Sunday, July 20, 2008

SurgeXperience 202

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

Since the last edition, there has been the death of a surgery pioneer -- Dr. Michael E DeBakey (1908-2008). I wrote a post on him last year. There were many mentions of him this past week. Here are the ones I ran across.
Michael E. DeBakey: Pioneering Surgeon, Educator & Inventor
Thank You, Dr. Michael DeBakey (NPR's Science Friday) -- has a link to a 1993 interview they did with Dr. DeBakey.
Michael DeBakey, 1908-2008 from Dr Reese, Medinnovationblog
Pioneering Heart Surgeon -- Washington Post Obituary
Michael E DeBakey, 1908-2008 -- Scrub Notes, Sketches from a Med Student's Brain
Excursions in Medical History: In Memoriam Michael Ellis DeBakey, Sept 7, 1908 - July 11, 2008 by T (Notes of an Anesthesioboist)
Remembering a Medical Legend, with Gratitude by Dr Sanjay Gupta; July 18, 2008
Surgical Giant by Buckeye Surgeon
Some Debakey quotes:
"Man was born to work hard"
"Once you excise the skin, you find they are all very similar"
"I like my work very much. I like it so much I don't want to do anything else."
RIP, Dr DeBakey....

Aggravated DocSurg writes a moving tribute to a patient in Sara's Smile.
The day I first met her is one not easily forgotten. A new patient on my schedule, I knew nothing of her past; there was just a note requesting a cervical lymph node biopsy. I was greeted with a warm hello and a welcoming smile.

Then there is the message you hope never to send (or receive). Paul Levy talks about it (and then follows up here).
Before I start, I want to refer you to an excellent story summarizing the case written by Stephen Smith at the Boston Globe.
So, here are a few things you might want to know. The things that went wrong are summarized above and simply should not have happened. The test for our place is to figure out how to make the right things happen 100% of the time. As we work on that, I'll keep you informed.

Buckeye Surgeon that looks at disclosure and honest in discussing surgical errors that occur with patients in his post "tangled up in blue".
Why did the kidney fail? I asked.
-When they were doing my hysterectomy, the "urether" got tangled up in some adhesions, she said.
-When was the hysterectomy?
-Oh lord, maybe 30 years ago.
-I see.
-They had to go back in and try to untangle it a few days later, but the kidney died anyway, she said.

Bongi, other things amanzi, gives us another glimpse into life of the surgeon and patient in his recent post captive
the next morning the patient wasn't only alive, but he was doing very well. he was still on a ventilator, but we expected to wean him in a day or two.
then two cops walked in carrying a ridiculous amount of heavy chains and shackles. they walked up to my patient and sort of dumped them on the bed with a loud clang. they then told me they were going to chain him down.
and in this post family
it was the usual story and i didn't think too much of it until the next morning....... the patient's mother came in to see how he was. i have treated numerous criminals, but this was a first. i found it interesting so i decided to chat to her to find out where such a criminal comes from.
the first thing she told me is that she was a theater sister and worked night shift in a local hospital. this took me totally by surprise. firstly i wanted to believe that my patient came from a broken home or had some similar pathology in his past. but more importantly, a theater sister is like family to me. i have spent countless nights across an open abdomen with theater sisters.

Buckeye Surgeon had two posts that I think go together--Bowel Obstruction (photo from his post) and Internal Hernia.
Well, I saw a lady last week with a classic SBO on initial imaging. A year and a half ago, she had undergone a laparoscopic right hemicolectomy for a villous adenoma at a "major midwestern university program". I put an NG in but she didn't get better.

Dr Michael O'Connor, The Ether Way, in his post on Evil Humors writes about attending M&M conferences.
As an educator, one of my greatest responsibilities is this: to convey to my students, residents, and fellows an appropriate degree of circumspection regarding the limits of our knowledge and understanding.
‘I know what happened.’ Bullshit.
One of the wisest men I have ever met says: ‘ I don’t know what it was, but whatever it was, it was the worst case of it I ever saw.’
As for me, I know: it’s syphilis.

