement Rates?" DePaul Law Review, Winter 2005-06, in pdf
AMA meeting: Delegates seek to change law on organ donor incentives July 7
Economists' study says paying for organs would cut wait lists Jan. 28
Campaign targets TV's skewed view of organ donation Sept. 3, 2007
Prisoner organ donation proposal worrisome April 9, 2007
Kidney transplant turns doctor into activist July 17, 2006

************************************
I am an advocate of organ donation.  My driver’s license is states that I wish to be an organ donor.  I would have no problems with doing as Spain does and making everyone a “presumed” donor.  I applaud the AMA for pushing for ethically designed trials of financial incentives. 

Shout Outs

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

Christian Sinclair, M.D., Pallimed, is this week's host of Grand Rounds. Nice edition! You can read it here.

Welcome to another edition of Grand Rounds (v 5.5), the best of the medical blogosphere. Below I have taken the liberty to edit down to what I considered the most provocative, most interesting, or most literary posts published in the last week. I have included all submissions in the first comment of this post so that everyone can see all the posts submitted. (As far as the topic of changing goals of care, there were not enough posts that really focused on the topic so it will be shelved until next time.)

Mother Jones RN (Nurse Ratched's Place) is the host of the current issue of Change of Shift (Vol 3, No 8). It is the Be True to Your School Edition! Go check it out. (photo credit)

Nursing school is hard work. We all had our good days and our bad days, but we somehow made it through nursing school despite our bad hair days. Check out this picture. That’s me taking care of Snoopy back in 1977. Thank God I had my cap to cover that hideous perm! I got this picture out of my school yearbook. Pictures from yearbooks can do a couple of things. They can come back to haunt us as well as teach us about the history of the nursing profession.

Do you enjoy accents? I do. So does JMB (Nobody Important) and she has written an interesting post on them. She begins

You may wish to watch this video before you read further. If not, do watch it afterwards. It's brilliant. Just over two minutes.
21 accents from around the world by Amy Walker

Back in August, a fellow quilter,Helen in the UK, had a nice post on "A Little Something Different". In it she shared a pattern for a burial gown and bonnet set for a female preemie. Recently she shared the pictured (photo credit) burial garment for male preemies/newborns. Most local hospitals will have a need for something like this. Call and ask yours if you are interested in addressing this need.

When I showed burial garments before a couple of people were interested in the patterns. I'm afraid to say the pattern I used for the boy suit, by Barbara Wampler of Florida, is no longer available on the internet. The hat is identical to Barbara's bonnet pattern but with a small brim added. A similar gown, but with a draw sting base, is available from the Carewear site in their newsletter from June 06, but WARNING this is a large PDF file and will take a while to download depending on your connection. Page 27 onwards is the pattern in various sizes. The AC4C yahoo group has a similar pattern, in a smaller size, but with no waistcoat.

Carrie, NeoNurseChic, will be the guest on the Dr Anonymous' Blog Talk Radio show this week. She describes herself this way

I'm one of the many twentysomethings out there trying to make something of herself. I have a bachelor of music degree in piano performance from Penn State University (main campus) and a bachelor of science in nursing degree that I got through an accelerated second-degree program. I'm currently working towards obtaining my master's degree in nursing to become a pediatric nurse practitioner.

Sponge Count

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

It’s one of those things you do (or rather the OR staff does) at the end of a case.  I usually continue to sew the last layer of skin as the count occurs.  If there is ever a question, then I may help locate a “missing” sponge or lap.  Usually (in my cases) they are just bunched together or one got tucked into the drapes.  That will mean that the first “final” count was wrong, but the second “final” count correct. 

Apparently, according to a recent article in the Annuals of Surgery that was quoted in the AMA News: 

While cases of retained foreign objects are rare -- occurring once in every 5,000 surgeries -- discrepancies in counts happen in 13% of surgeries, according to an August Annals of Surgery study.

I can honestly say, all the counts on all the surgeries I have ever done  have been correct.  No sponges, laps, needles, or instruments have been lost.  My cases now are more organized than some of the major trauma cases I was involved in during my training.  I can see how the counts were sometimes off.  When you have what amounts to 2-3 different surgery teams (neuro, ortho, and gen surgery) all working on a single patient at the same time, it can get chaotic.  In times like that, you sometimes wonder if the initial count was correct.  In other words, sponges, laps, needles, etc don’t have to be lost for the final count (end of case) not to match the initial count (beginning of case).

My fear of loosing a sponge in a breast case means I don’t use them.   If they come in the pack, I ask the scrub tech to put them on the back field to be used as part of the dressing.  Years ago, I finally managed to make the “the powers that be” see that if the count was correct, then it was wasteful to not use the clean sponges as part of the dressing.  If an x-ray did need to be done for any reason in the recovery, I would happily just change the tagged sponges out for them.  Hasn’t happened (knock on wood).

I use lap sponges (see above photo) with the blue tags.  This tag helps keep them from being lost.


There is a push to get hospitals and surgery centers to buy gadgets (photo credit) like the SurgiCount's Safety-Sponge™ System featured recently over at Medgadget.  The surgical sponges are individually bar-coded and then counted with the portable scanner.  This would work nicely on scheduled cases, but I wonder how well it would work on those trauma cases when the sponges are needed three minutes ago.  Would be interesting to see it in action on those cases.

