Wednesday, September 30, 2009

Historical Skin Grafting Methods

After covering the burn section from the the old textbook, A Text-Book of Minor Surgery by Edward Milton Foote, MD (1908),  I thought I would continue with the skin grafting section.

Skin Grafting

The success of skin-grafting depends largely upon the care with which the grafts are handled at the time of operation and subsequently.  There are three distinct methods.

Minute grafts may be obtained either by snipping bits out of the skin or by scraping and macerating particles from the outer layers of thick epidermis.  They have not generally yielded good results.  The little islands of epidermis which they produce will often melt away unless the epidermis growing from the side of the ulcer reaches and surround them.

 Thiersch Grafts

Sheets of skin shaved off with a razor, and of sufficient thickness to include the deeper layers of the epidermis and possibly some of the dermis itself (so-called Thiersch grafts) have yielded far better results.  The site from which the grafts are taken should be cleansed with soap and hot water and washed with sterile normal salt solution (0.8 per cent).  The anterior surface of the thigh or the outer side of the upper arm are favorite places from which to take grafts.  The skin should be drawn tight and smooth with the fingers or hooks.  With a sharp razor, preferably grown flat on its under surface, strips of skin an inch wide and an inch or more in length and of a fairly uniform thickness can be shaved off.  The surface to which these are to be applied should be fresh, but should be wiped free from blood.  If it is a freshly made wound, hemorrhage should first be controlled by pressure as a blood clot under a graft will absolutely prevent its union.  If the surface is a granulating one, the granulations may be shaved off with a razor or simply wiped with sponges wrung out in hot sterile saline solution until the granulations are clean and fresh.  Here, too, oozing of blood must be at a standstill before the grafts are applied.  As the grafts have a tendency to shrink even though kept moist, it is necessary that they should fully cover the surface.  Over them may be laid strips of rubber tissue which are to be covered with compresses constantly kept moist with saline solution, or the tissue may be omitted and the compresses laid directly on the grafts.  In either case light pressure should be maintained by a bandage in order to insure a continuous application of the grafts to the underlying surface.  Some surgeons do not apply any dressing whatever for several hours, so that the drying of the serum shall firmly attach the graft to the underlying granulations.  After that a dressing of dry or moist gauze or rubber tissue is applied.

The subsequent treatment varies.  The dressing may be changed daily, great care being observed to keep the grafted area constantly moist and protected from any pressure which would cause the graft to slip.  Another plan is to change the dressing in three or four days.  Still another plan is to cover the grafts with moist or dry gauze, and not to change the dressing for two or three weeks.  Some surgeons apply a plaster of Paris bandage to protect the part from injury.

It will be evident in three or four days whether the grafts have become attached, but even those which appear to be loose should not be too hastily removed, since their deeper portions may have united with the underlying granulations.  In a week or more the grafts and portions of graft which have not attached themselves will have become disintegrated, or will be washed away with the pus.

The new skin obtained by minute or Thiersch grafts will never be the equal of normal skin.  It is easily distinguished from the surrounding skin years afterward.  It may resemble the surrounding skin under ordinary circumstances, but it does not react in the same way to temperature changes.  In this respect Wolfe grafts and plastic operations are superior to Thiersch grafts.

[Thiersch grafts are split-thickness skin grafts.]

Wolfe Grafts

The third method of skin-grafting consists in the use of grafts composed of the entire thickness of the skin.  In some instances success has followed this method when a graft eight inches long and two and a half wide has been employed.  The names of Wolfe and also of Krause have been given to this method of grafting.  These large grafts are nourished at first by effusion, and then minute vessels make their way into the grafts, and in some instances communicate with the vessels already existing.

The technique is similar to that employed for applying a Thiersch graft.  Asepsis without the use of germicidal solution and the control of hemorrhage by pressure are important points.  The grafts should be freed of fat.  They may be stitched into position, but this is not absolutely necessary.  it is of the utmost importance that the grafts should not be moved for several days.  Some operators apply dry sterile gauze, and do not change it for weeks unless there is a purulent discharge.  Before attempting to remove the dressing, the part should be soaked for an hour in warm boracic acid solution.  Other operators cover the grafts with rubber tissue and moist gauze.

According to the results which have been reported, one may expect success with about three-fourths of the grafts employed.  Some of the grafts attach themselves in part, other parts becoming necrotic.  Equally good results have been obtained by using the skin of a healthy person who has died from an accident only an hour or so previous.

If a Wolfe graft once becomes united, it is far superior to a Thiersch graft.  It has all the characteristics of normal skin, and prevents in great measure the contraction of the underlying scar tissue.  hence, Wolfe grafts are especially serviceable to cover defect about the joints.

[Wolfe-Krause graft is a full-thickness skin graft.  FTSG carry sweat glands, sebaceous glands, and hair follicles in the lower dermis.  This allow FTSC the capacity to sweat, have sebaceous secretions so the resulting skin is not as dry, and to have hair growth.  Skin from STSG’s are always dry.]

 

 

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Karl Thiersch -- German surgeon, 1822 -- 1895.

John R Wolfe – Glasgow ophthalmologist, 1824 – 1904.

Fedor Krause -- German surgeon, 1857-1937.

Tuesday, September 29, 2009

Shout Outs

Laika's MedLibLog  is this week's host of Grand Rounds.   You can read this week’s edition here (photo credit).

Welcome to the latest edition of Grand Rounds, the weekly compilation of the best of the medical blogosphere! I presume you would rather take a tour through the Netherlands, visiting windmills and tulips, but we will save this for another time. Right now, let’s take a trip around the library.

 

Dr Ves, Clinical Cases and Images – Blog, gives some links to some great tips on How to Prepare a Physician for a Media Interview (TV, radio, etc.)

1. Be prepared.
2. Expect off-the-wall questions.
3. Speak in plain English.
4. Be concise.
5. Guide the interviewer.
7. Don't guess.
8. Nothing's off the record.

 

Check out this 3-part video series produced by Dr Val Jones and featuring Paul Levy:

Safe, Quality Hospital Care, part 1
Paul Levy, President & CEO of Beth Israel Deaconess Medical Center in Boston, discusses his innovative approach to keeping patients aware of the safety record of his hospital.

Safe, Quality Hospital Care, Part 2
Paul Levy discusses how patients can have a better hospital  experience, by keeping themselves informed and having an advocate.

Safe, Quality Hospital Care, Part 3
Paul Levy discusses how to keep in touch with friends and family  while in the hospital, and how to get the best aftercare.

 

 

H/T to MedgadgetNow Oliver Sacks Talks About Visual Hallucinations in Blind People

 

 

                         

This week is Dr Anonymous doesn’t have a guest listed, but come join us anyway.  The show starts at 9 pm EST.

