SurgeXperiences 205 is Up!

 Updated 3/2017--all links removed as many are no longer active and it was easier than checking each one.

Dr Cris, Scalpel's Edge, is the host of this edition of  SurgeXperiences. It is her first time hosting.  I think she did an outstanding job!  Hope you will go read it here.

Welcome to SurgeXperience 205.  I was impressed by the variety of posts I received, and many fit the theme of “Evidence” . I have enjoyed reading through this content and I hope you do, too.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. The host for SurgeXperiences 206 will be The Sterile Eye on September 14th.  The deadline for submissions will be midnight on Friday, September 12th. Please submit your posts here.

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

Log Cabin Quilt in Blue & Green

A friend's niece was hit by a drunk driver earlier this month. Unable to do anything else for the girl, I ask if I could make her a quilt. I was told she likes blue and green. I like the log cabin pattern. It goes together quickly and the blocks can be arranged in various ways to showcase the colors -- straight setting, sunshine and shadow, furrows, and barn raising.

I picked out several blues and greens from my stash and made this scrappy furrows log cabin quilt. It is machine pieced and is 50 in X 63 in. I machine quilted it using the in-the-ditch method.

Here is a close up to show some of the fabrics.



Now I have a plea:
Please, have a safe holiday (Labor Day) weekend AND don't drink and drive.   Thank you.

My First Research Experience

Updated 3/2017--photos and all links (except to my article) removed as many are no longer active and it was easier than checking each one.

Dr Cris, Scalpel's Edge, will be hosting SurgeXperiences on August 31, 2008, and has asked for a "research bent" post. I must admit I have not done much research during my training or in practice. Between my first and second years of medical school (summer of 1979) I had the opportunity to work in the Biomedical Research Division at Ames Research Center, Moffett Field, California. It was my chance to work for NASA and I took it! I didn't have good enough eyesight to be an astronaut (very near-sighted), but I could have a small brush with them. Well, not really, I never meet any astronauts.

I spent that summer helping collect data for an anti-gravity experiment. The experiment was to try to

determine whether a different body position during bedrest (BR) could induce physiological responses that would be closer to those observed after exposure to weightlessness.

I helped collect and enter data -- age, height, weight, BSA, body fat, heart rate, systolic blood pressure, etc. I helped in lower body negative pressure testing. The findings from the study were:

1)BR resulted in a general decrease of exercise tolerance in both groups
2) the negative 6 degrees BR appeared to simulate the effects of weightlessness more effectively than horizontal BR when comparable space flight data were presented.

I enjoyed my summer and got my name on my first published paper.

Effects of antiorthostatic bedrest on the cardiorespiratory responses to exercise; Aviat Space Environ Med. 1981 Apr;52(4):251-5; Convertino VA, Bisson R, Bates R, Goldwater D, Sandler H.

Arte y pico Award

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

I’ve just been given this award by Chrysalis Angel.  This is why she says I deserve it:

For creativity, her site can not be beaten. She not only sutures for a living, but she sutures for fun. She makes some of the most beautiful, amazing quilts. I don’t know how she finds the time. She is also someone I call friend. I felt a connection with her immediately. She understands how I feel about babies with fur (dogs). You all will love her blog. She is also a huge amount of support for me right now, which I appreciate.

Thank you CA! 
The rules are as follows:
1.You have to pick five blogs that you consider deserve this award in terms of creativity, design, interesting material, and general contributions to the blogger community, no matter what language.
2. Each award has to have the name of the author and also a link to his or her blog to be visited by everyone.
3. Each winner has to show the award and give the name and link to the blog that has given him or her the award itself.
4. Each winner and each giver of the prize has to show the link of “Arte y pico” blog, so everyone will know the origin of this award.
5. To show these rules.

I, like CA, always worry about making these choices, but here goes:
1.  Penny Sanford's Porcelains -- Penny lives in Mississippi and is a sculptor, quilter, Westie dog rescuer, family historian, sharer of recipes, etc. 
2.  Nobody Important who describes herself as "Retired from hospital pharmacy, wasting too much time reading blogs and surfing the internet and now addicted to Second Life. Who said retirement was easy?"  Her blog covers books, family, travels, etc.
3.  Theresa, Rural Doctoring, who's blog I really enjoy.  She covers her medical practice (hospitalist and family doctor who delivers babies), books, rural life, and recently her time with Zippy the Lobster.
4.  T, Notes of an Anesthesioboist, who writes so well about practicing anesthesiology, learning to play the oboe, her family, books, etc
5.  The Sterile Eye who is a Norwegian medical photographer.  I love all the videos he shares with us.  He is very good at his job and writes well too.

Trigger Finger: Prognostic Indicators for Recurrence

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

Last July, I did this post on trigger finger (or stenosing tenosynovitis).

Stenosing tenosynovitis is more commonly known as trigger finger or trigger thumb. It involves the pulleys and tendons in the hand. These tendons and pulley work together to bend the fingers. The tendons work like long ropes going from the muscles in the forearm to connect to the bones of the fingers and thumb. In the finger, the pulleys are a series of rings (made of connective tissue) that form a tunnel that the tendons must pass through. This is very much like the guides on a fishing rod through which the line (or tendon) passes. These pulleys hold the tendons close against the bone. The tendons and the pulley (tunnel) have a slick lining that allows easy gliding.

When the tendon develops a nodule or swelling of its lining, it has difficulty passing through the pulley (which is not elastic, but fixed in diameter). The "popping" or "catching" feeling in the finger or thumb comes from the tendon "squeezing" through and giving as it makes it past the pulley. The swollen tendon is irritated more as it has to be squeezed through the pulley, producing more swelling. A vicious cycle of triggering, inflammation, and swelling. Sometimes the finger will become stuck (locked) and it may be hard to straighten or bend the finger. This is like having a finger swell and not being able to get your ring off.

So what causes this condition. Repetitive grasping of objects or an injury to the palm may irritate the flexor tendons. Medical conditions such as rheumatoid arthritis, gout, and diabetes may create swelling around the tendons which then lead to the "vicious" cycle of irritation/inflammation/swelling. Sometimes the cause is not clear.

The goal of treatment is to eliminate the catching or locking and allow movement without discomfort. To do this the swelling around the tendon must be reduced to allow smooth gliding of the tendon. Wearing a splint or taking anti-inflammatory medication by mouth or injection into the area around the tendon (a corticosteroid shot) are ways to reduce the swelling. Changing how the hand is used, better body mechanics to reduce the impact or repetitive motions helps. If nonsurgical forms of treatment do not improve symptoms, then surgery may be recommended. This surgery is usually performed on an outpatient basis. Most often it is done using local anesthesia, but a regional (where only the arm is numbed) or a general may be used. The surgery cuts the pulley (only one and the finger still has other pulleys to keep it near the bone) which gives the tendon more room to glide, removing the restriction (cutting the ring off the swollen finger). Active motion of the finger is generally begun immediately after surgery. Normal use of the hand can be resumed once comfort permits.

Recently, there was an article in the Journal of Bone and Joint Surgery on prognostic indicators that can be used to "predict" the recurrence of triggering after corticosteriod injection. See the reference below.

In the study, there were 124 trigger digits in 119 patients. Of these 70 digits (56%) had a recurrence of symptoms at a median of 5.6 months after the injection. Twenty-two digits (18%) underwent surgical release at a median of 7.4 months after the injection.

According to the Kaplan-Meier analysis, the estimated rate of freedom from symptom recurrence was 70% (95% confidence interval, 63% to 77%) at six months and 45% (95% confidence interval, 36% to 54%) at twelve months and the estimated rate of freedom from surgical release was 95% (95% confidence interval, 92% to 98%) at six months and 83% (95% confidence interval, 77% to 89%) at twelve months.

Insulin-dependent diabetes mellitus was identified as a strong predictor of symptom recurrence (p < 0.01). Younger age (p < 0.01), involvement of other digits prior to presentation (p < 0.01), and a history of other tendinopathies of the upper extremity (p = 0.02) were all independent predictors of a surgical release. The duration and severity of symptoms were not predictive of poor outcomes following injections.

