Tuesday, September 30, 2008

Shout Outs

Jeffery, Monash Medical Student, is this week's host of Grand Rounds.  It can be read here.

In this edition, I have a theme of “medicine and war”.  Personally, I have never experienced war, only simulated war-like conditions in military exercises. But my forefathers in Singapore have, during the Japanese occupation in Singapore during World War 2. The British could not defend Singapore and we fell to enemy hands. The Japanese Occupation forms a major part of Singapore’s history. When our government formed, we realised having our own credible defence force was necessary. As such, all able Singaporean males have to serve 2 years of conscript service. As my blog tag line says, i used to learn how to kill. Now in medical school, i learn how to heal.

 

A new to me blog, The Stitching Surgeon, whom I found thanks to T (Notes of an Anesthesioboist).  She describes her blog this way:

Sewing, photography and a little about a surgeon's life.

I do have a day job...that requires surgery. I also am a wife to my Darling Husband, mother to my cute cat Chloe, aunt to the cutest little girl in the world, sister to my best friend, daughter to the best parents in the world, and seamstress to all the many projects that float into my head.

 

From White Coat Rants, a link:

Throckmorton’s blog (also noted at Happy Hospitalist) that described how that described how Congress and Pete Stark would have to live their lives if they followed the regulations that were imposed upon physicians. See Stark Reciprocity. Very amusing and definitely worth a read.

 

Thank you Sandy (Junkfood Science) for your remembrance of Paul Newman.

While not a scientist or doctor, Mr. Newman loved these children. He envisioned a place where children could come, strictly for fun and to enjoy a carefree camp experience that could heal their spirits, encourage, inspire and restore hope and confidence. But it would also have 24/7 medical supervision, with all of the modern medical equipment and top medical professionals that any medical emergency might need. The first Hole in the Wall Camp opened in 1988 in the Connecticut woods and today, there are eleven camp programs around the world. Over 135,000 children have had the chance to attend a camp and be a kid again. The program also provides year-round support to families and caregivers, offering respite, counseling, support, training and other assistance.

 

Need a new iPod nanos?  Well, MedGadget is having a contest to name the some of the next Nobel Prize winners.  You have until Saturday, Oct 4, 2008 to submit your entries.

So here are the rules:

1. Anyone can enter by writing a comment to this post. Please make sure you leave your email address, so we can get in touch with you.

2. Identify either the scientist(s) or discoveries in Medicine, and/or Physics and/or Chemistry, for your chance to win an iPod nano, or even three of them.

3. If a winner lives outside the US, Canada, or EU, instead of sending the prize, we'll transfer an equivalent amount of ca$h via a PayPal account.

4. Deadline for entries is Midnight Pacific Standard Time on Saturday Oct. 4.

 

This Thursday there will be no Dr Anonymous' Blog Talk Radio show.  I am looking forward to when he returns.  In the meantime, if you missed any of the shows you can check out the archives.

 

I don’t know about you all, but it has been fun trying to keep up with Dr Val (photo credit) as she “guest hosts” on various blogs.  There is a bit of a joke based on the “Where’s Waldo?”   Now the question is: “Where’s Dr Val?”   To help you out, here are the sightings I know of:

at Kevin, MD (New Hampshire, USA)

 

at Kim, Emergiblog (California, USA)

 

at GruntDoc (Texas, USA)

 

at Insure Blog (Connecticut, USA)

 

my guest, Suture for a Living (Arkansas, USA)

 

at Happy Hospitalist (USA)

 

at Vijay’s, Scan Man’s Notes (India)

Dr Val's Radiology Humor (Sept 27, 2008)

 

at Dr Rob’s, Musings of a Distractible Mind (Georgia, USA)

 

at MedPolitics (USA)

 

at Dr Cris’, AppleQuack (Australia)

 

at Bongi’s, other things amanzi (South Africa)

 

at Ian, Wait Time and Delayed Care (Canada)

 

at Paul Levy’s, Running a Hospital (Massachusetts, USA)

 

And in case you missed it, her  live Blog Talk Radio segment at Blog World Expo (Sept 20, 2008) can be heard here.

Considering the places she has “been” in the last week, I suggest we dedicate this Beach Boy song, I Get Around (as done by the Red Hot Chili Peppers),  to her.  Enjoy!

Monday, September 29, 2008

Complex Regional Pain Syndrome

Complex Regional Pain Syndrome (CRPS) is a multi-symptom, multi-system syndrome that remain poorly understood. It was called reflex sympathetic dystrophy (RSD) when I first learned about it. I admit I still tend to call it RSD.

Historical Review

In 1864 Silas Weir Mitchell published his findings on gunshot wounds of nerves in a now classic article (2nd ref below). Then in 1867, Mitchell called this condition causalgia from the Greek word meaning "burning pain". Mitchell described the condition well, but was unaware of the etiologic connection to the sympathetic nervous system. Over the years other authors who did make the connection of the vascular and nervous systems in this condition have suggested names such as neurovascular dystrophy, post-traumatic vasomotor disorders, sympathetic neurovascular dystrophy, post-traumatic vasospasm, postinfarctional sclero-dactyly, traumatic angiospasm, causalgic state, minor causalgia, mimo-causalgia, and Sudeck's atrophy. It was in 1967 after Richards article (3rd reference) that the term reflex sympathetic dystrophy began to be used.

In 1995, the International Association for the Study of Pain (IASP) decided that the terms complex regional pain syndrome (CRPS) type I and type II were better than the respective names reflex sympathetic dystrophy and causalgia. The term "Complex" was added to convey the reality that this condition expresses varied signs and symptoms.

What is RSD / CRPS?

It is a condition that does not follow the normal healing path after an injury to a nerve or soft tissue. Development of RSD / CRPS does not correlate to the magnitude of the initial injury. The reasons that the sympathetic nervous systems assumes an abnormal function after an injury is still not understood. (photo credit)

The International Association for the Study of Pain (IASP) lists the diagnostic criteria for complex regional pain syndrome I (CRPS I) (RSDS) as follows:

  1. The presence of an initiating noxious event or a cause of immobilization
  2. Continuing pain, allodynia (perception of pain from a nonpainful stimulus), or hyperalgesia disproportionate to the inciting event
  3. Evidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the area of pain
  4. The diagnosis is excluded by the existence of any condition that would otherwise account for the degree of pain and dysfunction.

According to the IASP, CRPS II (also known as causalgia) is diagnosed as follows:

  1. The presence of continuing pain, allodynia, or hyperalgesia after a nerve injury, not necessarily limited to the distribution of the injured nerve
  2. Evidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the region of pain
  3. The diagnosis is excluded by the existence of any condition that would otherwise account for the degree of pain and dysfunction.

