Veteran's Day 2007

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

Thank you to all who serve or have served.

This includes my brother-in-law, Major Bart Herndon,

who is an Army Chaplain currently stationed at Ft Sill, OK

For more information on Veteran's Day (photo credit)

you can click here.

Second Travel Wallet

I finished the second travel wallet today. You can see the pictures of the first one here. This one I altered (Husqvarna pattern) slightly and used "salvaged" parts (the card slots and closure/flaps) from an old wallet. I also added a chain strap to this one and a key hook. I like this one best.

Mushrooms

Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

On my walk with my dog Rusty this morning, I ran across this decaying log just covered in mushrooms. It's the first log I've ever seen like this. I just want to share this amazing site!

I don't even want to begin to "educate" you as to which wild mushrooms are edible, but I think I did identify these. They look like the picture found here (ID 50). If so they are :

"This mushroom, almost certainly, is Hypholoma fasciculae (the Sulfur Tuft). It is also known as the Clustered Woodlover, and sometimes by Naematoloma fasciculare. It has features as seen in the picture, plus: it's cap is not sticky or slimy. the gills are yellow to greenish-yellow while young and become gray or purplish-black with age, thin stalk (yellow), spores are a deep dark purple/gray/brown and is growing from wood (buried or otherwise). THIS SPECIES IS POISONOUS- do not eat. There is a similar species, but grows only on conifers (Hypholoma capnoides) and it is edible. However, do not eat either of these mushrooms without a thorough knowledge of mushroom identification and practice doing so with the supervision of an experienced mycologist/mushroom hunter."

References

Edible and Poisonous Mushrooms--MCD online

Wild Mushrooms--Ohio State University Extension Fact Sheet

Tendon Transfers Used in Radial Nerve Palsy

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

Following high radial nerve paralysis

• the wrist needs an extensor (photo credit)
• the fingers and thumb need extensors
• the carpometacarpal joint of the thumb needs an extensor to replace the abductor pollicis longus

Most authors agree that tendon transfers provide good results if nerve reconstruction fails in patients with radial nerve palsy. There is continued disagreement on the best combination of tendon transfers to use in treating patients with radial nerve paralysis. The level of the radial nerve injury and a patient’s overall function and anatomy should be kept in mind when choosing the best surgical option available for that patient.

In 1916, Robert Jones described a tendon transfer for radial nerve palsy that included the pronator teres to the wrist radial extensors, the flexor carpi radialis to the extensors comminis, and the flexor carpi ulnaris to extensor indicis and pollicis longus. The transfer of both wrist flexors has since been abandoned by most surgeons because of the excess morbidity from the loss in wrist flexion.

Most authors agree that the extensor carpi radialis brevis and longus should be reconstructed using the pronator teres tendon. This transfer is so effective that it is often done at the time of nerve repair. It provides good wrist stability for power grip, making the hand useful even during the recovery period. Try flexing your wrist and then keeping your wrist flexed while trying to make a fist, as you would in a power grip to open a jar, etc. It is very difficult, almost impossible to have a true power grip without wrist extension or neutral position. (photo credit)

To provide extension for the fingers, it is best to use a wrist flexor as this is synergistic with finger extension. At one time it was common to transfer all wrist flexors in the case of radial palsy, but Zachary pointed out the need to keep stability on the flexor side too. Boyes emphasized the importance of keeping the flexor ulnaris in its position to give the important movement of ulnar deviation. There is no one "great" transfer here. The extensor digitorum communis can be reconstructed using the flexor digitorum superficialis (III), the flexor carpi ulnaris, or the flexor carpi radialis. The rerouted extensor pollicis longus can be reconstructed using the palmaris longus or the flexor digitorum superficialis (IV), and, in some cases, the abductor pollicis longus and extensor pollicis brevis can be reconstructed with the flexor carpi radialis. Dr. Susan MacKinnon prefers to use the pronator teres to the extensor carpi radialis brevis, the flexor carpi ulnaris to the extensor digitorum communis, and the palmaris longus rerouted to the extensor pollicis longus (when available); otherwise, we use the flexor digitorum superficialis. (photo credit)