Trigger Finger: Prognostic Indicators of Recurrence Following Corticosteroid Injection; The Journal of Bone and Joint Surgery (American). 2008;90:1665-1672; Tamara D. Rozental, MD, David Zurakowski, PhD and Philip E. Blazar, MD

Shout Outs

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

Theresa, Rural Doctoring, is this week's host of Grand Rounds. I submitted one of my posts from last week. You can read this weeks grand rounds here. Wonderful, scholarly edition!

Some of you may know I am an amateur Shakespeare scholar. I pursue the study of the Bard during my spare time, which means I don't pursue it very deeply. Medicine and blogging seem to be the great consumers of time lately, but this week's Grand Rounds gives me the chance to marry the three subjects together. I present to you a Shakespearean Grand Rounds, and I begin with a literary digression.

Change of Shift, Vol 3, No4, is up over at Emergiblog.

Chris, Made a Difference, recently posted regarding 73rd Cavalry volunteers who are treating Iraqi children and need supplies. For a list of the supplies and where to send them, so here.

I recently received from a friend, Deb, this great news about US troops at CSC Scania

(that's Convoy Support Center) south of Baghdad who are volunteering their time to run a clinic for Iraqis in need of medical care. These aren't people who were sent to Iraq as medical providers. Their official duty is to refuel trucks and keep them running on the convoy line running north and south through Mesopotamia. They treat up to 80 patients a day, many of them burned children. They report that they are seeing the same burns I saw so commonly: scald and oil spill burns from uncovered cooking sources in the home. They rely on donated service hours and donated supplies. If ever anyone needed a reason to be proud of our military, look no further than these troops.

Dr Smak will make you laugh with this post on Pelvic Dyslexia.
A Gory Eye Picture from Marianas Eye (you are forewarned).

What happens when one of the physicians in your practice gets injuried or dies? Read this -- Parables of Practice Management: A Tale of Three Clinics; Medical News of Arkansas, September 2--8; by Chad Carlson

When a physician has an equity stake in a medical practice and he or she is unexpectedly disabled or dies, the consequences for the rest of the partners (or the physician's heirs) can be severe. Failing to adequately prepare for forced transitions may seriously impair a successful practice and may even result in lawsuits................

Whether you're just beginning to write your story or you're already deep into the storyline, make updating your buy/sell agreement a priority. Establishing, structuring, and funding an adequate arrangement is a team effort. You should always have the involvement of a tax advisor and legal counsel.

Plan well and ensure for yourself, your family, and your practice, a very happy

Dr Wes shares with us "What your heart attack might be like" and includes a video ad from Great Britain. Well, worth watching and sharing!

Although one would hope the symptoms wouldn't get to this extreme, the ad makes the point that heart attacks aren't really just about chest pain: but also chest or arm tightness or a discomfort, dizziness, shortness of breath, nausea, vomiting, sweating, and the like..............

And one more thing to consider: if a friend wants to call an ambulance for you, let them. Remember they are objective observers, and might just save your life even despite yourself.

Check out Dino's recent two posts on Ramsay-Hunt Syndrome here and here. Then check out my own experience with Bell's Palsy here.

The patient's daughter had discovered a condition known as Herpes Zoster Oticus -- also called Ramsay Hunt syndrome. It is basically shingles of the geniculate ganglion, and it explains every single one of the patient's symptoms!

Essentially zoster of the ear, Ramsay Hunt consists of a painful vesicular rash in the external ear canal associated with a facial nerve palsy, vertigo, oral vesicles and taste disturbance. Treatment is with antivirals directed against herpes zoster, which I had already initiated, and steroids.

If you missed the Dr Anonymous' Blog Talk Radio show last week when I was his guest, you can listen to it here. Thank you all for showing up and calling in (Val, Theresa, Vijay, Bongi, Enrico, and Mary). This week is the ONE year anniversary show. I hope you will join us this Thursday night at 8 pm CST (or 1 am GMT) as we help Dr A celebrate.

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

For first time Blog Talk Radio listeners:

*Although it is not required to listen to the show, I encourage you to register on the BlogTalkRadio site prior to the show. I think it will make the process easier.

*To get to my show site, click here. As show time gets closer, keep hitting "refresh" on your browser until you see the "Click to Listen" button. Then, of course, press the "Click to Listen" button.

*You can also participate in the live chat room before, during, and after the show. Look for the "Chat Available" button in the upper right hand corner of the page. If you are registered with the BTR site, your registered name and picture will appear in the chat room.
*You can also call into the show. The number is on my show site. I'll be taking calls beginning at around the bottom of the hour. There is also a "Click To Talk" feature where you do not need a phone to call into the show - only a microphone headset. Hope these tips are helpful!

Breast Reduction: Safe in the Morbidly Obese?--Article Review

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

I found the article regarding breast reduction in the morbidly obese (reference #1) to be quite interesting. It does seem to be an important question with the increasing obese population and with the "never events" list being expanded. They give their reason for looking at the topic:

Background: With an increasing obese population, plastic surgeons are consulted by women requesting larger breast reductions, with body mass indices in the obese to morbidly obese range (30 to ≥40 kg/m²) and breasts considered gigantomastic (>2000 g resected from each breast). There have been few descriptions of outcomes in the morbidly obese population. Previous literature reports high complication rates in obese women and large-volume breast reductions.

The article is a retrospective review of 179 consecutive patients who had surgery at the University of Texas Medical Branch at Galveston during the time frame of June 1996 to April 2006. I hope they will do another review in a prospective manner and see how it compares.

... We obtained data points including height, weight, preoperative symptoms, medical history, smoking history, breast size, physical examination, type of reduction, amount of resection, and postoperative course including complications. All complications were recorded, and included hematoma, seroma, asymmetry requiring further surgery, stitch abscess, open wounds, cellulitis, fat necrosis, flap loss, changes in nipple sensation, nipple loss, nipple graft loss, and hypertrophic scarring. All were recorded, with no gradation as to severity. These were recorded throughout the patient's follow-up course, ranging from 1 month to 1 year.

The most common pedicle type was the inferior pedicle or central mound used in 134 patients. Free nipple grafts were done in 37 patients. There were 29 patients who had surgery for gigantomastia (more than 2000 gm per side). Six of these women had inferior pedicle/central mound reductions. The other 23 had breast amputations with free nipple grafting.

There patient population characteristics:
Average reduction mass -- 1259 gm per breast (117 - 4875 gm)
Average age -- 35 yrs (15 - 68 yrs)
Average body mass index -- 34 (range, 20.7 - 54.4)

World Health Organization: 18 to 24.9 kg/m² (normal weight), 25 to 29.9 kg/m² (overweight), 30 to 39.9 kg/m² (obese), and greater than 40 kg/m² (morbidly obese)

• 93 women in the obese category
• 34 women in the morbidly obese category

There were a total of 90 patients (out of 179) with complications, or an overall complication rate of 50 percent. The most common complication was delayed healing which accounted for 65% of the complications

The complications were broken down as follows:
Delayed wound healing -- 65%
Cellulitis -- 17.6%
Hypertrophic scarring -- 8%
Hematoma -- 3%
Seroma -- 3%
Fat necrosis -- 3%
Nipple graft loss -- 1%
Their Results:

The overall complication rate was 50 percent.

There was no statistical difference in the incidence of complications attributable to size of reduction, age, or body mass index (p = 0.37, p = 0.13, and p = 0.38, respectively).

Also, smoking status, method used (p = 0.65 and p = 0.17, and p = 0.48 and p = 0.1, respectively) and

comorbidities had no effect on complication rates (reduction size, p = 0.054; age, p = 0.12; and body mass index, p = 0.072).

There was no significant increase in the rate of complications for each body mass index group based on the reduction mass (p = 0.75, p = 0.89, p = 0.23, and p = 0.07).

They conclude that reduction mammoplasty is "a safe operation for patients regardless of their age, size of reduction, or body mass index." I don't insist that patient's loss weight prior to a breast reduction, but I do (and will continue to do so) tell them that they are at more risk of wound/healing issues.

