Sunday, October 12, 2008

SurgeXperiences 208

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active and it was easier than checking each one.

Welcome to the latest edition of SurgeXperiences! Fall is here in the northern hemisphere. The leaves are being to turn colors and the air is cooler. Perfect for a nice walk in the woods (don't forget the hunter orange) with my dog. I’ll leave this “bounty” of good writing for you to read at your leisure. Enjoy!
Bongi, other things amanzi, writes about pseudoaneurysm --
“there is nothing pseudo about a pseudoaneurysm except that it is not actually an aneurysm.”
How do you answer the question "are you thinking about specializing some day?" when you tell someone you are a general surgeon? Bongi tells about his response here.
Then read on as Bongi tells you how bullets can tumble and create unimagined damage to a person’s insides.
i know a bit about ballistics. it's more practical knowledge. i've seen enough gunshot wounds to pick up something here and there. the high velocity ones wreak havoc inside. the more usual 9mm doesn't compare but a well placed shot is still devastating. and then you get the exceptions. ricochet shots can be confusing. they tend to take strange paths through the body, sometimes following dissection planes (like surgeons) and causing less damage than you'd expect. and then you get the tumbler……….
Tumble reminded Quietus, The Sandman, of his own post, the new math.
……….Ruminating on the case, I became enlightened as to how the "new math" is done in Gaza. I'm reminded of Milo Minderbinder, a character from my favorite book "Catch-22." The character is a mess officer during WW II who turns the war into a lucrative business. He buys eggs at a high price and sells at a low price and still manages to make a profit in a dizzying transfer of goods all over the Mediterranean. This Gazan did the same thing, except with his life……….
Buckeye Surgeon writes about a case of vasculitis with an acute cecal infarct in a 27 yr old. (photo credit)
He also gave us a post on APBI verse whole breast radiation in Mammosite, but perhaps the most personal recent post was the one on a needle stick.
Bongi recently had a post about an experience getting stuck by a needle while operating on an HIV positive patient. It reminded me of a time during my residency I had forgotten………. There was something powerfully existential and substantive about it all. Rarely do we visit those dark places of the soul where our ultimate weaknesses are exposed. Rarely do we acknowledge our ineluctable mortality. It's too much. It throws us off our fragile equilibrium. There's too much to do in the here and now. But the time will come for all of us. The day of reckoning is unavoidable……….
T, Notes of an Anesthesioboist, writes about the doctors superstitions in one of her many thoughtful posts.
Whenever a patient says that my wariness increases a bit. It's doctor-superstition, I suppose, but it's been said that when patients have a feeling they're going to die, it's because...they're going to die. But I was hoping this was just her extreme nervousness talking rather than an actual sense of impending doom.
T writes movingly about the need to “before dying, leave word” about your end of life wishes.
Normally, getting asked to do an intubation in the ICU is one of the most satisfying parts of my job. I feel like I'm being asked for help….. and the task is potentially life-saving. …..But this one made me terribly sad…………We felt our hands were tied.
Chris and Drew, Pallimed, have written a nice post -- "Brain Death 40 years on"
My leading candidate for headline of the decade is "Are You Brain Dead? Depends on the Hospital." It is from a news article reporting on a study in Neurology (one of the few studies in the entire medical oeuve of 2008 that we have not blogged on)………
But variations in the definitions and use of "brain death" in an era of increasing demands for organ donation raise important ethical, legal, and practical questions. Last year Christian briefly blogged on organ donation after cardiac death. According to the article, cardiac-dead donors is the fastest growing proportion of donors……..
Bruce, Reflections in a Head Mirror, writes two thoughtful posts. The first speaks to the "interval between the biopsy and the report".
There is a time of limbo in Medicine that begins when the procedure is completed and ends when the patient learns the results. It occurs millions of times each year after everything from major surgeries to blood tests. Although it was not the point of her essay this week in The New York Times, Dr. Paula Chen touched on these moments as a friend's father waited for the results of a pancreatic biopsy.
Dr Pauline Chen writes about The Dance Before the Diagnosis and says “The diagnosis was in their body language.” Also, check out her blog here.
Bruce’s second post addresses the "naked truth about tonsil cancer".
“Doctor, I should not have cancer! I never smoked! I am only 45 years old! It doesn’t make sense!” The patient and his wife sit stunned and frightened.
My new patient is absolutely correct … he does not fit the traditional profile of patients with cancer of the tonsil.
Also check out this NY Times article transplant surgeon Dr Pauline Chen wrote (via Kevin MD) – The Choices Patients Make.
There are certain choices patients make that I have never understood, choices that from my perspective as a doctor seem to undermine their very chances for survival. Or at least undermine the efforts doctors, nurses and even complete strangers make on their behalf. ………..
I asked Ms. Silverstein about how she had dealt with such pressure.
