World No Tobacco Day

Updated 3/2017 -- photos and all links removed as many no longer active.

Today is Memorial Day in the United States.  It is also the day the  the World Health Organization (WHO) has chosen to bring worldwide focus on tobacco use prevention and cessation.  The theme of World No Tobacco Day 2010 is  "Gender and tobacco with an emphasis on marketing to women."

According to WHO, women comprise about 20% of the world's more than 1 billion smokers.  Young girls/women are often the target of  the tobacco industry marketing. 

As with tanning, young girls don’t often respond to being told about the serious health risks (cancer, COPD, emphysema, heart disease, stroke, etc) as they still feel invincible.  So perhaps instead of telling them that the adverse health effects from cigarette smoking account for an estimated 443,000 deaths, or nearly 1 of every 5 deaths, each year in the United States, we should focus on how smoking isn’t good for their looks.

So perhaps as WHO’s posters suggest, we should focus on how smoking is UGLY.  How smoking  can discolor their teeth and fingertips.  Perhaps we should focus on how smoking increases wrinkling and premature aging of the skin.

Perhaps if we show them the effects of mouth and throat cancer which are visible in a way that lung cancer isn’t, they might get it.

Sources
World Health Organization
Quit Smoking (US Dept of Health)
Centers for Disease Control and Prevention

SurgeXperiences 323 is Up!

Updated 3/2017 -- photos and all links removed as many no longer active.

Dr Jon Mikel, Unbounded Medicine, is the host of this edition of SurgeXperiences. It is the FIFA South Africa World Cup edition. Here is the beginning of this edition which you can read here. (photo credit)

I would like to express my gratitude to Jeffrey Leow of Vagus Surgicalis (Australian medical student with lots of interest and knowledge of surgery) and the creator of this Great Carnival. Australia is in Group D.

The host of the next edition (324) has not been announced, but don’t let that keep you from making your submissions. Be sure to make your submissions by the deadline: midnight on Friday, June 11th. 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 SurgeXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

Not Here to Judge

“What can I do for these scars?”
“Time and sunscreen,”  I reply, touching her skin.
Returning to the visit's scheduled complaint, discussing options.
“Thank you for not turning me away when I showed you my scars.” 
Stunned, I replied “Why would I do that?  How would I care for you?”
“Still, thank you.”

Taylor's Horses Quilt

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

I was asked by a fellow blogger if I knew anyone who could make a horse quilt for his 4 yo daughter.  What do you think I said? 

I looked through my quilt books and only found appliqué patterns, so I searched the web and found this paper-pieced horse block by Annette Truong. 

I wanted the quilt to be something she would like at 4 years of age and at 14 years of age.   I made the horses in blacks and browns and set the blocks into stars of  bright colors (pinks, greens, purples, blues, oranges). 

The quilt is machine pieced and quilted.  It measures 42 in X 56 in.

Here are some closer photos to show the horses and fabrics.
This horse reminds me of a palomino.
This is my version of the “old grey mare.”
Here’s a quarter horse.
Here is a photo of part of the back to try to show the quilting.

I received this tweet the day after Taylor received it.

@rlbates Taylor slept with "horsies" last night and dragged it everywhere she went :-) Awesome, nothing better than a child's smile :-) thx

I’m thrilled that she loves it!

Medical Museums in Arkansas

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

Medgadget and Gruntdoc have challenged us to visit our local medical museums and write about it. I live in Little Rock, Arkansas – the state capital and home of the only medical school in Arkansas. So this past Friday after looking online to see if the medical school has a museum, I headed over to the campus library. Turns out the school has an Historical Research Center (HRC) rather than a true museum.

The HRC has an impressive website where all the “proceeded” items are listed and searchable. The holdings of the HRC include “books, papers, artifacts, photographs, and audio and video recordings dealing with the history of medicine primarily in Arkansas.”

The goal of the Historical Research Center is to preserve UAMS history and the history of the health sciences in Arkansas. See our animated timeline. This is accomplished by the collection and preservation of classics in the health sciences, i.e., the History of Medicine and associated collections; and by collecting and preserving the archives of UAMS and Arkansas health scientists.

Due to lack of space and storage, the HRC doesn’t actively add old medical equipment or gadgets. The HRC has a few small areas throughout the main UAMS library where displays can be done. If you need to do research a topic of medical history, the staff will willingly help you.

The digital collections of the UAMS Library Historical Research Center provide access to selected archival materials related to the history of UAMS and of health sciences in Arkansas. Visit the digital collection. Also see our list of resources for historical research.

In fact, Amanda Saar who gave me the tour of the HRC mentioned a few other “true” museums in the state and I did more “google” searching myself. Here are the ones I found. I have not visited them in person due to time and distance, but perhaps in the future I will.

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Old Country Doctor Museum is located in Lincoln, Arkansas and was founded in 1994 by Dr. Harold Boyer, the son of Dr. Herbert Boyer, to honor his father and other Arkansas country doctors for their heroism, selfless service and unique contributions to the people and history of Arkansas. The museum is the second country doctor museum in the United States.  They can also be found on Facebook.

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The Randolph County Heritage Museum is not solely a medical museum, but they do have quite a collection of old medical “stuff” as can be seen in this youtube tour of the museum. It is located in Pocahontas, Arkansas.……………………….

Museum of Chico County Arkansas (MOCCA) is located in Lake Village, Arkansas. You can see photos, including the one below, on their online tour.

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Siloam Springs Museum is located in Siloam Springs, Arkansas.

At the Siloam Springs Museum, you can explore the past through permanent and rotating exhibits highlighting Indian culture, pioneer life, medicine and many other facets of our history.

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Gann Museum is located in Benton, Arkansas. The museum is housed in a 1893 building which served as the office of Dr. Dewell Gann. The building was built by patients who could not afford to pay him for their care. When Dr. Gann retired, he donated the building to the city and asked that it be maintained as a library. In 1980 the building was turned from the library to the museum.

In order to pay they dug bauxite from a nearby farm, hand-sawed it into blocks, allowed it to harden and then built the Doctor a medical office. It is the only building in the world to have ever been constructed out of pink alumina block. This area was once one of the world’s largest aluminum mining operations. The ore of aluminum is called bauxite and it is pink with little round metallic beads and streaks of white running through it.

The patients worked out their debt at a rate of ten cents an hour. The Doctor also took such things as cows, chickens and wild honey as payment as did many of the other doctors of the day.

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The Old Jail Museum in Greenwood is an unusual place to find a glimpse into how Arkansas medicine has changed in the past 100-plus years.

The exhibit contains memorabilia of 13 highly regarded physicians who worked in south Sebastian County dating back to the 1800s. Metal braces for broken bones, old photographs, doctors' bags, medicine bottles, baby scales, patient logs and bills, as well as medical instruments are some of the items on display through October at the museum located southeast of the Town Square on Arkansas Highway 10…..

Other items of interest include a straight edge razor used to cut umbilical cords, tiny bottles of medicines, stainless steel syringes, and one of the first electric nebulizer sterilizers. There are also some late 19^th century medical textbooks with pictures and medical advertisements such as those advertising house calls for $2.50 and delivery of a baby for $1.25….

The museum also has the complete baby ledger of Charles Bailey, MD, from when he started practicing in 1953 to the last baby he delivered in the 1980s.

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St. Francis County Museum is located in Forrest City, Arkansas.