REFERENCES

1. Breast Reduction: Safe in the Morbidly Obese?; Plastic and Reconstructive Surgery:Volume 122(2)August 2008pp 370-378; Roehl, Kendall M.D.; Craig, E Stirling M.D.; Gómez, Victoria B.A.; Phillips, Linda G. M.D.

2. A Comparison of Complication Rates in Large and Small Inferior Pedicle Reduction Mammoplasty; Plast. Reconstr. Surg. 115: 736, 2005; O'Grady, K. F., Thoma, A., and Dal Cin, A.

3. Analysis of Breast Reduction Complications Derived from the BRAVO Study; Plast. Reconstr. Surg. 115: 1597, 2005; Cunningham, B. L., Gear, A. J., Kerrigan, C. L., et al.

SurgeXperiences 205 -- Call for Submissions

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

Dr Cris, Scalpel's Edge, will be hosting SurgeXperiences on August 31, 2008. It will be her first time hosting.

Seeing as I have a bit of a research bent, the theme will be Surgery and Research. This is pretty broad, but you could consider evidence-based surgery, or even your experiences with research. I will accept posts on other topics as well, of course.

So even if you don't have a post that fits her suggested theme that's okay, just write some surgery related posts and send them her way (here).

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. The deadline for submissions will be midnight on Friday, August 29th. Please submit your posts here.

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

Restaurant Week(s)

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

The restaurants in my community are raising money for Arkansas Hospice. They call it Restaurant Week, but the time frame is August 15-30.

During River Cities Restaurant Week, Little Rock and North Little Rock’s finest spectacular restaurants will offer three, special fixed-price, three course dinner menus for just $35 per person (beverages, tax and gratuity not included). Some restaurants will also be offering three course lunch specials for $20 per person! Some restaurants prices may vary, so be sure to check out the menus for exact pricing per restaurant.

Modeled after the highly-successful Dallas Restaurant Week, River Cities Restaurant Week will be an annual culinary celebration that spotlights the diverse array of dining establishments. At $35 per meal for dinner and $20 per meal for restaurants offering lunch as well, this is your opportunity to try as many as you can.

The participating restaurants are many of the best in the area. A complete list can be found here.

An Easy Presentation Pillowcase

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

If you have read this blog for very long, you know that I make quilts (finished or just the tops) for the Quilt of Valor Foundation. The first year or so, all that was asked for was the quilt. Later they asked that we make a "presentation pillowcase" to go with the quilt. I must say I don't really enjoy making the pillowcases. I'd rather stick to making the tops, but that's part of it.

It hit me as I was walking through Wal-Mart this past fall and noticed the travel pillow case display that these would work wonderfully! They have zippers and are made of cotton, so easy to wash if needed. All I would need to do would be to decorate them. The pillow cases are inexpensive (less than $3) and are for 15 in X 20 in pillows. This is large enough for the 50 in X 70 in quilts to be folded up and placed inside for "presentation".

For this example, I used the Clover fusible web, 5 mm, and ironed it to the back of a flag with the edges folded under.

I then ironed the flag to the pillowcase. You could stop here, but I then hem-stitched the flag to the pillowcase to ensure that it would hold long-term.

The finished pillowcase can then be used to hold the quilt top, backing fabric, and binding when sent to the long-arm quilter. Later it will hold the finished quilt and used to "present" the quilt to the soldier.

You can find instructions for other presentation pillowcases here.

Women in Surgery

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

I have noticed several posts / articles on women (or the lack) in surgery.
Women in Surgery; The Differential: Medscape Med Students; Lucia Li; August 1, 2008

In one of my regional placements, I met a surgeon who said that “women are killing surgery”; what he meant was that as the majority of medical graduates are now women, most of them will shun surgery for its stereotypes. This will reduce the number of good candidates going into surgery, lowering its standards. Surgery needs to attract women for continued excellence in practice. I am uncertain about the benefits, or even the need, for positive discrimination, but educational initiatives which promote surgery as a realistic career option for women are vital.

WSJ article: Women Remain Scarce in Neurosurgery; Jacob Goldstein; August 14, 2008
WSJ article: For Female Surgeons, Barriers Persist; Jacob Goldstein; August 16, 2008
Mothers Don't Let Your Daughters Grow Up to be Doctors; posted by Fizzy, Mothers in Medicine Blog; August 18, 2008 [not just don't let them be surgeons, but don't let them be doctors]

I went looking for more information:
Women in Neurosurgery, WINS
Association of Women Surgeons
Women in surgery: do we really understand the deterrents?; Arch Surg. 2006 Apr;141(4):405-7; Gargiulo DA, Hyman NH, Hebert JC

MAIN OUTCOME MEASURES: Potential deterrents to a surgical career.

RESULTS: Men and women had a similar interest in a surgical career before their surgical rotation (64% vs 53%, P = .68). A similar percentage developed a mentor (40.0% vs 45.9%, P = .40). Women were far more likely to perceive sex discrimination (46.7% vs 20.4%, P = .002), most often from male attending physicians (33.3%) or residents (31.1%). Women were less likely to be deterred by diminishing rewards (4.4% vs 21.6%, P = .003) or workload considerations (28.9% vs 49.0%, P = .02). They were also less likely to cite family concerns as a deterrent (47.8% vs 66.7%, P = .02) and equally likely to be deterred by lifestyle during residency (83.3% vs 76.5%, P = .22). However, women were more likely to be deterred by perceptions of the "surgical personality" (40.0% vs 21.6%, P = .03) and the perception of surgery as an "old boys' club" (22.2% vs 3.9%, P = .002).

Women in General/ Trauma Surgery; The Student Doctor Network Forum; thread began in 2007 and continues
Women in Surgery--Past, Present and Future; Dixie Mills MD; Department of Surgery, Maine Medical Ctr; Sept 2003 (PDF)
Website of the week--Women in surgery; BMJ. 1999 September 25; 319(7213): 860; Douglas Carnall
Women in Non-Traditional Residencies; P&S Journal: Spring 1995, Vol.15, No.2; By Kristen Watson

The daughter of a neurosurgeon, Dr. Epstein claims that following in her father's footsteps was a "congenital defect." Aspiring to be a surgeon since age 4, ..........

Dr. Epstein says most women in medicine do not pursue academic posts because they are actively discriminated against in the university setting. She also claims that female neurosurgical attendings in university positions are assigned less interesting cases and are given less operating time. "You have to have tremendous determination and work twice as hard for the recognition," Dr. Epstein says. And she does work hard, with more than 80 published works to her credit, some in collaboration with her father.

"We need more women to go into surgery and stay in it," Dr. Epstein says, "women who don't choose the 'mommy track'-working 9 to 5 just three days a week. We need more women in surgery full time." Dr. Epstein says it is not impossible for female doctors to manage both a full-time career and a family, but, like most of her peers, she has no children.

There are many more articles, but I'll stop there. It would appear that things have not changed much over the course of time.   I'm not sure I agree with Dr Epstein on managing a full-time career and a family.  As with the male surgeon, I think that would greatly depend on your spouse.  I do think it has to be very tough to do, but balancing life's responsibilities is tough anyway you look at it. 

I can't say that I was encouraged to become a surgeon. There was one female general surgery resident, one female orthopedic resident, one female ENT resident, no female urology residents, and no female neurosurgery residents at UAMS when I was a student and no female surgeons on staff in any surgery department. [I left out the Ob-Gyns simply because they are in a department of their own, not because I don't consider them surgeons.]  Currently at UAMS the dean is a female pediatrician, Debra Fisher MD. Here are the current female surgeons on staff at UAMS.

General Surgery

• V. Suzanne Klimberg, M.D. (Surgical Oncology--Breast)
• Anne Mancino, M.D. (Surgical Oncology -- Breast)
• Diane H Rhoden, M.D. (General/Endoscopic Surgery)
• Ronda Henry-Tillman, M.D. (Surgical Oncology -- Breast)

ENT (Otolaryngology)

• Lisa Buckmiller, M.D.