The primary difference between type I and type II is the identification of a definable nerve injury. For more information check this eMedicine article and this website (RSD Foundation). You will also find a nice video animation on the RSD Foundation site that shows how an injury might trigger RSD / CRPS.

TREATMENT

The cornerstone in the treatment of RSD / CRPS is normal use of the affected part as much as possible. This is done through education, pain control, and physical therapy. (photo credit)

The RSD Foundation is a site full of information. There you will find not only the Clinical Practice Guidelines for Reflex Sympathetic Dystrophy (Third Edition): The Clinical Practice Guidelines have become the standard for diagnosis and management of RSD / CRPS, but also videos of Sympathetic Nerve Blocks. If you have an interest in RSD / CRPS, I would strongly suggest their site.

REFERENCES

Reflex Sympathetic Dystrophy; Green's Operative Hand Surgery, 2nd Edition; Chapter 15, L. Lee Lankford, MD

Gunshot Wounds and Other Injuries; JB Lippincott, Philadelphia, 1864; Mitchell SW, Morehouse GR, Keen WW (I have not read, but this is the classic article references in Green's Text and elsewhere)

Causalgia: A Centennial Review; Arch Neurol 16:339-350, 1967; Richards, RL (have not read, but another classic article referenced in Green's text and elsewhere)

Complex Regional Pain Syndrome; eMedicine Article, April 2008; Steven Parrillo DO

Complex Regional Pain Syndrome: Comparing Adults and Adolescents; Medscape Article, 2002; Lorraine M Taylor MSN, CFNP

NINDS Complex Regional Pain Syndrome Information Page; National Institute of Neurological Disorders and Stroke Website; last updated July 31, 2008

Complex Regional Pain Syndrome (CRPS); StopPain.org (Dept of Pain Medicine & Palliative Care)

Medical Treatment Guidelines, Complex Regional Pain Syndrome (CRPS), formerly know as reflex sympathetic dystrophy -- Washington State Department of Labor and Industries (pdf file)

International Research Foundation for RSD / CRPS

Reflex Sympathetic Dystrophy Syndrome: Consensus Report of an Ad Hoc Committee of the American Association for Hand Surgery on the Definition of Reflex Sympathetic Dystrophy Syndrome; Plastic & Reconstructive Surgery. 87(2):371-375, February 1991; Amadio, Peter C. M.D.; Mackinnon, Susan E. M.D.; Merritt, Wyndell H. M.D.; Brody, Garry S. M.D.; Terzis, Julia K. M.D., F.R.C.S. (C), Ph.D. Modison, Wise.

Severe Reflex Sympathetic Dystrophy [Correspondence and Brief Communications]; Plastic & Reconstructive Surgery:Volume 101(1)January 1998, p 243; Giraldo, Francisco M.D., Ph.D.; Gaspar, Diego M.D.

Complex Regional Pain Syndrome or CRPS Treatment; Health & Recovery Blog; August 4, 2008

Sunday, September 28, 2008

SurgeXperiences 207 is Up!

Buckeye, of recent Dr Anonymous BTR fame, is the host of this edition of  SurgeXperiences. It is his  second time hosting.  I think he did an outstanding job!  Hope you will go read it here.

Welcome to another scintillating edition of SurgeXperiences. It's my 2nd time hosting, which is cool. Jeffrey Leow has done a terrific job in establishing this thing as the definitive Grand Rounds for surgery. Next time anyone sees him around the neighborhood; buy him a drink.

 

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. Unsure at this time who will be the host for SurgeXperiences 208 on October 12th.  The deadline for submissions will be midnight on Friday, October 10th. Please submit your posts here, and if you would like to host a a future edition, please contact Jeffrey who runs the show here.

Here is the catalog of past surgXperiences editions for your reading pleasure.

Saturday, September 27, 2008

Volunteer Firefighters

 

This evening our local volunteer fire department, West Pulaski Fire Department, is holding its annual catfish dinner to raise money. We always go. We feel it is important to support them, as well feel fortunate to have them available. We live just (less than 3 miles by the road, even closer as the crow flies) outside the city limits. The money raised helps them buy new equipment or replace worn out equipment/gear.   Last year the money raised was used for thermal cameras.  This year they are going to use the money raised for protective gear.  (photos credit)

A volunteer fire department (VFD) is an organization of men and women who have joined forces to perform fire suppression and other related emergency services for a local jurisdiction. According to the National Volunteer Fire Council, "There are just over a million active firefighters in the US, of which just over three-fourths are volunteer firefighters. Nearly half the volunteers serve in communities with less than 2,500 population."

The term "volunteer" refers to a group of part-time or on-call firefighters who have other occupations when not engaged in occasional firefighting or response to other emergencies. Although they may have "volunteered" to become members, and to respond to the call for help, they are compensated as employees during the time they are responding to or attending an emergency scene, and possibly even for training drills. An on-call firefighter would probably be expected to volunteer time for other non-emergency duties as well (training, fundraising, equipment maintenance, etc).

As last year, we'll be there this evening to support our local "volunteer" firefighters. They serve very good catfish (photo).

Friday, September 26, 2008

Mr J's Zoo Quilt

This quilt is for a friend's son, Mr J. The only request was "bright colors". I came across the almost pastel zoo fabric (only about 0.5 yd) in the fabric my neighbor had given me a few months back. I thought it was perfect for a small boy and found the blue and green in the same fabric stash. It seemed that the "attic windows" block would work. I only had enough of the zoo fabric for the 12 blocks which didn't make the quilt large enough. As luck would have it, the same fabric-gift-stash had the wonderful strip fabric in primary colors which made a perfect border.

The quilt is machine pieced and quilted. It is 38.5 in X 48 in. The borders are mitered. Here is a detail picture of some of the blocks.

For the backing, I came across this great hippopotamus fabric. There wasn't quite enough, but I had more of the blue to add to it. So Mr J will have animals on both front and back of his quilt.

Thursday, September 25, 2008

Guest Post by Dr Val--Lip Plumping With Restylane: What Your Doctor Might Not Tell You

I have a great plastic surgeon friend who offered to fill a facial scar for me. I was bitten in the face by a dog when I was very young, and the small (1/2 inch) divot of flesh from my cheek still bothers me slightly. I’ve generally ignored it but thought it might be fun to see if it could be corrected in any way – so I happily agreed to try a Restylane (hyaluronic acid) injection.

My surgeon and I decided not to use any numbing medication because it distorts the contours of the face, making correction more challenging. So I tried my best not to squirm as he inserted a fairly long needle parallel to my nose and began pumping in several cc’s of thick, acidic goo into the tough old scar.

He had to insert the needle a couple of times to add more product, and then he had to squish it around by pinching my cheek with his thumb and forefinger. Without massaging the filler, it might settle into a lump. Again I tried not to budge, but he had to wipe one tear from my left eye as it disobediently escaped. I could see that he felt badly that he had caused me pain. I reassured him that it wasn’t that bad (I fibbed.)