QuietusLeo, The Sandman, writes about a night on call in The "eyes" have it.
A 51 year old semi-conscious man was brought in. Full of shrapnel holes, right leg broken, a finger or two mangled, left eye looks like mush, pools of blood forming around him and most importantly an expanding hematoma in the neck.

Dr Bruce Campbell, Reflections in a Head Mirror, talks about distractions in a recent post
Difficulties increase the nearer we get to the goal.”-Goethe
Have you ever noticed this, as well?
and about how some patients are just Boneheaded.

Someonetc, our orthopedic attending, tries to show by example how to be a good doctor in I am the boss of me.
Today, I sit in my office after 7 waiting for a case and I am not on call. Why? I feel it is the right thing to do for the patient. On the other hand, my all of resident have gone home. I guess I can't expect that they too would feel the need to stay, but I can still hope.
So, I continue to model.

Dr B, Surgery....Passionately, writes about telling a patient that you disagree with the previous doctor in her post, Prove It.
One of the hardest things, I think, in medical practice, is attempting to prove to a patient that you (as a specialist) are in the right, when, in fact another surgeon in your specialty has proven some other thing to said patient. (still with me?)

David Gorski, Science-Based Medicine, wrote about a death by "alternative" medicine and asks who's to blame?
This patient was in serious trouble. You would think that, finally–finally–she would have realized her mistake in not having gone with surgery and conventional medicine.
You would be mistaken.
The patient still steadfastly refused all surgery, chemotherapy, and radiation. Against all evidence that the course she had chosen thus far had not resulted in the elimination of her tumor that she expected, she nonetheless insisted on continuing with various alternative medicine treatments. Against all evidence to the contrary, she continued to refuse any form of “conventional medicine.” She still believed that her ” healer” could save her life, even though she now had a large, bleeding, stinking mass in her breast stuck to her chest wall that had three years ago been a pea-sized cancer that could have easily been excised with a small surgical procedure.

Dr Au, the Underwear Drawer, writes about her last day as a resident (she's now an attending anesthesiologist in Atlanta-- congratulations) in her post "a fitting end"
How fitting, really, to do a heart transplant as one’s last case of residency. Much like the process of medical training, an organ transplant takes the ordinary and transposes it into extraordinary circumstances—in this case, taking the heart of a freshly deceased patient and having it work in the body of a patient who still might be saved. The recipient that day was a 57 year-old man with dilated cardiomyopathy................... The patient's old heart was huge, congested, an angry and mottled looking purplish mass looking more like a dead thing in a butcher’s window than anything else. We worked together to get the patient onto cardiopulmonary bypass, the surgeons snipped the old heart out, and suddenly the chest cavity was huge, empty, a yawning expanse waiting to be filled.

Dr Oliver, Plastic Surgery 101, has a very nice post on "What's Oncoplastic Surgery?"
This is conceptually just lumpectomy or mastectomy done better. The concept uses rotating breast tissue to fill defects at the time of lumpectomy or larger "quadrantectomy" procedures. These are maneuvers we use with breast reduction and mastopexy procedures adapted to some of the cancer surgery procedures.

How about appendicitis in pregnancy? Check this out at Radiology Picture of the Day (credit)

KeaGirl, UroStream, wants to remind patients that ALL of your medical history is important in her post not so insignificant.
I am always astounded at the details that patients omit on their medical history form. I'm clued in when I look at their medication list and see 3 different antihypertensive medications, yet they don't list hypertension as one of their medical condition. Usually the explanation is something like: "but with the meds, I don't have high blood pressure anymore....

Dr Val writes about living with faces that are very different from those around you in Saving Face: Kiddies and Kitties.
What struck me about the girl's story was how she described how it felt to be teased growing up, and how the worst part of the teasing was that no one stuck up for her. I've seen kids do this kind of thing before, and I can imagine how painful it is when no one has the courage to go to bat for you.