Upcoming Dr. A Shows

10/1 (10pmET): Dr. A Show
10/8 (10pmET): Dr. A Show
10/13 (10pmET): Dr. A Show: Pre-BlogWorld Expo Show

You may also want to listen to the shows in his Archives. Here are some to get you started:

GruntDoc, Sid Schwab, Dr. Val, Kevin MD, Rural Doctoring, Emergiblog, Crzegrl, Dr. Wes, TBTAM, Gwenn O'Keeffe, Bongi, Paul Levy, John Halamka, and ScanMan

 

NPR has a wonderful story of “Madeleine Albright's Jewelry-Box Diplomacy” with pictures of some of the pins she wore.  Beautiful!  (photo credit)

 

The need remains, so if you quilt or sew consider making a few “patriotic friendship star” blocks  for the Quilts of Valor.   You can find the pattern and information for mailing the finished block(s) in the pdf file (photo credit).  The block should use red & white or blue & white color scheme.

International Quilt Festival is coming very soon and we need you to help us make this year a success!

Written instructions (pdf file) 
Link for YouTube mini-instruction.

Mail finished blocks by Oct 11th to:

Deb Granger
6111 Ganton Ct
Hudsonville, MI 49426

Here are the blocks I made:

 

     

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Monday, September 28, 2009

Historic Treatment of Burns

Recently, I has a request for information on the history of burn treatment, so today’s post will cover the burn section from the the old textbook, A Text-Book of Minor Surgery by Edward Milton Foote, MD, I discovered recently.

Burns

The burns of the head which the surgeon is called upon to treat are not usually very deep. The scalp is protected by hair, and if flames or steam rise into the face sufficiently to burn deeply, they will usually be inhaled and produce fatal internal injury. Most of the deeper burns of the face are, therefore, the result of a gas explosion or electric flash caused by short circuiting. The importance of avoiding a scar is, of course, very great, so that slight burns should be carefully attended to.

Burns have been variously classified according to the depth to which the tissue is destroyed. For practical purposes, they may all be placed in three classes.

Burns of the First Degree --

The symptoms are swelling, redness, and tenderness of the skin. There is no visible destruction even of the epidermis, although this usually peels off in strips a few days later. A familiar example is a mild sunburn. There is increased redness of the burned area for a week or more, but no permanent scar.

Treatment of Burns of the First Degree --

The chief indication for treatment is the relief from pain. This is best accomplished by smearing the surface with one of the lighter ointments which contains a considerable amount of water, such as rose water ointment, or one of the ointments sold under the names of Lettuce Cream, Cucumber Cream, etc. Cow’s cream is excellent for the purpose. Recovery promptly follows the application of any non-irritating substance.

Burns of the Second Degree --

Much of the epidermis within the burned area is destroyed. There are blisters either full of serum or collapsed, or the injured epidermis may have been more or less removed. Hairs within the burned area are also burned away. There is redness, swelling, and tenderness, and a more or less free oozing of serum, and possibly of some blood. Repair in this class of burns takes longer than in burns of the first degree, but no slough of the true skin occurs. If the whole thickness of the epidermal layer is here and there destroyed, these areas are very small and are rapidly covered by spreading of the deeper layer of epithelial cells. There is, therefore, no permanent scar. Redness will persist longer than in burns of the first degree, possibly for a month or more.

Treatment of Burns of the Second Degree --

The chief indication for treatment is the relief of pain. The permanent result is certain to be good. There are four plans of treatment: One is to apply a dressing soaked with oil or spread with ointment in order to protect the injured surface from the air and from changes in temperature. A second plan is to cover the burn with strips of rubber tissue or with gauze wet with normal saline solution. The third plan is to treat the burned area with an antiseptic dressing, which may be allowed to dry or which may be kept moist. The fourth plan is to leave the burned area exposed to the air in order that it may dry up. Various dusting powders are employed to further this last plan.

The author favors the first or the second of these four plans, believing that these dressings are more comfortable to the patient, and that they favor the vitality of those portions of the skin which have been injured but not destroyed by the burn; and because such dressings, provided plenty of ointment is used, or plenty of water if a wet dressing is employed, can be removed with less pain and damage than other dressings which are allowed to dry out. Powders are objectionable, since they form, with the exuded serum, hard crusts which are veritable culture tubes for bacteria. It is impossible to make or keep aseptic an area of skin which has burned below the superficial portion of the epidermis. Protection against infection depends, therefore, on the vitality of dressing. Hence, the latter should be soothing to the skin rather than deadly to the bacteria.

A good example of an oily dressing is carron oil, a mixture of equal parts of linseed oil and lime water. If this is used the gauze should be thoroughly saturated with it, as otherwise the oil will soak into the outer dry dressings, and the inner layers will become very firmly attached to the skin. For this reason an ointment is preferable in most cases. A good one is composed of one dram of boric acid to the ounce of Vaseline. The ointment should be sterilized by setting the jar which contains it in a pan of boiling water. It can, of course, be sterilized in a steam sterilizer. The ointment should be used freely. A good plan is to spread it over the burned area with a spatula, much as one spreads butter with a knife. Dry gauze can then be applied in pieces small enough to fit the part, and the dressing fixed by a loose gauze bandage.

The principle of the normal saline solution when used as a dressing for a burn is the same as when used as a dressing for a skin graft. It is to reproduce as far as possible the normal surroundings of growing epithelium. If this plan is adopted, the burned area should be immersed in a saline solution, or lightly sponged with swabs saturated with the same. It is then covered with several thicknesses of gauze saturated with saline, and evaporation is prevented by covering the whole with a sheet of gutta-percha tissue, or strips of gutta-percha tissue may be applied directly to the burned surface, and these in turn be covered by the wet gauze. When the dressing is applied in this manner, a sheet of impervious material may be applied externally, or this may be omitted and the gauze kept wet by more frequent saturation with saline or boiled water.

Picric acid is recommended by those who favor antiseptics in the treatment of burns of the second degree. Gauze is saturated with a one per cent solution, either before or after it is applied to the burned surface. This dressing is supposed to control the pain, but I have seen patients suffer severely after its employment. It has a tendency to dry up the exudate, so that in many cases burns treated in this way are greatly improved in appearance. The intense yellow color of the picric acid stains the clothing.

A mild antiseptic solution suitable for use in burns of the second as well as of the third degree, is a four per cent solution of aluminum acetate. The gauze should be saturated with it, and then kept wet by the addition of sterile water from time to time.

If it is decided to treat the burn by the dry method, it may be left exposed to the air or cleansed and dusted with a powder, such as bismuth subnitrate, or bismuth subgallate, or nosophen.

Burns of the Third Degree --

Portions of the corium, and possibly still deeper structures have been destroyed by the heat. It is easy to be misled in this matter by the early appearance of the skin. In a burn of the first or second degree the affected skin is red from the congestion of the vessels in it. If the vitality of the corium is destroyed, the blood cannot circulate through its vessels, and the skin will therefore appear white. The difference between this skin and normal skin is easily recognized if one looks for changes in color due to pressure made upon it. Such changes will, of course, be wanting in the deed skin. Furthermore, such a white, dead area will invariably be surrounded by a hyperemic zone in which the burn is only of the second degree. I have known several instances in which intelligent physicians overlooked a burn of the third degree, being misled by the lack of redness of the skin. This dead skin will, of course, slough, and in time will become entirely loose. During this process, which sometimes takes two weeks or more, there is danger that the slough will interfere with the exit of underlying pus.