Located in the restored, historic Rush-Gates home; exhibits include the J.O. Rush relic collection, reconstructed doctor's office, geology and fossils from Crowley's Ridge, county, veterans, and African-American history. Temporary and seasonal exhibits year-round; also serves as the central visitors center for the Crowley's Ridge National Scenic byway

Dealing with Unhappy Patients

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

There is a nice article in the May issue of  Plastic Surgery Practice which discusses how to deal with unhappy or difficult patients.  No matter the area of medicine or surgery, you are bound to have one or two of these patients over the years.  It never hurts to learn or review tips in dealing with them.

In the article Rima Bedevian interviews Julie Ann Woodward, MD who is chief of the oculoplastic and reconstructive surgery service at Duke University

how to successfully deal with them – with compassion and humanity without allowing them to “run you over” or manipulate a difficult situation into a potentially litigious one.

 

Here is Dr. Woodward’s Checklist:

We all have them – not even the very best physician can deny this…. I learned many of the tips described below from observation during my fellowship, from talking with colleagues, and from personal experiences.

PREOPERATIVE STAGE

1)  Slightly downplay expectations – eg, “Laser skin resurfacing will not get rid of every wrinkle.  You may still need some fillers.”

2)  Talk in numbers and give percentages whenever possible – eg, “Twenty percent of patients may need an adjustment with this procedure.”

3)  Stress the time required to heal.

4)  Beware of a patient who abuses your staff’s time.  If so, tell her, “I’m sorry, the staff and I can’t meet your expectations.” 

5)  If a patient seems uneasy and difficult, encourage them not to do the surgery.  The money you collect from a difficult patient will not be worth your time.

POSTOPERATIVE STAGE

1)  never disagree with what a patient sees is wrong, even if you do not see it at all.

2)  Remind the patient that healing can take from 6 months to a year.

3)  Take action – If the patient does not like the look of their scar, inject a small amount of steroid or make an appointment 4 to 6 month out for a touch-up.  In my experience, most patients will be happy by then and will not even want the touch-up.

4_  See the patient with increased frequency and show that you care.  Call them frequently.  Don’t be afraid to gently touch the patient’s arm in a calming way.  The worst thing a physician can do is to send the patient away for a month and hope that they will cool down.  Even if it is stressful for you, ensure the patient will return frequently.

5)  A happy patient will tell two friends, and an unhappy patient will tell everyone on the planet via the internet.  As unethical and inaccurate as we know these Web sites can be, they are here to stay.  If a disgruntled patient posts a negative comment on a Web site, contact five of your happy patients and encourage them to post positive comments to push the negative comment down on the Web page.

6)  Consider doing touch-ups either for free or for a nominal fee – but set limits.  Do not give free Botox/Dysport touch-ups.  These patients will want free touch-ups every time.  They will “doctor shop” the entire medical community to locate the practices willing to give freebies.

7)  Maintain positive interactions with your colleagues so that you can refer patients for second opinions.  Ask them in some cases to see patients with worrisome outcomes.

DEALING WITH ANOTHER PHYSICIAN’S UNHAPPY PATIENT

1)  never say anything bad about another physician.  The patient will naturally seek the physician with a higher level of self-confidence and who does not speak poorly about colleagues.  Negative comments about colleagues will usually come back to bite you.

2)  Disgruntled patients who come to you from other practices will probably be unhappy with whoever treats them, even if you dramatically improve their situation.  You may want to encourage that patient to return to the physician who did the original surgery.

3)  Consider giving a friendly call to the physician who did the original surgery to let them know you have seen the patient.  mention that you supported that physician’s original work.  you might establish a new referral source from this call.

4)  never return a patient’s money.  Most lawyers will say that patients will view this as an admission of guild, and it usually is an excuse for them to just go out and complain to more people.

Julie Ann Woodward, MD

 

 

 

REFERENCES

How to Deal with Unhappy or Difficult Patients; Rima Bedevian; Plastic Surgery Practice, May 2010, pp 26-29.

Shout Outs

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

Dr V, 33 Charts, is the host for this week’s Grand Rounds.   It’s the “Artsy Doctors, Genes and Creepy Imagery” edition.  You can read this week’s edition here.

It’s been a tough week for the anti-vaccine movement but an important week for pediatric health. Yesterday the UK’s General Medical Council announced that Andrew Wakefield, who’s fraudulent manipulation of data spawned the vaccine-autism cottage industry, would be ‘struck’ from the medical register. This action by the GMC is one more nail in the coffin of the man who has singlehandedly turned back the clock on two generations of pediatric public health. Check out Respectful Insolence for some pithy commentary and a pointed, must see interview with Matt Lauer. This issue finally seems to be circling the drain………

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Dr Lisa is in Haiti and has been blogging her experience. I hope you will check it out. You can begin with her first post from there, First Haiti Thoughts

Landing in Port Au Prince, my first glimpses of Haiti revealed a lush Caribbean island like so many others. The large central mountains, relics of the islands volcanic origin, the rocky coastline, the lush vegetation, then we landed and we were shuttled to the boarding terminal. Damage from the earthquake was still visible in the buildings at the airport. Then we left the airport grounds, and on our short drive, the disarray of the city was obvious. Although despite the extant destruction there were many signs of regrowth.

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Check out this Daily Beast article by Ayaan Hirsi Ali:  Why Are American Doctors Mutilating Girls? 

The American Academy of Pediatrics recently put forward a proposal on female genital mutilation. They would like that American doctors be given permission to perform a ceremonial pinprick or “nick” on girls born into communities that practice female genital mutilation.

Female circumcision is a custom in many African and Asian countries whereby the genitals of a girl child are cut. There are roughly four procedures. First there is the ritual pinprick. This is what Pediatrics refers to as the “nick” option………..

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Tony Brayer  was interviewed by My Life Stages about her experience as a patient:  Enough is Enough -- When Knee Pain Hits the Tipping Point  (photo credit)

…………Not long after that, she scheduled her surgery for the 2009 Christmas holiday. Now recovering from a total replacement of her right knee, she recently talked about her experience as a doctor, patient and woman.

What was the moment at which you knew you needed to have knee replacement surgery?
I never considered that this was something I would be facing. I was in denial. I would try to hide it. I didn’t want anyone to see me limping, and I was surprised when people noticed that something was wrong. I had a lot of pain that I just pushed through. But one day I was getting ready for work and out of the blue, I just burst into tears and said, ‘I just can’t do this anymore. I am really crippled.’ That was my wake up call……….

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As we head into summer you may want to check out the Environmental Working Group’s list of the best and worst sunscreens can be found on their  searchable database.  A few of the best rated include:  Al Terrain Aquasport Performance SPF 30, Badger Sunscreen for Body and Face SPF 30, California Baby Sunscreen SPF 30, and Vanicream Sunscreen Sport SPF 35.

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Dr Wes has done a review of a film I wish all of us could see: The Vanishing Oath: A Review.  He now has reported that the Chicago premiere was a success.

I would like to take a moment to thank the over 120 people who took time out from their busy schedules to attend the Chicago premiere of The Vanishing Oath at the Wilmette Theatre last evening. For many, it was the first time people they were exposed to the challenges that confront physicians daily in our current health care system…..

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Medical Industry News linked to this article by Diane Suchetka:  Burn victim hopes her story calls attention to dangers of surgical fires.  The article includes before and after burn photos.

There are two Lauren Wargos.

One is so beautiful, you can't stop looking at her. The other was so disfigured, you had to look away.

One wants to remember. The other to forget.

One would rather not talk about what happened. The other wants the whole world to know.

Months after the surgery, Lauren Wargo's one eye would still not close all the way, she had trouble reading and her face was scarred.