 SurgiCount Medical website


REFERENCES
Sponges, surgical instruments miscounted in 13% of surgeries:  Getting the count right in the operating room is a challenge. New technologies could make things easier.  By Kevin B. O'Reilly, AMNews, Sept. 22/29, 2008.
"The Frequency and Significance of Discrepancies in the Surgical Count," abstract, Annals of Surgery, 248(2):337-341 August 2008; Greenberg, Caprice C MD, Regenbogen, Scott E MD, Lipsitz, Stuart R ScD, Diaz-Flores, Rafael MD, Gawande, Atul A MD
NoThing Left Behind: A Surgical Safety Project to Prevent Retained Surgical Items

SurgeXperiences 209 – Call for Submissions

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

The next edition of SurgeXperiences (209) will be hosted by Resident Anesthesiology Guy at his blog "The Choloform RAG" (photo credit).    That edition will be published on October 26th.   He describes himself

Anesthesiology resident, formerly from LDS country, now at the head of the bed in the eastern United States. Used to blog at Creating the Godcomplex.

The deadline for submissions is midnight on Friday, October 24th.  Be sure to submit your post 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.

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.

Kiri Shawl Finished

I posted information on this shawl early last month.

Here is a knitted shawl that I have been working on for several months now. It gets put aside whenever there is a quilt to work on, but I am slowly getting it finished. I am a self-taught knitter. I have only done a couple of simple sweaters (intimidated by the necks and sleeves) and was not really happy with how they turned out. I usually stick to hats and scarves. A love of lace work has drawn me into knitting shawls. The pattern is from All Tangled Up and is called Kiri Shawl (pdf of pattern). I am using Kid Merino yarn (color 4677). I'll finish it eventually and will show you the finished shawl then.

Well, I finally finished it and promptly gave it to my friend, Dr Val,. Here is a picture of the “blocking” process. The women at the Yarn Shop told me to put the shawl on a towel and use the steam setting on the iron. Just hold the iron near the shawl and give it a blast of steam.

Here is the shawl after blocking it. It turned out pretty good.

Lymphedema

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

As a follow up to yesterday’s post on the new technique ARM, I thought I would repost this one from December 2007.

Lymphedema is a very debilitating and progressive condition with no known cure. The unfortunate patient faces a lifelong struggle.

Frequency:

• In the United States, the highest incidence of lymphedema is observed following breast cancer surgery, particularly among those who undergo radiation therapy following axillary lymphadenectomy. Among this population, 10-40% develop some degree of ipsilateral upper extremity lymphedema.
• Worldwide, 140-250 million cases of lymphedema are estimated to exist, with filariasis being the most common cause.

Lymphedema may be classified as primary or secondary, based on underlying etiology.

Primary lymphedema represents a developmental abnormality of the lymphatic system. It is further subdivided into three forms depending on age at presentation. These conditions are most often sporadic, with no family history, and involve the lower extremity almost exclusively.

• Congenital lymphedema represents all forms that are clinically evident at birth. It accounts for 10-25% of all primary lymphedema cases. Females are affected twice as often as males. The lower extremity is involved 3 times more frequently than the upper extremity. Two thirds of patients have bilateral lymphedema, and this form may improve spontaneously with increasing age. There is a subset of patients with congenital lymphedema who have a familial sex-linked pattern of inheritance, which is termed Milroy disease. It accounts for 2% of primary lymphedema cases. The histology of the lymphatic channels often demonstrates an anaplastic pattern without subcutaneous lymphatic trunks but with normal dermal plexus.
• Lymphedema praecox is the most common form of primary lymphedema. It is also known as Meige disease. By definition, it becomes clinically evident after birth and before age 35 years. This condition accounts for 65-80% of all primary lymphedema cases and most often arises during puberty. Females are affected 4 times as often as males. About 70% of cases are unilateral, with the left lower extremity being involved more often than the right. Histologically, these patients are likely to demonstrate a hypoplastic pattern, with the lymphatics reduced in caliber and number.
• Lymphedema tarda does not become clinically evident until age 35 years or older. It is the rarest form of primary lymphedema and accounts for only 10% of cases. Histologically, patients are likely to demonstrate a hyperplastic pattern, with tortuous lymphatics increased in caliber and number. They often display absent or incompetent valves.

All three forms of primary lymphedema likely originate from a developmental abnormality that is present, but not always clinically evident, at birth. Some cases may become evident later in life when a triggering event or worsening of the condition causes the lymphatic transport capacity to exceed the volume of interstitial fluid formation, causing the patient to be unable to maintain normal lymphatic flow.

Secondary lymphedema represents an acquired dysfunction of otherwise normal lymphatics. Secondary lymphedema has an identifiable cause that destroys or renders inadequate the otherwise normal lymphatics.