Treatment of Burns of the Third Degree --

We have, then, in burns of the third degree, three indications for local treatment – the relief of pain, protection of the injured but living tissues, and drainage of any pus pockets which may form. A moist antiseptic dressing best fulfils the requirements. In most cases morphine should be given either hypodermically or by mouth during the first twenty-four hours. Few persons can sleep without an opiate the first night after a burn, even if they can endure the pain while awake.

The moist dressing should be applied warm and kept warm. The gauze may be saturated with aluminum acetate, as mentioned above, or boric acid, or any other feeble antiseptic. The dressing should be kept constantly moist, and in some instances a continuous bath is desirable.

Frequent dressings are to be avoided, but if the dressings become saturated with pus and serum, the comfort of the patient is usually promoted by changing them. Sloughs should be cut away as soon as they loosen, but not before. If a large area is burned, the central portions of the skin may loosen before the edges. If so, incisions should be made through the slough or portions of it excised to permit free escape of pus and secretions.

The repair after a burn of the first or second degree is accomplished by the normal growth of the epidermis. In every burn of the third degree the removal of the sloughs is accomplished by the growth of granulations beneath them. These granulating areas must be covered by the lateral growth of the epithelial cells, either from the edge of uninjured skin, or from islands of epithelium which have been left, or from the epithelium which line the fat and sweat glands. This new epithelium at first has no color of its own, and simply looks like a dark red glaze over parts of the granulating surface. Later, as the epithelial cells multiply, a whitish appearance results. It will be evident, therefore, in two or three weeks whether the burned area will become covered with epithelium within a reasonable time. An epithelial edge will grown about an eighth of an inch a week. A granulating area, therefore, which is an inch in its smallest diameter, will require a month for its complete repair. Areas larger than this, and which are without epithelial islands should be skin-grafted.

There is one other thing to be borne in mind during the repair, and that is the possibility of cicatricial contraction. This can be avoided to a certain extent by the judicious use of plaster bandages and splints to keep the burned area fully extended during the healing process; but a far better means of prevention is the early covering of the granulating surface with pedicled flaps, or when this is not practical, with Thiersch, or better, with Wolfe grafts. In this way the amount of scar tissue is kept at a minimum and the power of contraction will be slight.

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Sunday, September 27, 2009

SurgeXperiences 307 – Call for Submissions

SurgeXperiences 307 (October 4th)  will be hosted by Robin, survive the journey.    The deadline for submissions is midnight on Friday, October 2nd.  Be sure to submit your post via this form

Robin describes herself

Life is full of surprises, some of them simple, some of them not. Some are wonderful, some are not. However, long-term, chronic illness (Cushing's Disease) is probably the most surprising for many of us. It was for me. This is a story of my journey and what I've learned along the way.

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.   If you would like to be the host  in the future, please contact Jeffrey who runs the show here.

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

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Friday, September 25, 2009

Another Scrappy Baby Quilt

As with last week’s quilt, this one was made to use up some of my over-flowing scrap boxes. It is machine pieced and quilted. It is 38 in X 42 in.

Check out the fun things to find: dog, fox, cheetah, horses, bee, flowers.
Here you can see more bugs, a zebra, carolers, hot peppers, and some great colors.
The back fabric is a soft flannel.

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Thursday, September 24, 2009

Treatment of Nasal Fxs – an Article Review

Nasal fractures are extremely common.  Deciding which technique to use for a given nasal fracture can be challenging.  The recent article (full reference below) in the Arch Facial Plastic  Surgery does a very nice job of condensing down the treatment of nasal fractures into a logical approach.

They start with the classification of nasal fractures (photo credit)

  • Type I, “simple straight” --  unilateral or bilateral displaced fracture without resulting midline deviation.
  • Type II, “simple deviated” – unilateral or bilateral displaced fracture with resulting midline deviation.
  • Type III, “comminution of nasal bones”  -- bilateral nasal bone comminution and crooked septum with preservation of midline septal support; septum does not interfere with bony reduction
  • Type IV, “severely deviated nasal and septal fractures”  -- unilateral or bilateral nasal fractures with severe deviation or disruption of nasal midline, secondary to either severe septal fracture of septal dislocation.  May be associated with comminution of the nasal bones and septum, which interfere with reduction of fractures.
  • Type V, “complex nasal and septal fracture” – severe injuries including lacerations and soft tissue trauma, acute saddling of nose, open compound injuries, and avulsion of tissue.

The treatment of nasal fractures has classically been divided into open reduction (OR) and closed reduction (CR). 

Closed reduction involves manipulation of the nasal bones without incisions and has been the time-honored method of fracture reduction for thousands of years. It generally produces acceptable cosmetic and functional results, but its detractors point out that 14% to 50% of patients have deformities after CR.

Open reduction techniques for nasal fractures may include a range of techniques including septoplasty, osteotomies, and full septorhinoplasty.

Interesting, the study authors state,

There was no statistical difference between the results of an open repair and closed repair in terms of revision rate, patient satisfaction scores, or surgeon evaluation scores. Furthermore, our expert raters failed to find a difference in outcome based on the type of repair. Based on this data, it would seem that our patients did not perceive any difference in outcome, ie, patients were just as likely to be happy with the results of a closed repair as they were with open repair. These results contrast with those of many studies in which the surgeon's assessment shows a clear bias toward one technique or another.

The authors supplied this wonderful algorithm for treatment of nasal fractures (photo credit)

 

 

REFERENCE

The Treatment of Nasal Fractures: A Changing Paradigm; Arch Facial Plast Surg. 2009;11(5):296-302; Michael P. Ondik; Lindsay Lipinski; Seper Dezfoli; Fred G. Fedok

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Wednesday, September 23, 2009

Suicides and Our Soldiers

This topic has become more real for my family. My first cousin’s son-in-law committed suicide this past weekend. He had had difficulty adjusting since his return from Iraq, but the family was still caught off-guard. If you can make it any worse, he chose his wife’s birthday to take his life. Fortunately, neither she nor their toddler son was home at the time.

The issue of soldier suicide concerns many. Maj. Gen. William D. Wofford, Arkansas' National Guard Adjutant General, recently made a public plea for help asking family members, friends and employers of the state's 10,000 Guardsmen to watch for personality changes or signs of stress overwhelming his soldiers and airmen. There has been four suicides in Arkansas Guardsmen since January.

As Dr Chad Morrow points out the suicide risk for active duty males is now higher than for the general population.

This is particularly noteworthy considering that the military entrance process screens out serious mental illness prior to entry onto active duty, and that the rate of suicide in military males has historically been significantly lower than comparable civilian populations.

Morrow goes on to touch on “the three-way interaction between burdensomeness, belongingness, and acquired capability.” He suggests that “belongingness is less robustly related to suicidal desire than burdensomeness.”

I don’t know if my young cousin-in-law’s suicide could have been prevented. He came back from Iraq physically intact. I’m not sure how much help he sought or took advantage of. I do know he has left loved ones who now have to face their grief, the loss of his presence, and many questions.

