Doc To Doc

Quote

2014-06-10T23:26:00.000-04:00

"Surgery- the fine art of removing diseased parts with the expectation that the patient will be better."

Surgical-Tutor

2011-09-15T23:07:00.001-04:00

Learning Surgery can be a daunting task, but thankfully the days of trying to read Schwartz's Principles of Surgery, what I generally refer to as trying to read the unofficial "Encyclopedia of Surgery," are behind us. A great web resource can be found at Surgical-Tutor, a British site.

There is considerable depth to this site, and looks like something for everyone. Students and junior residents will benefit from the numerous Clinical Tutorials, which go over common cases, illustrated with images. There are also banks of radiology images, and pathology as well. I especially enjoyed the Journal Club section, which had important articles, all nicely summarized by topic.

Also notable is that the high quality content is all free, so this is one site to bookmark.

Surgical-Tutor

Decompressive Craniectomy in Diffuse Traumatic Brain Injury

2011-09-14T23:08:00.001-04:00

In the patient with a severe traumatic brain injury (TBI), it is of the utmost importance to control intracranial hypertension, and to maintain cerebral prefusion. There are several strategies to accomplish this, but a secondary therapy is a decompressive craniectomy.

The New England Journal did a randomized trial on 155 adults with severe TBI and diffuse injury, looking at decompressive craniectomy versus best medical therapy. On the one hand, the craniectomy had a shorter ICU length of stay, less overall procedures and less time of elevated intracranial hypertension (ICH). While achievement of these results is important, other endpoints paint a different picture. These include that the overall mortality did not change, and the GCS scores at 6 months (the so called extended Glascow Outcome Scale), were worse in the craniectomy group of patients.

Unfortunately, this study reinforces why this procedure is so infrequently performed.

N Engl J Med 2011; 364:1493-1502

Quote of the Day

2011-09-13T23:29:00.001-04:00

"Specialists know more and more, about less and less, until they eventually know everything... about nothing."

Dexamethasone To Reduce Hospital Stay

2011-09-12T22:24:00.004-04:00

I have to say that the addition of a steroid, to a patient with an active infection often feels like an oxymoron. After all, just when the patient is battling a severe illness, why would we want to shut it down? Of course, I am not talking about those cases of relative adrenal insufficiency, where the steroid becomes a treatment for this, and is not functioning primarily as an immunomodulator. Anyway, in the recent study from the Lancet, the steroid used was dexamethasone which has minimal mineralocorticoid effect anyway.

Meijvis and colleagues randomized 304 patients with community acquired pneumonia (CAP) to receive dexamethasone 5 mg IV daily for 5 days, or a placebo in a double blind fashion. This was done in 2 emergency departments, and those in need of immediate admission to an ICU were excluded, which implies that there were few, if any, critically ill patients included in this study.

At any rate, there was no mortality difference, and the dexamethasone patients had a mean length of stay (LOS) of 6.5 days, which was a day shorter than their control counterparts. However, there was a price to be paid as there was a significant increase in hyperglycemia in the steroid group.

Lancet. 2011 Jun 11;377(9782):2023-30. Epub 2011 Jun 1.

Not Too Old For Surgery

2011-09-11T22:59:00.001-04:00

My general philosophy is that age alone is rarely a contraindication to surgery. In fact, elderly patients generally have less physiologic reserve, and often do better with an early surgical approach to most problems.

While many elderly do fine with traumatic brain injury, and require only observation, with little to no intervention, a recent study in the Journal of Neurosurgery shows that patients over 80 years old, did as well as their younger counterparts after surgery for intracranial hematomas. While the length of stay increased as well as the complications in the elderly group, the overall mortality and return to functional status did not differ.

More info

Yales Goes With iPad

2011-08-31T22:30:00.000-04:00

I remember the note service in medical school, and it was a royal pain in the butt. All those notes, and after a few weeks, there were piles of paper everywhere, and the night before the test you would realize you were missing some transcript. So then I got organized, and put them in these humongous binders, that before too long were about to explode.

Now Yale is taking a new approach. They are using an iPad, and a top of the line, 32 GB 3G with a Bluetooth keyboard at that. Add in that they can now load a full year worth of notes, and I am seriously sold at this point.

Just don't tell me it is a computer...