Anyway, I left the office with an ice pack on my cheek and later ran my finger over the area to see how it felt. To my surprise, it was pretty firm - like a tiny Tootsie Roll under my skin. My surgeon said it would soften up in a week or so.

It’s been about 4 weeks now since the injection and the lump is indeed smaller, but not that much softer. The contour of the scar is indeed improved, though the result is not miraculous. But this experience got me thinking: what about those people who use Restylane in their lips?

You’ve seen those Hollywood actresses who have plumped their lips with fillers, right? Well – I guess there’s something that their doctors might not have mentioned – the plumpness probably has a somewhat lumpy, firm texture. I imagine it might feel like kissing someone who has small tumors in their lips. Ewwww!

So ladies, before you get a plumping treatment for your lips, think about the potential consequences – they may look good, but will they feel good? Fortunately, Restylane only lasts 6 months… but that might be a long time to be less kissable! (photo credit)

Wednesday, September 24, 2008

Doctors with Depression

This past Friday there was an article in my local paper about a documentary that highlights doctors with depression and the reasons why they often don’t seek help.  The documentary is Struggling in Silence.  It was scheduled to be aired on our local PBS station, AETN, on Saturday.  I intended to watch it, but missed it.  It aired at 5 am on Saturday morning.  For some reason, I thought it was to air Saturday evening, so I didn’t even set the VCR.  A colleague was interviewed for the documentary.  His name is Dr. Robert Lehmberg.   He practiced plastic surgery here in Little Rock for years, but retired almost a year ago and is now a hospice and palliative care doctor at UAMS and the Central Arkansas Veterans Healthcare System.  I know Dr Lehmberg (and think highly of him), but never realized how he struggled with depression.

The following is from the “Doctors with Depression” website:

Every year, three to four hundred physicians take their own lives — the equivalent of two to three medical school classes. This is an alarming trend in a country focused on increasing the availability and quality of healthcare. Struggling in Silence: Physician Depression and Suicide is a one-hour, high definition public television documentary that sheds light on this hidden and perplexing phenomenon.

Struggling in Silence is part of a nationwide outreach campaign. The aim of the campaign is to explore the professional policies and the culture of stigma that prevent physicians and medical school students from seeking help for the common and treatable mood disorders that can lead to suicide. The campaign will also educate the community at large about mood disorders and medical safety in the hopes of creating a more supportive environment for physicians in treatment.

We have had our share  of physician suicides here in Arkansas.  In Aug 2004, we had a double tragedy.  A third year UAMS medical student  died after jumping out of a 10th floor window on the UAMS campus.  Later his wife, a neurosurgery resident, was found stabbed to death in their home.  It is believed that he killed her prior to jumping to his own death.

That same year (2004) at Christmas, Dr Jonathan Drummond-Webb committed suicide by swallowing prescription painkillers.  He was a brilliant Pediatric Cardiac Surgeon at Arkansas Children’s Hospital.

The film also mentions how Dr G Richard Smith, chairman of the psychiatry department at UAMS, and colleagues with the Arkansas Psychiatric Society and the Arkansas Medical Society managed to petition our state medical board to change the state licensing procedure to protect the privacy of any physician who is in or has had mental health treatment (check out clip three).  This change took place after the three deaths so close together in 2004.

I would encourage you to check the website for when the film might be aired in your area or to purchase the video/DVD.

More importantly, if you are “suffering in silence”, please, seek help.  In Arkansas, the Arkansas Medical Foundation is a great place to start.  Contact information can be found on their website.

The Arkansas Medical Foundation is here to provide for the identification and treatment of healthcare professionals who suffer from impairment, in order to promote the public health and safety and to insure the continued availability of skill of highly trained medical professionals for the benefit of the public. The AMF was created to oversee the Physician's Health Committee (PHC).

Tuesday, September 23, 2008

Shout Outs

Dr Val, Voice of Reason, is this week's host of Grand Rounds.  She  and Mr. Colin Son are now the stewards of Grand Rounds as the blog carnival enters its 5th year.

Here is Dr Val’s message to us:

This day happens to be historic for me as well, since I have just taken the leap into blogging independence. I’m excited that “Dr. Val and the Voice of Reason” lives on at the Getting Better Blog. I am committed to integrity, transparency, and medical accuracy – presented in a warm, and down-to-earth manner. Unfortunately, my new site is not live yet, so KevinMD and Kim from Emergiblog have graciously allowed me to crash guest blog at their sites for this edition of Grand Rounds.

Enjoy!

 

Emily (Crazy Girl, Flight Nurse) is the host of  the current issue of Change of Shift (Vol 3, No 6).  It is the Pirate Edition!  (photo credit). Go check it out.  Arrrrrrrrrrg!

Glad ye lubbers could find the place. Grab ye a bit o’ grog and settle in for this here edition of Change of Shift!

*hack*

*cough*

Okay. I am not as good as others at spewing the pirate lingo, but hosting CoS this close to International Talk Like A Pirate Day was just too good to pass up!

For those of you who are not familiar with this all important holiday, I would suggest some background reading. Although I may be forced to walk the plank, the first blog post is being linked to without permission, or prior notification. I think this here scallywag will be forgiven in the Spirit of the season as this post is by the holiday’s Captain, (columnist) Dave Barry.


Kimball Atwood over at Science-based Medicine has begun a series on the Pitfalls in Regulating Physicians.  I hope you will check it out.

I had intended today’s posting to be a summary of a real case faced by a state medical board. It is a case of licensed physicians treating patients with a substandard, dangerous, and unequivocally illegal method. My intent was to use it as an illustration of how difficult it can be for medical boards to discipline such practitioners, even when the treatment involved is obviously, blatantly bad. Only yesterday I was informed by the pertinent board that because this case has yet to be resolved, I may not discuss it. So be it: I’ll save the specifics for another time. Instead I’ll offer a general example of a dubious treatment as a prelude to Part 2 of this series, which will attempt to discover some of the reasons that medical boards might, under such circumstances, be ineffectual.

 

 Audio slideshow: The art of mathematics

To the untrained eye, these vivid images might appear to be random sets of colourful swirls and circles.

But they are in fact precise visual representations of mathematical theory known as dynamical systems.

Some of the images - created by mathematicians from across the world - have gone on display at the University of Liverpool.

Here, mathematician Lasse Rempe explains how they are made - and considers their artistic merits.