It's that last Lauren Wargo who's stepping up now, four years after her face was burned during surgery to have a mole removed from her eyebrow. She's doing it, she says, because she wants to make sure what happened to her doesn't happen to anyone else. ……

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Medgadget is sponsoring the The 2010 My Medical Museum Competition along with Dr. Allen Roberts, aka GruntDoc.

This contest is an opportunity to showcase your medical museum's treasures, as well as to document your local medical history and explain how clinicians and scientists in your area contributed to medicine. So, make a presentation and tell everyone a fascinating story.

To get everyone on equal footing, we've implemented a dynamic publishing platform where you create an online presentation. The My Medical Museum website will let you upload pictures, file reports, embed videos, and make a presentation that will impress the judges. Collaboration is fine, too -- form a group and grant access so your teammates can contribute.

The Grand Prize is a brand-new Wi-Fi 32GB Apple iPad, no less.

So, what else are you waiting for? Gather your friends, family or fellow medical geeks and head over to explore your local medical museum. Develop your presentation and finalize it by Sunday, June 13, 2010.

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It’s time again for the web-based quilt festival hosted by Amy – Blogger’s Quilt Festival, Spring 2010.  I submitted my “First Quilt” as part of the festival.  There is a long list of blogging quilters who are participating.  Grab a cup of coffee or tea and have fun checking them all out.

Welcome to the third Blogger's Quilt Festival!  I'm so glad that you are here - and I hope that you plan to enter a quilt in the Festival!  Everyone is welcome to participate, this is a relaxed festival with no judging, no gloves, and beverages are allowed, encouraged even!  :)

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Dr Anonymous’ BTR show guest this week will be Dr. Jay Lee, Family Physician & Health Policy Expert. The show begins at 9 pm ET.

Upcoming shows (9pm ET)

6/3: Dr. Deb Clements, Family Physician who recently was in Haiti
6/10: Ray Saputelli, NJ Academy of Family Physician

Consultations

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

Recently Dr. Debra Benzil (Women Neurosurgeons: Hearts and Hands) wrote a post suggesting doctors are often their own worst enemies.  As I continue to read through Dr. Robert Goldwyn  essays, “The Operative Note: Collected Editorials” (published in August 1992), I came across this one which suggest the same. 

I contend that his essay could apply to consultations for many different medical and surgical issues in how we physicians treat our patient and each other.  The bold emphasis is mine.

 

Consultation for Breast Reconstruction

The woman who has just heard that she has breast cancer faces not only the prospect of deformity and death, but also the quandary of having to decide among various treatments:  mastectomy – radical, simple, or segmental; node dissection; chemotherapy; or irradiation – alone or in combination.  Should this patient later want breast reconstruction, she must sort through another set of alternatives.  A few years ago, the choice for patient and plastic surgeon was relatively easy – an implant or nothing.  The advent of musculocutaneous flaps has allowed more latitude and, in may instances, superior results.  Even the implants have changed and now exist in a bewildering array:  saline- or gel-filled, in various sizes, shapes, and thicknesses, as well as the expander type.  My purpose here is not to list the indications, advantages, and disadvantages of each or to advocate one over another.  Numerous articles in this Journal have already done so.  This editorial is to make two pleas:  for each of us to take the time to explain to the patient the different methods for rebuilding the breast and the reasons for our specific recommendation, and for each of us not to denigrate the plan or person of another plastic surgeon who may have suggested something different to that patient. Results, though improving, are still not ideal and should not foster dogmatism.  The fact that the number of plastic surgeons has increased makes it easier for patients to obtain additional opinions.  In my own practice, I have heard such statements as “Dr.  ____ says that the flap from the abdomen is the only way to do it.”  Or “Dr.  ___ said that implants should never be used if you can avoid it.”  and “Dr. ___ told me and my husband that it is rarely necessary to use a flap because an implant can do the same thing more easily.”  One wonders whether that surgeon knows  how to do a latissimus dorsi or rectus abdominis flap.

I realize, of course, that patients misquote doctors; nevertheless, I am sure that much depends on what door a patient enters.  One surgeon may be in hsi Radovan expander phase; another in the flush of his first rectus flap; or a different surgeon may be fossilized, unwilling to try anything other than an implant.

Advising a patient about breast reconstruction involves the same principles as counseling in other areas of medicine.  What are the objectives and what methods are available for attaining them?  Am I capable of providing that treatment?  If so, should I proceed?  If not, I should refer.  In all these deliberations, the patient must be an informed participant.  Involving the patient and helping her choose a course of action is not the same as making the patient decide on her own.  The doctor who lists the serval ways of reconstructing the breast as a waiter would recite the entrees for the evening abrogates his or her responsibility.  The patient did not come to the surgeon to flounder in the sea of indecision while the surgeon sits comfortably in a nearby lifeboat.

Since reality is seldom perceived beforehand, photographs of average results of breast reconstruction, showing scars in the recipient and donor sites (if a flap is to be used), are helpful.  So is having the patient speak to or perhaps, see another patient who has already been through the ordeal.  One has to make clear in the record and to the patient that this does not imply guaranteeing a similar result.  In fact, on occasion, I have referred a patient to someone who is unhappy with the result if I sensed the new patient was screening out information about what could go wrong. 

Breast reconstruction is a challenging aspect of our specialty.  With several thousand plastic surgeons working in the world, ingenious developments will be forthcoming.  Tolerating ambiguity is necessary if we are to advance.  Is there unanimity in how to repair a cleft palate or how to treat cancer of the tongue or breast?  Breast reconstruction has come of age; there are now several ways of doing it.  Despite this variety, I expect that surgeons of the next generation will do better for patients than we can now.  Perhaps the need for breast building will have disappeared if an alternative to mastectomy proves effective and safe.  In the meantime, we must remain sympathetic to the patient, who bears the greatest burden. We should not make her lot more difficult by behavior that is unprofessional toward colleagues and damaging to those whom we are supposed to serve.

SurgeXperiences – 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 that occurs every two weeks. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.  

Due to a lack of a host for May 18th, SurgeXperiences 323 has been moved to May 30th.  The host will be Dr Jon Mikel, Unbounded Medicine. 

Be sure to make your submissions by the deadline: midnight on Friday, May 28th.  Submissions can be made either via this form or directly by emailing Dr. Mikel  at jonmikel+surgexp@gmail.com.

If you wish to host SurgeXperiences 324 or any future edition, please contact Jeffrey who runs the show here.

Here is the catalog of past SurgeXperiences editions for your reading pleasure.

Familiarity

A warm, friendly voicemail:  “Dr. Bates, I’m CB.  Dr. Z sent you a referral letter 5 years ago.  I’m now ready to proceed with whatever needs to be done.”

I don’t recall the letter and feel disappointed there's no chart on CB.   I just knew I had met her. 

Nutcracker Grandmother's Fan

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

This quilt was made for my niece, Kerina, back in 1995. A lovely child and a lovely young woman. Check out her website: Makeup By Kerina.

The quilt uses the grandmother’s fan block done using Christmas fabric/colors. I pieced the quilt, but had Scottie Brooks do the hand quilting for me. The quilt measures 72 in X 90 in.

As with my first quilt, I failed to take photos, but Kerina sent these to me. It turned out to be an “in-between” size as twin quilts are usually 65 in x 88 in and double bed-size quilts are 80 in X 88 in.

Here you can see the Nutcrackers which give the quilt it’s name.

Here is a view of the back which shows some of Scottie’s beautiful quilting.

Find Your Inner Guru

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


Here is another essay from Dr. Robert Goldwyn (full references below).  It shows his sense of humor.