Ophthalmology

• Laurie Gray Barber, M.D.
• Romona L. Davis, M.D.
• Inci I. Dersu, M.D.
• Bhairavi V. Kharod, M.D.
• Nicola M. Kim, M.D.

Orthopedic --

• Ruth L. Thomas, M.D.

Urology -- None
Plastic Surgery (there wasn't a plastic surgery dept when I was a student and still no residency program)--None
Neurosurgery -- none

When I was a student, I looked up to the two female surgery  residents (the general and orthopedic mentioned above). I did receive a small amount of mentoring from the orthopedic resident, but had no true contact with the general surgery (she was finishing up when I was a 3rd year student). I fell in love with surgery as a third year student. I wish I had used the female ortho resident more as a mentor and maybe found a staff surgeon to use as a mentor. I wish there had been more encouragement along the way, but there is no reason to rehash the past here.

I would encourage any female student interested in surgery to actively find a mentor (male or female). Don't let anyone talk you out of it.  We need good surgeons, male or female.

Paronychia

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

This past weekend I treated my own paronychia. Haven't figured out how I developed it, as I had no hang nails, don't chew on my fingernails, no recognized trauma to the digit. I initially treated the red, tender area around the nail with antibiotic ointment and a Band-Aid (to keep the ointment in place and to protect the area from any further injury). At first there was no "fluctuant area" and no localized pus pocket. That was until Sunday morning. Check out the photo I took with my new iPhone (my husband's birthday gift to me). Being a seamstress, there are plenty of needle around my house. I sterilized one and gently lifted the top off the localized pus. I would not recommend that just anyone do this. Remember I am a trained professional.

Here is a repost of my article from last August:

Felons and paronychia make up one third of all hand infections. The thumb and index finger are most often involved. Wooden splinters or minor cuts are common predisposing causes, yet over half of patients will give no history of injury.

Felons are closed-space infections of the fingertip pulp (padding beneath the finger print area). Fingertip pulp is divided into numerous small compartments by vertical septa that stabilize the pad. Infection occurring within these compartments can lead to abscess formation, edema, and rapid development of increased pressure in a closed space. This increased pressure may compromise blood flow and lead to necrosis of the skin and pulp. It is most often caused by staph aureus. Felons that are untreated, are incorrectly treated, or have a prolonged course may lead to osteomyelitis. X-rays evaluation of the bone should be done in severe cases.

Treatment is incision and drainage. This will remove any pus present, but will also reduce the pressure within the closed compartment and restore blood flow.

1. The finger can be numbed with local anesthesia (digital block).
2. Make short skin incision with a number 11 blade over the area of maximum tenderness. Incise only the skin with scalpel. Do not cross the DIP joint crease (can create a contraction)
3. Evacuate any pus (and culture) using a blunt instrument, like a small hemostat. This will decrease the chance of injury to the digital nerve or the tendon sheath (can lead to acute tenosynovitis). Do not divide vertical fascial strands (septa) as this makes the fingertip pulp unstable.
4. Pack gauze loosely into the wound to prevent skin closure. Apply a loose dressing, splint finger, and elevate hand above the heart.
5. Followup in 2-3 days.

Incision Tips:

A longitudinal incision in the midline is effective without serious iatrogenic complications (nerve injury, tendon sheath injury). Lateral or transverse incisions frequently cause ischemia and anesthesia by injuring one or both neurovascular bundles. If a lateral incision is used, it is best to incise the non-contact aspect of the finger (ulnar side of fingers, radial side of the thumb). Fish-mouth incision can lead to an unstable painful fingertip.

Empirical antibiotic coverage for S aureus and streptococcal organisms should be provided. Given the rapid emergence of community-acquired methicillin-resistant S aureus, treatment with a drug more likely to be effective against this agent should be considered. Coverage for E corrodens may be indicated for immunosuppressed patients. Dicloxacillin, erthromycin, Keflex, nafcillin, and Bactrim DS are good ones to start the patient on while waiting for the culture. The recommended length of treatment varies from five to 14 days and depends on the clinical response and severity of infection.

Complications:
Osteomyelitis involving the distal phalanx.

The most serious complication is acute tenosynovitis. It may result from natural, contiguous spread of infection. It most often iatrogenic from inadvertent nicking of flexor tendon sheath with scalpel.

Other complications include skin necrosis, deformity of the fingertip, septic arthritis, and instability of the finger pad.

REFERENCES
Infections of the Hand: A Guide to the Surgical Treatment of Acute and Chronic Suppurative ... By Allen Buckner Kanavel (Google eBook)
Wheeless' Textbook of Orthopedics Online
Common Acute Hand Infections--AAFP
Felon by Glen Vaughn, MD--eMedicine article

Shout Outs

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

Kerri, Six Until Me, is this week's host of Grand Rounds. I submitted one of my posts from last week. You can read this weeks grand rounds here.   She does the old card system.  Great work!

Check out Happy Hospitalist's post on The Anatomy of Heart Cath, Medicare Style". He breaks it all down, then comments on it.

A nice post on case reports and HIPAA rules over at Clinical Cases and Images--Blog.

Some recent posts on "never events":

• Dr Val's Can Infections be Prevented in the Hospital Setting
• Buckeye Surgeon's Diane Suchetkas Continuing Anti-Doctor Crusade (be sure you read the comments)
• White Coat Rants' More on Medicare Never Events
• Ian Furst (Wait Times & Delayed Care) -- Never Events
• Plastic Surgery 101 suggests look before you leap (in logic) on hospital infections
• PSP blog writes WSJ on Hospital Infections:  "FUD's Up!"

Then there are a couple of interesting items on organ donations:

This WSJ article: Pay for Organ Donation Gains Traction, but Not at Kidney Foundation by Jacob Goldstein. I think I agree with the Kidney Foundation --

“Offering money for organs can be viewed as an attempt to coerce economically disadvantaged Americans to participate in organ donation,” the paper says.

And this Reuters news article is troublesome to me. I am with the Institute of Medicine here. Just waiting less than 2 minutes without brain death seems so wrong to me.

"Quick Harvesting of Hearts Raises Ethics Questions"

BOSTON (Reuters) - Doctors who waited just 75 seconds after the final heartbeat before removing the hearts of dying newborns for transplants said on Wednesday they improved their odds of success but have also raised ethical questions about organ harvesting.........

The technique is controversial because the waiting time recommended by the Institute of Medicine has been five minutes, unless the patient is brain dead. The three babies were not, although all had severe brain damage.

I'd like to give a head's up to Rural Doctoring's Next Big Idea.

And last, but not least for this week's Shout Outs is the Dr Anonymous' Blog Talk Radio show. I am this week's guest. It is Thursday night! I'm counting on all the help I can get from "my friends". The show starts at 8 pm CST (or 1 am GMT). I hope you will join us.

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

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

Inverted Nipple and Insurance

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

A recent reader of my inverted nipple post has asked for a reference to give to her insurance company.

"i've also been in contact with my insurance company, and they're telling me that if i can come up with an article proving that the severity of my nipple retraction will most likely prevent me from breast feeding, then they will cover my procedure. if you know of any articles that would be helpful. thanks!"

I have had no luck in finding such a reference. All the ones I have found use terms like may or might or can. Does anyone have such a reference?

Nipple inversion can cause functional problems. The condition can be a source of irritation and inflammation, and it may prevent lactation. (reference #1)

Moderate to severe inversion means that the nipple retracts deeply when the areola is compressed, to a level even with or underneath the areola. A nipple with moderate to severe inversion might make latching-on and breastfeeding difficult, but treatment and deep latch techniques can help. --La Leche League

Here are some links regarding techniques that may (there's that word again, no guarantee) help in successful breastfeeding.

Breast Feeding with Flat or Inverted Nipples -- Breastfeeding Essentials Website
Breastfeeding -- Women's Health.Gov
Breastfeeding with Flat or Inverted Nipples --ask DrSears

The websites of plastic surgeons that I visited have a version of this (credit)

Will my insurance coverage pay for my nipple inversion repair surgery?

