Saturday, December 22, 2007

SurgeXperiences 111
















Hey, let the good times roll! Welcome to the ultimate blog carnival for all things surgical! Exclamation points! Things have been a little hectic, being the end of the year and all, but I hope you enjoy a sampling of submissions from surgical stories around the world. I suppose the theme ought to have something to do with Christmas, but most of the submissions I received were a little on the somber side. So just pretend that there's a holiday cheer vibe coursing through the proceedings. Since case studies were a lacking this month, I decided to post one. Guess the diagnosis and treatment by the end of this carnival and I owe you some sort of super duper prize: 52 year old guy with a history of hepatitis C and B who presents with LUQ pain. He appears non-toxic, is afebrile and hemodynamically stable. He's uncomfortable with palaption of the left upper quadrant but without peritoneal signs. Abnormal labs include WBC of 1400 and hemoglobin 8.0 and platelets 48,000. Liver function tests are normal. CT abdomen/pelvis shows edema and fat stranding around distal pancreas and splenomegaly. That's all you get. And no cheating.

On to the Carnival:

Bongi gets the holiday season off to a rousing start with a post about the thrills of spending Christmas taking care of drunken revelers in the trauma bay. He also posts a potentially controversial story about "practicing" on a hopeless patient. Very compelling stuff.

The Monash medical student submits a nice review on the science of music in the OR. I love it that people are doing research and writing papers about something like this. In my OR I find I get agitated easier if there's no music. I like Coltrane or something mellow like Moby/Grateful Dead/Phish (but not classical, puts the rest of the OR team into a soporific trance) for long or difficult cases. For shorter, end of the day cases I like something with a little more tempo. The IPod shuffle is surprisingly not as satisfying; too much variety in genres. You're all over the place; Barber's Adagio for Strings followed by Metallica. Too jarring. I pick a CD and stick with it to the end. Anyway, those are my thoughts on OR tunes.

Great review of the history of artifical implants in medicine by Lakshmi from the blog Nanoscience.

Suture for a Living continues her consistently strong work with a highly informative post detailing the difference in anatomy, technique, and coding between panniculectomy and abdominoplasty. There's also great historical and technical review of reduction mammoplasty from a couple days ago. So many medical blogs are off the cuff and spontaneous, it's nice to read one that is so well researched and honed. Check it out.

Amusing little feature from Plasticizer about a "special" wine glass on sale for Christmas. If you have a long, unsightly nose, please forget it was me who linked this.

White Coat Rants reminds us all that the things we wear beneath our clothes aren't always private; you never know when you'll end up in a trauma bay.

Dr. Bruce Campbell, an ENT specialist from Wisconsin, writes about the way a veteran surgeon visualizes a major operation; not from beginning to end, but in retrospect. Very insightful. Plus, he quotes Kierkegaard at the beginning, thereby ensuring that you add a couple points to the old IQ by the end. He also has a great post about the "collaborative" nature of decision making in the modern physician/patient relationship, especially with regard to cancer treatment options. Younger patients, especially women with breast cancer, studies show, are more likely to be active participants in decisions. I have found this to be true myself. Conversely, older patients tend to be more passive; a whatever you think is best, doctor, sort of attitude. This is spot on as well. Old guys with colon cancer invariably shrug and say "you're the doctor. You tell me what to do" after you go through all the options and risks.

Dr Val writes about an unsatisfying experience with an orthopedic consultant for a mysterious elbow ailment. Every other week or so I'll get a lady with chronic abdominal pain in the office who has bounced around from PCP to GI doc to OB/Gyn without a diagnosis. It can be very frustrating for patient and doctor.... just goes to show, the human body isn't a car that you can simply run through a diagnostic computer. Some things, we'll never figure out.

From the blog Ten out of Ten comes a post about an ER doc trusting his instincts and relentlessly chasing down the true diagnosis; excellent job!

Dr Alice
blogs about her first awkward experience telling a patient that he has cancer. We've all been there. It doesn't come naturally, breaking awful news to someone.

Bright Lights, Cold Steel relates an unfortunate bad outcome after a gastrectomy/vagotomy. Leaks happen; the lesson, as always, is that survival correlates with identifying them early.

Counting Sheep recounts a story about enduring a five hour hopeless vascular surgery case, raising the important question: if what we're saving isn't compatible with dignified life, then is it worth the cost and effort to go through the exceedingly complex motions of saving it? Incidentally I like the phrase "mis-surgeonist". Pretty clever.

Panda Bear and myself also address the issue of futile care in posts from last week. Draw your own conclusions, or at least think about the ramifications of our ability to salvage patients from what had historically been death sentences with advances in critical care and increased understanding of the pathophysiology of SIRS/multiple organ failure.

On a lighter note, a cool little anecdote from Donorcycle about the distractible surgeon and how sometimes everyone is better off if you just stick a scalpel in his hand. My thoughts exactly!

No surgical carnival would be complete without at least something from Sid Schwab at Surgeonsblog. Although he hasn't posted anything new lately, here's a link to the "Sampler" post that gives an organized platter of great writing, insight, and humor.

Some other random tidbits: Orac on the Blue Man. Cameras built into light handles, allowing better filming of operations. A goofy simulation of what to do when a fire breaks out in the OR; my wife (an anesthesiologist) found it somewhat ridiculous. Someone also sent me a submission that basically was an add for mesothelioma screening; no thanks. That was part of the reason why I got rid of my AdSense; after I posted the inguinal hernia review, the little box at the bottom kept advertising for a law firm that specialized in Kugel Patch recalls and how to go about suing your horrible surgeon for malpractice. Yeah, I think I can do without the extra 26 cents a month that AdSense brings in. Anyway, Season's Greetings and Happy New Year to everyone. And thanks for all the submissions. Hosting the carnival is a great way to get introduced to all the medical blogs out there you wouldn't normally get to peruse. I strongly encourage those who haven't hosted to do so. No word on who's doing edition 112; volunteer if you can.

And the answer is: Splenic Vein Thrombosis, likely secondary to pancreatitis. No gastric or esophageal varices on endoscopy, but the pancytopenia of splenic sequestration would be the indication for splenectomy. The GI guy, however, is concerned about distal pancreatic neoplasm (doesn';t look like it to me) and wants to get endoscopic ultrasound/biopsy done first. Doesn't seem to me that EUS would change the plan, but whatever.

10 comments:

rlbates said...

Very nicely done! Merry Christmas to you all!

sterileeye said...

A very enjoyable read!

SurgeXperiences is such a brilliant initiative.

Thanks for the mention!

Bongi said...

well done, buckeye. nice is an understatement.

Jeffrey said...

Great edition! Have a joyful holiday season everyone! :)

Bruce said...

Strong work! Happy holidays.

Lakshmi (www.nonoscience.info) said...

Thank you for the trackback. Just a small correction. The blog is "nOnoscience", not quite "nanoscience" :)

Dr. Val said...

Really great and easy to read. Thanks for including me! :)

SurgeXperiences said...

The 12th Edition will be hosted at The Sterile Eye at http://sterileeye.com/

call for submissions here: http://sterileeye.com/2007/12/24/surgexperiences-112-call-for-submissions/

Rambodoc said...

I got the diagnosis, but you shouldn't have given it now. More fun in the comment box. Maybe next time?
Hi. Found you through Lakshmi at NOnoscience.

CresceNet said...

Gostei muito desse post e seu blog é muito interessante, vou passar por aqui sempre =) Depois dá uma passada lá no meu site, que é sobre o CresceNet, espero que goste. O endereço dele é http://www.provedorcrescenet.com . Um abraço.