• In the United States, it commonly results from damage or removal of regional lymph nodes through surgery (ie axillary dissection), radiation, infection, or tumor invasion or compression.
• Worldwide, the most common cause is filariasis, the direct infestation of lymph nodes by the parasite Wuchereria bancrofti.
• Other causes include vein stripping, peripheral vascular surgery, lipectomy, burns, burn scar excision, and insect bites.
• Recently, there has been an increasing number of morbidly obese patients presenting with lymphedema. "The rise in obesity is also contributing to the numbers of lymphedema patients. Ten years ago Dr. Fife didn't have any patients who weighed 500 pounds. Now, 2% or more of her patients are at this weight or heavier. Why morbid obesity leads to lymphedema is unknown, but one theory is that fat may block the system. "So as everyone gets fatter, we have more lymphedema," Dr. Fife said." --Dec 3, 2007 AMA Newsletter

If you are interested in the pathophysiology, please, read the eMedicine Article by Dr. Don R Revis, Jr, MD. You may also find more information at the links listed in the references below.
Clinical:

Patients present with varying degrees of severity, from mild swelling to severe disabling enlargement with potentially life-threatening complications. Lymphedema develops in a number of stages, from mild to severe:

Stage 1 (spontaneously reversible):

• Tissue is still at the "pitting" stage, which means that when pressed by fingertips, the area indents and holds the indentation. Usually, upon waking in the morning, the limb(s) or affected area is normal or almost normal size.

Stage 2 (spontaneously irreversible):

• The tissue now has a spongy consistency and is "non-pitting," meaning that when pressed by fingertips, the tissue bounces back without any indentation forming). Fibrosis found in Stage 2 lymphedema marks the beginning of the hardening of the limbs and increasing size.

Stage 3 (lymphostatic elephantiasis):

• At this stage the swelling is irreversible and usually the limb(s) is/are very large. The tissue is hard (fibrotic) and unresponsive; some patients consider undergoing reconstructive surgery called "debulking" at this stage.

When lymphedema remains untreated, protein-rich fluid continues to accumulate, leading to an increase of swelling and a hardening or fibrosis of the tissue. The swollen limb(s) in this state becomes a perfect culture medium for bacteria and subsequent recurrent lymphangitis (infections). Furthermore, the untreated lymphedema can lead to a decrease or loss of functioning of the limb(s), skin breakdown, chronic infections and, sometimes, irreversible complications. In the most severe cases, untreated lymphedema can develop into a rare form of lymphatic cancer called Lymphangiosarcoma (most often in secondary lymphedema).

Treatments for Lymphedema

Planning the treatment program depends on the cause of the lymphedema. For example: If the initial signs and symptoms of swelling are caused by infection (redness, rash, heat, blister or pain may indicate an infection), antibiotics will first need to be prescribed. Treating an infection often reduces some of the swelling and discoloration.

If the lymphedema is not caused by infection: Depending on the severity of the lymphedema, the recommended treatment plan should be determined using an approach based on the Complex Decongestive Therapy (CDT) methods which consist of:

• Manual lymphatic drainage--  Intermittent pneumatic pump compression therapy may also be instituted on an outpatient basis or in the home. These manual lymphatic devices are most appropriate prior to fibrosclerotic evolution, and they assist in preventing fibrosclerotic evolution of the condition. These devices provide sequential active compression from distal to proximal, effectively milking the lymph from the extremity.  (photo credit)
• Bandaging
• Proper skin care & diet-- Meticulous hygiene is necessary to remove keratinaceous debris and bacteria. Cleanse the skin regularly and dry thoroughly. Regular inspection is necessary to identify any open wounds or developing cellulitis. Bland skin moisturizers applied conservatively may ameliorate cracking and furrowing.

• Compression garments (sleeves, stockings, devices such as Reid Sleeve, CircAid, Tribute, as well as other alternative approaches)--  should be worn continuously during the day.  They may be removed at night when the extremity is elevated in bed, but they should be replaced promptly each morning. To encourage compliance, the elastic compression garments must fit appropriately. This requires that the garment be custom fit when the extremity is decompressed. The garment should also have graduated compression, increasing from distal to proximal, on the affected extremity.  (photo credit)
• Remedial exercises
• Self-manual lymphatic drainage & bandaging, if instruction is available.
• Surgical treatment is palliative, not curative, and it does not obviate the need for continued medical therapy. It is reserved for those who do not improve with conservative measures or in cases where the extremity is so large that it impairs daily activities and prevents successful conservative management. The goals of surgical therapy are volume reduction to improve function, facilitation of conservative therapy, and prevention of complications.

If you are a patient with lymphedema:

Continue to follow prophylactic methods at all times to prevent further problems.

• Avoid exposure to extreme cold, which can be associated with rebound swelling, or chapping of skin.
• Avoid prolonged ( > 15 minutes) exposure to heat, particularly hot tubs and saunas.
• Avoid immersing limb in water temperatures above 102° F.
• Avoid constrictive clothing or jewelry that might have a tourniquet effect.
• If possible, avoid having blood pressure taken on the at-risk arm.
• Avoid prolonged standing or sitting or crossing your legs.
• Wear proper, well-fitting footwear.
• Skin Care - Avoid trauma/injury and reduce infection risk

1. Keep extremity clean and dry.
2. Apply moisturizer daily to prevent chapping/chaffing of skin.
3. Attention to nail care; do not cut cuticles.
4. Protect exposed skin with sunscreen and insect repellent.
5. Use care with razors to avoid nicks and skin irritation.
6. If possible, avoid punctures such as injections and blood draws.
7. Wear gloves while doing activities that may cause skin injury (i.e., gardening, working with tools, using chemicals such as detergent).
8. If scratches/punctures to skin occur, wash with soap and water, apply antibiotics, and observe for signs of infection (i.e. redness).
9. If a rash, itching, redness, pain, increased skin temperature, fever or flu-like symptoms occur, contact your physician immediately.

