Don't you just love.......

Updated 3/2017-- video and all links removed as many no longer active.

Grunt Doc posted yesterday about having a run-in with a skunk. It left his car with a not so funny smell. My husband tells a story about a time when he and his friend Dave went to a car show. They had been sitting in the car with the doors closed, checking out all the features. Finished with their inspection, they exited. One of them farted just as they stepped out of the car. [My husband always says it was his friend, but knowing my husband it could easily have been him.]

Simultaneously, an exhibitor opened the door on the opposite side for a couple to enter the car and check it out. His words, "Don't you just love that new car smell."

Medical Tourists

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

The first or second year I was in practice I received a call from Dr Gaspar Anastasi. He had been the head of my plastic surgery residency while I was at Boston University Hospital. He was calling to ask me to do follow up for him on an otoplasty patient who lived in Arkansas. I readily agreed. In fact, I was honored that he would ask.

These days we think of the medical tourist as someone who goes to another country (ie. from the USA to Singapore for an operation), but in some ways the same issues may arise when the patient simply goes out-of-state to have a procedure done. They are not always ready, willing, or able to go back for follow up. This is especially true if a complication arises, be it small (missed stitch) or large (wound infection). They may have used up all their vacation time and not want to take the days off for travel.

I have had patients come to me from Nevada, Arizona, Texas, Louisiana, Tennessee, and Mississippi. Usually because they have family that lives here. They plan on staying with them while they recover. Still, I ask the ones who are more than 3 hours away if they are willing to stay around 10-14 days after surgery before agreeing to do the procedure. I ask them if they are willing to return if the need arises or if they have a local physician who is willing to help out. I try to make them think about what could happen. Even the ones who live closer I try to outline the follow up that will be expected.

There is a nice article in this month's Contemporary Surgery Journal discussing the ethics of caring for/refusing to care for a patient who comes to you with a complication after having their surgery elsewhere. You can read it here (may have to register).

A former patient presents with general malaise and reports having had low-grade fever. The examination is unremarkable, but laboratory tests indicate an infection not isolated to an organ system. Groin and blood cultures are positive for MRSA.

A while ago you diagnosed an abdominal aortic aneurysm in this patient, but she went to India for aortic endograft placement. You are considered an authority on graft infection. What should you do?

A. Tell her to return from whence she cometh.
B. Alert the media to the problem of cheap international medical care.
C. Advise the patient to sue in International Court.
D. Care for her as you would any patient.
E. Tell her that once a patient leaves your care, she leaves permanently.

My answer is D. Though I wish the patient would come to me for the entire "package", I would do what needed to be done. I would prefer to meet them before the initial surgery, but we don't always have that luxury. I would prefer that I could try to get them to do their care (if it is available, though specialized care is not always) closer to home or at least at a distance they are more willing to travel as needed. I would prefer that the surgeon call me and let me know that he would like me involved in the postop care.

Is it possible that this concept of international travel for surgery is here to stay? Most likely. So maybe the patient should find a "local" surgeon who would be willing to do the postoperative care when they return. The patient could then give their "international" surgeon the name, address, phone number, and e-mail address of the "local" surgeon so that information could be communicated and care coordinated.

What would your choice be?
Article:

The Medical Tourist Whose Outcome Went South; Contemporary Surgery, Vol 64, No 6, pp 290-291; James W Jones, MD PhD, MHA (This article was condensed from: Jones JW, McCullough LB. What to do when a patient’s international medical care goes south. J Vasc Surg. 2007;46;1077-1079.)

SurgeXperiences 124 is up!

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

The FINALE edition (124) of the FIRST season of SurgeXperiences is up! Dr T, Notes of an Anesthesioboist, is our host. (photo credit)

The loose theme for the collection was "Secrets and Surprises" - what season finale would be complete without a few of those?

Yet there's another ingredient that no real season finale would be complete without. It's The Unanswered Question. The Unsolved Mystery. Unfinished Business. Arguably it's why any of us keeps returning to any realm of inquiry or learning.

The world of medicine abounds with unanswered questions. While they might not show up here in the form of a conventional "cliffhanger ending," they're here all right...lurking behind the answers to other questions, the often-untidy "resolutions" to stories, and in situations that remain unresolved altogether and that keep us wondering about doctors, nurses, patients, the O.R., the characters in the vast series of episodes that comprise life in medicine today.

Very nice edition! I hope you will go over and enjoy reading.

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 1st edition of the second season will be be hosted by person who started it all --Jeffrey Leow, Monash Medstudent, on July 6th. The deadline for submissions will be July 4th. Please submit your posts here.