Nipple inversion repair is a cosmetic procedure and, therefore, not covered by insurance. ........... In rare cases where severe nipple refraction prevents breastfeeding, insurance may pay for all or part of the procedure.

REFERENCES regarding surgical treatment

1. The Inverted Nipple: Its Grading and Surgical Correction; Plastic & Reconstructive Surgery:Volume 104(2)August 1999pp 389-395; Han, Sanghoon M.D.; Hong, Yoon Gi M.D.

2. A Contemporary Correction of Inverted Nipples; Plastic and Reconstructive Surgery:Volume 107(2)February 2001pp 511-513; Scholten, Erik Ph.D.

3. Correction of Inverted Nipples with Twisting and Lockiing Principles; Plastic and Reconstructive Surgery:Volume 118(7)December 2006pp 1526-1531; Kim, Jeong Tae M.D., Ph.D.; Lim, Young Soo M.D.; Oh, Jung Geun M.D., Ph.D.

4. Simple Technique for Inverted Nipple Correction; Morris Ritz, Ram Silfen, David Morgan and Graeme Southwick ; Aesthetic Plastic Surgery Journ, Vol 29, No 1, pp 24-27

5. Surgical Correction of Inverted Nipples Using the Modified Namba or Teimourian Technique; Plastic & Reconstructive Surgery. 113(1):328-336, January 2004; Lee, Kyung Young M.D.; Cho, Byung Chae M.D.

6. Pictures of Correction Surgery (some may consider them graphic)
7. Nipple Inversion Repair; The Metropolitan Institute for Plastic Surgery, Washington DC

SurgeXperiences 204 is Up!

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

JeffreyMD is the host of SurgeXperiences 204. It is his first time hosting. His suggested theme is "my first time". It's a great edition and you can read it here.

And after you finish this edition, you may wish to check out the past ones. 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.

Olympians with Arkansas Ties -- Part 2

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

Earlier this week, the local newspaper ran an article that listed Arkansans in the Olympics. I had about half of the list in my earlier post. I would like to wish all of these (and all the Olympic athletes) good luck. I hope they all have their personal bests. Here are the others on their list:

Veronica Campbell received her Bachelor of Science degree in 2006 from the University of Arkansas in Fayetteville, AR. She is a member of the USA Track and Field Team. She will compete in the 200 meters and as a member of the 4x100-meter relay. Her personal website is here.

Alistair Cragg is a former Arkansas Razorback distance runner. He is a native of South Africa but will compete for Ireland. His events are the 1,500-meter and 5,000-meter.

Tyson Gay is a former University of Arkansas runner. He is a member of the USA Track and Field Team. His events are the 100 meter and 200 meter races.

 Funmi Jimoh -- haven't figured out her connection to Arkansas, but the paper has her in it's list. She is a member of the USA Track and Field Team. Her event is the long jump. Her personal website is here.

Deena Kastor is a former University of Arkansas cross country runner. She is a member of the USA Track and Field Team. Her event is the woman's marathon. Her personal website is here.

LaShaunte'a Moore is a former University of Arkansas runner. She is a member of the USA Track and Field Team. Her event is sprints.

Yi Ting Siow  joined the University of Arkansas swim team in January 2008 after transferring from Wisconsin. She is competing in the 200 individual medley and the 200 breaststroke. She was born in and will be competing for Malaysia.

 Nicole Teter  is a former University of Arkansas track athlete. She is a member of the USA Track and Field Team. Her event is 800 meters race.

Warm Embrace QOV

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

I'm not really sure what this pattern is called.  I found it in the magazine Quiltmaker (March/April 08, No 120 Issue).  The article title is "Warm Embrace", but no where in the article is the actual block name mentioned.  I had no luck finding it in Barbara Brackman's Encyclopedia of Pieced Quilt Patterns.  I do like the way the quilt came out and will probably use the pattern again.
Here is the top (or flimsy) that I made for the Quilt of Valor (QOV) program.  I will in the next week or so be sending it to someone else to do the actual quilting.The top is machine pieced.  It is 50 in X 70 in.  Here is a close up of some of the fabrics.  Each finished block is 10 in square.
Here is a photo of the pattern page from the magazine.

Disaster Preparedness

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

I received this brochure from my state medical society. I'm listing all the links (which I have checked) here so that I can use my Evernote to save them for easy access. Many of them would be useful no matter which state (or country) you live in.

Opportunities to Volunteer
AR Health Alert Network
AR Emergency System for Advance Registration of Volunteer Health Professionals
Citizens Corps
Arkansas Medical Reserve Corps Team
First Response Physicians
AR One Disaster Medical Assistance Team (DMAT)
Arkansas Crisis Response Team
American Red Cross
AR Voluntary Organizations Active in Disasters
Central Arkansas Cities Readiness Initiative
RESOURCE LINKS
Clinic and Business Preparedness
Federal Centers for Disease Control and Prevention for Businesses
CDC Pandemic Influenza Preparedness Checklist for Clinics (pdf)
Federal Department of Homeland Security Ready America for Businesses
Avian Influenza: WHO Interim Infection Control Guideline for Health Care Facilities
Disaster Medical Information
Federal Centers for Disease Control and Prevention
CDC Pandemic Influenza & Avian Flu General Information
AMA Center for Public Health Preparedness & Disaster Response
AMA Disaster Medicine & Public Health Preparedness Journal
electronic Core Disaster Life Support Course (free CME -- up to 4 AMA Category 1 credits available through 9/30/08)
National Organization on Disability Emergency Preparedness
AR Department of Health Public Health Preparedness
Personal & Family Preparedness/Patient Education
AR Blue Cross/Blue Shield Preparing for a Pandemic Booklet (pdf)
AR Disability and Health Program Emergency Preparedness
Federal Centers for Disease Control and Prevention
CDC Pandemic Influenza Individual Preparedness
Federal Department of Homeland Security Ready America
Federal Department of Health and Human Services
American Red Cross

A Surgeon's Outburst

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

I'd like to comment on the recent Boston Globe article on surgeons' outbursts and also on Maggie Mahar's post, Surgeons and Other Physicians: A Cultural Divide.  Both seem to be painting surgeons as the ogres or bullies of the medical community.  I'd like to think that I am neither.  There are better examples of surgeons than the Alex Baldwin character in the movie Malice. 

I agree it is not good form or good for the patient for these outbursts to occur, but generalizing to the point that most of your readers would think that 90% or more of surgeons behave this way is wrong. I have never thrown any equipment and rarely gotten angry to point of raising my voice or screaming in the OR. Each time I did, the nurse told me I was right.

I have witnessed some of the examples given in the article. Yes, those surgeons should be counseled and most likely should even be required to go to anger management classes. BUT maybe the reason for their anger should also be sought.

Was the faulty equipment putting the patient at risk? It is very frustrating to try three pair of scissors before you get one that will cut tissue or to have the electrocautery machine not work so the circulating nurse (bless her) has to go find one that does. Perhaps the hospital is at fault for not updating and replacing defective instruments and equipment.

Did the surgeon have to finally say "no more" to extraneous people entering the room? I have done that a few times. Someone comes in looking for a piece of equipment stored in the room you are working in (why wasn't it taken to the other room before my surgery got started?). Someone comes in to ask where such and such is (usually a new person who hasn't been properly oriented). My tolerance is such that I can take several (justified) interruptions in one case, but there is always a tipping point. Raising my voice to get the crew who is supposed to be helping me with my case refocused is my way of dealing with it, not throwing things. Still I would prefer to not have the issue.

Did the surgeon have to ask the nurse (or another crew person) to make their personal calls later? I have had to do this a few times, especially now that everyone has a cell phone. I try to be considerate when that person has a loved one in the hospital and are trying to get updates. Still, if they can't focus on their work (someone else's loved one) then maybe they should have taken the day off.

Those are just a few examples. I agree that we should never throw anything in the OR, but I do expect the equipment the hospital provides to work. I do expect the personnel they use to be professional and properly trained. I think of myself as part of the team, but that means we ALL have to put the patient first and work together.