Here are some of my random thoughts on suicide prevention in our troops:

They need to feel connected. We know that text messages have been helpful in getting patients to do better with their chronic diseases or take their meds. Is there anyway to use text messages to help them feel more connected?

Could the military and/or guard set up a “facebook” system for the troops where they could interact with each other? Virtual “group sessions” that would overcome distance (living too far from a VA Clinic), like telemedicine.

Solders, like physicians, have a higher completion rate on suicides than the general public. You can’t take away the training needed to do our jobs. The focus has to be on connecting, feeling useful/needed/capable.

Each individual has to reach out and grab the lifeline that is thrown his way.

Sources

Ark. National Guard asks for help as suicides rise; AR State Wire
By Jon Gambrell, Published: Sep 18, 2009

Suicide in active duty military personnel by Chad Morrow, Psy.D; Psychotherapy Brown Bag, September 1, 2009

Army Suicide Rates Hit Record High; Huffington Report by Pauline Jelinek and Kimberly Hefling; January 29, 2009

Fort Campbell hosts suicide run: Run for Resiliency at Destiny Park features 25 information booths By JAKE LOWARY; The Leaf-Chronicle, September 20, 2009

Tuesday, September 22, 2009

Shout Outs

Colin, Residency Notes, is this week's host of Grand Rounds.   You can read this week’s edition here (photo credit).  Happy Birthday Grand Rounds!

Grand Rounds is six years old. Considering things age in hyper dog years on the internet, that is a lifetime. What Nick Genes put together has been impressive. For the past year I’ve gotten to be a part of it. Today Grand Rounds, in my opinion, continues to serve an important function as part of the social network of medical bloggers. It continues to be a reference point for the medical blogosphere. It’s important; which is why I’m here putting this together at 3 am instead of sleeping prior to my call.

 

Medic 999 is the host of the latest edition of Change of Shift (Vol 4, No 6) !   You can find the schedule and the COS archives at Emergiblog.  (photo credit)

Today I have the privilege of hosting my first edition of Change of Shift, the blog carnival set up and run by Kim from Emergiblog, and designed to showcase nursing related blogs throughout the blogosphere…..

What’s nursing got to do with Medic999 and Paramedicine and emergency care?

 

Dr Charles analyzed the Hippocratic Oath.  In doing so, he managed to condense it down to 140 characters.  Here’s his.  How would you condense it?  (photo credit)

I pledge service to humanity, conscience, and dignity; I will endeavor to heal, protect, learn, resist cynicism, and inspire with this art.

 

I really like this post, Is breast cancer really the WORST enemy?, by Dr.  Marya Zilberberg, Healthcare, etc..  In the post she discusses screening mammograms, over-diagnosis, and over-treatment.

 

In light of the Illinois woman dying from burn injuries due to a flash fire in the operating room earlier this month, please review your safety protocols or check these from Cedar-Sinai: Cedars-Sinai's O.R. Fire Safety Training Effort.   (photo credit)

 

 

Check out this video by Kerry Sparling, SixUntilMe, where she discusses “Diabetes and Health Insurance Battles”  

 

 

If you need primers on the Flu, check out these:

 

This past week the FDA approved the collagenase injections for Dupuytren’s.  MedPage Today article discusses the study results:  “Enzyme Injections Ease Dupuytren's Contractures” by   Nancy Walsh.  (photo credit)

Injections of the enzyme collagenase into the hands of patients with Dupuytren's disease resulted in significant improvements in joint contractures and range of motion, a phase III study found.

 

                 

This week is Dr Anonymous doesn’t have a guest listed, but come join us anyway.  The show starts at 9 pm EST.

Upcoming Dr. A Shows

9/24 : Dr. A Show
10/1 : Dr. A Show

You may also want to listen to the shows in his Archives. Here are some to get you started:

GruntDoc, Sid Schwab, Dr. Val, Kevin MD, Rural Doctoring, Emergiblog, Crzegrl, Dr. Wes, TBTAM, Gwenn O'Keeffe, Bongi, Paul Levy, John Halamka, and ScanMan

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Monday, September 21, 2009

Historical Sutures

I apologize if any of you tire of my posts on surgical history from the old textbook, A Text-Book of Minor Surgery by Edward Milton Foote, MD, I discovered recently.  I continue to be fascinated by it.  Today, I want to share the section on sutures.

In no part of surgical technique is sterility of so great importance as in the preparation of ligatures and sutures.  They are implanted in wounded tissues, and any germs which they may contain are placed in the most favorable conditions for growth, being harbored in a foreign body (the ligature), and supplied with abundant nutriment in the form of extravasated blood and damaged tissue cells.  Any material for ligatures or sutures, therefore, which cannot be sterilized with certainty should be thrown out of the surgical armamentarium.  A number of surgeons have at one time or another decided that catgut fell under this ban, and have refused to employ it under any circumstances.  It is now pretty generally admitted, however, that it can be sterilized by a number of methods with sufficient certainty to warrant its general employment.

Sutures and ligatures are primarily divided into those which are capable of disintegration within the tissues, and those which remain unchanged either permanently or for a very long period of time.  The names absorbable and non-absorbable are applied to these two classes.  All the non-absorbable materials can be sterilized by boiling in water or in a steam sterilizer.

Absorbable Sutures

Catgut

Various animal tendons, strips of hide, and nerves have been employed as sutures and ligatures, but they have been almost entirely supplanted by catgut.  It is cheap, it can always be obtained in any size, and in strands of sufficient length, and if properly prepared, it has great strength.  Moreover, it is quickly disintegrated in the tissues, the ordinary sizes being wholly taken up in the course of a week or two, so that no foreign body remains in the wound indefinitely.  Its one disadvantage is the fact that it cannot be sterilized by steam or boiling water, for in both of these it cooks to a jelly in a few minutes.

Sterilization of Catgut – It can be boiled in alcohol in a water bath or sand bath, but as alcohol boils at 174° F, the temperature is not sufficient to kill all germs.  This method is therefore unreliable.

Catgut may be sterilized by dry heat.  Boeckmann’s method is as follows:  The catgut is soaked in ether one week to remove the fat.  Single strands are then wound in rings, and each wrapped in paraffin paper and sealed in a paper envelope.  The envelopes are placed in a dry sterilizer and heated to 300° F for three hours on two successive days.

Catgut may be sterilized by chemicals.  Claudius’s method is the simplest.  Commercial catgut without any preparation is wound in single layers on glass spools and dropped into a jar containing one part of iodine and one part of potassium iodid to one hundred parts of distilled water.  The jar is tightly covered and allowed to stand for one week.  For use the spool containing the catgut is removed and immersed in sterile water, in order to free the catgut from the excess of iodin.  Spools which have been partially used can be resterilized until the catgut becomes brittle, which it is apt to do if it remains for more than three months in the above mentioned solution.  After one week’s immersion in the iodin solution, the spools may be removed and kept in alcohol.  This is the simplest reliable method for sterilizing catgut in the office.