Be More Than You Are

Many years ago, I heard the legendary Mario Gonzalez-Ulloa exhort his audience with the words: Be More Than You Are. After the ovation, he left the auditorium but what he said has remained. I am still pondering its meaning. In the heat of the moment, the message seemed clear: rise above your perceived talents and personality; go beyond your supposed limitations, as did, for example, Schindler under more terrible circumstances.

In this world, where the haves possess much materially and little spiritually, a desperate need exists for guidance. Gurus, usually self-proclaimed, flourish in the vacuum. Some grow obscenely rich. Society seizes their utterances, which may be sentient or zany or both. The trick is to say something that combines the obscure and the obvious, the true and the false. If it has an inner contradiction (Be More Than You Are), it will stimulate thought or, at least, bewilderment.

Here are a few; readers will likely supply better ones.

Anticipate yourself (or, Be before you are.).

Live in the present, but remain in the past.

….….

A door can be open or closed.

We forget what we cannot remember.

Be extraordinary in an ordinary way.

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Remember who you are even though it is of no consequence.

There are three steps to everything: one, two, three.

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Be yourself but not quite yourself.

This may be the end, but it could be the beginning.

So do any of you have an inner guru?  What “advise” or “wisdom” would you give to us?


REFERENCES
Be More Than You Are; Plastic and Reconstructive Surgery. 103(1):299, January 1999;  Goldwyn, Robert M.
Be More Than You Are; Plastic and Reconstructive Surgery. 114():136, October 2004;  Goldwyn, Robert M.

Get Girls to Focus on Skin’s Appearance

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

A study from Joel Hillhouse, Ph.D., of East Tennessee State University, Johnson City, and colleagues has just been published in the May issue of Archives of Dermatology looking at which health-based intervention worked best in reducing skin cancer risks.  They found that “Emphasizing the appearance-damaging effects of UV light, both indoor and outdoor, to young patients who are tanning is important no matter what their pathological tanning behavior status.”

I have used this tack on not just young girls, but middle aged women to try to get them to curtail their tanning habits.  This includes sun and tanning beds.

I have a patient I have known for many years now.  I got her to use sunscreen on her face and neck years ago, but had limited luck with decreasing her sun tanning until recently.  She noticed how much better her face and neck has aged verse her chest/cleavage.  She has also begun having multiple skin cancers removed by her dermatologist (so I guess neither of us had as much influence as we would have liked) from her back, arms, and legs.

This patient’s chest/cleavage skin looks at least 10 years older than her facial skin.  She has finally reduced her sun tanning, but the damage is done.

Damaging effects of tanning bed or sun tanning can led premature aging of the skin giving it a dry, wrinkled, leathery appearance; as well as increase skin cancers (melanomas and non-melanomas). (photo credit)

Tanning beds are not a safer way to get a tan.  Safe sun practices include:

• Plan your outdoor activities to avoid the sun's strongest rays. As a rule, avoid the sun between 10 a.m. and 4 p.m.
• Wear protective covering such as broad-brimmed hats, long pants, and long-sleeved shirts to reduce sun exposure.
• Wear sunglasses that provide 100 percent UV ray protection.
• When outdoors, always wear a broad-spectrum sunscreen with a sun protection factor (SPF) of 30 or greater, which will block both UVA and UVB. Apply the sunscreen 30 minutes before sun exposure and reapply approximately every 1 1/2 to 2 hours.

REFERENCE

Effect of Seasonal Affective Disorder and Pathological Tanning Motives on Efficacy of an Appearance-Focused Intervention to Prevent Skin Cancer; Arch Dermatol. 2010;146[5]:485-491;  Joel Hillhouse, PhD; Rob Turrisi, PhD; Jerod Stapleton, BS; June Robinson, MD

The Plastic Surgeon Knows Best?

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

I tend to agree with what Dr. Robert Goldwyn had to say in this essay from his book “The Operative Note: Collected Editorials” (published in August 1992). 

The Plastic Surgeon Knows Best: 

A Hazardous Assumption

Two incidents, within four hours, seemingly disparate, were instructive nevertheless.  The first was in the barber shop, where I paid a long overdue visit.  The hair stylist – there are no more barbers left in the world – was a woman, whom I had not seen before.  She was one-half my age and a hundred times as attractive.  She was sitting in her own chair, brushing Lady Godiva length hair muttering that her friend – another “stylist” – had “ruined” her.

“She cut too much off,”  she said.

My fantasy was that her hair previously must have trailed like a bridal train.

This is a good sign, I told myself.  She will not prune me excessively, something that is easier to do with each year.  To my request for a “light trim,” she replied, “Don’t worry.  I’ll take care of it.  You’ll like the result.”

That last statement triggered an iota of apprehension but I gave myself over to her obvious charm and flying fiingers.  I must have dozed and awoke to a World War II soldier staring back at me from the mirror.  I look like an old recruit, perhaps a General Schwarzkopf but without his girth or tanks.

Then a more primal fear seized me.  Maybe my modern hair stylist was really an incarnated Delilah.  That thought sent my strength ebbing as I went to my car and then to the office – for the second incident.

This was a new patient, a twenty-eight year old writer, who was displeased with the outcome of her rhinoplasty done elsewhere.

“I told him that I wanted surgery only on the tip,” she said.  “I even wrote him a note to that effect and also specified it on the operative permit.  I couldn’t believe what I looked like when he took off the splint.  He had given me a total nose job.  When I protested and asked him what he had done to me during the operation, he got very angry and practically yelled, ‘It’s none of your business.  I was the surgeon and I know what is best for you.’ ”

Her plastic surgeon and my barber have forgotten that my hair and her nose belonged to each of us respectively and not to anyone else.  They also shared the same deficiency:  not listening.  But there is more involved:  namely, arrogance.  After they have finished with their work, we are left holding the result.  Of course, I do not equate my Marine hair cut with her new nose.  With God’s grace, in a few weeks I will regain what I had but she will not.

I believe it was Osler who advised us to listen to the patient because he or she will tell us what is wrong and if we listen longer, the patient will tell us what to do.  I am afraid that each of us occasionally ignores or forgets that verity.  The patient becomes somehow incidental to our treatment which we impose without proper regard for that person’s sensibilities and desires.

This phenomenon of not taking into meaningful account what the patient wants I have observed more among older practitioners.  Perhaps they feel that they are beyond the restrictions that usually apply to other plastic surgeons.  This kind of megalomania is not without possible severe repercussions  -- the kind that take place in a court room.

In our specialty, more crimes are of commission than omission.  fewer problems result from doing less than from attempting more.  One would think that the older plastic surgeon would appreciate doing less in order to conserve his or her strength.  Maybe the issue is one of routine:  performing “the operation” instead of the right operation.  The patient who receives more than he or she requested is about as grateful as the diner who was served Beef Wellington when he wanted a green salad.

 

When breast augmentation and reduction patients ask me what size they should “go for.”  I tell them my opinion, but also tell them they should decide “what they want.” 

I have been known to use the example of me making them a dress in a lovely green silk.  The dress fits perfectly, the color suits their skin/hair/eye coloring, BUT I find out too late they hate the color green.

So while it is my duty to listen, my patients must tell me what they want.  Then we can have a discussion about whether it is possible, etc.

Shout Outs

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

Maria Gifford, Better Health, is the host for this week’s Grand Rounds.    You can read this week’s edition here.

As newly-appointed content manager of Better Health and editorial assistant to Dr. Val Jones, I’ve been given the honor of hosting this edition of Grand Rounds — a weekly summary of the best health blog posts on the Internet.