Now let me give you some better examples of surgeons

• Dr. Eli Blumfield (played by Alan Arkin) from the movie The Doctor.  The one that William Hurt's character picked to do his surgery.   He was not only a great surgeon, but a good person.
• Benjamin Franklin "Hawkeye" Pierce (Alan Alda) from MASH, don't recall ever seeing him throw anything in the OR.  He mostly directed his anger at the policy makers, not the OR staff or patients.
• BJ Hunnicutt (Mike Farrell) from MASH, a gentle soul who missed his wife and daughter.  He didn't disrupt the OR with temper tantrums either.
• Sherman T Potter (Harry Morgan) from MASH, who kept Hawkeye and the others in line.  A good surgeon and administrator.
• Dr Richard McCarthy (real-life orthopedic spine surgeon) who was featured in an episode of Extreme Surgery back in 2004.  I was a medical student when I first meet him at Arkansas Children's Hospital.  He is a very good surgeon and a gentle man.  He is very highly regarded by all -- administration, nursing staff, colleagues, patients, etc.  I tried to find the episode link so you could see him in action, but failed.
• Dr. Sanjay Gupta, neurosurgeon and CNN correspondent.  Though I have never been in an OR with him, he doesn't seem as if he would be the type to throw tantrums.
• Dr Bruce Campbell, ENT and fellow blogger.  I have not been in the OR with him either, but you get the sense of a someone who is respectful and civil when reading his posts.
• David A. Kappel, MD, a plastic surgeon in Wheeling, WV.  I was influenced by him as a general surgery resident.  Someone who is very good at what his does, treats his OR crew well, and is a wonderful human being.
• Dr Dale Morris who was a general surgeon here in Little Rock, AR for years.  He has retired and is missed.  He was/is a very kind and skilled surgeon who always treated everyone well.

Let me also say that I am blessed to have had several good nurses and OR scrubs over the years teach me how to work as a team.    To name a few -- Jeannette Murphy, Vivian Mitchell, Joe Roe, Becky Bennett, and on and on.

You may also want to read this article from the WSJ and it's comments from last month on "Better Hospital Manners by Mandate".

Shout Outs

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

Dr. Daniel Goldberg, Medical Humanities Blog, is this weeks host for Grand Rounds. I submitted one of my posts from last week. You can read this weeks grand rounds here.     

That's all, folks.  Thanks for reading.  Comments always welcome.  As we like to say in Texas, y'all come back real soon, ya hear?

Kim over at Emergiblog is looking for other medical bloggers interested in  attending BlogWorld Media Expo September 20-21.

This is very exciting news!
We have an opportunity to meet as a med-blogging group at this year’s BlogWorld.
For those of us who have wanted a chance to have a med-blogger meet up, this is an opportunity to meet under the auspices of BlogWorld .
I spoke to Rick Calvert, the CEO and Co-Founder of Blog World and New Media Expo.

And don't forget to check out Change of Shift while at Kim's blog.

Dr Anonymous' Blog Talk Radio show is Thursday night! His guest this week will be Angelo & Brandice live from NME.  Then on August 21st, I will be his guest.  So mark your calendar.  I'll need all the help I can get from "my friends".  The show starts at 8 pm CST (or 1 am GMT). I hope you will join us.

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

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

Theresa, Rural Doctoring, has a wonderful post this morning on checking facts for yourself (and the patient).  I hope you will go read it -- Case --A Hair on the Back of My Neck .

Doctor David highlights a tremendous group in a recent blog post.  The group is the Make a Wish Foundation.  If you have not heard of this group, I would encourage you to learn more about them. 

One foundation that tries to make this a little bit better is the Make-A-Wish Foundation. This is a group that raises money to grant a single wish to any child with a life limiting diagnosis. The work they do is tremendous, and the smiles they bring to the faces of our children are priceless.

 
I stumbled upon (after he stumbled across my blog and e-mailed me) a new surgery blog.  The blog is "My Surgical Blog", listed as the Surgical Lounge in my sidebar.  I hope you'll give his blog a look.  Here's his introduction:

I am a 31 year old from India. I am working as a General surgeon in a Govt hospital in Delhi. My experience in this branch started from 2001 when I joined as a surgery resident, I have experience of working as a general surgeon and also have assisted in all types of cardiac surgeries.
Initially I had intended to blog about my daily hospital activities and cases but i will talk about some other things as well.

A fellow quilter,Helen in the UK, has a nice post on "A Little Something Different".  In it she share a pattern for a burial gown and bonnet set for a preemie.  Most local hospitals will have a need for something like this.  Call and ask yours  if you are interested in addressing this need.

However, the All Craft 4 Charity (AC4C) group has a monthly project theme and August is bereavement items for newborns and preemies.  I was moved to give it a go ... and this is a burial gown and bonnet set for a preemie.
The pattern wasn't difficult, but I'm really glad I had a far distant grounding in garment sewing. I made a lot of mistakes along the way - or should I say I had a lot of learning opportunities!! I'm really pleased with how it has turned out and hope to make another set before the month is over.

Maggot Therapy Revisited

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

Last week the WSJ posted an article on using maggots to "gag" superbugs which includes a video (don't watch if you are squeamish).

For more technical details on Ratcliffe’s work, there’s a recent paper in the journal Microbes and Infection.

Maggots’ flesh-eating ways have long been used to cleaning nasty wounds. Just a few years back the FDA even decided maggots could be regulated as medical devices for prescription wound care. .......take a look at the package insert for Medical Maggots.

Last October I wrote a post on maggot therapy. Here it is:

When I was a general surgery resident, we had a couple of patients come in with maggots in their wounds--both with venous stasis ulcers on their legs. As "icky" as it was to clean the maggots out of the wounds, it was down right impressive how clean the wounds were (and yes it was my job to do the cleaning). Those maggots sure had done a wonderful job of removing the necrotic tissue and leaving behind healthy granulation tissue.  So for Halloween, how about some bug therapy.

Maggot therapy waxes and wanes in popularity throughout time. Ambroise Pare (1509-1590) is generally given credit for first noting the beneficial effects of maggots in suppurative wounds. Napoleon's famous military surgeon, Baron D. J. Larrey (1766-1842) noted larvae of the blue fly in the wounds of soldiers in Syria during the Egyptian expedition. He noted that the maggots only attacked putrefying substances rather than living tissues and that they promoted their cicatrization. W. W. Keen commented on the presence of maggots in wounds during the Civil War, saying that the maggots were disgusting but did no apparent harm. The first scientific study of the use of maggots was done by Dr. William S. Baer of Baltimore, Maryland. He first mentioned this "viable antiseptic" for the treatment of chronic osteomyelitis in a discussion following an article by Bitting that appeared in 1921. Baer commented on the clean wound of two soldiers with neglected compound femur fractures and abdominal wounds who had lain neglected for 7 days on the battlefields of World War I in 1917. Inspection of the wounds showed that they were infected with thousands of maggots, but had healthy granulation tissue beneath. At that time, the mortality from such wounds with the best medical care was close to 75%, and therefore the maggots made a profound impression. He went on to study maggots in detail.

Maggots, by definition, are fly larvae, just as caterpillars are butterfly or moth larvae. Phaenicia sericata (green blow fly) larvae is the one used in maggot therapy.

A drawing of the life cycle of this fly appears below.

One-day-old larvae are only about 2 mm in length, and almost transparent. By the time the maggots are 3 or 4 days old, they have grown to about 1 cm (1/2 inch) long.

Maggot Therapy

Maggots may be used intentionally as biological debriding agents. They are an effective alternative to surgical debridement in patients who cannot go to the operating room for medical reasons. It is the larvae of the green blowfly (Phaenicia sericata) that is used. This larvae is sterilized with radiation before being used so that they will not be able to convert from the larvae to the pupae stage. They secrete enzymes that dissolve the necrotic tissue and the biofilm that surrounds bacteria. This forms a nutrient-rich liquid that larvae can feed on. Thirty larvae can consume 1 gram of tissue per day. They are placed on wounds and covered with a semipermeable dressing. The debridement is painless, but the sensate patient can feel the larvae moving. More importantly, maggots help to sterilize wounds, because they consume all bacteria regardless of their resistance to antibiotics (including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus). Maggots have to be replaced every 2 to 3 days. Maggot therapy can be administered on an outpatient basis, provided that visiting nurses are familiar with their use. This is a good technique for painlessly removing necrotic tissue and destroying antibiotic-resistant bacteria in patients who cannot undergo surgical debridement for medical reasons. They work well in infected and gangrenous wounds, with the best results reported in diabetic wounds.

