Member

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to radiologists & hospitals in India…

THINK TWICE

BEFORE BUYING ULTRASOUND SCANNERS

FROM A FAMOUS GERMAN COMPANY!!

Their equipment may be good, but the reliability is questionable compared to equivalent American & Japanese ultrasound scanners.

Read the fine print in their service contract.

If possible, insist on and get a 2 or 3 year extended warranty / free service window at the time of purchase.

Please email me if you want more details about what prompted this.

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Welcome to the latest edition of SurgeXperiences, the fortnightly carnival of blog posts related to surgery.

This happens to be the 50th edition. Ironically the number 50 has acquired an altogether unwelcome significance this week due to the unfortunate and untimely death of Michael Jackson aged 50. Mr. Jackson may very well be the King of Pop to fans and music lovers, but to most of us in healthcare he is probably better known as the worst example of celebrity plastic surgery on demand or as a prominent plastic surgeon describes him, the most famous “nasal cripple.”

Dr. Pamela Lipkin, a prominent plastic surgeon in New York City who has studied photographs taken of Jackson at a California court appearance in November — in which his apparently scarred nose was covered by a small transparent bandage — believes something went wrong. “What I think happened recently is that something in his nose — a graft, an implant, something — has now come out through the skin,” said Lipkin, a nasal specialist who is not Jackson’s doctor and has never examined him in person. “He’s really got a hole in his skin.” “Michael Jackson has what we call an end-stage nose, a crippled nose, a crucified nose — one that’s beyond the point of no return,” she said. People who have had so many surgeries on their nose that it becomes hard to breathe through are called “nasal cripples,” Lipkin said. Although Jackson’s face has been splashed across the tabloids in recent months, Brittan Stone, photo editor at the celebrity magazine Us, says the singer’s face is not being seen on magazines. “The one thing you can’t do with Michael is a beauty shot, because that shot simply just doesn’t exist anymore,” Stone said. “I don’t think you can put Michael Jackson’s face on the full-page of a magazine…. I think the flaws in his face become a little too evident, a little too frightening. It becomes like a medical study.”

GruntDoc nailed it when he wrote…

I’m willing to bet drugs (legal, clean, prescribed by a doctor) were involved, and that a review of the records will show some questionable prescribing. First Do No Harm, unless it’s a celebrity? Why are docs willing to engage in this kind of horrible, destructive prescribing? It’s reprehensible.

and

…somewhere in Beverly Hills there’s a Plastic Surgery group applying for TARP funds.

In other surgically related sad news this week, actress Farrah Fawcett lost the battle with anal cancer and a young Iranian woman was shot down in cold blood in the streets of Tehran as a doctor who happened to be nearby tried in vain to save her.

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bongi, who celebrated his birthday this week, shares an angry moment, a story that he isn’t very proud of; and this sad story of mindless violence in south africa that cost a man his leg.

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Ramona, the sewing surgeon, reviews an article on surgical glove perforation.

It is well known that the risk of getting a hole in one’s glove increases with the length of the surgery (especially when over 2 hours) or when dealing with spiked bone fragments.

Ramona also writes, in her usual scholarly way, about posture and how Poland’s syndrome came to be thus named.

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Buckeye uses a tale of rare successful surgical outcome in a patient with gangrene of the bowel to pose a difficult question…

So what do we do? We have the ability to truly save patients from insults that had previously killed human beings for thousands of years. How do we decide when it’s justified to throw everything in our armamentarium against a disease afflicting a patient? If 50% of patients are going to die no matter what you do, is it still defensible to aggressively treat all of them?

… also from Buckeye, we have an interesting short review of a journal article on seven American presidents who underwent surgical procedures during their lifetime. Buckeye covers trauma in a Level II centre and is of the opinion that CT scan ought to be the imaging modality of choice for cervical spine injury. I agree.

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TBTAM says she will choose colonoscopy over a CT anytime and shares some news about how when it comes to vitamins, more is not necessarily better.

The surgical blogosphere’s éminence grise Sid Schwab dreams of surgery.

Intraoperate thinks she ought not to get familiar with some patients or their families preoperatively.

Anesthesioboist T thinks it could happen to you so be prepared for the worst. Sometimes being prepared doesn’t help. But then, such is life, say I.