Burkhalter also advocated early tendon transfer because he believed the transfer acts both as a substitute during regrowth of the nerve or when lesions are irreparable and also as a helper during reinnervation. In a recent article, Kruft et al. reported that irreversible radial nerve paralysis should be treated with early tendon transfer. They reported 43 patients who underwent tendon transfer, with 38 patients ultimately returning to their original jobs. The authors qualified their results by stating that tendon transfers “never fully replace an intact radial nerve for the purpose of controlling the hand.” Elton and Omer observed that patients with radial nerve paralysis treated by tendon transfer often experienced extensor tightness, which prevented simultaneous flexion of the wrist and fingers. Barton described this as a “rather unnatural movement, seldom needed in ordinary life.” Many authors have thought that the greatest functional loss after radial nerve palsy was not the loss of finger extension, but instead the loss of power grip, which cannot be easily recreated with standard tendon transfers.

References
Current Approach to Radial Nerve Paralysis; Plastic & Reconstructive Surgery. 110(4):1099-1113, September 15, 2002; Lowe, James B. III, M.D.; Sen, Subhro K. M.D.; Mackinnon, Susan E. M.D.
Tendon Transfers for Radial Nerve Palsy-- Wheeless' Online Textbook of Orthopaedics
Atlas of Hand Surgery By Sigurd Pechlaner--Google eBook (very nice pictures of the transfers)
The Hand: Fundamentals of Therapy By Judith Boscheinen-Morrin, W. Bruce Conolly--Google eBook
Radial Nerve Entrapment by Mark Stern, MD--eMedicine article

Tendon Transfer--General Principles

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

Tendon transfers are done to restore a function that has been lost. It is a procedure in which the tendon of a functioning muscle is detached or divided at or near it's insertion, mobilized and reinserted into a bony part or another tendon to supplement or substitute for the lost function. Restoring something as simple as a pinch grip can create major improvement in the function of the hand. (photo credit)

Tendon transfers have been used in upper extremity reconstruction for well over a century. Early on, the technique was used for reconstruction following obstetric brachial plexus palsy or paralysis secondary to polio. As hand surgery evolved as a subspecialty, transfer techniques expanded. The middle part of the 20th century saw the development of transfers for multiple peripheral nerve paralyses, including median, ulnar, and radial nerve palsies. Some of the "Giants" who contributed to the field, include Bunnell, Boyes, Brand, Burkhalter, Goldner, Littler, Moberg, Omer, Phalen, Riordan, and Zancolli.

Indications for tendon transfers

• Irreparable nerve damage --Penetrating injuries can result in transection of the median, ulnar, or radial nerves or more centrally in the brachial plexus.
• Loss of function of a musculotendinous unit due to trauma or disease -- Rupture of the extensor pollicis longus (EPL) tendon is a common complication secondary to a distal radial fracture. Rheumatoid arthritis may be responsible for tendon rupture of any of the hand and wrist tendons, but it commonly leads to rupture of extensor tendons of the fingers or thumb (photo credit).
• In some non-progressive or slowly progressive neurological disorders -- These tends to be less responsive to surgical solutions, and can include stroke and neurologic diseases such as multiple sclerosis or cerebral palsy.

Contraindications:

• The only absolute contraindication to tendon transfer is a lack of appropriate donors.
• The availability of muscle-tendon units with less than grade 5 strength is a relative contraindication.
• Similarly, if only muscles that have been denervated and then reinnervated are available, this is also a relative contraindication.
• Transfers planned in individuals with progressive neuromuscular diseases should be carefully considered before proceeding because the underlying disease process may affect the transferred unit.
• Lastly, satisfactory results are difficult to achieve in transfers performed to produce motion in less-than-supple joints.

Most important functions of the Upper Extremity

Grasp power (FDP & wrist stabilisers)
Pinch (FDP, FDS & intrinsics)
Positioning the hand

Radial nerve injuries affect opening the hand for grasping. Low ulna and median nerve defects affect surrounding the object to grasp.
High ulna and median nerve injuries affect long flexors and grip

Axillary palsy and brachial plexus palsy -- unable to abduct the shoulder and here shoulder arthrodesis may be indicated to stabilise the upper arm to enable effective use of distal muscles. (generally transfers around the shoulder of little value)

Elbow function dependant on the musculocutaneous nerve. Pectoralis major transfer to biceps (Clark), proximal transfer of the common flexor origin (Steindler), triceps transfer (Bunnell) and may restore elbow flexion. Latissimus dorsi can also be used to restore elbow flexion.

Key elements crucial in tendon transfer operations.

