Reminders to Self

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

My husband had a screening colonoscopy last Friday.  His nurse in the recovery is the only one I had issues with.  I, not my husband. 

All went well, but let me tell you he is not an ePatient Dave.  He did not read his instructions about when to quit eating and the prep.  I did.  I then reminded him along the way:  “Only clear liquids today.”  “You must take the Ducolax at 3 pm.  Do you want me to text you a reminder?”

Sometimes the instructions we give patients are clear, but not always read.

The staff at the front desk were very kind and organized.  Calls had been made the day before and I had insured the insurance information they had was correct.   I did not tell anyone I was a doctor.  I’m not sure if my husband did later or not.

…..

When I was called back by the nurse, she mispronounced my name calling me Rhonda (which I forgave easily).  She did not introduce herself to me.

As we entered the recovery area, she did not take me to my husband and assure me he was okay.  She took me to the desk and abruptly said, “You need to sign this.”

No explanation of what “this” was, so I replied, “What is it I am signing?  I don’t sign anything until I have read it.”

She then said, “It’s the discharge instructions.  He’s already been given them.”

Note she had not reviewed them with me.  I would be the caregiver.  Note also that I had no way of knowing if she had reviewed them with my husband (who is not an engaged ePatient Dave) prior to sedation or in his current state of post-sedation fogginess.

She said, “Sign it when you’ve read them then” and quickly moved on to some other task.  I felt like a box that was simply being checked off.

I reviewed them, signed it, and moved over to my husband’s bedside.

The nurse with no name came by soon after and told him it was time to get up and go to the bathroom.  She led him over and said to me, “You can go to the bathroom with him.” 

Me, “Why would I want to go to the bathroom with him?”

Her, “Well, you don’t have to.”  [I think she found me difficult and perhaps uncaring.]

She left him alone in the bathroom with his clothes.  After standing there for about five minutes, I knocked on the door and entered.  “Are you okay?”  He was dressed, but swayed as he bent over to try to put his boot on.

Me to my husband, “You can sit in this other area where we are to wait on your doctor and put your boots on.  Here let me help you.”

In hindsight, I think she meant for me to help him get dressed in the bathroom, not to watch him actually use the bathroom. 

………

Reminders to myself

1.  Check names.

2.  Always introduce myself.

3.  Slow down and tell patients/family what is going on and why. 

4.  Patients and caregivers need to be given the instructions.

Longevity or Perfect Figure?

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

I’ve spent some time thinking about this survey.   I couldn’t find any better information on the survey than the press release from the University of the West of England (UWE).  Perhaps in the future it will be published in a journal for better review.

The  survey was apparently done by the  new eating disorder charity The Succeed Foundation in partnership with the University of the West of England (UWE).  The editor’s notes indicate 320 women (ages 18 – 65 years, average age 24.49)  studying at 20 British universities completed The Succeed Foundation Body Image Survey in March 2011.  

Notably, the survey found that 30% of women would trade at least one year of their life to achieve their ideal body weight and shape.

The research has also found that in order to achieve their ideal body weight and shape:

•        16% would trade 1 year of their life
•        10% would trade 2-5 years of their life
•        2% would trade 6-10 years of their life
•        1% would trade 21 years or more of their life

I would love to see an age breakdown of the respondents here.  Do we women become more comfortable with our bodies as we age?  Or did as many of the over 50 year olds want to trade longevity for “the perfect body” as the 20 year olds?

In addition to longevity, the survey also notes that in order to achieve their ideal body weight and shape, 26% of the women surveyed were willing to sacrifice at least one of the following:

•         £5000 from their annual salary (13%)
•         A promotion at work (8%)
•         Achieving a first class honors degree (6%)
•         Spending time with their partner (9%)
•         Spending time with their family (7%)
•         Spending time with their friends (9%)
•         Their health (7%)

Again, I would love to see an age breakdown.  It would be interesting to see how this might differ between the younger respondents vs the older (over 50 year olds) ones.

The survey results suggest that body dissatisfaction was common among the women surveyed, with 1 in 2 women saying that more needs to be done on their university campus to promote healthy body image.