Medical grade larvae are available from Zoobiotic Ltd and Monarch Labs.

REFERENCES

Maggot Therapy: The Surgical Metamorphosis; Plastic & Reconstructive Surgery. 72(4):567-570, October 1983; Pechter, Edward A. M.D.; Sherman, Ronald A. B.S.

From the Bible to Biosurgery: Lucilia sericata--Plastic Surgeon's Assistant in the 21st Century; Plastic & Reconstructive Surgery. 117(5):1670-1671, April 15, 2006; Whitaker, Iain S. M.A.Cantab., M.R.C.S.; Welck, Matthew M.B.Ch.B.; Whitaker, Michael J. M.A.Cantab.; Conroy, Frank J. M.R.C.S.

Maggot Debridement Therapy; Plastic & Reconstructive Surgery. 120(6):1738-1739, November 2007; Mumcuoglu, Kosta Y. Ph.D.

Clinical Approach to Wounds: Debridement and Wound Bed Preparation Including the Use of Dressings and Wound-Healing Adjuvants; Plastic & Reconstructive Surgery. Current Concepts in Wound Healing. 117(7S) SUPPLEMENT:72S-109S, June 2006 ; Attinger, Christopher E. M.D.; Janis, Jeffrey E. M.D.; Steinberg, John D.P.M.; Schwartz, Jaime M.D.; Al-Attar, Ali M.D.; Couch, Kara M.S., C.R.N.P., C.W.S.

Maggot Therapy Project

SurgeXperiences 204--Call for Submissions

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

JeffreyMD will be hosting SurgeXperiences on August 17, 2008. It will be his first time hosting. His suggested theme is "my first time". Though this could cover a wide range of firsts, I think he intends for it to be related to surgery. If you don't have a post that fits his suggested theme that's okay, just write some surgery related posts and send them his way (here).

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. The deadline for submissions will be midnight on Friday, August 15th. Please submit your posts here.

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

Olympians with Arkansas Ties

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

There may be more, but these are the ones I found or have heard of. I'd like to wish not only them, but all the athletes competing good luck. May they all have their "personal bests".

Margaux Isaksen lives and goes to school in NW Arkansas.  She will be participating as part of the Modern Pentathlon Olympic Team USA. Her personal website is here.

 April Steiner-Bennett who will be participating as part of the USA Track and Field Team. She lives and teaches school in NW Arkansas. Her event is the pole vault. Her personal website is here.

Christin Wurth-Thomas lives and works in NW Arkansas.  She is also part of the USA Track and Field Team. Her event is women's 1500 meter. Her personal website is here.

Wallace Spearmon Jr lives in Fayetteville, AR. He is also part of the USA Track and Field Team. His events will be the men's 200 meter and 100 meter. His personal website is here.

 Amy Yoder Begley, former Arkansas Razorbacks distance runner, is a member of the USA Track and Field Team. Her event is the women's 10,000 meter race. Her personal website is here.

 Muna Lee was born in Little Rock, AR. She is a member of the USA Track and Field Team. Her event is the women's 100m and 200m events.

Michael Robertson (photo credit) was born in Beebe, AR. He is a member of the USA Track and Field Team. His event is the men's discus.

Terry Tiffee (photo credit) was born in North Little Rock, AR. He will play IF (infield) as part of the USA baseball team.

Jeff Hartwig (photo credit)  is a former Arkansas State athlete who still lives in Jonesboro, AR.  His coach, Earl Bell, is the brother of one of my medical school classmates, Dan Bell MD (family practice in Eureka Springs, AR).  Jeff is a member of the USA Track and Field Team.  His event is the pole vault.  His personal website is here.

A Rail Fence QOV in Brown and Blue

This are two tops I have done using the rail fence pattern for the Quilt of Valor group. They have been mailed to a long-arm quilter who will finish them and mail them on to a recipient. Both tops are 50 in X 70 in, machine pieced.

I like this pattern. It allows good use of scraps and goes together quickly. And here is the blue one. Both tops used some of the left over Route 66 fabric that backed several of the Memory Quilts. This one used some of the left over blues from a previous QOV.

My First Surgery Rotation

JeffreyMD will be hosting SurgeXperiences on August 17, 2008. It will be his first time hosting. His suggested theme is "my first time". Though this could cover a wide range of firsts, I think he intends for it to be related to surgery.

My first clinical rotation in medical school as a third year student was surgery. My first six week rotation started in July 1980. The local weather guys have been referring to that summer as the year of the hottest July on record in Arkansas.

1980 - A record forty-two consecutive days of 100 degree heat finally came to an end at the Dallas-Fort Worth Airport. July 1980 proved to be the hottest month of record with a mean temperature of 92 degrees. There was just one day of rain in July, and there was no measurable rain in August. There were 18 more days of 100 degree heat in August, and four in September. Hot weather that summer contributed to the deaths of 1200 people nationally, and losses from the heat across the country were estimated at twenty billion dollars. (David Ludlum) (The Weather Channel)

I don't recall the outside heat that summer. We got to the hospital while it was dark out and got home after dark, so we missed the worst of the heat. I am sure I did my share of complaining, but I loved surgery. I was on the vascular service at the VA hospital. I was lucky enough to have good residents (Dr John Kendrick, Dr Michael Stairs, Dr. Robert Lambert), smart and skilled and who didn't mind teaching us. It was "peace time" so most of what we saw at the VA were guys with peripheral vascular disease (PVD) and/or diabetics who needed wound care or amputations. We junior medical students "took" call by sleeping in the hospital. It was our responsibility to draw blood, put in IV's, do H&P's on any admits, do dressing changes, chase down lab, and scrub in on the surgeries our patients had.

The first surgery I ever scrubbed in on was a late night BK (below knee) amputation of a diabetic gangrenous foot. I think the two male residents expected me to get faint or nauseated and have to leave. I didn't and even managed to do the surgical prep without contaminating anything. They actually taught me about amputation levels that night, and showed me how I would need to do the dressing changes and wrapping of the stump as it healed to get it ready for a prosthetic.

It was also on that service that I first learned how to debride wounds. A lot of wound debridement was done at the bedside during dressing changes. There is one man I remember so well. He had PVD and still smoked. His right leg was amputated at the hip. The wound was had not healed, and I had to do dressing changes 2-3 times each day, debriding non-viable tissue each time. He had been there a long time. My chief resident showed me how to do the dressing and debridement. When it was my turn to do the job alone, the gentleman (that is what he was) actually tried to make things easier for me. I think I cried (just wet eyes, maybe a tear or two down the cheek) my way through the first one, but he and I made it. He sang to me while I debrided his wound. He sang "Ramona.". I will never forget him.

The Right Thing

I did a precertification for a patient. The precert was for breast reduction surgery. My office had reminded the patient prior to her initial visit that my office was not in her insurance network. We asked her to check her policy to see if she had out-of-network benefits as we didn't want her to get "stuck" with the bill, as it were. My office balance bills, but tries to be up front about costs.

I did the initial visit, reviewed why she felt she needed a breast reduction, did the exam, took measurements and photos, and then after she left sent a letter with documentation (photos, etc) for the precertification.

She received the letter (copied to my office) below which states that she meets her insurance requirements for the surgery. It then clearly states "If Dr Ramona Bates performs the surgery it will not be eligible for reimbursement."

She called to schedule the surgery for early September. I called her back and reminded her that if I did the surgery her insurance would not cover it (not the surgeon, not the surgery center, not the anesthesia, none of it).

"Would you still like me to do your surgery or would you like me to try to find someone in your network?"