• Be sure that the tendon to be transferred can be spared from it's original location. The EIP has redundant function with the EDC and, thus, is expendable. Before transfer of the EIP, especially in a patient with rheumatoid arthritis, the surgeon should be confident that the EDC has not been affected by the disease and is functioning normally.
• Be sure that it is strong enough for its new task. Only muscles with power of 4+ should be considered donors as they always lose 1 MRC grade of power.
• Be sure it has enough amplitude for its movement. As a guide, amplitudes are as follows: Wrist motors 33mm; Finger extensors 50mm; Finger flexors 70mm.
• Be sure that is is under conscious voluntary control
• Be sure that its old action is synergistic with its new, or at least retrainable to it (photo credit--example of natural synergic movement: The effect shows extension of the fingers when the wrist is flexed and flexion of the fingers when the wrist is extended. If the tendons are not intact, this effect is lost.)
• Be sure that it can reach its new insertion without a sharp change of direction
• Be sure that it can get to its new location without going through dense scar tissue, through fascia, or across bare bone
• Be sure that the movement it is expected to produce is already freely possible by passive movement (no stiff or "frozen" joints)
• Be sure that they patient understands what is to be done and is ready to accept the postoperative discipline of exercises and training

Timing

The timing of a tendon transfer after an injury depends on the likelihood of spontaneous reinnervation and nerve recovery. If nerve repairs or nerve transfers were performed initially, then sufficient time has to be allowed to determine the outcome of the initial treatment before considering tendon transfers. Keep in mind that axons regenerate at a rate of approximately 1 mm per day. If one cannot determine from the initial injury whether the nerve was interrupted (neurotmesis) and if the clinical examination reveals a loss of motor or sensory function, determining if adequate recovery is likely is mandatory before considering tendon transfer as a reconstructive option. EMG performed immediately and then again at 6 weeks helps to determine which functions may be expected to recover. Lack of evidence of innervation at 6 weeks should prompt exploration and repair if possible. Once sufficient time has elapsed to allow for spontaneous or repaired recovery, consider reconstruction for missing functions. (photo of some splints often used in upper limb paralysis--credit)

Of note, some hand surgeons advocate early tendon transfers, particularly in patients with radial nerve palsies, even if recovery is still possible. In 1974, Burkhalter reported that the indications are

(1) the transfer can act as a substitute during regrowth of the nerve, which will thereby reduce the time of external splinting and improve early function
(2) the transfer can act as a helper and add power to normal reinnervated muscle function
(3) the transfer can act as a substitute when, statistically, the recovery after neurorrhaphy or nerve repair is poor.
References
Tendon Transfer Surgery--American Society for Surgery of the Hand
Hand, Tendon Transfers by Philip E Higgs, MD--eMedicine article
Tendon Transfer Principles and Mechanics by Premal Sanghavi, MD and Mohammad Ali, MD--eMedicine article
Surgical Reconstruction and Rehabilitation in Leprosy and other Neuropathies by Richard Schwarz, MD
Peripheral Nerve Problems --Military Report by Colonel George E. Omer, Jr., MC, USA (Ret.), and Colonel William W Eversmann, Jr., MC, USA (Ret.)

Paul Brand, MD (1914-2003)

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

There is a wonderful essay on pain, "Pain and Suffering", written by T over at her blog, Notes of an Anesthesioboist. Emilyoboe left a comment "have you read The Gift of Pain (alternately titled Pain: the Gift No One Wants) by Paul Brand and Philip Yancey? I think you might enjoy it, it relates a lot to what you're also saying about pain." These were my source of inspiration for this post. (photo credit)

I actually got to meet this wonderful man, Dr. Paul Brand. I was in such awe that I could hardly speak. I was doing a Flexible Internship at Earl K Long Hospital in Baton Rouge, Louisiana. They allowed me to do a hand surgery rotation with Dr. Ronnie Matthews. He was a friend (and student) of Dr. Brand's. He took me with him when he went to Carville to watch the two of them do some tendon transfer surgeries and see patients in the clinic there. Carville was the location of the US Public Service Hospital for Hansen's Disease patients. For over a century, from 1894 until 1999, Carville was the site of the only in-patient hospital in the continental United States for the treatment of Hansen's disease, the preferred designation for leprosy. It is now the site of the National Hansen's Disease Museum (photo credit and website link).