 

I received an e-mail last week from Don Elton, MD who is a pulmonary and critical care physician in South Carolina.  He has started a blog / forum called  ReformHealthCare.net  where he wants to discuss ways to "fix healthcare":

This site is created as a forum for discussing what’s wrong with the US healthcare system and most importantly what can and should be done to improve things. There’s plenty that’s right about the US healthcare system which is why in most parts of the world people, if given the choice, would rather be taken care of here if they’re really sick or need surgery but that doesn’t mean things are perfect by any means. There’s plenty of room for improvement both in terms of how care is delivered and most importantly how it is paid for.

Read the posts and articles and then contribute in a constructive way.

 

This Thursday  Buckeye Surgeon will be the guest on the Dr Anonymous' Blog Talk Radio show.  I am looking forward to this interview.  I hope you will join us this Thursday night at 8 pm CST (or 1 am GMT) both to listen to the show and to participate in the chat room.   That's where all the fun is.

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!
 

Monday, September 22, 2008

Psychological Considerations of the Bariatric Surgery Patient Undergoing Body Contouring Surgery--An Article Review

Earlier this month I reviewed an article on nutritional deficienciess in the post-surgery bariatric patient. Today I'd like to review an article on some of the psychological considerations of that same patient population. The article is the first one listed below in references.

They begins by stating their intentions:

This article discusses the psychological considerations of bariatric surgery patients who elect to undergo subsequent body contouring. Drawing from several recent comprehensive reviews, the article begins with a brief discussion of the psychosocial and physical functioning of persons with extreme obesity. Of particular interest is research on the relationship between obesity and body image. Dissatisfaction with one’s body image is believed to play a central role in the decision to seek plastic surgery, and the empirical studies of this relationship are reviewed. The article concludes with a discussion of future research priorities and suggestions for the plastic surgeon on the psychosocial assessment and management of these patients.

 

I'm not sure that the article lives up to the stated intentions, but they did have some salient points. Mostly, for me, they managed to point out that most studies only follow these patients for 1-2 years post-surgery or post-weight loss, so true long-term satisfaction/maintenance is unknown.

No study, however, has followed patients for more than 2 years postoperatively. As a result, it is unclear whether cosmetic surgery leads to longer lasting improvements in body image.

 

The best part of the article for me was the reminder that not all post-bariatric surgery patients (post-massive weight loss patients) are appropriate candidates for surgery. Their reasons for wanting surgery should be accessed as all cosmetic/reconstructive patients are to be sure their expectations are realistic and obtainable. (bold type emphasis is mine)

Many post– bariatric surgery patients are probably highly motivated to undergo body contouring. High levels of motivation, however, may not equate with psychological appropriateness. Patients may hold unrealistic expectations about the postoperative results, perhaps inaccurately gleaned from the mass media and “reality-based” television shows that have featured body contouring. Some may incorrectly anticipate that body contouring surgery will result in a total body transformation that makes their bodies comparable to persons who never experienced excessive body weight. At the same time, patients may have little appreciation of the fact that body contouring surgery often produces large, visible scars, skin irregularities, and residual deformities in body shape. Thus, patients should be reminded, on several occasions, that although surgery may improve body contour, it will not result in a “perfect” body shape.

 

This following list of questions is a from the article. I have altered their layout (not content) for easier reading/presentation.

Preoperative Psychological Assessment of the Body Contouring Patient

Motivations and expectations*

  • Why are you interested in body contouring surgery now?
  • How do you anticipate your life will be different following surgery?
  • How will you know if you are happy with the postoperative results?

Physical appearance and body image concerns†

  • What, specifically, do you dislike about the appearance of your body?
  • How unhappy do you become when you think about your appearance?
  • When does your body’s appearance bother you the most?
  • Do you ever think you spend too much time thinking about your body?
  • Do your feelings about your body ever keep you from doing certain activities?

Psychiatric history and status:

  • Have you ever had any significant problems with depression or anxiety?
  • Have you ever, or are you currently, under the care of a mental health professional?
  • Have you ever, or are you currently, taken a psychiatric medication?
  • If yes, who is prescribing this medication?

To further assess for depressive symptoms‡:

  • How is your mood?
  • Are you having difficulties falling asleep, staying asleep, or waking up prematurely?
  • Have you noticed any changes in your appetite?
  • How is your concentration?
  • Are you crying more than usual?
  • Are you more irritable than usual?
  • Are you interacting with family and friends?
  • Do you feel hopeless or helpless?
  • Do you have any thoughts about hurting yourself or ending your life?


*Patients should express that their motivations for surgery are internal (i.e., that they are having surgery for improvements in their body image and self-esteem) rather than external (i.e., that they are having surgery to please a spouse or romantic partner).

Their postoperative expectations should be realistic in terms of both the improvements in their appearance and the impact of these improvements on their overall quality of life (which may be modest or minimal).

†Patients should be able to articulate specific appearance concerns that are readily visible to the surgeon. This dissatisfaction, however, should not be accompanied by significant emotional upset (i.e., reports of daily sadness or tearfulness or excessive crying during the consultation) or reports of significant behavioral avoidance (i.e., reluctance to leave the house to work or socialize).
 
‡Patients who report excessive sadness, present with a flat or blunted affect, and who endorse the neurovegetative symptoms of depression (changes in sleep, appetite, and concentration) should be asked about other symptoms of depression. Those who endorse five or more symptoms may be suffering from a major depressive episode and should undergo a mental health evaluation before surgery.

 

 

A related blog post of mine on this subject is Suitability.

 

REFERENCES

Psychological Considerations of the Bariatric Surgery Patient Undergoing Body Contouring Surgery; Plastic & Reconstructive Surgery. 121(6):423e-434e, June 2008; Sarwer, David B. Ph.D.; Thompson, J Kevin Ph.D.; Mitchell, James E. M.D.; Rubin, J Peter M.D.

Maintenance of Weight Loss after Body Contouring Surgery for Massive Weight Loss; Plastic & Reconstructive Surgery. 121(6):2114-2119, June 2008; Shermak, Michele A. M.D.; Bluebond-Langner, Rachel M.D.; Chang, David Ph.D., M.P.H., M.B.A.

Sunday, September 21, 2008

SurgeXperiences 207 -- Call for Submissions

The host for SurgeXperiences 207 will be Buckeye Surgeon.  That edition will be published on September 28th. The deadline for submissions is midnight on Friday, September 26th. Please submit your posts here.

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 Friday, August 29th. Please submit your posts here.

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.

Saturday, September 20, 2008

For My Dog

Rusty, my chocolate Labrador, has a stuffed duck that he adores. He carries it around, tosses it in the air and catches it, brings it to me for playtime. He has had this duck for over six months now. The "quacker" in it still works. It has been washed a couple of times.

Earlier this week I noticed that it has a hole that needed repaired.


Since I adore Rusty, I got out the needle and thread and did the repair for him.


He is very happy that duck remains around for more playtime.