FREE Lymphedema Alertband for the arm or leg are available here (photo credit)!



References
Lymphedema by Don R Revis, Jr, MD -- eMedicine Article
Lymphedema -- Vascular Web Home
Morbid Obesity And Lymphedema Management by Caroline E. Fife, MD, Susan Benavides, CLT-LANA, & Gordon Otto, PhD; LymphLink, Vol 19, No 3, July-Sept 2007
Lymphedema -- Mayo Clinic website
18 Steps to Prevention Revised: Lymphedema Risk-Reduction Practices By Saskia R.J. Thiadens, RN--National Lymphedema Network

ARM Technique

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

I realize this is not a techniques that I or other plastic surgeons are likely to use, but the surgeon (V Suzanne Klimberg, MD) who developed this technique is from Little Rock, AR.  So I thought I would learn more about it and share it with you all. (photo credit)

The removal and analysis of the lymph nodes under the arm remains an important factor in determining the severity of disease in breast cancer patients, but can result in complications, including lymphedema of the arm.  Lymphedema of the arm can occur in 5-50 % of patients depending on the extent of the dissection.  The ARM technique was developed to try to prevent this complication.

ARM stands from Axillary Reverse Mapping.   This technique the way lymph fluid is drained from the arm rather than from the breast.  The nodes that “light up” are preserved, therefore preserving the lymph system that drains the arm.

"Mapping the drainage of the arm decreases the chances of unintended disruption of the lymph node system during surgery and reduces the risk of developing swelling in the arm," Klimberg said. "We are the first to study lymph node drainage in the arm and are now using the ARM procedure as standard procedure at UAMS."

Klimberg will soon begin conducting training seminars on the procedure throughout the country. The seminars will be sponsored by the global medical device company Ethicon, a branch of Johnson & Johnson

Clinical Trials such as this one at MD Anderson are being planned to test the validity of ARM’s claims to decrease lymphedema. 

Detailed Description:

Lymphazurin is a blue dye used usually in breast cancer surgery to trace the drainage pathway that flows to lymph nodes. The dye will travel to the lymph system and will end up in the lymph nodes that are draining the arm.

In this study, lymphazurin will be used to find the drainage routes from your arm, rather than your breast.

AXILLARY REVERSE MAPPING:

Before axillary lymph node surgery, your surgeon will inject lymphazurin into your arm. Your surgeon will watch how the dye flows and find the channels and nodes draining the arm. You will then have standard axillary lymph node (lymph nodes found under the arm) surgery. Any lymph nodes found that are dyed blue (lymph nodes that have traveled down the drainage pathways) that would normally be removed will be removed and sent to the pathology department. Pathologists will check the nodes to see if they have breast cancer cells in them. Also as part of routine care, all other axillary lymph nodes draining the breast will be removed and checked for breast cancer cells.

This is an investigational study. Lymphazurin is FDA approved and commercially available. The use of lymphazurin with axillary reverse mapping is investigational.

Up to 30 patients will take part in this study. All will be enrolled at M. D. Anderson.

REFERENCES

Axillary Reverse Mapping (ARM): A New Concept to Identify and Enhance Lymphatic Preservation; Annals of Surgical Oncology 14:1890-1895 (2007);  Margaret Thompson, MD, Soheila Korourian, MD, Ronda Henry-Tillman, MD, Laura Adkins, MAP, Sheilah Mumford, MA, Kent C. Westbrook, MD and V Suzanne Klimberg, MD (abstract)

A New Concept Toward the Prevention of Lymphedema: Axillary Reverse Mapping; Journal of Surgical Oncology, Vol 97, No 7, pp 563-564, 2007; V. Suzanne Klimberg, MD 

Axillary Reverse Mapping: Mapping and Preserving Arm Lymphatics May Be Important in Preventing Lymphedema During Sentinel Lymph Node Biopsy;  J Am Coll Surg. 2008 May; Boneti C, Korourian S, Bland K, Cox K, Adkins LL, Henry-Tillman RS, Klimberg VS.

Breast Cancer Treatment Developed by UAMS Surgeon Shown in Clinical Trial to Reduce Repeat Surgery Following Lumpectomy by 86 Percent; UAMS News Bureau Release  Oct. 19, 2005

Blog Action Day 2008 – Poverty

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

Blog Action Day 2008 Poverty from Blog Action Day on Vimeo.

There are many major systematic reasons for poverty. The Global Fund combats AIDS, Tuberculosis, and malaria which have a crippling effect on the fight against poverty. In 2008 The Global Fund is the official Blog Action Day charity. You are encourage bloggers to donate to this organization.

In order to track Blog Action Day fundraising, you are asked to make your donation via Change.org (Read their FAQ for details of how your donation will be processed)

Please, Donate Now.