Dr. Paul Brand was born to missionary parents (Jesse and Evelyn "Granny" Brand) and lived in Southern India until he was sent home at age 9 yrs to the United Kingdom for education. His father died in 1928 of malaria after Paul's return to the UK in 1923. Dr. Brand trained in Medicine at University College Hospital during the Second World War, and later gained his surgical qualifications while working as a casualty surgeon in the London Blitz. He meet his wife Margaret while at medical school. She was an ophthalmologist.

In 1946, he was invited to join the staff of the Christian Medical College & Hospital in Vellore, India. It was in India that the Brands first came across "leprosy beggars", deformed, blind and crippled by the disease. Deeply affected by the acute anguish and isolation of people afflicted with leprosy, he and his wife dedicated themselves to relieving their suffering.

After a visit to the Leprosy Sanatorium at Chingleput, Dr. Brand was motivated to explore the reasons for the deformities developed in those with Hansen's Disease. Through his research in South India, Dr Brand forever changed the world’s perceptions and treatments of leprosy-affected people:

• First, he pioneered the then startling idea that the loss of fingers and toes in leprosy was due entirely to infection and was thus preventable. Because leprosy attacks chiefly the nervous system, resultant tissue abuse occurs because the patient loses the warnings of pain – not because of inherent decay brought on by the disease. Paul Brand discovered the gift of pain, claiming that because leprosy destroyed the sensation of pain in affected parts of the body, pain-deprived people inadvertently injured and destroyed themselves.
• Second, as a skilled and inventive hand surgeon, he pioneered tendon transfer techniques with leprosy patients, and opened up a whole new world of disability prevention and rehabilitation for the most vulnerable and helpless in society.

In the late 1940s, he became the first surgeon in the world to use reconstructive surgery to correct the deformities of leprosy in the hands and feet. His wife Dr. Margaret Brand devoted herself to researching methods to prevent blindness in persons with leprosy. Later, Dr. Paul Brand was able to apply similar techniques to treat the limbs of persons with diabetes, as both diseases destroy pain sensation.

In 1950, with a donation from a missionary woman, Dr. Brand established the New Life Center, Vellore, as a model rehabilitation center for Hansen's Disease patients. The center was a village environment located at the residential area of the Christian Medical College campus. This helped dispel the stigma that was so prevalent even among medical professionals. Correcting deformities to restore the self-respect of patients and to integrate them into society was his cherished goal.

In 1966, he moved to the United States on invitation to take up the position of Chief of Rehabilitation Branch at the National Hansen's Disease Center at Carville. He worked there for 20 years and established a well-equipped and well-staffed research unit to study the complications of insensitive hands and feet, their prevention and management. His methods for prevention and management of plantar ulcers are now extensively used for treatment of patients with diabetes mellitus who have similar problems. Dr. Brand also popularized the technique of serial casting for the finger deformities (flexion contractures) that often result from Hansen's Disease, a technique that is now widely used by hand therapists to treat contractures due to many different hand injuries and conditions. When he retired in 1986 from the U.S. Public Health Service, he moved to Seattle and continued his teaching work as emeritus professor of Orthopedics in the University of Washington.

His appreciation of the importance and value of pain is well described in his book Pain: The Gift Nobody Wants. He saw pain as vital for the preservation of healthy tissue in anyone leading a normal life and he gives horrifying descriptions of the results of insensitivity in those with Hansen's Disease or congenital absence of pain. He goes on to question the pursuit of pleasure in Western Society and offers practical ways to ameliorate the effects of pain. I think I gained some of this appreciation for pain from him and his book. I don't (except in surgery) want my newly post-surgery patients to be completely pain-free while healing. I want them to use that pain to protect themselves from over-activity. I want to ease their post-surgery pain, not erase it.

References
THE LEPROSY MISSION, A Legend has passed into history Dr Paul Wilson Brand - 1914-2003 Obituary by Ms Janet Walmsley
Dr Paul Wilson Brand – 1914-2003; An Extraordinary, Gifted Orthopaedic Surgeon who Straightened Crooked Hands and Unravelled the Riddle of Leprosy
Dr. Frank Duerksen, a Leprosy Surgeon--an interview, influenced by Dr. Paul Brand

Travel Wallet and Toddler Quilt

I finished one of the travel wallets for my sister and her daughter. It turned out okay, but I think I will make the closure strip wider on the next and tweak the sections for cards (drivers license, credit card, etc). They received their passports just eleven days after applying for them. They are so excited about their trip to New Zealand.