"Well, I would really like to have my surgery in September. Do you think you could get me in to see someone soon enough that I could have it done then?"

"I'll try, but I can't guarantee that you might not have to consider a different time for the surgery."

So I called Dr PS1. He is in her network, but can't see her for the initial office visit until September and probably can't get the surgery scheduled until November or December.

Tried Dr PS2. This one, like my office doesn't participate in her insurance network.

Tried Dr PS3 and hit the jackpot for her! They can see her in a week and most likely get her scheduled (since the precert is already done) in early September.

I then called her back and told her the news. "Thank you Dr Bates. I don't know how I can ever really thank you."

 

Shout Outs

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

Jake Young, Pure Pedantry, is this weeks host for Grand Rounds. I submitted one of my posts from last week. You can read the South Park Edition of Grand Rounds here. Very nicely done.

It has been a rough month here at Pure Pedantry.

At one point last week, I think I trained rats for 8 straight hours. (My job in the lab is training rats.) And let me just tell you, that is not particularly interesting. Visualize getting a repetitive stress injury moving around an pissed off animal with a limited attention span but to whom your entire future is chained. Anyway, in order to entertain myself, I have been playing every episode of South Park in order in the background. (Yes, I know...very, very sad.) Sufficeth to say, this has resulted in me having South Park on the brain. Thus, this particular edition of Grand Rounds will be South Park themed.

I would like to thank everyone for this very welcome breather from slowly losing my mind for the good of science. Thank you all for your submissions.

Congratulations to Dr Val Jones!!!

I was welcomed as a new member of Washington, DC's 100-year-old National Press Club (NPC) today. My credentials for membership? I'm a blogger.

A nice article in the Lahey Clinic Medical Ethics Journal, Spring 2008, Vol 15, #2 Issue: The ethical challenge posed by surgical innovation by George J Agich, PhD (PDF file)

Dr Anonymous' Blog Talk Radio show is Thursday night! His guest this week will be Dr Alan Dappan. The show starts at 8 pm CST (or 1 am GMT). I hope you will join us.

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

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

Dr Wes will be doing a live on-line chat for an hour on August 6th, 2008 at 7PM CST. He recently did an hour-long radio show on atrial fibrillation (afib) with his colleague Dr. Jose Nazari, MD. The podcast is now up and can be listened to or download it here.

You can still get an occasional "fix" of Dr Sid Schwab's writing here. He writes a few posts for "Surgery Insider". The most recent is "Stop, Stop, You're Killing Me".

This is non-medical, but for us pet lovers you may appreciate it. A blog friend, Penny Sanford, received an "extra" figurine through a glitch. The error is being turned into good.

I suggested that if he could wait until the next month, I would pay for the second figurine and donate it to raise money for Westie Rescue.

This very gracious seller just donated it to be sold to raise money for Westie Rescue. I thought that was so very, very thoughtful and wise!

The figurine has been sent to Vickie Claflin now of Maryland Westie Rescue. She is the great lady who fostered Annie and Rebel and Mackie. She now has her own blog

about some of the Westies she has helped rescue in the past.

She will be offering the figurine for sale at one of the fund raising events Maryland Westie Rescue attends. You may remember that Maryland Westie Rescue recently rescued 31 Westies from a puppy mill, and Vickie was right in the middle of it!

Mangled Ear--a badge of honor?

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

Dr Sid Schwab alerted me to this news article.

A familiar chasm separates what women dig from what dudes imagine women dig. But for mixed martial arts, a combination of boxing, wrestling and jiu-jitsu that has found favor among young men, cauliflower ear has assumed a place alongside such evocative conditions as torn elbow ligaments in pitchers, knee tendinitis in marathon runners and torn anterior cruciate ligaments in female basketball players.
In gym locker rooms and online discussion forums, teenage boys trade advice on ways to gain that telltale look.
“It’s man’s ear,” said Nisar Loynab, 15, who trains at Capital Jiu-Jitsu in Alexandria, Va. “When you get cauliflower, you’re really a man.”

Interesting that this deformity is finding favor.  I posted the following on cauliflower ear last September. 

Cauliflower ear is an acquired deformity of the outer ear. It is not related to the vegetable--cauliflower and I have not been able to find why it came to be called such. Though there is some similarity between how the two look. 

Because of it's location, the ear is vulnerable to blunt trauma. A blunt blow to the external ear can cause bruising between the cartilage and the layer of connective tissue around it (perichondrium). When blood collects in this area, the external ear becomes swollen and purple. The collected blood (hematoma) can cut off the blood supply to the cartilage, allowing that portion of the cartilage to die, leading in time to a deformed ear. This deformity is common among wrestlers, boxers, and rugby players.

The cartilage of the ear has no other blood supply except that supplied by the overlying skin. When the skin is pulled from the cartilage, and/or separated from the cartilage by blood (as with accumulated blood from injury called a hematoma) or infection, the cartilage is deprived of important nutrients. Ultimately, the cartilage dies and the risk of infection is increased. Left untreated, the ear cartilage begins to contract on itself forming a shriveled up outer ear classically known as the cauliflower ear deformity. Once there is cartilage death and scarring (fibrosis), the resulting deformity is very difficult to reconstruct (if at all possible). Often the victim is left with a permanent deformity.

Common causes of cauliflower ear deformity include previous trauma, relapsing polychondritis, perichondritis, and Hansen’s disease. These are very diverse diseases, which vary significantly in their therapeutic strategies. With no history of trauma, these other causes should not be overlooked.

Treatment
"The review found no trials of good quality to demonstrate that any one technique, which removes the hematoma and prevents its recurrence, gives the best cosmetic outcome. The literature however generally suggests that treatment is better than leaving a hematoma untreated. Well designed studies are required."--4th reference below.

With that said, it is generally accepted that the hematoma needs to be evacuated. This may be done by incising the skin and removing the blood with suction or by inserting a needle and aspirating. After the hematoma is empty, a compression dressing is applied and left on for 3 to 7 days to prevent the hematoma from coming back.

The dressing keeps the skin and perichondrium in their normal positions, allowing blood to reach the cartilage again. Sometimes through-and-through ear sutures over dental gauze rolls or insertion of a Penrose drain plus a pressure dressing is used. Because these injuries are prone to infection, an oral antibiotic effective against staphylococci (eg, cephalexin 500 mg TID X 5 days).

When treated aggressively and promptly, the cauliflower ear deformity is unlikely. Any delay in diagnosis leads to more difficulty in managing this problem and the risk of deformity is greater.

Prevention

Wearing the right headgear when playing sports - especially contact sports - is a must. Helmets can not only save you from developing cauliflower ear but protect you from serious head injury as well. Always wear a helmet if you are biking, blading, riding your scooter, or playing any sport where helmets or other forms of headgear are recommended or required (like football, baseball, hockey, boxing, or wrestling). Products like Impact can add more protection when playing sports like rugby.

REFERENCES

Bilateral Cauliflower Ear Deformity: An Unusual Presentation of Cutaneous Rosai-Dorfman Disease; Plastic & Reconstructive Surgery. 113(3):967-969, March 2004; Oo, Kenneth K. K. M.B., B.S.; Pang, Yoke T. F.R.C.S., F.A.M.S.; Thamboo, Thomas P. M.B., Ch.B.

Relapsing Polychondritis, MedScape Article posted 02/24/2004; Peter D. Kent; Clement J. Michet, Jr; Harvinder S. Luthra

External Ear Trauma--Merck Medicus

Interventions for acute auricular haematoma; Cochrane Database of Systematic Reviews 2004, Issue 2. Art. No.: CD004166. DOI: 10.1002/14651858.CD004166.pub2; Jones SEM, Mahendran S

Cauliflower Ear--MedicineNet.com article

Management of Auricular Hematoma Using a Thermoplastic Splint; Arch Otolaryngol Head Neck Surg.2000;126:888-890; Henderson,JM, Salama, AR, Blanchaert Jr, RH

Wrestlers Cauliflower Ear; Care & Prevention; Anthony Donatelli, M.D.