Shout Outs

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

T, Notes of an Anesthesioboist, is this week's host of Grand Rounds. Nice edition! Thanks for including my post. You can read it here.

Today I've organized Rounds into six major sections (each preceded by a self-indulgent little nod to a movie from my personal list of favorites):
1. School Days - posts about our training experiences and their aftermath
2. Stories from the Trenches - one of the reasons I read medical blogs at all
3. Educational Materials - it's Grand Rounds, after all; but I'm optimistic that our audience won't have their heads nodding onto the back wall of the lecture hall as they helplessly snooze through some slides... :)
4. From the Patients' Side
5. Politics, Economics, "Systems" Errors, and Controversies
6. Medical Blogging: issues upon issues, now and forever

Via a twitter from Scan Man: India's surrogate mother industry A moral & ethical minefield of which he doesn't approve. I think it’s a tough position for those Indian women to be in. One I’m glad I’m not in.

Childless Asian couples from Britain are increasingly travelling to India to pay women to act as surrogate mothers for them.

In a country where there are no laws surrounding surrogacy, the industry has become a multi-million dollar business.

A video from the Centers for Disease Control and Prevention (CDC) who along with Families Fighting Flu, Inc. (FFF) has launched a compelling video documentary via YouTube. Please, get your children and yourself vaccinated for the flu vaccine. For more information about the flu and the influenza vaccine, please visit the CDC website or Families Fighting Flu’s website.

Via ShadowFax and Uveal Blues, some amazing high-speed pics of stuff getting shot or smashed. I agree, it makes for some beautiful pictures (photo credit). For some less than beautiful effects of bullets, check out Bongi’s post, tumble.

Do you or someone you know need a new camera strap or maybe just a funky one? Well, the Stitching Surgeon shows off the one she made for her sister (photo credit).

The Dr Anonymous' Blog Talk Radio show this week will be about Podcamp Pittsburgh.
I hope you will join us this Thursday night at 8 pm CST (or 1 am GMT) both to listen to the show and to participate in the chat room. That's where all the fun is.

Mammograms

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

Last October, I wrote this post on Mammograms.  I am reposting it today.

First, please, refer to my post on breast self-exam. It is important to do your monthly self-exam. It is important to do it properly. Also, check out this article on breast changes during your lifetime that are not cancer from the National Cancer Institute.
Mammography is a low-dose x-ray system to examine breasts. A mammography exam, commonly known as a mammogram, is used to aid in the diagnosis of breast diseases in women. Mammograms are used for both screening and diagnosis. (normal, credit)
Screening Mammogram
Mammography can show changes in the breast up to two years before a patient or physician can feel them. Cure rates are much higher when the breast cancer can be found at this stage. Current guidelines from the U.S. Department of Health and Human Services (HHS), the American Cancer Society (ACS), the American Medical Association (AMA) and the American College of Radiology (ACR) recommend screening mammography every year for women, beginning at age 40.
The National Cancer Institute (NCI) adds that women who have had breast cancer and those who are at increased risk due to a genetic history of breast cancer should seek expert medical advice about whether they should begin screening before age 40 and about the frequency of screening.
Diagnostic Mammogram
Diagnostic mammography is used to evaluate a patient with abnormal clinical findings—such as a breast lump or lumps—that have been found by her or her doctor. Diagnostic mammography may also be done after an abnormal screening mammography in order to determine the cause of the area of concern on the screening exam.
Important Things to Know and Do Prior to Mammogram
Before scheduling a mammogram, discuss any new findings or problems in your breasts with your doctor. At the time of the mammogram, inform the radiologist (or the techs) of any prior surgeries, hormone use, and family or personal history of breast cancer. Try not to schedule your mammogram for the week before your period if your breasts are usually tender during this time. The best time for a mammogram is one week following your period. Always inform your doctor or x-ray technologist if there is any possibility that you are pregnant.

• Do not wear deodorant, talcum powder or lotion under your arms or on your breasts on the day of the exam. These can appear on the mammogram as calcium spots.
  
• If possible, obtain prior mammograms and make them available to the radiologist at the time of the current exam. Or try to use the same facility each year so they will already have prior mammograms.
  
• Ask when your results will be available; do not assume the results are normal if you do not hear from your doctor or the mammography facility. Make sure you state who should get a copy of your mammogram results--family doctor, general surgeon, oncologist, plastic surgeon, etc.
  

What a Mammogram Can Show
The radiologist will look at your x-rays for breast changes that do not look normal. The doctor will look for differences between your breasts. He or she will compare your past mammograms with your most recent one to check for changes. The doctor will also look for lumps and calcifications.