Spent most of my time this past weekend working on a quilt for a toddler with cancer. He is undergoing chemotherapy. I did one of my "crazy" quilts. I hope it will help provide not only warmth in cold hospital rooms, but distraction as he searches for horses, trucks, monkeys, fish, bears, pumpkins, Elvis, dogs, colors and shapes, etc in the quilt. I am using the "clam shell" pattern for the actually quilting.

Find the truck, cowgirl, mitten, Santa, woman, horse, reindeer.

Find the zebra, mitten, fireworks.

Find Elvis, Winne the Pooh & Piglet, pumpkin, Air Man, dragonfly, sheep.

Find the monkey, sheep, bears.

Find the dog, fish, polka dots, checks.

Find the heart, pumpkin, flowers, truck, dog.

Inverted Nipples

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

As many as 2-10% of American women have at least one inverted nipple. Most cases of inverted nipples are congenital - some people are just born that way. However, some nipples become inverted after breastfeeding when scar tissue builds in the milk ducts. The anatomic defect lies in the relative shortness of the lactiferous ducts, which tether the nipple and prevent it from projecting. (photo credit)

There are different degrees or grades of nipple inversion.

• Grade 1: The inverted nipple is easily pulled out, maintains its projection fairly well without traction. Gentle finger pressure around the areola or gently pinching the skin causes the nipple to pop back out. It is believed to have minimal or no fibrosis. There is no soft-tissue deficiency of the nipple. The lactiferous duct should be normal without any retraction (photo)
• Grade 2: The inverted nipple can be pulled out, but not as easily as in Grade I. After releasing traction, the nipple tends to fall back and invert again. Grade II nipples have a moderate degree of fibrosis. The lactiferous ducts are mildly retracted but do not need to be cut for the release of fibrosis. On histologic examination, these nipples have rich collagenous stromata with numerous bundles of smooth muscle. Most inverted nipple will fall into this category. (photo)
• Grade 3: The nipple is severely inverted and retracted. It is very difficult to pull out these nipples manually. Despite application of pressure on the nipple to force it to protrude, it promptly retracts. A traction suture is needed to hold these nipples protruded. The fibrosis is remarkable and lactiferous ducts are short and severely retracted. The bulk of soft tissue is markedly insufficient in the nipple. Histologically, there are atrophic terminal duct lobular units and severe fibrosis.

Surgical Correction of Inverted Nipples

Correction for inverted nipples can be done on an out-patient basis. A patient may opt for local anesthesia, intravenous sedation and local anesthesia, or general anesthesia. Several different techniques have been developed and currently are in use for correction of the inverted nipple. The diversity of techniques indicates the lack of a good, sustainable, and durable solution for this quite common problem. (sketch is from the 2nd article)

Grade I--a non-incisional, purse-string suture technique

• The nipple is popped out manually. A small vertical incision (2 to 3 mm) is made at the 6 o'clock position at the base of the nipple. By using 5-0 nylon with a straightened needle, a purse-string suture is placed around the neck of the nipple. The knot is buried under the skin. One stitch is enough to close the skin

Grade II--will require a technique that releases the fibrosis and a purse-string suture

• The nipple is pulled out manually, and a 4-0 nylon traction suture is used for easy handling. An incision is made at the 6 o'clock position and deepened to the breast parenchyma. The fibrous tissues are released in the vertical direction by using scissors, and all lactiferous ducts are identified and preserved. Fibrosis is released to a degree that the nipple can maintain its projection without any traction (this is very important). An intradermal purse-string suture is done by using 5-0 nylon. Care should be taken not to apply too much force, which could compromise the blood supply of the nipple.