I am happy that Rusty remains around for more playtime with me. It has been a year since we lost Girlfriend, but she remains in my heart and thoughts.


Friday, September 19, 2008

Flower Basket Quilt

I finished my little quilt for the swap.  It is 17.5 in square, machine pieced and hand quilted.  The first picture shows the colors better than the second.  The pattern is a flower basket that I found on Jinny Beyer's website.  As I mentioned previously, I have always been a fan of her work.

Here is a close view to show some of the quilting stitches.  I hope the recipient likes this quilt as much as I do.  I am very pleased with how it turned out.

Thursday, September 18, 2008

Insurance/Healthcare Thoughts

I've been struggling to get a patient's insurance company to give consent for a panniculectomy. I have not been successful. I have appealed the initial reject. It was rejected a second time. There reasoning:

Upon reviewing the submitted information, I have determined that at this time "Excision, excessive skin and subcutaneous tissue; abdomen, infraumbilical panniculectomy" is not a covered benefit under the benefit plan. This determination is based upon the following plan language, found on pages (s) 74 and 125 of the member's Certificate of Coverage or Summary Plan Description:

"Excluded ..... Cosmetic procedures, including cosmetic surgery expenses, supplies, appliances and drugs, except for reconstructive surgery to repair accidental injury

Cosmetic Procedures -- services are considered Cosmetic Procedures when they improve appearance without making an organ or body part work better. The fact that a person may suffer psychological consequences from the impairment does not classify surgery and other procedures done to relieve such consequences as a reconstructive procedure."

I thought I had made it clear, both times, that this proposed panniculectomy was to be done at the request of the patient's dermatologist as the patient's chronic skin rashes/infection in the lower abdominal skin roll could not be treated adequately with conservative methods. How is the treatment of the patient's skin infection/hygiene issues cosmetic?

It seems to me that this patient's insurance company is failing him. This seems to be a recurring theme in recent weeks in the blog world. Check out the recent post and comment section by TBTAM -- In Case You Were Wondering If Health Care is Broken.

Also check out When an MD says Yes and Insurance says NO by Healthcare Today, September 9, 2008

If a credentialed provider determines a specific course of action is reasonable for medical therapy it is amazing that insurance companies can countermand that judgment. Providers may be working as patient advocates, but clearly insurance companies are looking out for their own selfish bottom line. Not a new revelation as most of us would agree.

Wednesday, September 17, 2008

Graduated Compression Stockings

It is well established that graduated compression stockings (photo credit) are useful in preventing deep venous thrombosis (DVT). Like many things, they only help if used and if used properly. A recent study showed that up to 26% of patients had the wrong size stockings. So in an attempt to help patients and professionals (nurses, physicians, etc), here is some information on choosing the correct size.
 

For the compression to graduate (20-30 mmHg at the ankle, 10-24 mm Hg at the upper calf, and 4-12 mmHg at the upper thigh), the fit is very important.

The sizes on most support stockings are determined using a few simple measurements, but these measurement are important in the proper fit. As the measurements are taken, they should be recorded and then compared to the sizing chart of the manufacturer (ie Jobst, Sigvaris, etc). This video shows how to take the measurements.

The following instructions and photos are from from the ForYourLegs website and are more complete.

STEP 1: Measure the circumference of your ankle. Measure around the narrowest part of your ankle above the ankle bone. Record this measurement...


STEP 2: Measure the circumference of your calf. Measure around your calf at it's widest part. Record this measurement...



STEP 3: Measure the length of your calf. Measure from the floor to the bend in your knee. Record this measurement...



STEP 4: Measure the circumference of your thigh. Measure around the widest part of your thigh just below your gluteal fold. Record this measurement...



STEP 5: Measure the length of your thigh. Measure from the gluteal fold to the floor. Record this measurement...



STEP 6: Measure around your hips. Locate the widest part of your hips or waist and measure all the way around. Record this measurement

If the patients thighs measure more than 25 inches, then knee high rather than thigh high stockings should be used. Off-the-shelf stockings can not maintain the correct graduated pressure when the patient's thighs are larger than 25 inches.

Now that the correct size has been chosen, how do you put them on? The following information is from the second reference below, ClotCare Online Resource.

Applying graduated compression stockings may be difficult if your leg is significantly swollen and/or the pain is severe. To make it easier to put the graduated compression stockings on, first lie down and elevate your feet above the level of your heart for several minutes to reduce the swelling in your legs and ankles as much as possible. Then put on the stockings as you would any pair of socks or pantyhose.

Here are some tips for best results when using graduated compression stockings:

  • Wear gradient compression socks or stockings everyday.
  • Use rubber gloves to get a better grip on the fabric.
  • If you cannot tolerate wearing the stockings all day, wear them for a few hours at a time and increase the amount of time daily.
  • Put compression stockings on first thing in the morning.
  • If your skin is moist apply cornstarch or grease-free talcum.
  • Keep legs and feet warm to promote good circulation.
  • Stockings will typically last 3-6 months.
  • Proper fit is essential for effectiveness.
  • Take notice of weight loss or gain as this may affect the fit.
  • Pay special attention to washing instructions.
  • Do not allow wrinkles in the stockings.
  • Do not cut or alter stockings.
  • Never fold or roll them down.
  • Remove stockings if prolonged numbness or tingling occur or if you note bluish discoloration.

There is a very nice video on Dr Joseph Caprini's website discussing the use of and application of compressions stockings. Go to his site and then click on the "Rational and Use of Compression Stocking" button, choosing broadband or dial up. Really worth watching.

 

Here are several manufacturers who make compression stockings.

Jobst -- includes instructions on donning and care.

  • Jobst Anti-Em/GP stockings are latex free
  • Three styles are available: Knee-Hi, Thigh-Hi and Waist-Hi

Medi

Sigvaris

Juzo -- included instruction on donning and care.

 

REFERENCES

Graduated Compression Stockings Should Be Properly Sized and Used; Medscape Article, Sept 9, 2008; Laurie Barclay MD and Desiree Lie MD

What are graduated compression stockings, where do I get them, and how do I put them on?; ClotCare Online Resource, updated June 2007; Ruth Morrison, R.N., B.S.N., C.V.N., Henry I. Bussey, Pharm.D., FCCP, FAHA, and Marie B. Walker

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Tuesday, September 16, 2008

Shout Outs

Mother Jones, Nurse Ratched's Place, is this week's host of Grand Rounds. You can read this weeks grand rounds, Medicine Show edition, here (photo credit). Wonderful!