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

Memory Quilt II

I posted about the first memory quilt made back at the end of May. Here is the second one I have finished. It is from the strips and has three pockets (all working pockets). This one is 50 in X 70 in. It is machine pieced and quilted. I used the Baptist Fan pattern for the quilting.

Here you can see some of the shirt labels and one of the pockets.

The fabric used for the back of this one features Route 66. The man who is being remembered with these quilts had planned to drive Route 66. He never got to take that trip.

Ring Finger Avulsion

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

Dr Smak:

Mr. Zink was the coolest teacher in my middle school. Everyone liked him: nerd, jock, cheerleader alike. He taught science, and if you were lucky you got him two years in a row. In those few minutes after the lesson finished, but before the bell rang, he would tell us the grossest stories that he knew.
I still remember them. The one about the kid playing basketball with his class ring on, who left his ring and its attached finger on the rim after a dunk, connected by all the tendons from his finger to his shoulder. (Can that really happen?)

Yes, that can happen. Well, not the "to his shoulder" part as the tendons to the fingers don't originate that high in the arm, but the avulsion of the ring finger can and does. (III type injury) A typical story may be

She had avulsed the skin off her ring finger of her right (dominant) hand whilst attempting to jump over a spiked fence, catching her ring on the spike.

The physics/mechanics of the injury is explained well here.

The first 1998 study conducted under Dr. David M. Kupfer, Department of Plastic and Orthopaedic Surgery, University of San Diego in California, involved dropping a 30-pound weight attached to a ring bearing finger hanging from a hook, from a 9-inch height.

Results showed that in more than 90% of cases, the injuries caused by rings and wedding bands are Class II (29%) and Class IV (61%). On the tested sample (41 fingers), Class I injuries (10%) occurred at less than 80 N and the first ring avulsions at 111 N. Maximum finger resistance is 346 N with average resistance at 154 N. Film records also show that the skin is the finger’s strongest part. Once the skin tears, the remaining finger degloves or quickly avulses. Accordingly, although thin and narrow or tight rings are less resistant to traction and cause the skin to shear under traction, they are more dangerous than wide, thick rings.

Classification of Injury (Urbaniak)
Class I

• Circulation adequate.
• Standard bone and soft tissue treatment is sufficient.

Class II

• Circulation inadequate.
• Vessel repair preserves viability permitting immediate or delayed repair of other tissues

Class III

• Complete degloving or completed amputation.

• Judgement is essential because, although a complete amputation can be revascularised and viability restored, the potential for function is limited.
• In degloving injuries, the potential for useful function exists, but revascularisation is not easy or may not be possible.

These injuries are best avoided.

Be careful if you are in the building/construction, logistics and transportation industries. Consider not wearing your wedding ring while at work (that's exactly what I have told my husband).

Remove any rings or wedding bands during activities where the risk of injury is especially high. This includes many DIY activities, gardening, and handling heavy objects.

Your thumb, index, and middle fingers are most crucial for hand function. Consider wearing rings only on the ring or pinkie.

REFERENCES

Ring Avulsion Injury: The Do's and Don'ts of Initial Management; The Internet Journal of Orthopedic Surgery ISSN: 1531-2968; A Atrey, MRCS, P Landham, MRSC, T Lasoye, FRCS

Recommendation on the Risk of Wearing Rings and Wedding Bands; THE CONSUMER SAFETY COMMISSION (15th December 2005)

Finger Avulsion Injuries: A Report of Four Cases; Indian Journal of Orthopaedics, Vol 42(s), pp 208-211, 2008; Fejjal N, Belmir R, El Mazouz S, Gharib NE, Abbassi A, Belmahi AM

Microvascular management of ring avulsion injuries; J Hand Surg Am 1981;6:25-30; Urbaniak JR, Evans JP, Bright DS. [Pubmed]

Some Shout Outs

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

Grand Rounds 4:39 comes to us from the South Pacific this week. It is hosted by David Khorram at his blog, Marianas Eye. David is an eye surgeon and author. You can check out the book here. Back to grand rounds, here's what David has to say:

I’ve always wanted to be a newspaper editor, not because I want to edit, but because I want to write headlines. And not for a respectable paper like the New York Times. Maybe for a newspaper, like the Enquirer -- you know, where an editor can have some creative freedom with the facts. So, finally, I get my chance with this week's Grand Rounds. Sometimes the headlines I’ve written relate to the post, sometimes, they are just a whacked out free associations. Like all headlines, their purpose is to get you to read the posts. I hope I can entice you. There are some really great writers out there. Great job everyone.

I say he did a great job! Hope you will check it out.