Grade III--requires a technique that releases the fibrosis, often the ducts will need to be cut, dermal flaps will be needed along with the purse-string suture

• The nipple is pulled out forcibly by using a traction suture. The neck of the nipple is marked. Two or three deepithelialized flaps are elevated at the 10, 2, and 6 o'clock positions. The deepithelialized dermal flap is bigger than the skin excision. The tissue beneath the nipple is dissected, and the fibrosis is released. The retracting lactiferous ducts are cut mainly from the central portion of the nipple. All the fibrosis and retracting ducts are released until the nipple can maintain its eversion by itself without any traction. The dermal flaps are turned down through the tunnel and sutured together to give bulkiness to the nipple. A 5-0 buried purse-string suture is placed at the base of the nipple. The newly everted nipple is maintained by a sombrero splint in place with sutures for 1 week to keep the nipple projection. (diagram is from 4th article--modified Namba technique)

Recently (see 3rd reference article) a technique using nipple piercing has been described. It is worth considering in Grade I and II inverted nipples. The authors suggest trying it in Grade III also, and maybe it is worthwhile when you consider that bone length can be achieved with distraction therapy. If the patient would gently tug on the nipple ring each day, the duct/skin can often be stretched.

Correction using Nipple Piercing

• With the patient in a sitting position, an entrance and exit point is marked on the nipple base in either horizontal or vertical plane, depending on the patients’ preference. Then with the patient in the supine position, the nipple is prepared with Betadine. Local, may or may not be used. A usual piercing technique was used. A 14-gauge needle was passed horizontally through the base of the nipple. A 5/8 -inch stainless steel nipple ring is advanced following the needle and through the tract. The procedure is completed within seconds. No local anesthetic is used. The nipple ring is cleaned daily. At 4-6-month follow-up the nipple ring is removed. (photo credit)

Risks of Surgical Correction:

The most dreadful complication can be compromise of blood supply to the nipple caused by dissection of fibrosis and a strong, tight purse-string suture. This complication is more likely in grades II and III, for which retraction is more severe. Other complication/risks include re-inversion, infection, tissue injury, excessive bleeding, and adverse reaction to anesthesia. The procedure may also result in noticeable scars, permanent pigment changes, or slightly mismatched nipples. Nipple protrusion with stimulation may change. If nipple inversion recurs or asymmetry is significant, a second procedure may be needed. The temporary effects of inverted nipple surgery can include loss of breast sensation or numbness. There is no guarantee that breast feeding will be possible after correction of inverted nipples.

References

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

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

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

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.

Pictures of Correction Surgery (some may consider them graphic)

SurgeXperiences 108

 Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

SurgeXperiences 108 will be up on 11 Nov at Aggravated DocSurg. Please submit any surgical-related articles via this page. I would encourage contributions from surgeons, nurses, anesthesia folks, students, and patients alike. Any experiences related to surgery are welcome. (photo credit)

Perioperative Corticosteroid Coverage

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

I have a patient who has been treated long term with a low dose of corticosteroids for her arthritis. She wants to have an abdominoplasty early next year. She is healthy otherwise and is a nonsmoker. I will remove slightly less skin than I would have so there is less tension on her incision, but if she will work with me things will go well. I told her she and I would need to discuss her steroid use perioperative, and that her steroid use may delay her healing. More important to me is the possibility of an impaired response to the stress of surgery and anesthesia. This can happen due to the suppression of hypothalamic-pituitary-adrenal axis (adrenal insufficiency) that happens with prolonged corticosteriod use. (photo credit)

I was taught the following (first reference):


In-patient surgery

• Methylprednisone (Solu-Medrol) 20 mg IM on call to surgery


• During surgery infuse hyprocortisone (Solu-Cortef) 100 mg IV over 8 hr


• Day of surgery: hydrocortisone 50-100 mg IV every 8 hr


• POD #1: hydrocortisone 25-50 mg IV every 8 hr


• POD #2: hydrocortisone 25 mg IV every 8-12 hr


• Thereafter: Resume maintenance steroid dose if there are no complications which prolong stressful period, for example, infection.

Out-patient surgery

• Methylprednisolone 20 mg IM on call to surgery


• During surgery infuse hydrocortisone 50 mg IV over 4 hr


• Evening of surgery give double usual daily dose of prednisone


• POD #1: Resume maintenance therapy


• IV fluids should contain saline

I was pleasantly surprised to see that a fellow blogger, Notes from Dr. RW, recently posted on just this subject. He covered the subject from the hospitalist point-of-view. Here is his summary of current recommendations:

Minor procedure (endoscopy, inguinal hernia repair):

• 25 mg hydrocortisone or its equivalent on day of procedure only.

Moderate procedure (abdominal surgery):

• 50-75mg hydrocortisone on day of procedure and taper quickly over 2-3 days to patient’s maintenance dose.

High risk procedure (cardiovascular surgery, extensive abdominal):

• 100-150 mg hydrocortisone initially, then taper over 1-2 days to patient’s maintenance dose.