• Lumps (or "mass")--The size, shape, and edges of a lump sometimes can give doctors more information about whether or not it is cancer. A growth that is benign often looks smooth and round with a clear, defined edge. On the other hand, breast cancer often has a jagged outline and an irregular shape. (benign lump, photo credit)
  
• Calcifications--A calcification is a deposit of the mineral calcium in the breast tissue. Calcifications appear as small white spots on a mammogram. There are two types:
  

1. Macrocalcifications are large calcium deposits often caused by aging. These are usually not cancer.
2. Microcalcifications are tiny specks of calcium that may be found in an area of rapidly dividing cells. If they are found grouped together in a certain way, it may be a sign of cancer. (photo credit)

Depending on how many calcium specks you have, how big they are, and what they look like, your doctor may suggest that you--1) have a different type of mammogram that allows the radiologist to have a closer look at the area, 2) have another screening mammogram, usually within 6 months, or 3) have a biopsy done.
Mammograms are not perfect, but are currently the best method to find breast changes. If your mammogram shows a change in your breast, sometimes other tests will be needed to better understand it. These follow-up tests include ultrasound or more mammograms views. The only way to find out if an abnormal result is cancer is to do a biopsy. It is important to know that most abnormal findings are not cancer.
References

• Mammography--RadiologyInfo
• Mammograms--National Cancer Institute
• Mammograms in Women under 50--TBTAM
• MRI Urged for High Breast Cancer Risk--WebMD

SurgeXperiences 208

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

Welcome to the latest edition of SurgeXperiences! Fall is here in the northern hemisphere. The leaves are being to turn colors and the air is cooler. Perfect for a nice walk in the woods (don't forget the hunter orange) with my dog. I’ll leave this “bounty” of good writing for you to read at your leisure. Enjoy!

Bongi, other things amanzi, writes about pseudoaneurysm --

“there is nothing pseudo about a pseudoaneurysm except that it is not actually an aneurysm.”

How do you answer the question "are you thinking about specializing some day?" when you tell someone you are a general surgeon? Bongi tells about his response here.

Then read on as Bongi tells you how bullets can tumble and create unimagined damage to a person’s insides.

i know a bit about ballistics. it's more practical knowledge. i've seen enough gunshot wounds to pick up something here and there. the high velocity ones wreak havoc inside. the more usual 9mm doesn't compare but a well placed shot is still devastating. and then you get the exceptions. ricochet shots can be confusing. they tend to take strange paths through the body, sometimes following dissection planes (like surgeons) and causing less damage than you'd expect. and then you get the tumbler……….

Tumble reminded Quietus, The Sandman, of his own post, the new math.

……….Ruminating on the case, I became enlightened as to how the "new math" is done in Gaza. I'm reminded of Milo Minderbinder, a character from my favorite book "Catch-22." The character is a mess officer during WW II who turns the war into a lucrative business. He buys eggs at a high price and sells at a low price and still manages to make a profit in a dizzying transfer of goods all over the Mediterranean. This Gazan did the same thing, except with his life……….

Buckeye Surgeon writes about a case of vasculitis with an acute cecal infarct in a 27 yr old. (photo credit)

He also gave us a post on APBI verse whole breast radiation in Mammosite, but perhaps the most personal recent post was the one on a needle stick.

Bongi recently had a post about an experience getting stuck by a needle while operating on an HIV positive patient. It reminded me of a time during my residency I had forgotten………. There was something powerfully existential and substantive about it all. Rarely do we visit those dark places of the soul where our ultimate weaknesses are exposed. Rarely do we acknowledge our ineluctable mortality. It's too much. It throws us off our fragile equilibrium. There's too much to do in the here and now. But the time will come for all of us. The day of reckoning is unavoidable……….

T, Notes of an Anesthesioboist, writes about the doctors superstitions in one of her many thoughtful posts.

Whenever a patient says that my wariness increases a bit. It's doctor-superstition, I suppose, but it's been said that when patients have a feeling they're going to die, it's because...they're going to die. But I was hoping this was just her extreme nervousness talking rather than an actual sense of impending doom.

T writes movingly about the need to “before dying, leave word” about your end of life wishes.

Normally, getting asked to do an intubation in the ICU is one of the most satisfying parts of my job. I feel like I'm being asked for help….. and the task is potentially life-saving. …..But this one made me terribly sad…………We felt our hands were tied.

Chris and Drew, Pallimed, have written a nice post -- "Brain Death 40 years on"

My leading candidate for headline of the decade is "Are You Brain Dead? Depends on the Hospital." It is from a news article reporting on a study in Neurology (one of the few studies in the entire medical oeuve of 2008 that we have not blogged on)………

But variations in the definitions and use of "brain death" in an era of increasing demands for organ donation raise important ethical, legal, and practical questions. Last year Christian briefly blogged on organ donation after cardiac death. According to the Economist.com article, cardiac-dead donors is the fastest growing proportion of donors……..

Bruce, Reflections in a Head Mirror, writes two thoughtful posts. The first speaks to the "interval between the biopsy and the report".

There is a time of limbo in Medicine that begins when the procedure is completed and ends when the patient learns the results. It occurs millions of times each year after everything from major surgeries to blood tests. Although it was not the point of her essay this week in The New York Times, Dr. Paula Chen touched on these moments as a friend's father waited for the results of a pancreatic biopsy.

Dr Pauline Chen writes about The Dance Before the Diagnosis and says “The diagnosis was in their body language.” Also, check out her blog here.
Bruce’s second post addresses the "naked truth about tonsil cancer".

“Doctor, I should not have cancer! I never smoked! I am only 45 years old! It doesn’t make sense!” The patient and his wife sit stunned and frightened.
My new patient is absolutely correct … he does not fit the traditional profile of patients with cancer of the tonsil.