This week’s submissions cover a nice mix of issues important to health and medicine, which I’m presenting in alphabetical order (excuse my somewhat ultra-conservative ways, as I’m originally a product of the Mayo Clinic, and even after jumping ship nearly five years ago, I’m still affected due to my unchanged, self-inflicted physical location — I’ll find my social-media legs soon, I’m sure!)

From geriatrics to Viagra, PET scans to personality disorders, dentists to American Idol, you’ll find it in this ever-so-tidy session of Grand Rounds.

Read, learn, enjoy…
Best of health,
Maria

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The Muse, RN  is the host of the latest edition of Change of Shift (Vol 4, No 23) !   You can find the schedule and the COS archives at Emergiblog. (photo credit)

HAPPY NURSES WEEK! ! !

It is my extreme pleasure to bring you all this edition Change of Shift!  My thanks and enduring gratitude to Nurse Kim @ Emergiblog…. beside whom, I just know, I’d love to work….

Here’s to all the Greatest Nurse Bloggers who submitted for this edition AND to their Blogrolls where I ‘discovered’ at least one additional blogger to showcase.  (pssst – thanks for listing the nursing and medical blogs that you follow on your sites!  Its a GREAT way to find each other.)

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Dr Wes has done a review of a film I wish all of us could see:  The Vanishing Oath: A Review

…..As background, the film is a three-year project born in 2007 just before the great US health care reform debate began. Over 200 hours of interviews were conducted explore a simple question: why Dr. Flesher had grown to hate medicine.

It would have been easy for Dr. Flesher and Ms. Pardo to make his story nothing but a rant, but instead, we find that their story is an honest attempt to understand how someone so enthusiastic at the start of their training could become so quickly discontented with the realities of emergency room care and our bloated health care delivery system…….

Addendum: The film will be premiered in Chicago on 25 May 2010. Seating is limited.

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It’s Primary Voting Day in my home state, Arkansas, as well as many other states.  I hope you will get out and vote if you live in one of these states.  In Arkansas, KATV Channel 7 has a nice website with lots of information on the races, the candidates, etc.

The one in Arkansas which seems to be garnering the most national attention and money is the Democratic Senate race between incumbent Senator Blanche Lincoln, Lt. Gov Bill Halter, and businessman D.C. Morrison.

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 Medgadget is sponsoring the The 2010 My Medical Museum Competition along with Dr. Allen Roberts, aka GruntDoc.

This contest is an opportunity to showcase your medical museum's treasures, as well as to document your local medical history and explain how clinicians and scientists in your area contributed to medicine. So, make a presentation and tell everyone a fascinating story.

To get everyone on equal footing, we've implemented a dynamic publishing platform where you create an online presentation. The My Medical Museum website will let you upload pictures, file reports, embed videos, and make a presentation that will impress the judges. Collaboration is fine, too -- form a group and grant access so your teammates can contribute.

The Grand Prize is a brand-new Wi-Fi 32GB Apple iPad, no less.

So, what else are you waiting for? Gather your friends, family or fellow medical geeks and head over to explore your local medical museum. Develop your presentation and finalize it by Sunday, June 13, 2010.

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Dr Rob in his 46th House Call Doctor podcast discusses Anaphylaxis and Serious Allergies

What Is Anaphylaxis?

The most serious and potentially life-threatening allergic reaction is a condition known as anaphylaxis. Anaphylaxis happens when an allergen is recognized by antibodies, which you’ll recall from last week’s article are special proteins in the body that recognize invaders. When antibodies mistakenly identify a normally benign substance—like peanuts-- as an invader in the body, the antibodies immediately combine with certain white blood cells, releasing histamine and other substances that have a profound effect on the body…….

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Thank you @sandnsurf for tweeting this “Patterns of Visual Math - Naturally Occurring Fractals http://tinyurl.com/2d7wmc”    The fern may be a simple example, but you need to check out the others.  Beautiful!

FRACTAL FERN: One very simple way to understand fractals and the meaning of "lteration" is to examine a simple recursive operation that produces a fractal fern thru a "chaos game' of generating random numbers and then placing them on a grid.

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Dr Anonymous’ BTR show guest this week will be Larry Bauer from the Family Medicine Education Consortium.   The show begins at 9 pm ET.

Upcoming shows (9pm ET)

5/27: Dr. Jay Lee, Family Physician & Health Policy Expert

FTM Chest Contouring – Lessons Learned

I wrote a post, Chest Wall Contouring in Female-to-Male Transsexuals, in December as I prepared to do my first such surgery.  I was up front with him about him being my first FTM though not my first mastectomy.

Well, I had to perform a second procedure to correct the first.   Here is what I learned from this experience:

1.  A minimal scar is not worth having extra skin remain.  

I opted for the first surgery to use a peri-areolar incision/scar feeling it would allow enough skin excision and leave less of a scar.  The scar was smaller, but even after months to allow full contraction of the remaining skin turns out not enough skin excision.

The extended concentric circular scar looks good with a nice chest contour.

2.  The inframammary crease must be fully obliterated.

I knew this from my reading.  I thought I had done so.  I recommend freeing up the skin from the chest wall a good 2 inches below the marked crease to ensure it’s destruction.

3.   Use drains.

No matter how well you think you have controlled the hemostasis.

 

I am happy with the results after the revision.  The patient is too if his smile and statement are any indication -- “I can now look at my chest without revulsion.”

Many Cuts Later – May 16th

I began this blog three years ago with a post entitled “First Cut (I mean draft).”  I now have well over 1,000  posts (cuts which I hope haven’t been torture to endure)  and many new friends.  

I have been interviewed because of my blog for both the  medical and quilting components.  I’ve even been interviewed by Dr. Anonymous (link removed 3/2017).

I have been included among the Better Health bloggers and gone to Las Vegas where I meet many of you in person.

Thank you all for including me in the blogging community. 

Reprise -- So Many Stitches

Here is a quilt related repost from May 22, 2007.  I have not done any work in the past three years on this quilt.  Perhaps I will this year.

I have been working on this appliqué quilt top for a while now. It keeps getting put aside as I piece another QOV top or make another baby quilt for a friend. This top/quilt has no deadline. Sometimes that is a lovely thing. Sometimes a deadline will help motivate me, as it does others. I'll finish it someday, even if it's years from now.

I enjoy making these ruches roses, but I must admit I don't really enjoy making the leaves. Each ruched rose takes approximately 200 stitches. Each one can easily take an hour to make before stitching it to the background fabric. The instructions for making a ruched rose can be found in American's Heritage Quilts published by Better Homes and Gardens, 1991.

I think I am more a piecer than appliquér at heart though I love appliqued quilts--Baltimore Album quilts, Hawaiian quilts. I enjoy using the rotary cutter to "mass" cut pieces which I can't do when I do applique. There's that cutting and sewing that quilts and surgery have in common. Don't have to finish a quilt in one sitting, as I do any surgery. That makes it much more relaxing.

Flying Squares Baby Quilt

This quilt is made from left over 2.5 in squares of fabric cut for other projects.  I have trouble just tossing unused pieces.  The block is called flying squares.  The quilt is machine pieced and quilted.  It is 39.5 in X 45 in.  I have sent it to a friend who’s wife is pregnant.

Here is a close shot to show some of the fabrics.  Notice the pink rabbit playing a violin.
Here is another close shot to show some of the fabrics – flowers, fire hydrants, circles, feathers, etc.
Here is yet another close shot to show the fabrics:  hearts, bugs, flowers, parasols, etc.

More on Allergan Botox Suits

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

A year ago the FDA required Allergan to add a black box warning Botox and a Risk Evaluation and Mitigation Strategy (REMS)  to it’s safety labels for all botulinum toxin products.  The agency took the action because of two main reasons. 