It is important for all of us (surgeons, anesthesiologist, internist, etc) to remember how long term use of prednisone can affect patients.


References
Hand Clinics--Rheumatoid Arthritis; chief editor Paul Feldon, MD; May 1989;page 119
Perioperative Management of the Rheumatic Disease Patient; Joe T. Kelley III, MD, Doyt L. Conn, MD; Bulletin on the Rheumatic Diseases, Vol 51, No 6 (free access on-line)
Corticosteroid Supplementation for Adrenal Insufficiency; Douglas B. Coursin, MD; Kenneth E. Wood, DO ; JAMA, 2002;287:236-240
What is Adrenal Insufficiency?--EndocrineSurgeon

Talk in the OR

 Updated 3/2017-- video and all links (except to my own posts) removed as many no longer active.

I'm going to try to give you a glimpse of what we talk about in the operating room. Let me make it clear that if you take me to a party I am the "wall flower" type. Something happens in the operating room and I engage in conversation much more so than elsewhere. I love talking to the crew (male or female). So let me give you a brief introduction:

Yesterday I had 4.5 hours of surgery (two surgeries) to do in the operating room. We won't go into what type. My crew at the outpatient surgery center included four other women, ages 42 yrs to 58 years. One has two children, 1 yr and 3 yr. One has a daughter in nursing school. One has middle school and high school children and is involve in a divorce. One has grown children and a couple of grandchildren. Me, I have my dog, nieces & nephews, and neighbor's children.

The first patient sets the stage for our early conversation. As she is falling asleep, she comments "You're playing my song. How cool!" The radio was very low, but she heard Jimmy Buffett singing MargariteVille.

So after "tucking" her in we move on to my niece and sister winning the trip from said radio station to New Zealand to see Elton John in concert. From there to music we enjoy. Singers who could sing anything and we would love it. The ones with voices that just soothe. For me Dean Martin, another agrees. For another it is Willie Nelson.

We move on to Halloween. Did anyone have many or any trick-or-treaters? None of us did. The one with small children tells us about their costumes--bumble bee (1 yr old) and "mean army man" (her 3 yr son's description of himself). She describes their outing, shows pictures on her cell phone. I tell them of my two trick-or-treaters. I only ever have two--my neighbors children (girl 6 and boy 10). She was Elvira. He was a ghoul with these wonderful fake hands with loong fingers! I mention how my neighbors allow me to make goodies (popcorn balls, candied applies, brownies--different each year) for their children. We comment on how different Halloween is from our youth.

We catch up on mutual friends. A CRNA we all know recently had a BCCA removed from her upper lip. She is big on her looks (and she is very pretty) so was depressed while healing but is in better spirits now. I ask if they knew that MG's father-in-law had pancreatic cancer in addition to his esophageal cancer. It is a second primary cancer. We talk about the family fighting that is already beginning about his estate. MG has told me that some of the siblings and their wives are rumbling about the dad's business he "gave" to MG and her husband. The truth is that MG and husband bought it from the dad. The CRNA in the room mentions that her husband's grandmother recently passed. No family squabbles there, but they have had to be careful going through the house. Apparently the grandmother, having grown up during the Depression, had a habit of putting money away in odd places (books, the odd jar, etc).

School sports get some time. The mother with teenage children comments on how serious some parents take the games. She dislikes the intensity of this and is "anti" sports. I and another couple of the women, while not condoning the parents behavior, defend sports. We had gotten a lot from playing --learned how to work as a team, to show up for games and practice, etc. This somehow leads to talking about the apparent increase in number of teachers these days who seem to get involved with their students. We all agree that for us, the female teachers that engage in the this behavior are worse than the men. We try to analyze ourselves and decide it is because we think those women should be more nourishing and so we hold them to a higher standard. (yes, we are sexist).

Food gets a great deal of time. Which restaurant is the surgery center (no internal cafeteria) ordering take-out from today? Did you remember to put your request in? Have you tried their spinach-blueberry salad? Comments are made on places we have eaten lately, good dishes we had, restaurants that we forgot about and need to revisit. One comments about a recipe she found in the local newspaper a while back--Elvis Presley Pound Cake. Tells us how good it is. Promises to make one for us and bring us the recipe. Talk about Thanksgiving food. How do you do your turkey? One has a large deep fryer and tells about deep frying turkeys, offers to do one for another of the girls. Offer accepted. Cornbread dressing or no--its split.