•         46% of the women surveyed have been ridiculed or bullied because of their appearance.
•         39% of the women surveyed reported that if money wasn’t a concern they would have cosmetic surgery to alter their appearance. Of the 39% who said they would have cosmetic surgery, 76% desired multiple surgical procedures. 5% of the women surveyed have already had cosmetic surgery to alter their appearance.
•         79% of the women surveyed reported that they would like to lose weight, despite the fact that the majority of the women sampled (78.37%) were actually within the underweight or ‘normal’ weight ranges. Only 3% said that they would like to gain weight.
•         93% of the women surveyed reported that they had had negative thoughts about their appearance during the past week. 31% had negative thoughts several times a day 

Yes, I know as a plastic surgeon I make a living (in part) from cosmetic procedures, but I feel strongly that my nieces and other young women should be grow up to love themselves and their bodies.  

Related posts:
Steriod Use in Girls  (February 21, 2008)
Get Girls to Focus on Skin’s Appearance  (May 19, 2010)
Maternal Influence  (January 3, 2011)


REFERENCE

30% of women would trade at least one year of their life to achieve their ideal body weight and shape; UWE press release, March 31, 2011

Shout Outs

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

iMedicalApps is the host for this week’s Doctor Watson issue of Grand Rounds! You can read this week’s edition here (photo credit).

This is the first time iMedicalApps is hosting Grand Rounds, and to those not familiar, Grand Rounds is weekly collection of medical blog posts with different themes — hosted by various blogs.

To be perfectly honest, I had no idea what Grand Rounds was until very recently. When I started iMedicalApps in November 2009, we were a rag tag team of physicians and medical students, and I had no experience with the “medical blogosphere” — I didn’t even know it existed, I just wanted to review medical apps and provide a quality resource for medical professionals.  ………..

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These two are both breast cancer survivor related.  Powerful!

HT @medicallessons who tweeted “Make Them Hear You: Voices of Metastatic Breast Cancer - http://t.co/4Jmkzrh”

Last weekend, the Metastatic Breast Cancer Network (MBCN) launched an e-newsletter called “Voices.”

The name reminded me of a video MBC and LBBC  helped with last year: “Faces of Metastatic Breast Cancer.”

The low-key video shows a variety of women doing every day things with their families and commenting on MBC. It’s not a public service awareness message–it’s not preachy. Some people are serious, but many are laughing, playing with their kids and so on. It’s well worth a look!

Here are some other women who have inspired me: 

Molly Ivins:

“Having breast cancer is massive amounts of no fun. First they mutilate you;
then they poison you; then they burn you. I have been on blind dates better
than that.”
–Molly Ivins 1944 – 2007, columnist, political commentator and humorist

Plastic surgeon @mchrysopoulo tweeted about a video his group put together and posted on their Facebook page: Tattoos that tell Breast Cancer stories. Go watch the video!

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Recently @seattlemamadoc shared her “Ultimate Disaster Kit” segment and interview she did.  Great advice!

Where can people find out more about emergency preparedness?
· On my Seattle Mama Doc blog, I recently wrote a post about emergency preparedness.
· I’d also recommend checking out the American Red Cross’ Website and 3 Days 3 Ways for more information.

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H/T to @crzegrl15 who tweeted:  Nursing hero: Evacuation of war-wounded in Libya: first-person account by MSF nurse http://bit.ly/gaiZS6

Editor's note: Alison Criado-Perez, a nurse with Doctors Without Borders (Medecins Sans Frontieres, or MSF) shares this first-person account of evacuating war-wounded people out of Misrata. Ali is a nurse working for MSF in Libya and Tunisia. She has previously worked in Nigeria, Colombia, Uganda and Central African Republic. The video embedded in this blog post shows Ali actually treating a patient on the boat described in the account shared below. ………

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H/T to @Allergy who shared this on twitter:  Lost in translation: the warning "I am deathly allergic to nuts" accidentally became "I am absolutely dying for nuts" http://goo.gl/h8Myp

Ted Leonsis, founder of the company that owns the Capitals, Wizards, and Mystics sports teams, along with Verizon Center in Washington D.C., ……

He's also had to deal with his allergy in a foreign country. He recently visited Paris, and before leaving, asked the stewardess to translate into French the following message: "I am deathly allergic to nuts. Please do not serve me any nuts or nut products." He then passed the note to a server at a French restaurant. The message was lost in translation, accidentally becoming "I am absolutely dying for nuts. I must have nuts." The error was discovered when the waiter brought ten plates of nuts out for Leonsis. ……….