Dr David Loeb will be the guest this week on the Dr Anonymous Blog Talk Radio Show. Dr David is a pediatric oncologist at John Hopkins. It should be a very interesting interview. I hope you will join us in the chat room.

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!

And a reminder to get those posts in for the FINALE edition of the FIRST season of SurgeXperiences! The host will be anaesthesist Dr. T at her blog Notes of an Anesthesioboist on Sunday June 22, 2008. Deadline for submission is midnight Friday June 20th. T's request:

Tonight I was honored once again to be invited to host the SurgExperiences blog carnival for its final edition of the season, SurgExperiences 124, to be posted on June 22. I am considering the theme "Secrets and Surprises," but the last time I thought I might have a theme, the collected works morphed into something else - so again, the "theme" isn't written in stone!

Please submit your posts here or email her directly at anesthesioboist@gmail.com with a link to your post.
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.

Strokes

"Beep*Beep*Beep"

I tried to drag myself from the deep slumber I was in. It was 1:30 am, Sunday night or Monday morning depending on how you look at it. No quite what Buckeye called the "witching hour" but close and my brain was acting as if it were.

I turned on the kitchen light so I could read the number and to help jump start my brain. It read 555-3028, Debra Peel. My brain--"who the heck is Debra Peel".

I punched in the number 555-3028. "Hello, this is Dr Bates. Someone had me paged."
"No one here paged any doctor."
"I'm sorry. This is the number I was given."
"This number is 555-0328."
"I'm sorry."

I hang up and try again, being very careful to punch the correct numbers. "Hello, this is Dr Bates. Someone had me page."

"Dr Bates, this is Mr Debra Peel. You operated on my wife three days ago." Now my brain fires with the memory of his wife and her surgery. It had been an easy surgery in a 61 yo healthy female. The surgery had take one hour and there had been no problems during or after (until now).

"Yes, Mr Peel. How can I help you?"

"My wife is complaining of a funny feeling in her right face and arm. Would her pain medication do that to her?"

"Mr Peel, will you tell me more about that funny feeling?"
"Dr Bates, here's my wife. I'll let her tell you."

Debra Peel, "Dr Bates, I had a bit of a right-sided headache with a tingling/numbness of my right face around nine. I took some Tylenol and went to bed. I thought it would just go away, but now it's worse and my right arm feels funny. Do you think my pain medication could be causing this?"

My brain is trying to access the input--no slurred speech, no audible breathing problems. "Anything else? Any chest pain?"

"No, I can breath fine. My chest doesn't hurt. Could my pain medicine be causing this?"

"Ms Peel, you need to go to the emergency room and let them access you for a problem in your head or heart. You need to hang up the phone and go to the emergency room now." My brain is thinking TIA or stroke.

"You don't think it could just be my pain medication?"

"No, Ms Peel. Your pain medication would effect both your arms, not just one. Please, go to the emergency room and let them check you out."

"Okay, we'll go to **Hospital"

I put the pager up, turned off the kitchen light, and went back to bed. My brain did not return to it's nice slumber. The next morning -- I mean later that morning--around 10 am, I called the Peel home to see if I could find out what had happened at the hospital.

"Hello, Ms Peel, this is Dr Bates. How are you doing? Did they find anything?"

"Dr. Bates, they did an EKG and a brain scan. I had an episode while I was there so they got to see it. They didn't find anything wrong though."

An hour later, my phone at the office rings and it's Ms Peel. "Dr Bates, the hospital called me back. The radiologist read the brain scan and found a blocked artery in my head. I'm suppose to go see my family doctor. I have an appointment tomorrow with him, so can we change my appointment with you to another time."

"Thank you, Ms Peel, for letting me know. Sure, would you like to come in today for me to remove your sutures?"

The symptoms of stroke are distinct because they happen quickly:

• Sudden numbness or weakness of the face, arm, or leg (especially on one side of the body)
• Sudden confusion, trouble speaking or understanding speech
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance or coordination
• Sudden severe headache with no known cause

Patients' Fears and Dreams

Patients will sometime have dreams (nightmares?) before their surgery similar to the "got up to give my book report and I had no clothes on" ones from our younger school days. Some of them are understandable -- you can "see" a thread that connects the procedure and the anxiety and the dream. A good example of this is the 4th Season episode of Roseanne "Less is More" which dealt (very nicely) with her breast reduction surgery. In the episode she had a dream where she woke up after surgery and actually had larger breasts. She was dressed as Madonna in the "cone bra". I've had breast reduction patients tell me versions of this one.

Recently an abdominoplasty patient was talking to me before surgery. I was trying to answer any last minute questions or concerns. She needed to tell me about the dream she had the night before.