White Coat Rants shares a practical tip from a patient (photo credit) or another use for duct tape in his post, "It's Like the Force -- Only Better".

Happy Hospitalist shares his uncle's experience with surgery in Egypt.
My parents flew to Egypt to be with my Uncle Maher for an elective total knee arthroplasty. This is my mother's diary of observations:
June 19th--Again the airline Gods willing, we will get on a Delta flight that leaves JFK at 4:20 on Tuesday, June 24 and arrive in Cairo at 10:35 am on Wednesday, June 25. That is, if all goes according to plans. Maher's surgery is scheduled for July 5, so we are getting there earlier than necessary, but .....

Here is the first X-ray (credit) from a series that Dr Shroom, The Knife Man, did recently. Begin here with his post The Missing X-rays of Uncle Shroom, then go to Mea Culp Part 2, Mea Maxima Culp, and then the Finale.
Part of the 'mea culpa' series. Hopefully, a very occasional series. In several parts.

With the new iPhone released recently, Mark Borkowski writes:
I have been approached by a UK plastic surgeon who wants to discuss publicizing his new treatment. The phone call was a bit of a long ramble but essentially he wants to be the first British practitioner to surgically alter thumbs to make using an iPhone easier. I hope he is not a prankster reacting to this post.

IntraopOrate has begun a series of posts that tell the tale of how she became a surgical assistant and got to this point "meanwhile back at the ranch"
It started Sunday afternoon while he was on ER call, which means general surgical cases from the ER are referred to him. First case, a perfed (perforated) viscus at the jejunum. Fairly straightforward repair with a patch of omentum thrown over the top for added strength and healing power. He complimented me on having quiet hands. I was flattered.
Drnjbmd, Medicine from the Trenches, writes about why he chose surgery as his profession:
I was hooked on Surgery from my first case. It was a total colectomy with four females operating. My chief resident was female, the junior resident was female, the attending was female and I was female. We talked about shoes and Chanel suits during the case. I tied tons of knots and helped the junior resident close the incision. It was heaven. I found out that I loved Trauma and I couldn't wait to be on call every third day. I had the time of my life and I loved everything about surgery.
I'm not sure if this is a picture (credit) of T, Notes of an Anesthesioboist, or whether she is just getting prepared to look a patient in the mouth (what's that about?).
"I feel pretty,
Oh, so pretty,
I feel pretty and witty and bright!
And I pity
Any girl who isn't me tonight..."
But don't worry, T (and her fellow surgeon) will sing to you to put you at ease. Check out this post on "Songs in the OR"
Then, a little louder, "But somewhere in my wicked, miserable past there must have been a moment of truth." Dr. Warbucks, though feeling a little impatient over the delay with the blood pressure cuff, had gotten into the Rodgers and Hammerstein spirit.
As I secured the LMA into place, he stood up, put on his x-ray apron, and belted in my direction, "For here you are, standing there, loving me, whether or not you should!"
So I replied, and we finished together, "So somewhere in my youth or childhood, I must have done something good."
Sterile Eye may be on break to enjoy the summer outdoors with his kids, but he left us some amazing videos of sarcoma surgery. If you haven't seen them, here's the link.

If you like learning by watching videos, then check out these presented by ORLive:
Innovations in Stroke Prevention: An Update in Carotid Stenting presented by William A Gray MD, Y Pierre Gobin MD, and James McKinsey MD; New York-Presbyterian Hospital, NYC, NY; July 15, 2008
Replay of Heart Transplant Procedure; Sept 19, 2007

Dr Alice, Cut on the Dotted Line, writes that urine is good. She is now a second year surgery resident.
I got to do my first transplant today.
More precisely, I assisted the attending for the first time today; but I have high hopes of getting to do more of the procedure later on. I really didn’t want to ask for anything more; I was still figuring out the anatomy (well, ok, so the external iliac artery and vein are not that complicated; but the way that the donor artery, vein, and ureter fit in is), and I don’t have much experience sewing blood vessels yet.