Catgut may be so treated with chemicals that it can be boiled in water.  This result may be obtained by soaking the catgut in a solution of formaldehyde, but during the entire process the catgut must remain tightly stretched upon glass plates or large spools.  A simpler method is that of Elsberg.  The raw gut is freed from fat by immersion in ether or chloroform, or a mixture of one part chloroform and two parts ether.  It is then wound tightly in a single layer on large glass spools, having a hole in each flange in which the ends of the gut can be tied.  The spools are boiled for ten minutes in a saturated solution of ammonium sulphate with one per cent of carbolic acid.  The spools are then removed with sterile forceps, rinsed for half a minute in warm sterile water, and placed placed in strong alcohol.  Partially used spools can be resterilized, and the solution of ammonium sulphate in which they are boiled can be used indefinitely by the addition of water to take the place of that which has evaporated.

Catgut may be sterilized by boiling in some substance which has a higher boiling point than water, and which at the same time will not so alter the catgut as to render it weak or brittle.  One of the best substances for the purpose is cumol, which boils at about 330° F.  The method is a little too complicated for office use.

Catgut may be sterilized by immersion in alcohol heated under pressure in order to obtain a high degree of temperature.  This requires special apparatus, and is not a method suitable for general office use.

Catgut sold in sealed glass tubes is usually prepared by one of the two methods last mentioned.  Catgut prepared in this manner costs from ten to twenty-five cents a piece.

Commercial catgut comes in coils of one hundred feet, costing in the sizes usually employed from fifty cents to one dollar a coil.

Chromic Catgut

As stated above, plain catgut disintegrates in the tissues within a few days.  Under certain circumstances this is a disadvantage – for example, in suturing the various fascial planes in order to cure a hernia, it is desirable that the sutures shall not give way until the granulation tissue becomes firm.  For such purposes, catgut is prepared to resist disintegration by soaking it in potassium bichromate or chromic acid for twenty-four to forty-eight hours.  A good method for office use is that of Elsberg, mentioned above, with the addition of one part of chromic acid to one thousand parts of the ammonium sulphate solution.

The longer the catgut remains in the solution of chromic acid or bichromate of potash, the harder it becomes, and the longer will it resist disintegration in the body.  Chromic catgut or chromatized catgut is sold as “ten day catgut,” “twenty day catgut,” etc.  These figures are not very reliable estimates, and should not be too implicitly depended upon.  If the catgut remains too long in the hardening solution, it will become practically indestructible in the tissues of the body.  Buried sutures of such material have often been removed months afterward without their showing the slightest change.

 Kangaroo and Other Animal Tendons

Kangaroo tendon was formerly employed a great deal for the deep sutures in hernia operations.  The tail tendon of the kangaroo naturally splits into round cords which make excellent sutures.  The fibers in the leg tendons have to be pulled apart mechanically, like the fibers in the tendons of the domestic animals.  This gives a rough thread of uncertain strength.  many of the kangaroo tendons sold at the present time have very little value.  Chromic catgut is gradually taking its place.

 

Non-Absorbable Sutures

Silk

Twisted or braided silk is by far the commonest material employed for sutures.  Some surgeons also employ it for ligatures on account of their fear of infection from imperfectly sterilized catgut.  Black silk is preferable to white for most sutures, as the stitches are more readily seen and removed.  Silk possesses the very great advantage of being easily boiled in water at the time of the operation.  Any good black sewing silk answers the purpose satisfactorily, although many surgeons prefer to buy specially prepared and sterilized silk sutures in sealed glass tubes, costing from fifteen to twenty-five cents each.

For tying large pedicles, floss silk is often employed.  This is a loosely twisted, very flexible, and strong thread, and answers the purpose remarkably well.  The practice of mass ligation, however, is falling into disuse, as it is now generally recognized that the blood-vessels should be ligated separately, and the wounds in the other tissues should be closed by suture with finer thread.

Silkworm Gut

This material, which is familiar to every fisherman, is obtained from the silkworm just before he spins his cocoon.  It is at the time in a viscid state, and is pulled out into a long string and allowed to dry.  This gives a hard, elastic smooth thread, almost like wire.  These threads can be obtained in bundles of one hundred of dealers in fishing tackle.  Such bundles cost from forty cents upward, according to the size and length of the individual threads.  They can be sterilized by boiling in water or by steam; or they can be obtained in sealed glass tubes, costing from fifteen to twenty=five cents each.  Silkworm gut is even less irritating in the tissues than silk, and is an excellent material to employ when deep sutures are required.

Horsehair

Black or brown hairs from the tail of a horse make excellent sutures for skin wounds.  They should be washed with soap and water, and then with alcohol.  When needed they are easily sterilized in boiling water or in steam.  They are not as strong as silk, but they are able to resist all the tension which any suture ought to have.  They can also be obtained ready sterilized, six in a tube, at twenty cents; or dry in bottles or envelopes at a considerably cheaper rate.

Cotton and Linen Thread

Although silk is generally used in preference to other manufactured threads, this is largely a matter of custom.  cotton or linen thread is easily sterilized by boiling, does not irritate the skin, and forms a perfectly satisfactory suturing material.  No one need hesitate to use either in an emergency, nor, for that matter, in his regular practice.  If a colored thread is used, it should have a fast dye, or else it should be boiled long enough to extract so much of the dye as is easily soluble.

Celluloid Thread

Thread dipped in celluloid is often employed in operations upon the stomach and intestine on account of its impervious character.  It is prepared in the following manner:  A gray linen thread is boiled in one per cent solution of carbonate of sodium, wrapped in sterile gauze, dried in hot air, and then dipped in a solution of celluloid which is heated in a hot air sterilizer.  I is dried and then placed in a sterile receptacle until wanted.

Silver Wire

Pure silver wire is used for suturing bones, and also by some operators for sutures of the cervix, perineum, harelip, etc.  The sizes usually employed are Nos. 24 or 30.  Such wire costs about two dollars and fifty cents an ounce.  It is also used in the manufacture of filigrees, employed in some operations for hernia.  Other kinds of wire, and notably an aluminum bronze, are employed a good deal in Germany, but have never obtained much popularity in this country.  Antiseptic powers are claimed for them by their advocates.

 

 

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Sunday, September 20, 2009

SurgeXperiences 306 is Up!

Bongi, other things amanzi, is the host of this edition of SurgeXperiences. You can read this  edition here (photo credit).

welcome to south africa for this week's surgexperiences. enjoy the small view of this world in one country as well as some great posts.

 

The host of the next edition (307), October 4, will be survive the journey.  The deadline for submissions is midnight on Friday, October 2nd. Be sure to submit your post via this form.

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.

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

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Friday, September 18, 2009

Scrappy Baby Quilt

I  accumulate a lot of fabric scraps over time as I have trouble throwing them away.  Over the past few months I have been trying to use some of them up.  This baby quilt is 36 in X 36 in.  It is machine pieced and quilted. 

You may recognize some of the fabric from previous quilts (here, here, here, here -- to point out a few)
I found these Cabbage Patch doll panels at a garage sell years ago.  I decided to use them for the back of this quilt.

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Thursday, September 17, 2009

Historical Surgical Drains

Today, I’d like to share the section on surgical drains from the old surgery text, A Text-Book of Minor Surgery by Edward Milton Foote, MD, I first mentioned on Monday.