Gizmodo

http://www.islandpacket.com/2011/07/24/1736402/hospital-emergency-rooms-taking.html

2011-07-29T23:09:00.000-04:00

http://www.islandpacket.com/2011/07/24/1736402/hospital-emergency-rooms-taking.html

Palm Scanning

2011-06-18T18:31:00.000-04:00

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iSurgery

2010-06-03T21:46:00.002-04:00

I have no idea what they are saying, but it looks like they are looking at the aortic arch. It would be nice to be able to see the CT images without leaving the operating room table. Will iPad's become standard OR equipment?

Poor Man's V.A.C.

2010-04-18T21:58:00.001-04:00

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The Multidisplinary Team

2010-02-23T22:50:00.003-05:00

It has been shown several times that having an intensivist in an ICU is associated with better outcomes. However, they shouldn't get all the credit. Taking care of the critically ill is never for one person alone to do. At least one of factors for the better outcomes is due to having a multidisciplinary team making rounds, at least according to the Archives of Internal Medicine. So, next time you see a crowd of folks making rounds in the unit, just realize that they are making a difference.

Arch Intern Med. 2010;170(4):319-320.

Check & Double Check

2010-02-17T22:50:00.002-05:00

Visit msnbc.com for breaking news, world news, and news about the economy

I have to say that the video doesn't mention that small things can easily be lost in the retrocardiac region. I have heard that some centers don't even count the 7-0 prolene needles because they are so small, and easily lost. While the patient may have numbness, AFAIK there is no way that a bulldog clamp left in that area could cause hand numbness.

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Laparoscopic Surgery Not Better For Surgeons

2010-02-16T22:53:00.002-05:00

While there are many benefits for patients of minimally invasive surgery, it is not at all ergonomic for the surgeon. I know some surgeons that argue that using the Davinci robot system is the safest way to avoid it. However, not all surgery will be done that way as that is a 2 million dollar device. In the meantime, the wrist can certainly be affected by the reptitive motion of laparoscopy.

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King Tut Died of Leg Fracture, Malaria

2010-02-16T22:46:00.001-05:00

The abstract in JAMA can be found here.

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Vscan Portable Sono

2010-02-15T22:56:00.005-05:00

The applications of ultrasound in medicine are expanding quickly. One example is in critical care monitoring where it is rapidly gaining acceptance for determination of fluid status in a patient. Now GE is releasing their Vscan sono. At a price of $7900, it should allow it to reach the bedside in more ICU's. It has such features as an hour of battery life, portability, and a USB dock to download images. Until the iPod Touch gets an ultrasound app, this may be as portable as it gets.

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Snow Day!

2010-02-10T22:24:00.000-05:00

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Noncardiac Surgery Guidelines

2007-09-28T16:27:00.000-04:00

From The NY Times:

The nation’s two leading heart groups issued new guidelines yesterday about what should be done for patients with heart disease before they undergo surgery on other parts of the body.

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Traveling Patch

2007-09-21T12:43:00.000-04:00

From WebMD:

Researchers have developed a skin patch that prevents the curse of many trips abroad: travelers’ diarrhea.

In a study of more than 150 travelers to Mexico and Guatemala, the novel vaccine cut the risk of moderate to severe diarrhea by 75%. Those who did get sick had a shorter, milder course of illness, says researcher Herbert DuPont, MD, director of the Center for Infectious Diseases at the University of Texas School of Public Health in Houston.

The patch releases a low level of the toxins of E. coli that causes Traveler's diarrhea. This stimulates the immune system of the patient. Then, when they are infected by the bacteria, they already have some preformed antibody which is protective. Neat, huh?

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Keep the Lunch, Lose the Box

2007-09-21T12:38:00.000-04:00

From San Jose Mercury News:

The state's public health department asked parents Thursday to toss certain Chinese-made lunchboxes potentially containing dangerous levels of lead - the same ones it distributed in a campaign to promote healthy eating.

The department distributed more than 350,000 of the canvas lunchboxes, only to find out that at least three that were tested in a batch of 56,000 contained "significant" levels of lead.

I think this is an argument to brown bag it.

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Diana's Death- Looking Back

2007-08-31T13:24:00.000-04:00

From CBS News:

Glamorized in life, Princess Diana continues to be scrutinized 10 years after her death.