Theresa, Rural Doctoring, is a hospitalist in rural California. She tells a story of being asked to do a pre-operative clearance on an orthopedic surgeon. You'll have to read the post for the punch-line.
One day I was trying to get ready to go to the hospital when I got a page. It was one of the orthopedic surgeons asking me to consult on a patient.
"The nurses called me and they're freaking out," said the orthopod. "The guy threw up red stuff and they're afraid he's got a GI bleed. I'm supposed to take him to the OR at nine-thirty."

TC, Donorcycle, writes about the best call she ever made.
So there he is, going about his daily business, doing whatever with the missus and BANG! Drop everything, pack your toothpaste and jammies-you're going to the hospital for a new kidney! And I get to be the person who tells him it's Christmas, your birthday and the 4th of July all rolled into one.

Uveal Blues is an ex-USA-expat ophthalmologist with a strong interest in international healthcare. He gives us this post on Countries Make Push to Increase Eye Donors.
The non-acceptance of corneal transplantation in the third world continues to be a problem. It is encouraging to see that efforts to increase acceptance are being made in Syria. I should also acknowledge that Dr. David Paton, who started Orbis' Flying Eye Hospital, also started the first eye bank in the Middle East. (The article also quotes my friend, Dr. Hunter Cherwek, the current medical director of Orbis).

Plasticized gives us another example of the extreme alterations some people do to their bodies (photo from his post)

Our Next Generation of Surgeons/Anesthesiologists/etc:
Med Obsession My Life has officially begun 4th year orientation.
The first day was sooo fun. ..........Today, I did my first hysterectomy… on a cadaver!

Derrx, Silent River, writes about "The Junior Intership (12 months of REAL medical drama...) -- Part 2"
Surgery, probably the most diverse rotation of them all... when i say diverse, it's because of the different subrotations each has to go into. i dont exactly recall which rotations came first so i'll go with whatever comes to mind first. anyway, when i think of surgery, the first rotation i will remember would be that of Amang Rodriquez.

Dragonfly, The Dragonfly Initiative, writes in her post Orthopaedics for beginners
Orthopaedics is (so far) going better than expected. In one afternoon (joint replacements are not exactly quickies) I get to realise 2 of my childhood dreams - surgeon and astronaut. Now if only there was a way to be an life saving, space exploring prima ballerina....
and then in her post the hidden world of arthroscopy likens it to
Like taking a tour through an underwater cave .
On our left are fronds of seaweed/synovium, waving in the currents of irrigation fluid.

Jeffrey (Monash Medical Student) sent me this link to a cartoon (photo credit).

Ms Ellisa writes a great post about learning (and teaching) in My Airway.
He raises his hand and stops her.
He says:
"No. Not that. If you don't know the BASIC A-B-C-D's you will LOSE him, no matter what else you know"
And he turns to me, points at me with the same already raised hand, now in approval- the same in which he clutched her face in the dirt (okay okay I'll dial it down :) ) points at me and says - in words roughly translated because you can't find the exact translation in English -
"Say it baby!"
And I simply explained that "A", is "Airway", and you have to make sure he can breathe first, before doing anything else...

Some of our patients and their stories
Martha Watson gives us her side in "The juicy details of my hand surgery"
If you are planning to have bone surgery in your hands, it truly is incredibly painful. Immediately afterwards, it feels like you shut your finger hard in the car door, and just for kicks, did it again and maybe once more, to see if it couldn’t hurt any worse..........
My favorite type of anesthesia for hand surgery is the Bier Block, a combination of tourniquet and a local anesthesia (numbing shot). ........... You’d think a shot in the armpit would be horribly painful, but really it’s not at all. This surprised me the first time I had it done, as this was the thing I feared most about that operation................