Glass and Metal Drainage Tubes

The use of rigid tubes for drainage is not now so general as it was at one time. Glass tubes are easily cleaned both inside and outside, and it is easy to see whether they are clean or not; but owing to their rigidity, they are apt to cause pain, so that their field is a restricted one. There are instances in which it is important to use a tube which will not collapse, and then a glass, or hard rubber, or metal tube is employed; but the ordinary purposes of drainage are accomplished just as well by the use of a flexible rubber tube, or one of the still more flexible gauze drains. Glass drainage tubes cost from ten to forty cents each, according to their shape and size.

 

Soft Rubber Drainage Tubes

Rubber tubing of various calibers forms a satisfactory material for drainage. Such tubing costs from seven to twenty cents a foot, according to the size and quality. The drainage tube can be prepared from a piece of tubing as follows: A piece of tubing of the required size, and having a smooth surface, is selected and cut to the required length. The end which enter the body is cut obliquely, and its sharp edge trimmed away with a pair of scissors. With a pair of curved scissors two or more oval openings are cut in the sides of the tube, beginning near its inner end, so as to permit the escape of pus in case the end of the tube is obstructed by contact with the tissues. The long axis of these openings is made parallel to the long axis of the tube, so that the tube shall not be unnecessarily weakened. A little practice will enable one to cut these openings neatly; or if one is very particular, then they may be burned out with a Paquelin cautery. This gives an opening with a smooth rounds edge, like the opening of a velvet eye catheter. (photo of Paquelin cautery – credit)

Catheters make excellent drainage tubes. Additional holes should be cut in them if necessary. The rounded tip may be left or removed, according to circumstances. If it is allowed to remain, insertion of the drainage tube is thereby facilitated.

In draining large wounds, and especially if irrigation is to be employed, two tubes should be used and fastened together at the top by a safety pin. This insures freer drainage and allows the irrigating fluid to flow into one tube and out of the other.

 

Gutta-percha Drains

Gutta-percha tissue is an excellent drainage material, especially for fresh wounds. It is employed in two ways: A piece of tissue, an inch or two wide, is folded upon itself until it makes a strip a half inch wide, more or less. Such a flat strip occupying very little space in a wound, and not adhering to the tissues, scarcely disturbs the aseptic healing of a wound. It is frequently inserted between the sutures of a wound at the close of operation in order to facilitate the escape of blood and serum. Moreover, if the operator is not sure of his asepsis, a drain of this character will allow the escape of any pus which may form, and prevent its burrowing in the deeper tissues. Two days after operation the wound should be re-dressed. If its appearance is satisfactory, the rubber tissue drain is removed, and the wound is allowed to unite primarily. If there is a seropurulent or purulent discharge the surgeon may decide to allow the drain to remain in place longer, or he may think it better to remove some of the sutures and introduce larger drains.

 

Cigarette Drains

Gutta-percha alone gives a flat drain; combined with gauze it forms a found or oval drain. This is know as a cigarette drain. A roll of gauze of the required size is wrapped with rubber tissue, as the tobacco in a cigarette is wrapped with paper. hence the name “cigarette” drain. The gauze should project slightly from the lower end of the drain, and should not be too tightly rolled. If the gutta-percha tissue shows a tendency to unwind, its edge may be stuck down with chloroform. Drains of this character are often employed in deeper wounds, for the same reasons that a flat gutta-perch drain is employed in shallow wounds; for example, after appendectomy, when there is a possibility that suppuration may form in the deeper tissues. Such a drain can be easily removed, since the only portion which can become adherent is the gauze at its lower end. For this reason the gauze should not project far beyond the gutta-percha tissue.

When gutta-percha tissue grows old it becomes brittle; hence it should be tested before it is used as a drain, lest a portion of the drain break off and remain in the wound. The tissue can be cut with scissors or torn. It has a distinct grain, so that in tearing it in one direction the motion should be quick; while in tearing it in the other direction, one must tear it very slowly in order to follow a straight line.

A finger from a rubber glove, or a finger cot from which the tip has been cut away, makes an excellent casing for a cigarette drain.

 

Gauze Drains

Gauze is often used for drainage, either plain or impregnated with different chemicals. Its chief disadvantage is the fact that it adheres so closely to the surface of the wound. These adhesions give way in five days to a week, but by that time granulations may already have grown into the meshes of the gauze. In spite of this drawback, gauze is used for drainage far more than any other material, both because it is always at hand, and because it is so flexible. It is not, however a good thing to use in the case of a sensitive patient on account of the pain caused by its removal. The most favorable time for the removal of a gauze drain is five or seven days after its insertion in a fresh wound.

The gauze drain may be of any size. A flat drain is formed by folding in the edges of a strip of gauze so that no loose threads appear. The two ends of the strip are then brought together, and the fold is inserted into the wound. This method facilitates the insertion of the drain, and also prevents loose threads from remaining in the wound when the drain is withdrawn.

A roll of gauze may be covered with gutta-percha tissue, making a cigarette drain. In this manner adhesions between the gauze and the surface of the wound are effectually prevented, and the drain can be easily removed at any time.

 

A Handkerchief Drain

If the wound is a a large one, and it is desired to keep it distended with a large quantity of gauze, adhesions may be reduced to a minimum by adopting the so-called Mikulicz method. This is also called a handkerchief drain. A single layer of gauze like a handkerchief is spread over the surface of the wound, and poked into all the recesses into which it is desired to carry the drains. Large flat gauze drains made in the manner above described are then carried into the different portions of the wound. The handkerchief limits adhesions between these central drains and the wound, so that they can be removed without much difficulty at any time. When they have been removed, the handkerchief itself being only a single layer, can be peeled off from the surface of the wound to which it is adherent.

 

Horsehair Drains

Small drains may be made of threads or horsehairs, by tying a number of them together, twisting the bundle, doubling it on itself, and allowing it to twist backward. Drains of this character are especially serviceable in scalp wounds, on account of the ease with which they can be inserted between the stitches.

 

 

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Wednesday, September 16, 2009

Historical Surgical Dressings

The surgical dressings section of the old surgery text, A Text-Book of Minor Surgery by Edward Milton Foote, MD, I first mentioned on Monday is very interesting.

Cotton

Cotton in its raw state has very little absorbent power because of the oil and gum with which its fibers are covered. When the cotton has been bleaches by chemicals, and the oil extracted, its absorbent power is very great. This fact, together with its cheapness and lightness, the toughness of its fiber, and its ready sterilization by steam or dry heat make it almost the ideal material for surgical dressings.

Unbleached Cotton

This is cotton in its natural state, freed from dirt, combed, and put up in pound rolls. It is non-absorbent and has a greater elasticity than the absorbent cotton. It is therefore preferable as a padding for splints, and to diffuse the pressure of a non-elastic bandage….It costs about thirty five cents a pound…..

Absorbent Cotton

as supplied by the manufactures of surgical dressings, is freed from dirt, gum, and oil, combed and sterilized, and so wrapped in tissue-paper that with a little care it remains aseptic until it is all used. It is furnished in packages of various sizes, from a half ounce to one pound, costing thirty-five cents a pound in pound packages. On account of its lack of elasticity, it is inferior to unbleached cotton as a padding for splints, etc.