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H/T to @grahamwalker who shared this tweet:  Awesome. NEJM Clinical Practice review on "Care of Transsexual Persons." Very progressive of them. nejm.org/doi/full/10.10…

It truly is a very nice article which I would encourage all physicians to read.

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Threads has a wonderful article on the recreation of this jacket created for Plimoth Plantation in Massachusetts: Threads seamstress contributed to jacket on display at Winterthur Museum

The jacket is currently on loan to the Textiles Gallery at Winterthur Museum, Library and Garden in Wilmington, Delaware: The Plimoth Jacket: A Paradise in Silk and Gold (photo credit)

On loan to Winterthur from Plimoth Plantation, the Plimoth Jacket is not an exact reproduction. Rather, it was re-created from two examples in the Victoria & Albert Museum in London. One was chosen for the cut and construction of the jacket and the other for the design of the embroidery. Both originals date to the 1620s. ……

The sewing, embroidery, and lace were all entirely done by hand. The lace spangles (the tear-drop shaped sequins hanging from the lace) were created using tools made specifically for the project. The tools and techniques replicate those from the 1600s. Even the lining was hand-woven and dyed with natural indigo.

Learn More
View a PDF presentation about the creation of the jacket.

Rare Facial Replantation Performed at UAMS

UAMS mails out a publication called UAMS Consult a few times each year. I found a pdf file of their March 2007 issue online (no longer active, 2013) but couldn’t find the current one with this case report. So I’m taking the liberty (they may ask me to take it down) to publish it here.

The 20-year-old patient presented to the UAMS Emergency Department via ambulance from Malvern, about 50 miles away. The patient’s nose, upper lip and most of his right cheek were amputated by the edge of a hollow metal pole that came through the patient’s windshield during the single-vehicle rollover accident. He also had multiple facial fractures with extensive damage to the palate and teeth.

At the accident site, the property owner directed emergency responders to the severed portion of the patient’s face some distance from the vehicle. The avulsed tissue was properly stored and brought to the ED along with the patient.

Only One Choice

Mauricio Moreno, MD, director of the UAMS Head and Neck Cancer Division and a fellowship-trained microvacsular surgeon, saw the patient in the ED and determined that the only choice was to attempt one of the largest known composite facial replantation surgeries in medical literature.

The ischemia time was critical to the outcome since most successful replantations of facial tissues are performed in less than 8 hours. Due to inclement weather, an effort to fly the patient to UAMS had been aborted, and nearly six hours had passed when the patient was taken to surgery.

Without a successful replantation, the patient’s prognosis was poor for both function and appearance. No amount of plastic and reconstructive surgery would provide a cosmetically satisfactory result, and the patient’s ability to eat, drink, or speak would be severely affected.

Prior to surgery, Moreno consulted with UAMS’ Marcus Moody, MD, a facial plastic and reconstructive surgery specialist, who agreed that the facial bone fractures could be repaired at a later date.

The Challenge

Success depended on reintroducing blood supply via a microvascular anastomosis of the facial artery to the angular artery and microvascular anastomosis of the retromandibular vein to the facial vein. Given the nature of the injury, the vessels were severely damaged at the point where they were transected. In order to overcome this problem the vessels were dissected from the transection site until they appeared less damaged, and the anastomosis was made at that point. This was one of the most technically challenging aspects of the case. Very short vessels forced the release of some tissues in the face and neck in order to achieve a tension-free anastomosis.

Moreno worked as quickly as possible, completing the replantation in about two hours, maintaining the total ischemia time just under eight hours.

Six days after surgery, while the patient remained sedated in the ICU, the retromandibular vein thrombosed and the patient was taken back into surgery to repair the clotted vessel. Two days later the same vessel thrombosed again requiring a third – and final – microsurgical procedure.

The episodes of thrombosis likely were related to the vessel trauma that resulted from the accident.