“There is no question that I am eternally and profoundly grateful for life and for my good fortune in receiving a donor heart just in the nick of time,” she responded. “But my heart transplant life is a mixed bag, a miracle with a flip side: a wonderful, awful, amazing, terrible existence.”
Then she added, “I have not lived a well day since my surgery — not one — and this is a difficult truth to bear. And sometimes, on the very rare occasion, it wears me down to the point of wondering if the illness and struggle are worth it.”…………
Jeffrey, Monash Medical Student, writes a nice post “to err medically”. Something none of us wish to do.
Prompted by Dr Val’s guest post at other things amanzi, i’m reminded of a story my surgical professor recently told us, during his tutorial on fluids and electrolytes management in surgical patients.
Quite some time ago, a patient was in the hospital had a percutaneous endoscopic gastrostomy (PEG) tube in for some reason or other…………..
Dr Alice, Cut on the Dotted Line, talks about prejudice
It didn’t make me any more enthusiastic that the picture I got from the chart before going into the room was of a patient seeking pain medication. Sure, she had a couple genuine chronic conditions with biopsy documentation of their existence; but she was on a lot of narcotics, plus some valium thrown in. She had been on disability for years, even before this most recent, serious problem cropped up.
I was in for a surprise……….
Dr B (surgery, cooking, passionately) writes that "finger dislocations are REALLY easy to reduce if they are gotten to in time".
"Did you reduce it?!"
"Reduce...? It looked less swollen and better, so I sent him home."
You've GOT to be kidding me. That is what I wanted to scream into the phone, but I kept my composure.
Also, check out this one in which Dr B states never -- not once until yesterday
I am not proud. I am, in fact, rather ashamed. But the other emotions I feel are anger, distaste, and, quite frankly, dread.
I took the gentleman from this post to the OR last week... last Monday, to be exact……….
Did you know Bruce has a second blog, Behind the Head Mirror? he says its for the stuff that doesn’t fit his other blog. Both are excellent! Check out this post comparing training surgeons to teaching kids to drive.
Driving a car is a lot like learning to be a surgeon. No matter what you might believe, you begin by being completely incompetent; neither driving nor surgery is intuitive. You learn incrementally and develop skills. You find out how to get out of jams and tight spots. You learn to anticipate what might happen and make adjustments. You develop the ability to to plan three or four steps ahead.
This Little Owl talks about experiences as a medical student on her surgical rotations. All in all positive, so we may have another surgeon in the mix. You can read her take in Surgery Clerkship Highlights.
Like I said previously, I intended to keep track of my experiences this year, so it’s time to play catch up.
I started the clerkship on June 30 and ended on September 19. I worked with several groups: pediatric surgery, ENT (ears, nose and throat = otolaryngology), the surgical consultation service (mostly hepatobiliary surgeries), and the dedicated hepatobiliary service……………….
Saif writes about his experience observing a radical prostatectomy while in Oaxaca. He is an undergraduate at UC Davis who hopes to be a doctor someday. After this experience, perhaps a surgeon.
After watching this surgery, I am CERTAIN I want to be a surgeon. It was amazing in so many ways. It requires high levels of visual and physiological knowledge, and a level of intricacy and skill that can only be gained through lots of experience and talent. You have to be able to know the human body on an instinctive level, using intuitive knowledge to navigate the viscera as if it were the back of your hand. Surgery is an AMAZING art and it seems to require the usage of the left and right brain, which I think is the best way to stimulate the mind. I love it because it's a high level skill set, which makes the field really special, it's not something everyone can do. I think I fit into this field because I'm a very visual-spatial thinker and it's a field really based on using that sort of talent to develop it into an expertise. The surgery was 4.5 hours, which felt like 30 minutes
Little Karen, Just Up the Dose, relates a story about a child birth -- “sometimes it does happen just like in the movies :)”
From Scan Man’s casebook, a post with films on a major renal trauma from a fall and another on infantile hemangioendothelioma. Very impressive films! Go check out the rest of them along with his explanations.
A tweet from Scan Man after “Successfully hydroreduced an ileocolic intussusception in a 7-month old child. Maintaining my 100% record.” It is a very nice article.
scanman Med/Surg/Nursing-twits Check out this article and the accompanying videos for the technique of US-guided hydroreduction 06:48 AM October 04, 2008 from twh
Shadowfax, Movin’ Meat, posted on something you don’t see everyday. Thankfully, we don’t. The films, once again, are impressive and involve “a trauma patient who was in her third trimester of pregnancy”.
911Doc, M.D.O.D. (photo credit), wrote a couple of nice ER tales on patients who needed surgery. The first is Coup-Contra-Coup (what's a helmet?) and the second is In a Word..."Balls".
Dr Oliver, Plastic Surgery 101, asks "Does it make sense to screen asymptomatic breast implant with MRI?" and then answers it for us.
One of the peculiarities of the USFDA process during silicone implant reintroduction in 2006 was the labeling on the devices recommending routine MRI surveillance of implants for rupture. When you step back and look at the proceedings and "unique" American history with breast implants, you can see that this was more a political concession to the anti-implant activist lobby then evidence-based medicine.