Dry cotton is not a suitable material to bring into contact with a wound either during operation or afterward. In the former case its fibers are likely to stick to the wound, and also to the fingers of the operator. In the latter case, if the discharge is small, it is likely to evaporate and seal the cotton to the wound or to the surrounding skin with a scab which is difficult of removal. If cotton is used for sponging, during an operation, balls of suitable size should first be saturated with saline or some antiseptic solution, and then squeezed dry.

Substitutes for Cotton

Lamb’s Wool

Lamb’s wool has great elasticity, does not become soggy when exposed to moisture, and absorbs readily oily substances and glycerids. When cleaned and sterilized it is therefore an excellent material for vaginal tampons.

[So very different from today!]

Gauze

Bleached absorbent gauze is the most important item in surgical dressings. The firmness of the material varies according to the number of threads to the inch. The quality should be selected according to the purpose for which it is desired. Thus a gauze which has 24 X 32 threads to the square inch is suitable for sponges or for dressings, but has not sufficient firmness to make a good bandage. On the other hand, a gauze with 40 X 44 threads to the square inch, used for bandages, is unnecessarily expensive when used for sponges or dressings. It is, however, an unwise economy to select for sponges and dressings a gauze with too large a mesh. Such a gauze absorbs so little that an additional quantity is required in every case, so that the total expense is very likely increased.

Gauze suitable for sponges and dressings, have 26 X 32 threads to the four to five cents a yard, by the piece of 100 yards. This price is increased to eight or even ten cents a yard when the gauze is purchased in small pieces, previously sterilized and hermetically sealed.

Unbleached Muslin

Muslin, bleached, or more often unbleached, is used for slings, for handkerchief or first aid dressings, and for roller bandages.

The muslin employed for bandages need not be of the best quality, since even the cheaper grades are sufficiently firm for the purpose. Such a muslin costs about eight cents a yard, by the piece. A muslin bandage has certain points of superiority over gauze. It is firmer and will maintain its shape for a long time if well put on. It is not so easily soiled, and can be washed and ironed and used again many times. This is often an item of importance in dressing chronic ulcers of the leg, etc., as patients with such diseases are often obliged to practice rigid economy. Muslin tears readily, with a fairly sharp edge, so that the homemade bandages present a good appearance.

[Can you imagine reusing dressings like this? Would you ask yourself or your nurse to wash and iron the muslin for tomorrow’s dressing change?]

Flannel

The flannel selected for bandages need not be finely woven, but it should be all wool, in order to give the bandage its maximum of elasticity, which is the special merit of this type of bandage. The chief objection to a flannel bandage is its expense. It can be repeatedly washed and dried, provided lukewarm water and mild soaps are used, so that it is especially useful as a bandage of the legs, for chronic ulcer associated with edema. Whether red flannel or white flannel is employed is a matter of taste. The former has no superiority to the latter, and the dye sometimes comes out and stains the skin. Flannel bandages are easily torn, or they may be cut on the bias, the elasticity being thereby considerably increased. The latter form of bandage tends to become narrower with use – a point which should be taken into consideration in cutting the bandage. A patient should be directed to purchase two yards of flannel, every thread of which is wool, cut it on the bias into strips four inches wide, lay the ends of these, and sew them together flat, in order to avoid unnecessary ridges. This will give him three bandages, so that he can wash one while the other two are in use. A similar plan may be followed in making torn flannel bandages, although if one wants as many as six or eight, he will naturally use a piece of flannel as long as the bandage required. Flannel suitable to this purpose costs at retail about forty cents per yard and is about twenty-eight inches wide.

[I find this whole description of making bias flannel bandages wonderful, but especially the concern over the skin staining from the red dye.]

Canton Flannel

Canton flannel is used chiefly for making many tailed bandaged and other bandages of the abdomen. It is too thick to make a satisfactory bandage of an extremity or the head. It has no elasticity. It tears well, and costs about twelve cents a yard at retail.

Stockinette

Stockinette is a cotton fabric knitted in cylindrical form. It is sometimes employed for bandages on account of its elasticity. It can be washed and used repeatedly, but its thickness makes it a very clumsy material, and it is as expensive as flannel, costing twenty-five cents per bandage of five yards.

Large cylinders of stockinette are used instead of an undershirt to prevent a gypsum or plaster of Paris from coming into contact with the skin. One yard or more of the material is cut off, and near one end two holes are cut for the arms. Thus all seams and buttons are avoided.

Gutta-percha Tissue

This material is gutta-percha spread into thin sheets, and treated in such a manner that its surface is not sticky. It is sold in sheets a yard square, and costs from fifty to sixty cents a yard, according to the weight, whether light, medium, or heavy. For certain purposes this is the best impervious material that we have. It is absolutely non-irritating to the skin or to the wound, or to a mucous membrane. It never adheres to a wound, and for that reason makes an excellent drain when folded upon itself to make a narrow strip, or when it is used to cover a slender roll of gauze. It is often employed in burns and skin-grafts, to keep the wounded surface moist, and to protect it from contact with the dressing. Unfortunately, it cannot be sterilized by heat, as it shrivels up when placed in water even a little above the temperature of the body. it is commonly sterilized by immersion in a strong bichlorid solution for some time before its employment. Before it is used it should be rinsed with saline solution or sterilized water.

Oiled Muslin, Silk, and Paper

As now prepared, oiled muslin has none of the sticky, disagreeable features formerly attached to both oiled muslin and silk. It is flexible, opalescent, and costs about seventy-five cents a square yard. Oiled silk prepared in the same manner, but only thirty inches wide, costs a dollar a yard. These materials are serviceable to prevent evaporation from a poultice or wet dressing, and to prevent saturation of the bed clothing or clothing of the patient during the continuance of a wet dressing. Cheaper grades of oiled muslin can sometimes be obtained in dry-goods stores. Oiled paper makes a fairly good substitute for oiled muslin, and costs only three cents a yard by the roll of twenty-five yards. It is twenty-four inches wide.

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Tuesday, September 15, 2009

Grand Rounds Vol. 5 No. 52

Welcome to the latest edition of Grand Rounds, the weekly compilation of the best of the medical blogosphere! Let’s take a trip around the blogosphere with a nod to “Around the World in Eighty Days

The story starts in London on October 2, 1872. Phileas Fogg is a wealthy English gentleman who lives unmarried in solitude at Number 7 Savile Row, Burlington Gardens. …..Later, on that day, in the Reform Club, Fogg gets involved in an argument over an article in The Daily Telegraph, stating that with the opening of a new railway section in India, it is now possible to travel around the world in 80 days.

Since I live on the North American Continent, we’ll begin our journey here. Consider taking a walking tour of the monuments if you are ever in Washington DC. (photo credit)

This past week has brought the reform of health care to the forefront (had it left) again with President Baraka Obama’s address. These first post all deal with reform issues.