Comments are made about the hostage situation that happened the day before in the small town of Bee Branch, Arkansas. A man had taken his ex-wife and 4 yo daughter hostage with a knife. The situation had lasted 14 hours. He had held the knife to his DAUGHTER's neck to get his ex-wife's attention. We are all outraged and saddened. We think he must be crazy. We decide we would rather think that he is mental unhealthy rather than just mean. This leads to a discussion of the poor infrastructure of our state's (and nation's) mental healthcare.

We go back to mutual friends. Anyone seen or heard from MR since she left? Is she still liking her work over at the VA? Sure miss her. What about JS? Sent her a birthday card with phone number and e-mail, but haven't heard from her. (well, I guess I could pick up the phone and call) Someone has heard that P is unhappy. Someone comments that sometimes it's not the place, but the person.

We talk about nursing school. The daughter in school is being talked into a PhD in nursing by her instructors. I ask why one would want a PhD in nursing? What does she want to do--teach? The mother says her daughter is really good with patients, loves geriatrics. I ask if she'll be able to do patient care with a PhD or will she be told "You're over qualified."? I suggest (and I know I may be wrong here) that she might want to look into nurse practioner or physician assistant degree. I give her a name of a nurse practioner I know who I think would be willing to talk to her daughter.

We get off on cleavage and heels. I comment that I think that little "jiggle" at the top of the breast is lovely and difficult to get with implants. (If you don't know what I mean, take at look at Jennifer Love-Hewitt in the Hanes bra commercial) The woman with the 17 yr daughter comments that she thinks (for 17 yr) her daughter wants to wear her neckline too low [the old mother-daughter conflict]. We all comment on our own comfort level for neckline. I never undo more than one button on a button-down shirt. E says she goes for three. Wow! I just don't have the nerve. Heels get coverage. We all agree that they make our legs look better. We all agree that we can comfortably do 2-2.5 inch heels, but over 3 inches gets very uncomfortable to our feet. I relate to them the name for stilettos I learned from a Boston scrub nurse during my plastic surgery residency--"FMP's" One asks what that means--"F*ck Me Pumps" I reply. I tell them that I now (the prude that I am) have a hard time wearing heels that are very high without thinking about that. The things that get stuck in your head.

I try to tell them about blogs (though Dr Rob does a much better job). What is that? I tell them about a few of the ones I read--the Gyn from Manhattan (TBTAM), the radiologist from India, the scrub tech who loves trauma, the ER nurse, the general surgeon in Africa just to mention a few. The "loves trauma " makes us all review how we enjoyed it before our bodies complained so much the next day. The reference to Africa makes us remember the Pediatric cardio-thoracic surgeon we had here a few years ago who committed suicide on Christmas Day. It makes us sad, the loss, the failure of medicine to adequately treat his long history of depression.

So there is a glimpse of the conversation that we had yesterday. My husband often asks me what we talked about in the OR. I find it hard to retell. I'm not at all sure that you will get the true flavor. I enjoy being there. Somehow the mask, the place, loosens my tongue more than any drink can do. All this and the patient still gets our attention. When necessary, all talk ceases.

Travel Wallets

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

Recently my niece and my sister (her mom) won a trip from a local radio station. It's a trip to New Zealand to see Elton John in concert December 6, 2007! They also get a back stage pass to meet him. The package included two round trip tickets, a rental car, hotel for a week, new luggage, the concert tickets, and some spending cash! What a great trip for them! They both had to apply for passports. My niece has never had one and my sister has changed her last name since she last used hers.

I offered to make them wallets for their passports. I found two patterns on-line. The first one (it's the one I'm using) is from Husqvarna includes instructions, material list, and full size patterns pieces in a pdf file, Traveling Wallet. The second one is from Adorn Magazine. The pattern pieces for the Passport Wallet (pdf file) have to be enlarged. There are no instructions online. Instead you are referred to "For wallet instructions, see page 70, Adorn Summer ’07", but I think you could use the instructions and your own sewing skills to get you through it. Also, there are photos of this one here on Flickr. And I may just make them some luggage tags using this pattern from Janome.

I'll share the results with you when I finish. In the mean time, enjoy the music video below of Sir Elton John.
About New Zealand
Official Elton John website