A woman who lives in Florida writes about her experiences in My Brain Surgery
Angiograms are not fun. But it was very interesting that I had my own personal fireworks/laser show behind my eyes. I saw little flashes of light every time they injected the dye. The doctor said I was seeing the synapses of my brain firing. It was quite amazing. Sometimes at night when I close my eyes I can still see faint flashes. Weird huh? It has been three years since my surgery. There are some remaining after effects. I have diminished vision in my right eye. I lost memories. I lose my train of thought very easily. My mind goes blank just like a TV during a power outage in the middle of a movie.......

Molly's Trek (which all began with Strep Throat) is an incredible story of a simple sore throat that went on to wreck havoc with her health and her journey back. If you go back through the posts, you will find multiple surgeries (wound debridemont, skin grafts, amputations, hand surgeries) and now her therapy. Here is an excerpt from the most recent post after hand surgery:
For example, we know nerve regeneration continues in Molly's hands which is evident because she says she feels like she has better control and command of objects she is holding.

Pepe received a lung transplant on July 3, 2008. Posts since then indicate that she has had many postop complications, but hanging in there. This is from July 13, POD 11
She had a new X-ray that showed recession of her pneumonia in the lower lobes. She also had a second bronch in which the doctor cleared much of the mucus and took more biopsies that remained negative for rejection. All great news. Pepe is tired and in some pain but much more comfortable, breathing more easily despite a lingering "roughness" from the remaining infection. Her sat is up to 94 percent on 10 liters. Her PaCO2 has dropped dramatically, into the 40s, not far from normal.

What do you do when you are a patient who needs to use medical adhesives and are allergic to them? Well, it seems that Amy Tenderich, Diabetesmine, is unfortunately going to find out.
You’re the only one in the family who needs medical adhesives, and now you’re allergic to them. Isn’t that ironic or something?” my 11-year-old blurted out on the way home from the dermatologist late last week.

One of our fellow doctors who just happens to be a patient writes a blog called The Tale of My Left Foot. Read her take on being a cancer survivor.
Oh you're a cancer survivor that's incredible. To which I had to take pause.
Cancer survivor- not a label I apply to myself. The very term seems off to me. The whole concept of survivor is final- like there is a great battle and you survived it, or some natural disaster, or some other calamity...............

Some thought provoking posts (not necessarily surgical)
Amanzimtoti writes a thoughtful post on Third world aid.
We recently had an American delegation from PEPFAR (the United States President's emergency plan for AIDS relieve) visit our clinic. I didn't stick around for the circus because preceding the visit a list of demands was given to the clinical manager. Now PEPFAR isn't even one of our major sponsors - from what I understand the money they've given us was just enough to put up some shelves in our pharmacy. Don't get me wrong, we're grateful for any donations, but if you're going to give money for a worthy cause, you should do it out of the goodness of your heart, not so you can make them jump through hoops for you.

Dr. Shaheen Lakhan, Brain Blogger, submitted this thoughtful post, Ethical Obligations of Health Care Workers During a Pandemic
The romantic notion of selfless sacrifice in medicine may be the exception rather than the norm in the face of a global pandemic, which would stretch our already over-stretched resources to the breaking point. Although history has given us many noble figures in medicine, how noble will we be if we are faced with a highly virulent strain of flu to which none of us are immune, and to which a vaccine to prevent the illness might not be available until after the outbreak of the disease has already begun?

Is Death the Enemy? by Dr Jay, Missionary Doc in the Making
You know, death is an interesting event. As a physician in training it kind of feels like failure....
So now that I have set the morbid tone of my entry, :), my day actually started out with beginning of two new lives. Today, I assisted in a C-section where the mother was pregnant with twins…two beautiful baby girls............
After witnessing two new lives enter this world, I witnessed two leave it. As we were rounding on the male medical ward (which I noticed is composed of mostly HIV reactive patients) we were evaluating a patient who was experiencing dypsnea...........He looked at me and said, “Kaposi sarcoma“. There is nothing we could do; the sarcoma had infiltrated his lungs and progressed so far that you could see the vascular papules on his hard palate.