The FDA labeling currently suggests MRI's at 3 years post op and then every 2 years subsequently. It will be interesting with the coming form stable "gummy bear" implants whether or not this recommendation is still maintained………….
Sterile Eye tells us how he “came to this”
This is the story of how I ended up working as a medical photographer. It’s not a very long, but quite winding road, that turned out to come almost full circle.
He is as Norwegian medical photographer and if you haven’t seen any of his videos of surgery he shares on his blog, then check out these posts and this one.
Dr Val (check out her new blog: Getting Better with Dr Val) writes about MRgFUS.
MR guided focused ultrasound is truly a “Star Trek” level medical breakthrough. The first questions in my mind were: will insurance companies pay for such therapy? Can people actually have access to this technology? The answer to both, as you might expect, is “no.”
A heart warming story from John Pages, Cebu Sports Blog, who enter the Hong Kong marathon but didn’t finish due to leg cramps. The post is about a heart surgeon, Peter Mancao, who stopped to help him rather than just running past.
Make Mine Trauma, IntraOporate, gives us an oldie but goodie that shares a day in the life of a trauma junkie.
As you may recall I was lamenting on Monday about not getting any trauma or on call action. Here's how my other night went. Phone rings at 2150 hrs.
Would you like to assist on an ex-lap for blunt trauma?
Of course I would because that is what I live for.
David Harlow, Health Care Law Blog, writes about his interview of Douglas S. Brown, General Counsel, UMass Memorial Health Care and the reinvention of their Cardiac Surgery program. features two Beverly Hills plastic surgeons, Dr. Stuart Linder (“BodyDocBlogger”) and Dr. Robert Kotler (“FaceDocBlogger”). In a recent post, they discuss 10 Things that can go wrong in plastic surgery.
HerniaSymptomsBlog has a post that reviews Abdominal Hernia Symptoms and Treatments.
Stories from Patients
Begin here and then read the multiple post that follow as Annika’s mom “live blogs” her liver transplant.
We got a call this morning: a new liver for Annika.
That needs an exclamation point, but I'm too nervous.
Please please please keep her safe.
Please please please send peace to this donor family.
Mitchy tells of a recent hospitalization during which she had surgery for her ulcerative colitis in her post “Scribblings from the Mitchy Side - Hospitals, doctors and surgery, oh my!”
BuffaloesAreWild writes about Waiting in the Hospital and his attempt to learn patience.
Leslie, Room for One More, writes “She’s Out of Surgery”, a post about her adoptive daughter undergoing cleft lip surgery.
Dr Jerry Elrod, Senior Moments, writes from a personal viewpoint about prostate cancer: surgery and its side effects.
Surgery in the News/Links
Another tips from Scan Man, the University of Virginia Health System website has a very nice article with pictures (scalpels, credit) on Surgical Instruments from Ancient Rome. If you like medical/surgical history, you’ll want to check it out.
Vascular Surgeon Used Skills to Support Troops by Cathleen F Crowley; September 29, 2008
Surgery Fine-Tunes Legendary Banjo Player's Brain; Eddie Adcock Played Banjo While in Surgery Till Hands Were Just Right by Maureen White and Lee Ferran, Oct 3, 2008; ABC News -- watch the amazing video has an interview with Dr Harry Kraus who is a practicing surgeon and a missionary with Africa Inland Mission. He is the author of eleven novels and two works of nonfiction, including Crossway’s Breathing Grace and The Cure.
Medgadget reports on the first man to get a double arm transplant (photo credit).
Karl Merk, 54, a German farmer, lost his arms six years ago in an accident involving a combine harvester.
Woman Denied Bariatric Surgery by Insurance Company: Is Size Discrimation to Blame? by Jessica, Sept 30, 2008 at Jezebel
Surgeon Operates on Wrong Knee at Miriam Hospital by Felice Freyer; Sept 20, 2008; The Providence Journal
25 Awesome Virtual Worlds for Doctors, Nurses, and Patients By Laura Milligan, Oct 8, 2008; Nursing Degree Guide
Twelve Hollywood Stars that Reject Plastic Surgery by Colin Stewart, Sept 30, 2008; OC Register
Plastic Surgery Industry Sags with the Economy by Lindsey Tanner, Oct 3, 2008; The Huffington Post
Plastic Surgeon from Dr 90210 Placed on Probation for Negligence; Oct 7, 2008; Law of Hollywood Land
Surgeon's claim handwash caused drink driving test failure, rejected; Oct 11, 2008;
SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.
The next edition of SurgeXperiences (209) will be hosted by Resident Anesthesiology Guy at his blog "The Choloform RAG" on 26 Oct, 2 weeks from now. Be sure to submit your post via this form.
Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.


Vijay said...

Am I the only one, or do others also think that whenever you post SurgeXperiences, it rivals that week's Medical Grand Rounds!! :)

Great job. It's going to take me a while to check out all the links.

Anonymous said...

Terrific, comprehensive post! Thanks for including me, Ramona. :)

Øystein said...

Great edition, once again! Thanks for including me.

I love your inclusion of a "Surgery in the news" section.

rlbates said...

Thanks Vijay, Val, and Oystein. I'm glad you like it.

Unknown said...

Wow you really know how to host a carnival!
Thanks for the mention even though I didn't submit it formally (mea culpa).
I'm such a delinquent.

Bruce said...

Thank you, thank you, Ramona! You're the best! How do you do it???

Jeffrey Parks MD FACS said...

Well done Ramona....