Welcome to this week’s edition of Grand Rounds. I want to thank Colin and Dr. Val for allowing me to serve as host. I also want to thank everyone for their submissions. I got hit with an avalanche of email, and I’m sorry that I was not able to post every submission that I received. Healthcare consumers use to do a lot of crazy things in order to stay healthy. Quack medicine has been around for a long time, and many early remedies were laced with cocaine, heroine, and mercury. Then things really got strange with the advent of electricity. Take this gadget for example. Its inventor, Dr. Snake Oil, claimed that his battery charged gizmo would cure all the ills of mankind. I wonder where you were suppose to stick this thing. Medical history is full of weird stuff and some of it is pretty entertaining. Please enjoy the Grand Rounds Medicine Show.


A new blog by a general surgeon (thanks, Vijay, for finding them) called Ant Ears, a metaphor for life long learning.  I look forward to reading more from him.  Here's why he calls his blog Ant Ears

"Ant ears” is surgical jargon for the perfect length.  The medical student will repeatedly be asked to cut suture.  Sometimes the knot will accidentally be cut, but most times the student will cut “too long” or “too short”.  Fifty or more attempts will usually produce a reliable knot cutter capable of trying more advanced techniques like tying suture around some non vital structure - maybe closing skin or holding a drain in place.

“Ant Ears” is the thoughts, rants, and experiences of a young doctor training as a surgeon - attaining the ideal much less than I like, but trying to always attempt it.

 

In case you haven't discovered these sites yourself, here are some nice places for medical information. 

  • Hand Surgery News -- Access to journal articles, CME's, plans to add on-demand video and web casts.  They state "a new resource for those dedicated to improving quality of life for patients through healing hands".  I think it is off to a decent start with great potential.
  • OR Live  -- live and previous webcasts of surgeries and lectures, CME's, podcasts.   I have watched several of the procedure videos.  Nice site.

 

Do You Really Want to See Your Doctor's Elbows?  is an article by Tara Parker-Post in the New York Times last week which discusses physician dress and infection rates.  I found the history section most interesting.  Here is a small sample:

* Hungarian Ignaz Semmelweis (1818-1865), from the Vienna Maternity Hospital, noticed that a ward attended by medical students had a death rate of about 20 percent while a ward attended by midwives had a death rate of 3 percent. Students regularly came straight from the anatomy dissecting rooms without washing their hands, then performed internal examinations. Infection rates plummeted when they started washing their hands with chloride of lime when they entered the ward.

* Polish surgeon Johannes Von Mikulicz-Radecki (1850-1905) was probably the first to use a face mask, and William Halstead (1852-1922) is said to be the first surgeon to use rubber gloves. He commissioned them from the Goodyear rubber company for a senior nurse who developed a skin irritation caused by repeatedly immersing her hands in antiseptic solution. Scottish surgeon William MacEwan (1848-1924) is credited with the introduction of a sterilisable surgical gown.

 

Check out the William P. Didusch Center for Urologic History Museum.  There you will find Collections, Exhibits, Milestones, and Press sections.  The Scope of Urology (collections section, photo credit):

has extensive collections of many medical "scopes"— cystoscopes, resectoscopes, microscopes and laparoscopes — in addition to catheters, lithotriptors and other medical artifacts. To view items from our major collections, select from the list below.

Cystoscopes, Resectoscopes, Microscopes, Laparoscopes, Lithotriptors, Catheters, Implants & Prostheses

 

 

This Thursday Kim, Emergiblog, will talk about the upcoming BlogWorld Expo on the Dr Anonymous' Blog Talk Radio show.  I hope you will join us this Thursday night at 8 pm CST (or 1 am GMT) both to listen to the show and to participate 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!
 
 
Last week, I received an e-mail from Sarah Marchetti who is working with CMS, the Centers for Medicare & Medicaid Services, to promote a new initiative being launched around Medicare.  I think it is worth passing on to anyone who reads this blog.
 
On behalf of CMS, I would like to invite you to a live Webcast unveiling Ask Medicare, a new caregivers initiative, that will be held at 12:00 PM to 1:00 PM EST on Thursday, September 18, 2008.
 
During the Webcast, caregivers and those interested, will have the opportunity to view the new Ask Medicare Web page, submit questions related to Medicare's new caregivers initiative and questions relating to care giving. A panel of experts, including Kerry Weems, Acting Administrator of CMS, will be introducing the new Ask Medicare initiative, the Web page and answering questions often asked regarding the resources available for caregivers, those questions submitted online may also be included in these discussions.

Currently, you can visit here to register for the Webcast and sign up for the Medicare e-newsletter. After the launch of the initiative, you will be able to access the Ask Medicare Web page through the same link.

Monday, September 15, 2008

Acute Burns -- When to Transfer

Plastic surgeons are often consulted for burns that present to the emergency department. The first decision to be made is whether the injury may be cared for at the presenting facility or should betransferred to a designated burn center. This assessment will include the size of the burn, the depth of the burn, the risk of morbidity and associated injuries (e.g., inhalation injury or trauma), and patient co-morbidities.

The American Burn Association developed the following criteria (pdf) for patients who need burn center referral/transfer:

  • Partial-thickness burns greater than 10% of total body surface area in patients who are younger than 10 years old or older than 50 years old (photo credit) [Rule of nines to estimate TBSA]
  • Partial-thickness burns over more than 20% of total body surface area in other age groups
  • Burns that involve the face, hands, feet, genitalia, perineum, or major joints
  • Third-degree burns in any age group
  • Electrical burns, including lightning injury
  • Chemical burns
  • Inhalation injury
  • Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect
    mortality rate
  • Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or death
  • Burn injury in children at hospitals without qualified personnel or equipment for the care of children
  • Burn injury in patients who will require special social, emotional or long-term rehabilitative intervention

Burn Depth -- It must be noted that burn wounds continue to mature, and damage to the skin continues for 24 to 48 hours secondary to several factors, including edema and coagulation of small vessels.

First-degree burns

  • Commonly caused by flame flash or ultraviolet exposure
  • Generally pink, dry, and painful
  • Epithelium is intact
  • No risk for scarring
  • Necrotic epidermis will generally slough within 1 or 2
    days, revealing intact epidermis
  • Require no specific care


Second-degree burns

  • Signify that the dermis has been damaged
  • Wet, pink or red, and edematous
  • Generally heal with local wound care
  • Further divided into superficial and deep,
    corresponding to likelihood of rapid healing and risk
    for poor scarring:
  1. Superficial second-degree burns
    More sensitive and hyperemic
  2. Deep second-degree burns (photo credit)
    Have higher potential for conversion to third degree
    (full-thickness) burns
    Monitor closely
    Early excision limits hypertrophic scarring

Third-degree burns (photo credit)

  • Involve full thickness of the dermis
  • Will not heal without surgery
  • Leathery, dry, insensate, and waxy
  • Notable absence of tissue edema compared with surrounding second-degree burned area


Fourth-degree burns (for picture go here)

  • Extend through the subcutaneous soft tissue to tendon
    or bone
  • Associated with limb loss or the need for complex
    reconstruction

The eMedicine article (5th reference below) by Edlich, et al is well worth reading. It includes a discussion of Skin Anatomy and Function, Burn depth, Pre-Hospital Treatment, Emergency Room Treatment, Fluid Resuscitation, Supportive Care, Burn Wound Management, and Nutritional Support.