Doc Gurley brings us a humorous take on the state of healthcare reform now : Obama's Speech: what's an internist to do? This post proves once again that, two years later, she's STILL reporting from an insane healthcare system.

Dr. Toni Brayer, Everything Health, rants on Pfizer and their recent fine for illegal marketing. She (and I) is really sick of seeing just how much money there really is in "healthcare" that never goes to any type of patient care.

Kim, Emergiblog, discusses how the proposed funding for the new health care system is based on finding waste, abuse, “And Then There’s Fraud.”

Ryan, ACP Hospitalist, tells us “patients finding shopping around for medical costs easier online” as they take up comparison shopping.

Henry, InsureBlog, brings us a guest-post discussing the Ethics of “ObamaCare”

Marya, EviMedGroup, discusses "Healthcare reform: so much more than costs”

Sam, Canadian Medicine, discusses the perplexingly paradoxical evidence about the relationship between economic growth and population health: "Good or bad? Assessing recessions' health effects"

Louise, Colorado Health Insurance Insider, takes on Outcome Based Incentives for Doctors. Will it encourage doctors to avoid the sickest patients or will it compensate them for spending more time with them to provide quality care?

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Moving on to the European Continent, join me in a walking tour of Scotland. (photo credit).

Mark, Medic999, tells us the story of a wonderful family he had the pleasure to meet. The experience touched him deeply (as you will be), as did the single gesture from the patient at the end of the job.

Ever wonder if you deserve the praise given when you are introduced. So has Alison, Shoot Up or Put Up, who has Type 1 diabetes. After being introduced recently as a “diabetes expert,” she wondered “Diabetes expert. Who? Me?

Laika, Laika's MedLibLog, cautions us in The Trouble with Wikipedia as a Source for Medical Information. You should listen to this medical librarian.

Dr Zhang, The Cockroach Catcher, writes about NHS & McKinsey: The Professor & 10%

Dr Shock has written a thoughtful post, Empathy during Medical Education, discussing the decline in empathy which occurs during the third year of medical school. Third year is when medical students have more patient-care activities.

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Off now to Asia to walk the Great Wall, one of the greatest wonders of the world. It was listed as a World Heritage by UNESCO in 1987, stretching approximately 8,851.8 kilometers (5,500 miles) from east to west of China. (photo credit)

There weren’t any submissions from bloggers in Asia, but our Dr Lisa, a neonatologist, tells us about her trip to Mongolia starting with Mongolia: Day 1.

Sumer’s Radiology Site shares some great pictures of Caroticocavernous Fistula-MRI

Vijay, Scan Man’s Notes, has delved into India’s medical politics of late: Support the NCHRH Bill

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Off now to walk around the Australian Continent. So many places to see (photo credit), but I can tell you I’m not sure I’d want to walk upon this.

Life in the Fast Lane gives us “Toxicology Conundrum 016” which discusses an intentional overdose of warfarin.

Bite the Dust tells us about the Refeeding syndrome and vitamin supplementation RGH E-Bulletin.

Outback Ambo tells us of some of the hazards of driving in the outback of Australia in A country relief - Chapter 1, Episode 5: On dodging water buffaloes and kangaroos.

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A walking safari on the African Continent would be a wonderful thing to experience. (photo credit)

The great story teller Bongi, other things amanzi, writes a cautionary tale for us in 200%

No Cure for Stupidity speaks of frustration and a little rant discussing the the two tiers of healthcare in his country.

Karen, Just Up the Dose, tells a tale of “a staff nurse came running out of the gastro ward with the floppy body of Yoliswa, a two-year old kwash we'd had with us for a few days, in his arms” in her post Kwashiorkor.

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Can you imagine taking a walking tour on the South American Continent? What would you chose? The Andes? The Rainforest? Again, a continent with so much to experience. (photo credit)

Flavio, Pharmamotion, writes a post that educates us on the classification of serotonin receptors and the drug classes that act on serotonergic transmission: Serotonin (5-HT) pharmacology: receptors, agonists and antagonists

Jon Mikel IƱarritu-Castro, Unbounded Medicine discusses Carcinophobia is often an indication for prophylactic mastectomy.

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Time for me to head back home to the North American Continent. How about taking a hiking tour of the Anasazi Ruins in New Mexico? (photo credit)

T, Notes of an Anesthesioboist, reflects on a difficult (and controversial) situation in, The Problem With Asking, "What Are You?"

Barbara, FlorenceDotCom, sends us this tongue in cheek advice regarding a serious topic: "Don't throw the skater under the Zamboni when you're already on thin ice."

Paul, Medicine for the Outdoors, discusses how the Sawyer point-one water filtration device described might potentially be one of the biggest practical technology breakthroughs to benefit public health that has come along in quite some time.

Barbara, In Sickness and In Health, asks Has Your Partner made You Laugh? Laughing together makes everything better -- if only for a few moments.

Ves, Clinical Cases, tells us how 4 Healthy Habits Sharply Reduce Risk of Serious Disease.

Allergy Notes wants to Dispel Internet Myths about Allergy.

Dr Kim, Medicine and Technology, asks “Do You Bargain with Your Doctor?
How to Cope with Pain gives us a review of two exciting new treatments for pain that re-train the brain to drop the pain signal without using surgery or medicines in her post New Brain-based Treatments for Pain.

Dr. Jolie Bookspan, The Fitness Fixer, reminds us that it’s still hot in many places and a chance to learn the several overlooked medical benefits of exercise and heat and improving heat tolerance. Take her advise when you Exercise in the Heat.

Lauren, Novel Patient, who is a patient with multiple chronic illnesses gives advice on staying organized: 10 Ways To Stay Organized With A Chronic Illness

Reality Rounds wants you to make the most of any horrible situation your work in medicine may bring you: “Embrace the Suck.”

Robin, survive the journey, discusses growth hormone and it’s bad rap due to misuse (abuse by healthy, adult athletes and body-builders): Growth Hormone for Survival: It's not always controversial

Nancy, Teen Health 411, writes to remind us that as parents and adults our alcohol use influences how our teens face substance abuse: Fathers' Alcohol Use and Substance Use in Teens

Chris Langston, John A. Hartford Foundation’s blog sends us a post entitled: Team or Mob? in which he discusses the team approach in medicine. Are well working together or against each other?

Stacy, ACP Internist, gives us a swig of “medical news of the obvious

With help for our jet lag, here’s Daryl, Listed as Probable, discussing it’s affects on teams who fly from one coast to the other with little time to adjust: East Coast vs. West Coast

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Thanks to Dr. Val Jones at Better Health and Colin Son for keeping the carnival up and running and to Nick Genes for starting it all way back when!

This edition ends the 5th year of Grand Rounds. Residency Notes gets the honor of starting off the 6th year of Grand Rounds with Vol 6 No1 next week.

Consider making a trip to Las Vegas next month to join us at the at BlogWorld/New Media Expo 09. Information on registration can be found here and rooms are available at the Venetian at a discount!

 

 

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Medscape Interviews

Surgeon Sews for Fun, Sutures for a Living by Nick Genes, MD, PhD (May 7, 2008)

Suture for a Living by Colin T. Son, MD ( September 15, 2009)