Leeches Help

Because the tissue was unable to accommodate the increased blood flow, medical leeches were flown to UAMS and applied to the replanted tissue for 72 hours. The leeches corrected the venous insufficiency, which can have the same deleterious effect as when replanted tissue gets too little blood supply.

The replantation was a success. It appears to be the largest composite nasal replantation in the medical literature of about 15 cases described worldwide.

Ninety percent of the tissue survived; only a small portion of the patient’s nose and right cheek did not survive, but that tissue can be replaced.

The patient lost vision in his right eye, and the right side of his face is paralyzed as a result of the trauma. Multiple procedures will be needed to repair the numerous facial fractures, restore facial symmetry and achieve the best possible cosmetic and functional outcome.

………..

Kudos to UAMS.

Animal Word Quilt -- Finished!

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

It’s finished!

I recently gave it to the husband/wife team of veterinarians who have taken care of my dogs over the years. You can check them out at their website or Facebook page.

The quilt is machine pieced and quilted. It is 52.5 in X 62.5 in.
I love this
Still haven’t decided which word block I like the best. Sometimes I think it’s just certain letters like the “k” in monkey or the “a” in toucan or the “a” in gator
or the “E” in horse or the “b” in bear or the “d” and “o” in dog.
Or this “C” in cow which ended up sticking out into the border. I had to hand applique that portion down.
Here is the back.

Previous posts on this quilt:
Word Play Quilting
Animal Names Word Quilt – WIP

Breast Self Exam Poster

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

HT to Street Anatomy for the link to this great poster (photo credit)  by iHeartGuts!

Related posts:
Breast Self-Exam (October 8, 2009)
October – Breast Cancer Awareness Month (October 2, 2008)
Mammograms (October 13, 2008)
Breast Cancer Screen in Childhood Cancer Survivors – An Article Review (February 2009)
Indications for Breast MRI – an Article Review (March 2009)

The Angry Face Syndrome

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

I must say when I first read the title of this article (full reference below) I thought it was a joke. Apparently, I was just unaware this syndrome exist.

The authors state, “The finding of frontal bossing, deep radix, straight nasal dorsum, and an over projection of the nasal tip constitutes the angry face syndrome.” (photo credit, from article)

The authors note, “When the syndrome components of frontal bossing, a deep radix, and nasal tip projection are present but include a significant nasal dorsal hump (instead of a straight dorsum), the angry face syndrome does not apply. Somehow the dorsal hump negates the message of anger to the observer.”

Their solution is a rhinoplasty

with attention to a major radix augmentation graft and substantial reduction of the nasal tip projection. In addition, as with the illustrative cases described herein (Figures 1, 2, and 3), we also correct other offending features at the same time (eg, dependent nasal tip, boxy tip, poor alar support, alar base width, wide nasal bones).

Their conclusion:

In all of our years of teaching rhinoplasty, we have always maintained that in considering surgery, the patient must understand that nothing in the external world will change because the of the patient's rhinoplasty. The only thing that will change is the way the patient feels about himself or herself, ie, their self-esteem.

Rhinoplasty for the angry face syndrome, however, may be the exception to the rule.

REFERENCE
The Angry Face Syndrome; Pastorek NJ, White WM; Arch Facial Plast Surg 2011;13(2):131-133; doi:10.1001/archfacial.2011.14

Shout Outs

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

Kim, Emergiblog, is the host for this week’s Angry Birds issue of Grand Rounds! You can read this week’s edition here (photo credit).

Welcome to the Angry Birds edition of that weekly compendium of medical blogosphere goodness, Grand Rounds! I’ve chosen my addiction du jour, Angry Birds, as the theme for my 7th turn as host.

For those who are not familiar, Angry Birds is a game in which Green Pigs steal Bird eggs, causing the Birds to become angry, start screeching and begin catapulting themselves from sling shots in an attempt to destroy the Pigs, who house themselves in various structures and giggle at the Birds.

Got it?
Okay then! Let’s get started!  ………..

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Last Tuesday @EvidenceMatters alerted me via twitter to a panel discussion regarding Vitamin D “Vigorous panel talk: Boosting Vit D - Not enough or too much? Liveblog: http://bit.ly/gL9JuX Video: http://bit.ly”

The webcast of the panel discussion can be viewed here.