For any parent/surgeon/doctor, I hope your children might write this about you:
On behalf of children everywhere with doctor parents who worry, fret, and guilt themselves over the time they have to spend apart from their children...I want you to know that we love you, and even if it's hard when we're little to understand what you do, or why you're gone so long sometimes (though we tend to vaguely grasp even then the idea that "work" is very hard and busy and keeps you away even though you love us very much and wish all the time that you were here with us), we're proud of you and love you very much. We do our best to understand and accept these struggles with you, and we see better while looking back from older ages all of the sacrifices and difficulties you've endured for us, and just how much you've always loved us--and at all ages young to old, we love to hear you say it on nights when you're around to tuck us into bed. (read the entire post here)

How to Pick a Nursing Home for an Alzheimer's Patient to Pick a Nursing Home for an Alzheimer's Patient by Ray Mullman; July 14, 2008

Surgery in the News and on TV
If you get a chance to watch this episode of PBS' Wide Angle, I hope you will do so: Birth of a Surgeon, Midwives in Mozambique
The film Birth of a Surgeon follows Emilia Cumbane, one of the first midwives-in-training. She performs Cesareans and hysterectomies in makeshift operating rooms in rural Mozambique. We follow Cumbane from her home in the Mozambican capital Maputo, into intensive medical classes, through night shifts in the delivery wards, and watch as she fights for recognition of her surgical competence.

Coalition doctors remove tumor, save Afghan girl's life by Army Sgt. Daniel Love; Armed Force Link, July 15, 2008 (via Chris, Made a Difference)

Jeffrey, Monash Medical Student, gives a critique of the
Real Life Grey's Anatomy (Hopkins) and gives you this info:
You can even watch the episodes online for free.
Rise Seen in Medical Efforts to Treat the Very Old by Anemona Hartocollis; NYTimes, July 18, 2009 -- When is too old for surgery?

Doctor Gets 10 Years in Prison for Surgery Scam -- Surgeons like this make us all look bad.

Teen Nixed from Transplant List Because He’s a Foster Child -- Sadly, I can see why this rule exists. There has to be a support system of responsible care for the patient. There has to be someone responsible to make sure the anti-rejection drugs are taken as prescribed, make sure appointments are keep, etc. By putting it in the news, maybe a good Samaritan will come forward to "foster" this child.

Donor Kidneys Removed with Single Bellybutton Cut By Thomas J Sheeran; Associated Press, July 17, 2008 (commentary by Buckeye Surgeon here)

Costs, quality of life drive doctors from the baby business (via Kevin, MD)

Okay, folks, I went looking for a lot of these posts (I kind of enjoy doing this). Most were not submitted (as they are suppose to be). That said, please, SUBMIT your posts for the next edition of SurgeXperience here. The next edition will be published on Sunday, August 3. Deadline for submission is Friday August 1st. Our next host will be Bongi, Other Things Amanzi,who is much busier than I and most likely will not seek out your posts (no matter how good).

And Dr Schwab if you happen to still be reading blogs, we miss your writing. We miss you.
Thanks for allowing me to host this edition of SurgeXperiences. Hope you'll visit all the blogs. 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.


Jeffrey said...

great stuff! as always :)

The Happy Hospitalist said...

wow. great work.


rlbates said...

Thank you both.

Vijay said...

You have more posts here than some of the recent Grand Rounds!! Great work.

Anonymous said...

Wow, the surgeon blogs are multiplying... What a terrific, and robust collection! :)

Anonymous said...

Thanx for the mention :)

rlbates said...

Amanzimtoti, you are so welcome.

Bruce said...

Where do you find the time? Thanks so much!

Ms-Ellisa said...

Great work...! Thanks :)

Øystein said...

Thanks for including me in this great edition, Ramona.

I'll have to start blogging again soon :)