It also makes this point of when not to treat:

When not to resuscitate

When patient survival is extremely unlikely after burn injury, the clinician must be encouraged not to begin fluid resuscitation. Elderly patients with large burns (>80% TBSA) will not survive. This decision must be made after thoughtful communication with family members. When resuscitation is not undertaken, make patients pain-free, keep them warm, and allow them to remain in a room with family members.

There are many several prognostic burn indexes (APACHE I and III, etc). They are used as a gauge for patient mortality. This index suggests that the patient’s age plus their full-thickness total body surface area burn plus 20 percent for inhalation equaled the likely mortality rate. So at my age (51 yr), if I had an 80% TBSA burn I would have very little likelihood of survival.

However, advances from early excision of burn eschar, skin grafting, early enteral feeding, and wound closure with advanced techniques (skin substitutes) have altered the simple mathematical calculation. Patients with a prognostic burn index of 90 to 100 now have a mortality rate in the 50 to 70 percent range, with poorer outcomes at both extremes of age. Still note that in my example using me as a patient: 51 yr + 80% = 131% chance of death. If my TBSA burn was on 50%, then I might have a fair chance of survival in a good burn unit these days.


REFERENCES

Acute Burns; Plastic & Reconstructive Surgery. 121(5):311e-319e, May 2008; Grunwald, Tiffany B. M.D., M.Ed.; Garner, Warren L. M.D.

Acute Burns; Plastic & Reconstructive Surgery. 105(7):2482-2493, June 2000; Kao, Chia Chi M.D.; Garner, Warren L. M.D.

Treatment of Minor Burns; University of Utah Health Science Center's Burn Center

Emergency Care of the Burned Patient; University of Utah Health Science Center's Burn Center

Burns, Thermal; eMedicine Article; August 7, 2008; Richard Edlich MD, David Drake MD, William Long III MD

Sunday, September 14, 2008

SurgeXperiences 206 is Up!

The Sterile Eye is the host of this edition of SurgeXperiences. It is his third time hosting. As always, he has done an outstanding job! Hope you will go read it here (photo credit).

Welcome to the 6th edition of season 2 of SurgeXperiences, the one and only surgical blog carnival. It’s my third time hosting this, and it’s been a very interesting each time. I initially came up with the theme “visuals” for this edition. But as the submissions started to flood my inbox, I soon abandoned it. So although I provide you with some visuals, the blogging this time is too diverse to box in.

The images in this edition are all microscopic photos of stained histologic sections and cytologic smears of different types of cancer. In all its horror, even cancer can at some level be beautiful. This edition of SurgeXperiences presents posts on both the beauty and horrors of the surgical world.

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 host for SurgeXperiences 207 will be Buckeye Surgeon on September 28th. The deadline for submissions will be midnight on Friday, September 26th. Please submit your posts here.

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.

Saturday, September 13, 2008

Hospitals in Hands of Voters

I posted this over at Med-Politics Blog and am now re-posting here with the outcome of the vote added at the end.

This is one of the headlines on the front of my local news. The article can't be read there without a subscription, but can be read here in full as it was reprinted on the AARP website.

Statewide, at least 11 small community hospitals receive some community support, typically in the form of sales taxes or millages, said Paul Cunningham, senior vice president for the Arkansas Hospital Association. Most of them have had local taxes approved within the last five or six years.

Nationwide, community hospitals are struggling under the weight of low reimbursement rates, high levels of charity care, increasing demand from an aging population, and difficulties recruiting doctors and other medical personnel to rural areas, said Rick Wade, senior vice president with the American Hospital Association.

I think this will only become ever more common as reimbursements are lowered or not paid (never events). For all those who feel that medical care is a right and not a privilege, how do you propose to prevent hospitals and clinics from closing due to lack of funding? It doesn't really matter about coverage, if there is no access, does it? Massachusetts is finding that out.

I don't have the answers. I have never aimed to get rich on the backs of folks who need my care, but I like to be able to pay my bills. I like to be paid a fair "wage". I will never be paid as the ousted CEO's (nor do I think I should) of Fannie Mae and Freddie Mac have been, but neither have I ever made what the public thinks I do.

Update on the vote outcome:

The vote outcome didn't make the front page of the paper. It was on the 3rd page of the B (or Arkansas) section of the paper in the Wednesday paper, but it was above the fold. Once again, I can't link the the newspaper article as you need a subscription to read it.

The 85-yr Hot Spring County Medical Center will stay open. The county voters over-whelming approved a 5-year, one-half percent sales tax. (4,844 for and 633 against)

Voters in Chicot County also approved a sales-tax increase to support Chicot Memorial Hospital in Lake Village. Theirs is a 5-year, 1 percent sales tax. (1,244 for, 586 against)

Friday, September 12, 2008

Planning

Earlier this summer I saw a young woman in my office who wanted to have an elective surgery. She is married with a young toddler. I noticed that she wasn't on birth control pills, so I asked if she was planning a pregnancy in the near future. Her answer was no.

So I asked how she was preventing that from occurring and teased "you only have to have sex once to get pregnant". She laughed and said she and her husband were being very careful and using condoms.

I gave her my usual spiel that it would not be a good idea to get pregnant within a year of the surgery we were discussing. She said she would see her family doctor and get back on BCP. All this discussion was done in terms of trying to think ahead and plan when the best time for her desired surgery would be. Did she want another child within the next year or two, then perhaps she should wait and have the surgery afterwards. Did she want the surgery now and the second child in two to three years?

She wanted the surgery now, so we went ahead and scheduled her. The day of surgery, her urine pregnancy test (everyone with a uterus gets one) came back positive. It was rechecked and came back positive again.

She didn't get to have her surgery as planned, but will be having her second child. She would have preferred having the surgery now and the baby later, but is very happy to be having her second child.

I impulsively offered to make her a baby quilt (consolation prize). An easy thing for me to do as I had six of these blocks already done and not promised to anyone. No, I don't make a habit of making quilts for patients, but occasionally will.

This is another of my "crazy" quilts. It is a great way to use of scraps. This quilts is 37.5 in X 50 in.

It is machine pieced and quilted. Here are a few of detail shots to show the fabrics. Adults and children can use it to interact and "seek and find" things. For example --peacocks, bears, football player, butterfly, and feather.

Or in this one --soccer ball, cowboy, feather, fairy, checks, and colors (orange, purple, blue, green, etc).
In all the fabric my neighbor had given me, there was this which I used for the backing.