Patient-- I remember hearing you say as I went to sleep in the operating room, "I can't make a straight cut with the patient on this water bed."

Me -- A water bed?

Patient -- Yes. I know it makes no sense, but I was on a water bed. And my brother-in-law was assisting you and he was wearing a clown outfit.

Me -- Well, are you okay with going ahead this morning. We don't have any waterbeds here.

Patient -- Yes. I'm just a little nervous, but I really want the surgery.

Everything went well. The incisions were straight as I didn't have to fight the waves of a water bed. I was thankful for that (smiling to myself here).

SurgeXperiences 124 -- Call for Submissions

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

It time for the FINALE edition of the FIRST season of SurgeXperiences! This edition will be hosted by anaesthesist Dr. T at her blog Notes of an Anesthesioboist on Sunday June 22, 2008. T's request:

Tonight I was honored once again to be invited to host the SurgExperiences blog carnival for its final edition of the season, SurgExperiences 124, to be posted on June 22. I am considering the theme "Secrets and Surprises," but the last time I thought I might have a theme, the collected works morphed into something else - so again, the "theme" isn't written in stone!

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 June 20th. Please submit your posts here or email her directly at anesthesioboist@gmail.com with a link to your post.

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.

Please, help make this a truly great finale and submit a post. Thanks Jeffrey for getting this surgery carnival started.

Adventures with Zippy

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

Zippy the Lobster is making the rounds of Dr Rob's blog friends. He is trying to raise awareness and money for pediatric brain tumors. He was recently here in Arkansas to spend time with Rusty and me. He arrived in Arkansas after visiting the Calhoun's in Louisiana (Charming BB). We all had a great time. You can check out his pictures of his Arkansas visit here. You can visit Zippy's blog that chronicles all his adventures here. You can make a donation to his nonprofit (Childhood Brain Tumor Foundation - MD) here.

Before leaving Arkansas to visit PK in Oklahoma, Zippy helped me make a fruit basket to take to the Father's Day picnic.

Happy Father's Day to all you fathers out there!

Raising Money for Childhood Cancer Research

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

Many of you know that Dr Smak's son Henry was diagnosed with brain cancer last fall. His sister Anna will be hosting a lemonade stand July 4th. You can help. Here's how:

The Scheck house will be hosting our very own Alex's Lemonade Stand on the 4th of July.

Alex's Lemonade Stand Foundation is a unique foundation that evolved from a young cancer patient's front yard lemonade stand to a nationwide fundraising movement to find a cure for pediatric cancer. What makes the foundation different is that it's model inspires people who would not be likely to donate to childhood cancer to make donations with the reassurance that "no donation is too small".

The fourth of July is traditionally in our neighborhood an insanely huge community yard sale. Since it falls on a Friday this year we expect big crowds. Our garage is packed full of yard sale fodder, proceeds which also will be donated to the foundation.

In addition to raising money from the lemonade sales, Anna is soliciting friends and family to pledge an amount of money for each cup of lemonade sold. This obviously greatly accelerates the earnings, and will hopefully motivate our "customers" to buy plenty of lemonade! If you're interested in sponsoring Anna, please email Bryan at mailto:bryanscheck@gmail.com so we can sign you up. We have donations ranging from 25 cents to a dollar a cup (!), and we have set an ambitious goal of raising $1000. Additionally, some people have felt more comfortable giving a flat donation, which we are also very grateful to receive.

There is a website designed to take the donated money here (link no longer active, 3/2017). Once the big day is over, we will call or email you to let you know what your donation is based on cups sold. You can then donate over the website.
Thank you for joining us in the fight against childhood cancer... one cup at a time!

I hope you will help them surpass their goal. I have sent my e-mail to Bryan already.

I Received My Quilt

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

Back in April I was invited to participate in "Another Little Quilt Swap". I finished my little quilt (laced ribbons quilt) in May and mailed it to ____. Wednesday I got home to find I had received my quilt. Paula Dennee, otherwise known as Paula the quilter, is the maker of mine. She named it "One of These Things is Not Like the Others" and you can see it posted on her site here. I absolutely love it! She sent a note along with the quilt to explain her inspiration. She gave me permission to share it. It makes me love it even more.

I wanted to include a note about your little quilt. The first time I went to your blog was April 18. That picture stayed in my mind and this little quilt was the result.

In an email she shared this regarding the quilting which you can appreciated in the picture of the back.

O. And did you notice that I quilted it in the swirly type motion used for breast self exam? I certainly had fun making this. So glad you liked it.

Paula, I am thrilled with this quilt. Thank you so very much.