The consensus report:  Dietary Reference Intakes for Calcium and Vitamin D

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I caught part of this great  @radiorounds episode (#509) this past Sunday afternoon.  The episode kicked off “Donate Life” month and  focused on the topics of organ donation and the organ shortage crisis.  It aired live on April 3 and will be available on April 5 on their iTunes page!   

The featured guests included:

• Dr. William K. Rundell, Director of Transplant Surgery at Miami Valley Hospital in Dayton, Ohio and Clinical Professor of Surgery at the Wright State Univ. Boonshoft School of Medicine

• Dr. John Donnelly, Asst. Professor of Family Medicine at the Wright State Univ. Boonshoft School of Medicine… and a pancreas transplant recipient

• Dr. Alex Tabarrok, Professor of Economics at George Mason University and co-author of the economics blog Marginal Revolution

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Victoria (@vpmedical), Beyond the Bedside, wrote her own post in response to mine:    Hand Transplant vs. Prosthesis

…. As a life care planning expert in amputation injury and limb loss, I find hand transplantation somewhat disturbing.  I can appreciate the technology and biological advances that have allowed transplantation to occur. …….

One need only to review the case of Mr. Jeff Kepner, a bilateral hand transplant patient, to understand the concerns of such a procedure.  One year after his transplant he still regretted his life changing decision. In his words……….

Be sure to read the comment from Wolf on my post.  It is very insightful.

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Engadget had an article by Christopher Trout yesterday:  Bionic eye closer to human trials with invention of implantable microchip

We've had our eye -- so to speak -- on Bionic Vision Australia (BVA) for sometime, and with the invention of a new implantable microchip it's coming ever closer to getting the bionic eye working on real-deal humans. The tiny chip measures five square millimeters and packs 98 electrodes that stimulate retinal cells to restore vision. ……...

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A lovely essay on the origin of how human hair wigs are sourced, created and distributed by Julia Sherman:  She Goes Covered

Following the global hair trade, from the braid-laden Peruvian highlands to the sheitel machers of Borough Park.

I.     In the fall of 2009, Helene Rosen, her husband, Yoni, and eight of their eleven children moved from Baltimore to Cusco, Peru, to harvest human hair.1 Helene is a forty-four-year-old Orthodox Jew and self-proclaimed “master sheitel designer” who began making wigs fifteen years ago, for ten dollars an hour; her custom hairpieces now sell for up to two thousand. “You can bring me any wig,” she said this past winter, sitting at the table in her spare dining room in Cusco, “and I can tell you how old it is, how much it has been worn, and if it has ever been repaired. I can tell you everything about it.”   ……….

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Arkansas Literary Festival begins this Thursday (April 7-13).  One of the authors this year is the son of a long time friend (from college days, a fellow physics grad who now works for Lockheed Martin in laser research). 

Benjamin Hale is a graduate of the Iowa Writers Workshop, where he received a Provost's Fellowship to complete his novel, which went on to win a Michener-Copernicus Award. He has been a night shift baker, security guard, trompe l'oeil painter, pizza deliverer, cartoonist, illustrator, and technical writer. He grew up in Colorado and now lives in New York. The Evolution of Bruno Littlemore is his first novel.

To visit Benjamin Hale's website, click here

Decision-Making in Severe Lower Leg Trauma

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

About the time I was reading the journal article on decision-making process for patients with severe lower leg trauma (full reference below), @sospokesaroj shared news article via twitter:  Nine-year-old loses leg while saving little sister’s life.

Another news article on the accident notes

Surgeons worked on Anaiah from 1 p.m. to midnight on Friday, Davis says, to try and save a shattered left leg.

On Saturday the leg was amputated. The brute force of the accident also broke Anaiah’s right leg, fractured her neck, damaged her spleen and destroyed one kidney.

Which brings me back to the journal article which is a qualitative analysis of patient preferences for amputation or reconstruction. Twenty patients with type IIIB or IIIC open tibial fractures participated in the study. These patients had undergone either amputation (4 primary, 5 secondary) or reconstruction (14) between 1997 and 2007. There were 15 men and 5 women, mean age was 47 (23 – 68) years.  Semi-structured interviews were conducted and qualitative outcomes were assessed.