Thursday, September 11, 2008

Remembering 9-11-2001

I found this list, via Martha Rankin (Adult Education Matters Blog). She credits Larry Ferlazzo. Larry compiled a list of helpful sites for remembering 9/11 in the ESL (English as second language) classroom. Check out these excellent resources:

Inside 9/11 is from the National Geographic. It has short video interviews, along with transcripts, of key people connected to the event, including survivors.

America’s Day Of Terror from the BBC has a lot of excellent information. In fact, it might have too much for English Language Learners, so you might want to point students to particular sections of the site.

The Cable News Network has a special page of video and audio clips related to the attack.

New York Magazine has a Photo Gallery of that day’s events.

Voice of America has a series of audio broadcasts, with text, about the 9/11 Anniversary and its effects years later.

The Biography Channel has a Profiles of 9/11 Photo Gallery.

Here are some other sites:

The White House Remembering 9-11

Remember September 11 on Seventh Anniversary of 9/11; New York City Memorial Events By Pamela Skillings, About.com

Patriot Day, Remembering September 11, 2001; US Army Website

National September 11 Memorial & Museum at the World Trade Center (photo from this website--"Reflecting Absence")

Wednesday, September 10, 2008

Surgical Loupes

I received my first surgical loupes as a first year plastic surgery resident. They are 2.5X loupes made by Designs for Vision. I still have and use them. My second pair of loupes was a 4X from Zeiss which I find heavy and difficult to wear. It is exciting to get your first (and next pair and next) pair of loupes! It is also humbling to wear them the first time and get nauseated because you moved you head too fast and too often. Practice at home with anything -- reading, sewing on a button, disarticulating a chicken wing, just looking at your fingers.






I found the following history of surgical loupes in the chapter on "The History of the Operating Microscope" in the book The History of Modern Cataract Surgery by Marvin L. Kwitko, Charles D. Kelman. You can read it on-line as part of Google's eBooks and see the pictures there of the early loupes.

The history of the surgical microscope dates back to 1876, when simple loupes that attach to the spectacle frame or to a headband became available. These were made of convex lenses that were decentered to allow convergence and to use the prismatic effects of the periphery. C Von Hess used such a loupe together with an electrical illumination device attached to a headband. In 1886, a mechanic named Westien constructed a binocular instrument from two loupes to be used by a zoologist. Zehender later attempted to modify this instrument for use in ophthalmology, giving rise to the Zehender-Westien double loupe. It had a firm base and a lens for lateral focal illumination. Further development of a binocular magnifying instrument progressed along two pathways: one for diagnostic purposes and one for surgical use, leading to the eventual development of the slit-lamp and the corneal microscope. This instrument gave a magnification of 5X-6X, but had to be worn on a headband, which was one of the drawbacks of these original surgical magnifiers. The instrument was heavy and, although Westien tried to reduce the weight of these loupes to facilitate their use, it remained too heavy for the surgeon, and, hence, never became popular.

By 1912, Von Rohr and Stock had constructed a spectacle loupe that was lighter and less magnifying than Westien's. This had a working distance of 25 cm and a magnification of 2X. Gullstrand was the first to use these loupes of Von Rohr. This led to the development of a binocular loupe that could be attached to spectacles and bifocals, a model that is still used today by ophthalmic surgeons for a variety of surgical procedures. By simply tilting his head, the surgeon can view the field either through the spectacle lens or through the loupes, thereby allowing him to make use of the magnification only when needed during the procedure. It was found that a magnification of more than 2X was not desirable, due to the fact that the slightest movement of the head would cause large movements of the image because of the high magnification. These movements led to difficulties in handling tissues. Furthermore, optical principles prevented a magnification of more than 2X with these loupes. It therefore became evident that a stable device was needed for higher magnification in surgical procedures.

Binocular surgical loupes are used by many surgical specialties. There are times when they are preferred over the operating microscope. These would include any procedure when the patient's position and /or surgeon's position make it difficult or impossible to use the microscope. Other times, not as much magnification is needed to warrant the use of the microscope. The microscope is necessary when doing vascular anastomoses on children or vessels less than or equal to 1.5 mm.

Wearing surgical loupes can be a challenge, especially in long cases. The higher the magnification, the heavier they are. These are the common problems encountered when wearing them:

  • Slippage of the glasses down the nose -- Anyone who has ever worn glasses know this issue. It is worst with the added weight of the loupes. This can be decreased by using tape to attach the browbar of the glass frame to the forehead. Another trick is the use of a long cord or band attached to the earpieces and tightened behind the head. This can be difficult to work with if you add a headlamp into the mix. The newer loupes have a built-in or clip-on headlamp.
  • Postauricular pain -- Increased by the length of time the loupes need to be worn and be the weight of the loupes. This can be helped by preventing slippage and by padding the ear pieces.
  • Discomfort on the nasal bridge -- This is dependent on the nosepiece, the weight of the loupes, and the length of the procedure. If possible, change the nosepiece or pad it.
  • Fogging of the glasses -- This is caused by breathing behind the mask (which can't be helped). You can decrease or prevent the fogging by taping the top of the mask to your skin creating a barrier in this area. It is best to use paper tape to prevent skin irritation from the tape/adhesives.

There are many companies that make surgical loupes. Here are a few:

Designs for Vision

Keeler Surgical Loupes

Sheer Vision

Surgical Acuity

Zeiss

REFERENCES

A Practical Guide to Surgical Loupes; J Hand Surg (Am), 1997 Nov: 22(6):967-74; Baker JM, Meals RA

Comparison of the Operating Microscope and Loupes for Free Microvascular Tissue Transfer; Plastic & Reconstructive Surgery. 95(2):270-276, February 1995; Serletti, Joseph M. M.D.; Deuber, Mark A. B.A.; Guidera, Paul M. M.D.; Reading, George M.D.; Herrera, H. Raul M.D.; Reale, Vincent F. M.D.; Wray, R. Christie Jr. M.D.; Bakamjian, Vahram Y. M.D.

Keeping Spectacle-Mounted Loupes on Comfortably; Plastic & Reconstructive Surgery. 99(2):591,592, February 1997; Graham, Kenneth E. F.R.C.S.(Ed), F.R.C.S.(Glasg)

How to keep your glasses on painlessly(Letter); Plast. Reconstr. Surg. 69: 1026, 1982; Zuker, R. M.

Adhesive Bands to Prevent Fogging of Lenses and Glasses of Surgical Loupes or Microscopes; Plastic & Reconstructive Surgery. 117(2):718-719, February 2006; Karabagli, Yakup M.D.; Kocman, Emre A. M.D.; Kose, A Aydan M.D.; Ozbayoglu, Ceyla A. M.D.; Cetin, Cengiz M.D.