Also check out this NY Times article transplant surgeon Dr Pauline Chen wrote (via Kevin MD) – The Choices Patients Make.

There are certain choices patients make that I have never understood, choices that from my perspective as a doctor seem to undermine their very chances for survival. Or at least undermine the efforts doctors, nurses and even complete strangers make on their behalf. ………..
I asked Ms. Silverstein about how she had dealt with such pressure.
“There is no question that I am eternally and profoundly grateful for life and for my good fortune in receiving a donor heart just in the nick of time,” she responded. “But my heart transplant life is a mixed bag, a miracle with a flip side: a wonderful, awful, amazing, terrible existence.”
Then she added, “I have not lived a well day since my surgery — not one — and this is a difficult truth to bear. And sometimes, on the very rare occasion, it wears me down to the point of wondering if the illness and struggle are worth it.”…………

Jeffrey, Monash Medical Student, writes a nice post “to err medically”. Something none of us wish to do.

Prompted by Dr Val’s guest post at other things amanzi, i’m reminded of a story my surgical professor recently told us, during his tutorial on fluids and electrolytes management in surgical patients.

Quite some time ago, a patient was in the hospital had a percutaneous endoscopic gastrostomy (PEG) tube in for some reason or other…………..

Dr Alice, Cut on the Dotted Line, talks about prejudice

It didn’t make me any more enthusiastic that the picture I got from the chart before going into the room was of a patient seeking pain medication. Sure, she had a couple genuine chronic conditions with biopsy documentation of their existence; but she was on a lot of narcotics, plus some valium thrown in. She had been on disability for years, even before this most recent, serious problem cropped up.

I was in for a surprise……….

Dr B (surgery, cooking, art...life. passionately) writes that "finger dislocations are REALLY easy to reduce if they are gotten to in time".

"Did you reduce it?!"
"Reduce...? It looked less swollen and better, so I sent him home."
You've GOT to be kidding me. That is what I wanted to scream into the phone, but I kept my composure.

Also, check out this one in which Dr B states never -- not once until yesterday

I am not proud. I am, in fact, rather ashamed. But the other emotions I feel are anger, distaste, and, quite frankly, dread.
I took the gentleman from this post to the OR last week... last Monday, to be exact……….

Did you know Bruce has a second blog, Behind the Head Mirror? he says its for the stuff that doesn’t fit his other blog. Both are excellent! Check out this post comparing training surgeons to teaching kids to drive.

Driving a car is a lot like learning to be a surgeon. No matter what you might believe, you begin by being completely incompetent; neither driving nor surgery is intuitive. You learn incrementally and develop skills. You find out how to get out of jams and tight spots. You learn to anticipate what might happen and make adjustments. You develop the ability to to plan three or four steps ahead.

This Little Owl talks about experiences as a medical student on her surgical rotations. All in all positive, so we may have another surgeon in the mix. You can read her take in Surgery Clerkship Highlights.

Like I said previously, I intended to keep track of my experiences this year, so it’s time to play catch up.

I started the clerkship on June 30 and ended on September 19. I worked with several groups: pediatric surgery, ENT (ears, nose and throat = otolaryngology), the surgical consultation service (mostly hepatobiliary surgeries), and the dedicated hepatobiliary service……………….

Saif writes about his experience observing a radical prostatectomy while in Oaxaca. He is an undergraduate at UC Davis who hopes to be a doctor someday. After this experience, perhaps a surgeon.

After watching this surgery, I am CERTAIN I want to be a surgeon. It was amazing in so many ways. It requires high levels of visual and physiological knowledge, and a level of intricacy and skill that can only be gained through lots of experience and talent. You have to be able to know the human body on an instinctive level, using intuitive knowledge to navigate the viscera as if it were the back of your hand. Surgery is an AMAZING art and it seems to require the usage of the left and right brain, which I think is the best way to stimulate the mind. I love it because it's a high level skill set, which makes the field really special, it's not something everyone can do. I think I fit into this field because I'm a very visual-spatial thinker and it's a field really based on using that sort of talent to develop it into an expertise. The surgery was 4.5 hours, which felt like 30 minutes

Little Karen, Just Up the Dose, relates a story about a child birth -- “sometimes it does happen just like in the movies :)”

From Scan Man’s casebook, a post with films on a major renal trauma from a fall and another on infantile hemangioendothelioma. Very impressive films! Go check out the rest of them along with his explanations.

A tweet from Scan Man after “Successfully hydroreduced an ileocolic intussusception in a 7-month old child. Maintaining my 100% record.” It is a very nice article.

scanman Med/Surg/Nursing-twits Check out this article and the accompanying videos for the technique of US-guided hydroreduction http://is.gd/3vVU 06:48 AM October 04, 2008 from twh

Shadowfax, Movin’ Meat, posted on something you don’t see everyday. Thankfully, we don’t. The films, once again, are impressive and involve “a trauma patient who was in her third trimester of pregnancy”.

911Doc, M.D.O.D. (photo credit), wrote a couple of nice ER tales on patients who needed surgery. The first is Coup-Contra-Coup (what's a helmet?) and the second is In a Word..."Balls".