In February, I wrote about the lawsuit in Orange County, California by a mother who alleges that the Botox treatments used to decrease muscle spasms weakened her daughters respiratory muscles, therefore causing her death.

Kristen Spears’ mother has sued Allergan alleging that her daughter died from a fatal reaction to the Botox treatments Kristen received for treatment for cerebral palsy. In March, Orange County Registar ran this article by Colin Stewart:  Allergan wins Botox death trial.

Yesterday Katherine Hobson, WSJ Blog, wrote an article:  Allergan Now Batting .500 in Botox Lawsuits

Yesterday an Oklahoma jury awarded $15 million to a woman who claimed she experienced pain and other problems after receiving the shots, reports the Orange County Register. (The O.C. is Allergan’s home base.) Though the jury ruled for Allergan on a product liability claim, it found the company was negligent in its off-label promotion of the drug, plaintiff’s attorney Ray Chester tells the Health Blog.

The Orange County Register article by Colin Stewart:  Jury blames Botox

An Oklahoma jury Tuesday reached a $15 million negligent-damage verdict against the maker of Botox in the case of a 47-year-old woman who suffered years of pain after getting the wrinkle-smoothing injections.

The suit was filed against Irvine-based Allergan by Dr. Sharla Helton, an obstetrician and gynecologist in Oklahoma who fell ill and eventually lost her job after getting the injections in 2006.

She blamed Botox for double vision, breathing difficulty and years of continual pains in her arms, hands and feet.

The article states “wrinkle-smoothing injections” were done, doesn’t specifically tell us why Dr Helton had Botox injections, but leaves us to assume it was facial expression lines.  Botox can be used safely, but should be done by a trained physician.  I would not recommend the DIY trend.

Related posts:
Excess Sweating  (April 20, 2009)
BOTOX -- Black Box Warning (May 7, 2009)
Neurotoxins: Dysport and Botox (January 6, 2010)
Black Market Botox  (January 27, 2010)
Botox Gets Bad Press (February 10, 2010)
Botox for Upper Extremity Spasticity 9March 17, 2010)

Reprise – Scalp Avulsion Injuries

This one I wrote in response to the horrific injury a young girl suffered in a Ferris wheel accident.  It was posted originally August 8, 2007.

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

Recently a post by Scalpel about a successful scalp replantation, after a 11 year old girl somehow gets her hair caught in a ferris wheel. Pictures of the case (and photo credit) can be seen here (not for the faint-of-heart). So I thought I'd share more about this injury.

 

The nature and mechanism of scalping injury have been reported by Koss et al. They emphasized "that it requires an oblique force to produce scalping, thus giving rise to the theory that the scalp tears at either of the bony ridges. The actual extent depends on the site, amount of hair caught, and the direction of the force." This was reemphasized by Bhattacharya et al. In all these descriptions, the extent of avulsion was from the supraorbital ridge to the nuchal line posteriorly. A case of avulsion of the face in continuity with the scalp reported by Dr. Abraham Thomas (1998) broke this pattern and showed that the actual extent depended on the speed and force of injury from the mechanical device and also the attitude and protective movements of the patient (successfully replanted--face and scalp). It was 1976 when the first successful replantation of a totally avulsed scalp was reported by Miller & others with return of normal hair growth and frontalis muscle funtion.

Scalp Anatomy:
The layers of the scalp are easily remembered by the mnemonic SCALP:
S (skin) is the thickest in the body, measuring between 3-8 mm.

C (subcutaneous tissue)- The vessels, lymphatics, and nerves course through the subcutaneous layer just superficial to the galea.

A (aponeurotic layer) --The galeal aponeurosis, the strength layer of the scalp, is contiguous with the paired frontalis muscles anteriorly, the paired occipitalis muscles posteriorly, and the temporoparietal fascia laterally.

L (loose areolar tissue) is also known as the subgaleal fascia, the innominate fascia, and the subaponeurotic plane. The loose areolar tissue of this plane allow for scalp mobility. Scalp avulsions routinely occur through this layer, leaviing pericranium intact.

P (pericranium) is tightly adherent to the skull and should be left intact in scalp reconstruction to allow for "back-grafting" of the donor site or for a means of alternative recontruction in the event of a failed local tissue transfer.

The scalp is supplied by arterial branches and vena comitantes of the internal and external carotid systems into four distinct vascular territories. Extensive collateralization (connections between the four territories) of these vascular territories allows total scalp replantation based on a single vascular anastomosis. The scalp is innervated by branches of the three divisions of the trigeminal nerve, cervical spinal nerves, and branches from the cervical plexus.

Replantation is the treatment of choice in scalping injuries and should always be considered, even in case of a badly damaged scalp. Specific procedures regarding pre-, intra- and postoperative care are crucial to success in replantation. These include: haemodynamic stabilization of the patient without causing damage to possible donor vessels; cooling, cleaning and further proper care of the avulsed specimen; use of antibiotics and haemodilution to optimize the intra- and post-operative situation.

When replantation is not possible then as in the past the goals are to obtain calvarial (bone) coverage to prevent calvarial desiccation, sequestration, and sepsis. However, today, the reconstructive surgeon should also strive for a cosmetically appealing result in addition to merely achieving coverage. The best replacement for scalp tissue is scalp tissue. There is no other donor site in the body that will approximate the same hair-bearing qualities of scalp tissue.

A wide variety of techniques has been used to close scalp defects. They include:

• Primary Closure--For small defects this is often the best option. Defects less than 3 cm in diameter can be closed primarily, but this varies depending on location. If primary closure is selected, any defect in the galea should be closed first with buried resorbable sutures, and skin edges should be reapproximated using suture or staples.
• Skin Grafting and Tissue Expansion--Placing split-thickness skin grafts can provide a quick and effective means of defect closure. Skin grafts require an adequately vascularized wound bed and are not successful if applied directly to exposed bone. Intact pericranium is typically sufficient to support a skin graft. Tissue expansion usually provides ample tissue with preservation of scalp sensation, color, thickness, and hair; however, it ultimately requires a minimum of 2 operative procedures. Patients should understand beforehand that this requires a commitment of at least 1-2 months
• Local Flaps--Local flaps are the workhorses of small to midsized scalp reconstructions. These flaps consist of skin, subcutaneous tissue, and galea, although occasionally small superficial defects may be adequately reconstructed using a flap elevated in the subcutaneous plane. Any local flap is best raised over named arterial systems. Raising a large flap and then covering the donor site with a skin graft is probably safest. One should avoid suture lines in areas where prosthetic material might be exposed.
• Free-tissue transfers--Before the advent of free-tissue transfers, closure of scalp defects covering more than 15-20% of the scalp was essentially impossible with a single procedure. Free flaps provide for single-procedure closure of large defects or complicated wounds involving scalp and bone. They can also provide improved wound healing in the setting of radiation or infection. However, they are time-consuming and expensive, and they all involve at least some donor site morbidity. Therefore, they should be reserved for appropriate situations when local flaps, skin grafting, or healing by secondary intent is not an option.
• Vacuum assisted Closure Device (VAC)--A vacuum assisted closure device has been used for large defects over the dura to promote the growth of granulation tissue. This tissue is then covered with a skin graft. The device works by applying uniform subatmospheric pressure to the wound, allowing it to develop a better blood supply, decreased bacterial counts, and robust granulation tissue.