It must be noted that current research has shown minimal difference in functional outcomes between patients who have below-knee amputation and those who have lower limb reconstruction following a severe open tibial fracture.

The interviews highlighted several issues involved with medical decision-making. Participants described not having a role in deciding which medical treatment to choose.

“I didn’t decide! Hospital decided for me…They all made the decision; I didn’t make no decision on nothin’.  I didn’t even see it.  All I know is that [my wife] told me that when she came to the hospital they told her that they had to take it off.”  --- Male, 67, primary amputation, 12 year post-injury

“I was conscious until I got here [to the hospital], but when I got here… from that time I was in a morphine daze for several days.  And most of those decisions were being made by my wife.”  --- Male, 53, primary amputation, 8 years post-injury

“I’m lucky my brother was here for 3 months, I mean he was here like the day after it happened… Because I wasn’t terribly coherent, I mean, it’s not that I wasn’t conscious, I was on a lotta drugs.  I had my own little morphine clicker.”  --- Female, 56, reconstruction, 8 years post-injury

As you can see from the interview snippets included (and there are others in the article), family and spouses played a greater role than the patient in decision making, often because of patients being medicated when needing to make a treatment choice.

The article notes both amputation and reconstruction patients described being satisfied with the outcomes of their surgical treatments, but also expressed second thoughts about their treatment choices.

“I have to say I am happy with the results of the surgery, who my surgeon was.  However, the problems …. Mine are not what everybody gets.  Some people never have bone spurs, some people never have neuromas.  But I do.  And why people that have trauma injuries suffer more than pain, I don’t know.  Why do we get a bursa?  It’s just there.  It’s painful.  There’s nothing they can do about it.”  --- Female, 62, primary amputation, 9 years post-injury

“I was kinda angry about it, you know, like why did they have to take my right [latissimus dorsi] one? ‘cause I’m right handed.  Like, why couldn’t they take my left?  I was really mad about it.”  -- Male, 36, reconstruction, 12 years post-injury

“No, as of today, sitting here I wouldn’t have changed my decision [to do the reconstruction], but we did second guess it, several times, as we went through the multiple surgeries and everything else that came as a result of that.”  --- Male, 41, reconstruction, 10 years post-injury

 
REFERENCES

A Qualitative Analysis of the Decision-Making Process for Patients with Severe Lower Leg Trauma; Aravind, Maya; Shauver, Melissa J.; Chung, Kevin C.; Plastic & Reconstr Surgery Vol 126(6):2019-2029, December 2010; doi: 10.1097/PRS.0b013e3181f4449e

Shadowfold Play I Quilt

The center motif of this small art quilt is an exercise in using the techniques from the book Shadowfolds by Jeffrey Rutzky and Chris Palmer.  The book is full of interesting was to make geometric designs by creating folds in fabric.

Using border fabric I added a mitered border.  The border is machine quilted.  I used the beads to quilt the center motif which was made using white fabric.  There is a layer of blue-green fabric between the quilt and the batting so the folds show more.  The quilt measures 9.5 in square.

Here is a close up to show the border, the folds, and the beads.
The back is a lovely gold fabric with triangles for ease of hanging.  A bamboo skewer is used along with a picture hanging hook.

Hugs and Kisses Quilt

This is one of my early quilts.  I finished it back in April 1992.  It was made for my husband.  It is machine pieced and quilted.  It measures 42 in X 67 in.  

Here you can see the fabrics and quilting.
I was just learning to machine quilt at that time.  I used a method that involves quilting in segments and then sewing the segments together.  I actually like the way the back looks, but often on the front the quilting (at least for me at that time) didn’t match up.
Here is another view of the back.

New York Times Punked Once Again

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

The NY Times initiated a pay wall earlier this week. The timing is fortuitous as they have been taken again by an April Fool's prank. You may recall how New York personal-injury lawyer and blogger Eric Turkewitz began last year’s prank with his April 1st post where he claimed he’d been appointed official White House law blogger. He and a cohort of bloggers and tweeters posted corroborating responses and updates throughout the day. Eventually the Times picked up the story.

Get more details of this year’s prank here.