Dr Oliver, Plastic Surgery 101, asks "Does it make sense to screen asymptomatic breast implant with MRI?" and then answers it for us.

One of the peculiarities of the USFDA process during silicone implant reintroduction in 2006 was the labeling on the devices recommending routine MRI surveillance of implants for rupture. When you step back and look at the proceedings and "unique" American history with breast implants, you can see that this was more a political concession to the anti-implant activist lobby then evidence-based medicine.

The FDA labeling currently suggests MRI's at 3 years post op and then every 2 years subsequently. It will be interesting with the coming form stable "gummy bear" implants whether or not this recommendation is still maintained………….

Sterile Eye tells us how he “came to this”

This is the story of how I ended up working as a medical photographer. It’s not a very long, but quite winding road, that turned out to come almost full circle.

He is as Norwegian medical photographer and if you haven’t seen any of his videos of surgery he shares on his blog, then check out these posts and this one.

Dr Val (check out her new blog: Getting Better with Dr Val) writes about MRgFUS.

MR guided focused ultrasound is truly a “Star Trek” level medical breakthrough. The first questions in my mind were: will insurance companies pay for such therapy? Can people actually have access to this technology? The answer to both, as you might expect, is “no.”

A heart warming story from John Pages, Cebu Sports Blog, who enter the Hong Kong marathon but didn’t finish due to leg cramps. The post is about a heart surgeon, Peter Mancao, who stopped to help him rather than just running past.

Make Mine Trauma, IntraOporate, gives us an oldie but goodie that shares a day in the life of a trauma junkie.

As you may recall I was lamenting on Monday about not getting any trauma or on call action. Here's how my other night went. Phone rings at 2150 hrs.
Would you like to assist on an ex-lap for blunt trauma?
Of course I would because that is what I live for.

David Harlow, Health Care Law Blog, writes about his interview of Douglas S. Brown, General Counsel, UMass Memorial Health Care and the reinvention of their Cardiac Surgery program.

YourNewBodyBlog.com features two Beverly Hills plastic surgeons, Dr. Stuart Linder (“BodyDocBlogger”) and Dr. Robert Kotler (“FaceDocBlogger”). In a recent post, they discuss 10 Things that can go wrong in plastic surgery.

HerniaSymptomsBlog has a post that reviews Abdominal Hernia Symptoms and Treatments.

Stories from Patients

Begin here and then read the multiple post that follow as Annika’s mom “live blogs” her liver transplant.

We got a call this morning: a new liver for Annika.
That needs an exclamation point, but I'm too nervous.
Please please please keep her safe.
Please please please send peace to this donor family.

Mitchy tells of a recent hospitalization during which she had surgery for her ulcerative colitis in her post “Scribblings from the Mitchy Side - Hospitals, doctors and surgery, oh my!”

BuffaloesAreWild writes about Waiting in the Hospital and his attempt to learn patience.

Leslie, Room for One More, writes “She’s Out of Surgery”, a post about her adoptive daughter undergoing cleft lip surgery.

Dr Jerry Elrod, Senior Moments, writes from a personal viewpoint about prostate cancer: surgery and its side effects.

Surgery in the News/Links

Another tips from Scan Man, the University of Virginia Health System website has a very nice article with pictures (scalpels, credit) on Surgical Instruments from Ancient Rome. If you like medical/surgical history, you’ll want to check it out.

Vascular Surgeon Used Skills to Support Troops by Cathleen F Crowley; September 29, 2008 TimesUnion.com

Surgery Fine-Tunes Legendary Banjo Player's Brain; Eddie Adcock Played Banjo While in Surgery Till Hands Were Just Right by Maureen White and Lee Ferran, Oct 3, 2008; ABC News -- watch the amazing video

Crossway.blog has an interview with Dr Harry Kraus who is a practicing surgeon and a missionary with Africa Inland Mission. He is the author of eleven novels and two works of nonfiction, including Crossway’s Breathing Grace and The Cure.

Medgadget reports on the first man to get a double arm transplant (photo credit).

Karl Merk, 54, a German farmer, lost his arms six years ago in an accident involving a combine harvester.

Woman Denied Bariatric Surgery by Insurance Company: Is Size Discrimation to Blame? by Jessica, Sept 30, 2008 at Jezebel

Surgeon Operates on Wrong Knee at Miriam Hospital by Felice Freyer; Sept 20, 2008; The Providence Journal

25 Awesome Virtual Worlds for Doctors, Nurses, and Patients By Laura Milligan, Oct 8, 2008; Nursing Degree Guide

Twelve Hollywood Stars that Reject Plastic Surgery by Colin Stewart, Sept 30, 2008; OC Register

Plastic Surgery Industry Sags with the Economy by Lindsey Tanner, Oct 3, 2008; The Huffington Post

Plastic Surgeon from Dr 90210 Placed on Probation for Negligence; Oct 7, 2008; Law of Hollywood Land

Surgeon's claim handwash caused drink driving test failure, rejected; Oct 11, 2008; 3News.co.nz

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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 next edition of SurgeXperiences (209) will be hosted by Resident Anesthesiology Guy at his blog "The Choloform RAG" on 26 Oct, 2 weeks from now. Be sure to submit your post via this form.

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.