REFERENCES:

Reconstruction of Acquired Scalp Defects: An Algorithmic Approach; Plastic & Reconstr Surg, Vol 116(4):54e-72e, September 15, 2005. Leedy, Jason E. M.D.; Janis, Jeffrey E. M.D.; Rohrich, Rod J. M.D.

Psychological Sequelae of Failed Scalp Replantation; Plastic & Reconstr Surg.; Vol 113(6):1573-1579, May 2004. Mowlavi, Arian M.D.; Bass, Michael J. B.S.; Khurshid, Khurshid A. M.D.; Milner, Stephen M.D.; Zook, Elvin G. M.D.

Total Face and Scalp Replantation [Case Report]; Plastic and Reconstructive Surgery, Vol 102 (6) November 1998, pp 2085-2087; Thomas, Abraham M.S., M.A.M.S., M.Ch., F.A.I.S., F.I.C.S.; Obed, Vijay M.S., M.Ch.; Murarka, Anil M.S., M.Ch.; Malhotra, Gopal M.S., M.Ch.

Scalping Injury; Plast. Reconstr. Surg., Vol 55: 439, 1975; Koss, N, Robson, M, and Krizek, TJ

Successful Replantation of an Avulsed scalp by Microvascular Anastomoses; Plast. Reconstr. Surg. Vol 58: 133, 1976.; Miller, G D H, Anstee, E J, and Snell, J A

Reprise – Pigmented Birthmarks

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

When I wrote this piece (July 14, 2007), it was due to this lovely one by TBTAM and this one by Intueri. I was literal in looking at the picture. They wrote wonderful literary pieces.

You should check out all the other literary ones from that challenge:

• Emergiblog
• All Sounds to Silence Come
• Musings of a Dinosaur

Birthmarks fall into two categories: pigmented or vascular (I'll deal with those in the future). Birthmarks (both types) are present at birth or develop shortly after birth. Pigmented birthmarks can be brown, tan, black, or bluish/bluish-gray. The cause of pigmented birthmarks is unknown. Most birthmarks are not inherited. There is no known way to prevent birthmarks. People with birthmarks, just like everyone else, should use a good quality sunscreen with a high SPF when outdoors in order to help prevent skin cancer. In most cases, health care professionals can diagnose birthmarks based on the appearance of the skin. Many folk tales and myths exist about the causes of birthmarks, but none of these stories have been proven to explain the true causes of birthmarks. Photo credit

Types of Pigmented Birthmarks

• Cafe-au-lait spots are light tan or light brown spots that are usually oval in shape. They usually appear at birth but may develop in the first few years of a child's life. Cafe-au-lait spots may be a normal type of birthmark, but the presence of several cafe-au-lait spots larger than a quarter may occur in neurofibromatosis (a genetic disorder that causes abnormal cell growth of nerve tissues).
• Congenital nevi are moles that are present at birth. These birthmarks have a slightly increased risk of becoming skin cancer depending on their size. Larger (covers an area larger than the size of a fist) congenital nevi have a greater risk of developing skin cancer than do smaller congenital nevi. All congenital nevi should be examined by a health care provider and any change in the birthmark should be reported.
• Pigmented nevi (moles) are growths on the skin that usually are flesh-colored, brown or black. Moles can appear anywhere on the skin, alone or in groups. Moles occur when cells in the skin grow in a cluster instead of being spread throughout the skin. Moles may darken after exposure to the sun, during the teen years and during pregnancy.
• Mongolian spots usually are bluish and appear as bruises. They often appear on the buttocks and/or lower back, but they sometimes also appear on the trunk or arms. The spots are seen most often in people who have darker skin. They usually fade (often completely) by school age without treatment.

Treatment of Pigmented Birthmarks
Pigmented birthmarks are usually left alone, with the exception of moles and, occasionally, café-au-lait spots. Moles, particularly large or giant congenital nevi, often are surgically removed, though larger ones may be more difficult to remove. Café-au-lait spots can be removed with lasers (highly concentrated light energy) but often return. If a mole exhibits potentially cancerous changes, a biopsy may be performed. Large or prominent moles that affect appearance and self-esteem may be covered with special cosmetics.

Warning Signs Since there is an increased risk of skin cancer in congenital nevi, see a doctor if you notice a change in color, size, or texture of a mole or other skin lesion. Also, see a doctor right away if there is any pain, bleeding, itching, inflammation, or ulceration of a congenital mole or other skin lesion.

Domestic Violence

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

A car door slammed.  My husband rose quickly and went to look out the kitchen window.  Not sure who held the two flashlights, he shouted “Who’s there?  Identify yourself.”

“County Sheriff officers,”  the reply came.

I opened the front door (as my husband went to put up his gun).  Rusty ran through the door and down the walk towards the officer who quickly went back out the gate.  “He’s friendly,” I called.

“Do you know YN?” 

“Yes, she lives across the street.”

“We received a call saying her boyfriend had beaten her up and she has a head injury.  We can’t get anyone to answer the door.”

By this time my husband had reappeared.  “Give me a minute to get some shoes and go over with you.”

“Do you know your neighbor well,”  the office asked as we waited for my husband to dress.

“Only well enough to say hello.  Wave as we pass.  She recently told us about having a restraining order on her boyfriend.  He’s not suppose to come around.  She asked us to keep an eye out.”

The office speaks into his walkie-talkie, “There’s a restraining order.  We’re in the correct place.   Headed back with the neighbor to look again.”

My husband comes back out the door and heads over with the officers.  I head back inside.  The clock says 3:35 am.

When he returns, he tells me they got no answer.  Her car isn’t there either.  She had called for help using her cell phone, but had not given a location.  Returns calls from the sheriff’s office all were going to voice mail.

We tried to get back to sleep, hoping they would find her.

 

AARDVARC.org stands for “An Abuse, Rape and Domestic Violence Aid and Resource Collection” and has a list of numbers by county in the state of Arkansas for help.

In Pulaski County:

Crisis Response Team (Maumelle)                   501-803-3388
Dorcas House (Little Rock)                                 501-374-4022
Victim/Witness Program                                      501-340-8000
Women and Children First (Little Rock)         501-376-3219

Another source for Arkansas Shelters is Arkansas Coalition Against Domestic Violence.  

If you are in danger:
Call 911
Your local hotline or
U.S. hotline 800-799-SAFE (7233)
Teen Dating Abuse Helpline:
866-331-9474

Shout Outs

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

Dr Charles, The Examining Room of Doctor Charles, is the host for this week’s Grand Rounds.    Check out his post:  Caring for the Patient Who Is a Zombie.  You can read this week’s edition here.

Welcome to Grand Rounds, a weekly collection of excellent writings submitted by medical bloggers.  The theme for this week is minimalism – I’m going to restrain myself and let the authors speak for themselves:……….

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Dr Wes has done a review of a film I wish all of us could see:  The Vanishing Oath: A Review

…..As background, the film is a three-year project born in 2007 just before the great US health care reform debate began. Over 200 hours of interviews were conducted explore a simple question: why Dr. Flesher had grown to hate medicine.

It would have been easy for Dr. Flesher and Ms. Pardo to make his story nothing but a rant, but instead, we find that their story is an honest attempt to understand how someone so enthusiastic at the start of their training could become so quickly discontented with the realities of emergency room care and our bloated health care delivery system…….

Addendum: The film will be premiered in Chicago on 25 May 2010. Seating is limited.

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KevinMD’s post, False patient contact information worsens emergency care, was eye-opening to me.  I did not realize this was such a significant and growing issue.

In a study from the Journal of Emergency Medicine, out of of 1,136 patients, “only only 42 percent could be successfully contacted using the numbers provided [and] nearly 28 percent of the patients gave wrong or disconnected numbers.”