An early-morning traffic accident in a Paris tunnel killed Diana's companion, Dodi Al-Fayed, and the driver of their car. But Diana was conscious after the accident and did not appear to be seriously hurt. In truth, she was bleeding internally.

Had the accident occurred in the United States, Diana would have been rushed to a hospital. However, the French have a different system: They first try to stabilize the patient at the scene. Still, as CBS News correspondent Erin Moriarty reports, that difference doesn't explain the series of missteps and delays in Diana's medical care that experts say never should have happened.

After I watched this clip on the CBS News, I was in awe at the horrible care that the Princess had received. I had heard it was the custom to send the Doctor out to the scene of the accident in Europe, which is not usual in the states. An anxious trauma patient needs to have hemorrhagic shock excluded long before any sedation is even considered. They used up their "golden hour" long before she ever got to the hospital. Her care is a good argument for "scoop & run" in these types of situations.

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Skinny In Colorado

2007-08-31T13:17:00.000-04:00

From MSNBC:

Coloradans are among the skinniest people in the nation, according to a new obesity report, but don't go celebrate with a slice of New York cheesecake.Colorado's waistline is expanding just like every other state's.
According to the Trust for America's Health, which compiled the report released Monday,Colorado has some of the lowest rates in the country of overweight residents, physical inactivity, hypertension and childhood obesity. Overall, it ranks as the leanest state in the study.

Is is any wonder? With all of those outdoor activities in that state, I know why they are thinner out there. Between mountain bike riding, skiing, hiking and climbing, those folks never sit still out West.

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Stay On the Right Side

2007-08-24T13:49:00.000-04:00

From CNN:

An 86-year-old man has died three weeks after a surgeon operated on the wrong side of his head, and state health authorities were investigating whether the mistake contributed to his death.

The patient, whose name wasn't released, died Saturday. The state medical examiner was determining the cause of death, according to a spokeswoman for the state health department.

The man underwent emergency surgery at Rhode Island Hospital on July 30 to treat bleeding in his brain, according to a state report released Thursday.

There's really no excuse for not having consulted the CT scan before starting the case. Still, it can be quite easy in the "heat of battle" to proceed on the wrong side. I remember as a first year resident on call, the OR called me at around 5 am as they were getting ready to prep the patient for surgery that day, and he was an early case. The patient was going for a combined carotid/CABG operation, but they didn't have consent for the carotid portion. When I asked which side I should consent them for, the patient didn't know, but the nurse insisted on the right carotid. I looked in the chart, and the nurse assumed that because the right side was 100% blocked, that was the surgical side. Wrong! She didn't realize that once a carotid is occluded, it can't be operated on, and it was really the left side, which was 70% occluded. Now that it was becoming an issue, I called the attending vascular surgeon at home, and confirmed with them which side was the operative one, as by the time they arrived, the patient would be under anesthesia, and draped with the surgical side of the neck exposed. While I hope that the surgeon would have known which was the correct side, I can easily envision things proceeding less than perfectly. Thankfully, this is my only surgical side story, and it was a save.

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Minute Clinic Controversy

2007-08-24T13:43:00.000-04:00

From MSNBC:

The growth of clinics in retail stores comes amid a shortage of family physicians that only promises to worsen.

Medical groups predict a shortage of 200,000 doctors in the United States by 2020. About 20 percent of Americans live in areas with a shortage of primary medical care, according to PricewaterhouseCoopers.

Wal-Mart operates 78 in-store clinics in 13 states, where the cost of a “get well” visit ranges between $40 and $65.

About half of those surveyed who visit Wal-Mart clinics have no insurance, according to spokeswoman Deisha Galberth. Another 15 percent said if there had not been a clinic, they would have gone to an emergency room instead.

As far as I'm concerned, if it offers an affordable alternative to the overloaded Emergency Rooms, than it is a good thing.

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Workplace Safety

2007-08-24T12:31:00.000-04:00

From The Toronto Star:

Ontario's front-line health care workers will soon be better protected against job-related injuries and life-threatening infections.

The province announced yesterday it will provide nurses and other health care workers with new respirators and safety needles in an effort to make their workplaces safer.

One more reason to move to Canada. What are we doing again in the US?

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