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Birth control bills turned 50.  Check out this NY Times article by  Gardiner Harris:   It Started More Than One Revolution  (photo credit)

The birth control pill has been called the most important scientific advance of the 20th century, and no wonder. Fifty years after its approval by the Food and Drug Administration, it is still one of the leading methods of contraception, in the United States and around the world………

One last bit of lore about the pill: no one is even sure when to celebrate its birthday. Ten years ago, the agency honored the occasion on June 23, the date that the F.D.A. gave formal approval for Searle to market the product. This year, the agency is celebrating on May 9, which coincides with the period 50 years ago when it announced its intention to approve the pill when a few technical details were ironed out. That this happens to be Mother’s Day this year may have played a role in the decision…..

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In celebration of  the pill’s birthday, OB Cookie made Contraceptive Confections.  The post includes directions.  (photo credit)

Disclaimer: This cake contains no contraceptive properties and does not prevent pregnancy

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I want to visit this museum featured in Sterile Eye’s recent post:  The Medical Museion (photo credit)

The illustration above shows a woman having the back of her neck pierced with a large needle. And what was this supposed to cure? The common cold, which was believed to be caused by too much phlegm around the brain. So naturally, the cure would be to drain phlegm, for example through a hole in the neck. The patient usually recovered, as you do from a cold, which the doctor no doubt attributed to this excellent treatment…

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May 4, 2010 marked the first installment of Big Think's newest video interview series, Moments of Genius, sponsored by Intel.

This first set of video interviews features Martin Cooper, inventor of the cell phone; David Ho, the AIDS researcher famous for pioneering combination therapy in treating HIV-infected patients; and Arlie Petters, a mathematical physicist at Duke who is out to prove the existence of a fifth dimension.

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Dr Anonymous’ BTR show guest this week will be medical student and video blogger, Bryan McColgan.   The show begins at 9 pm ET.

Upcoming shows (9pm ET)

5/20: Larry Bauer from the Family Medicine Education Consortium

Reprise – Tailoring

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’m coming up on my 3rd blogiversary, so this week I’m going to feature a few from my first year of blogging.  This one, Tailoring,  is from June 25, 2007.  I altered it slightly to make it easier to read.

There is a “tailor” in every plastic surgeon, especially when it comes to the surgeries needed for massive weight loss patients (MWL).   (Photo credit)

The brachioplasty procedure is used to reduce the excess arm skin (sleeve, if you will) so that it fits the underlying subcutaneous tissue/muscle/bone frame.

When adjusting a pattern for a large upper arm, slashes are made in two directions to add fabric for the sleeve. When doing the brachioplasty, think about reversing the adjustments made for the sleeve. Now transfer these adjustments to the underside of the arm so that the resulting scar will be least visible. The bi-directional adjustments are made (1) along the length of the upper inside of the arm and (2) by Z-plasty into the axilla. With fabric/patterns you must remember to keep the adjusts parallel to the grainline. In surgery, we have to remember the anatomical structures that we don't want to injure (nerves, blood vessels, lymphatics), scar placement, and not to resect too much skin and thereby forming a constriction band.

The ideal candidate for a brachioplasty (arm lift) has what we call highly deflated arms. In other words, lots of loose skin and not much underlying fat tissue. Those with significant residual fat around the arms may benefit from liposuction of the arms done at an earlier stage than the skin excision. If much liposuction needs to be done at the time of skin excision, this can greatly increase the post-surgery edema (swelling) that will occur. Swelling can be a significant problem postsurgery. It is important to limit elbow flexion (static, okay when arm is being used) and to keep the arms elevated when not being used for the first 2-3 weeks. When resting, it is helpful to gently open and closed the hands/fists--squeeze on an anti-stress ball.

Scar placement is important for more reasons than just to be “not as visible”. It is important that the Z-plasty part of the scar is well placed in the axilla so that no axillary contracture is formed. This can limit shoulder/arm motion. Good scar (incision) placement decreases the risk of injury to the cutaneous skin nerves, so there will be less chance of postoperative skin numbness.

Scar placement is usually either in the bicipital groove or more posterior at the most inferior point of the upper arm while it is raised and abducted (positioned away from the body). The second choice is less visible in everyday activity. Either way, the scar is there. The scar can be quite apparent, so this procedure should never be undertaken if the patient is not willing to make this trade-off (less skin, but a significant scar). Pre and Post-operative photos here.

REFERENCES:

The L Brachioplasty: An Innovative Approach to Correct Excess Tissue of the Upper Arm, Axilla, and Lateral Chest; Hurwitz, Dennis J. MD, Holland, Sarah W. MD; Journal of Plastic & Reconstructive Surgery;Vol 117(2):403-411, February 2006.

A Technique of Brachioplasty; Strauch, Berish MD, Greenspun, David MD, Levine, Joshua MD, Baum, Thomas PAC; Journal of Plastic & Reconstructive Surgery;Vol 113(3):1044-1048, March 2004.

Textbook: Body Contouring After Massive Weight Loss by Al S Aly, MD
Shaping Futures Web Site (you must register for access to the procedures)

SurgeXperiences -- Call for Submissions

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

SurgeXperiences is a blog carnival about surgical blogs that occurs every two weeks. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.  

The host of the next edition (323) has not been announced, but don’t let that keep you from making your submissions.  It is scheduled to occur on May 16th.   Be sure to make your submissions by the deadline: midnight on Friday, May 14th.   Be sure to submit your post via this form.

If you wish to host SurgeXperiences 323 or any future edition, please contact Jeffrey who runs the show here.

Here is the catalog of past SurgeXperiences editions for your reading pleasure.

 

Happy Mother’s Day to you all!

President's Cancer Panel Report

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

While most of the news sources are reporting Cancers from Environment 'Grossly Underestimated' in response to the recently released the 240 page report from the President’s Cancer Panel, I want to focus on the small steps individuals can take to lessen their personal exposure to environmental carcinogens.

Collectively, these individual small actions can drastically reduce the number and levels of environmental contaminants.

• Children are most susceptible to damage from environmental carcinogens. As much as possible, parents and child care providers should choose foods, house and garden products, toys, medicines, and medical test that will minimize the child’s exposure to toxics.

Individuals and families can reduce chemical exposures by:

• Family exposure to numerous occupational chemical can be reduced by removing shoes before entering the home and washing work clothes separately from the other family laundry.
• Filter home tap or well water to decrease exposure to numerous known or suspected carcinogens and endocrine-disrupting chemicals.
• Store and carry water in stainless steel, glass, or BPA-free containers.
• Reduce expose to pesticides by choosing food grown without pesticides and washing produce to remove residues.
• Avoid or minimize consumption of processed, charred, and well-done meats to reduce expose to carcinogenic hydrocarbons.
• Properly dispose of pharmaceuticals, household chemicals, paints, and other materials to minimize drinking water and soil contamination.
• Reduce exposure to secondhand tobacco smoke in your home, car, and public places. If you smoke, then seek help to quit.
• Adults and children can reduce exposure to electromagnetic energy by wearing a headset when using a cell phone, texting instead of calling, and keeping the calls brief.
• Reduce exposure when possible from medical sources, but asking if the test is necessary. In addition, to help limit cumulative medical radiation exposure, consider creating a record of all imaging or nuclear medical tests received along with the estimated radiation dose of each test.
• Adults and children can avoid overexposure to ultraviolet light by wearing protective clothing and sunscreen when outdoors. Avoid exposure when the sunlight is most intense.

Source

National Cancer Institute --- Complete report available (pdf)