Bruce Campbell is eloquent as usual in this post titled transcience.

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Apple CEO Steve Jobs received a liver transplant and the medbloggers have differing opinions. Orac does a comprehensive, partly speculative medical review. Buckeye has a different take.

Surgeon and columnist at The New York Times Pauline Chen writes on Medicine in the age of Twitter.

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From Whitecoat we have this news story of a promising new test for Appendicitis that involves only a urine test.

The implications of this test are huge. Appendicitis is one of the more difficult diagnoses to make clinically and missed appendicitis is an often-litigated issue, prompting many physicians to order expensive CT scanning in anyone with right lower quadrant pain. As many as 30% of appendectomies end up showing no appendicitis. If LRG testing has a low false positive rate (i.e. test is positive when there is no appendicitis) and a low false negative rate (i.e. test is negative when appendicitis is really present), it would save a lot of unnecessary surgeries, would decrease the number of CT scans being performed, and would significantly reduce the transit times in ED patients who have lower abdominal pain.

Again from Whitecoat we have a picture quiz and a short write-up on wound dehiscence with evisceration. In case you haven’t been following (where have you been if you’re a medblogger?) here is the latest episode of the riveting Trial of a Whitecoat.

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Surgeon and inventor Catherine Mohr talks about surgical instruments and the evolution of surgical technology…

[h/t Sterileeye & GrrlScientist]

Talking of surgical robots, here is one that uses a “frighteningly large needle” to remove shrapnel.

Scientists at IIT-Kharagpur have developed an artificial heart inspired by the cockroach and built like an onion.

Liquorice gargles may help reduce post-intubation sore throats in surgical patients, say doctors in India.

Cardiothoracic surgeons in an Indian hospital performed a risky and complicated open heart procedure on a 14-year-old Ugandan girl to replace the mitral valve, repair a leaking tricuspid valve and maze procedure to correct her abnormal heart rhythm.

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Links from regulars:

Sterileeye shares a link to a list of the Top 50 Surgical Bloggers.

Jeffrey Leow points us to a video on Brain Surgery from the Doctors Channel and to this news story about James Maki, the second face transplant patient in the U.S., who is taking his incredible story to the public in an effort to encourage organ donation.

From Flickr, a macabre photo of a knee arthroscopy training lab.

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Ending with a bit of humour…

…from Mike Cadogan we have a comically macabre poem that tells the tale of the last moments of a dying surgeon, who fears he will not be allowed his eternal rest, and what happens after his death

…and from Close To Home gives us a new disease, that I personally think ought to be included in ICD 10.

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Acknowledgments:

I’ve included a few posts here without getting prior permission from the authors. I know it’s not wrong to do that in a blog carnival, but in case any of you feel that your post ought to be removed from this listing, let me know and I’ll remove it.

I apologize if I have missed any posts which were submitted or suggested.

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Image Credits:

All photos are from Flickr - Tagged - bharatanatyam except the third photo, the only one of a male dancer which would be tagged kathakali.

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There is no host yet for the next edition

SurgeXperiences 227

to be posted on July 12, 2009.

If you are interested in hosting, contact Jeffrey Leow

Deadline for submissions is on Friday, July 10.

Please send in your submissions early via this form.

You can subscribe to SurgeXperiences via RSS feed or email.

An aggregated feed of credible, rotating health and medicine blog carnivals is also available.

Start Slide Show with PicLens Lite

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The next edition

SurgeXperiences 226

which happens to the the 50^th edition

will be hosted by me in this blog on June 28, 2009.

Deadline for submissions is midnight on Friday, June 26. Suggested theme is surgical practices in different parts of the world.

Please send in your submissions early 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 SurgXperiences editions for your reading pleasure.

If you wish to host a future edition, please contact Jeffrey who runs the show (& is the host of the current edition) here.

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Start Slide Show with PicLens Lite

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via Buckeye Surgeon: Traumatic Cervical Spine Injury: Is CT now the preferred imaging modality?.

Over 1500 patients were accrued. Radiographic evidence of cervical spine injury was detected in 78 of the patients, with 50 having clinically significant injuries. Here’s where it gets good. CT scan of the cervical spine detected all 50 injuries (100% sensitivity) while the plain films only identified 18/50. Even in patients with clinically significant injuries, the plain films only had a sensitivity of 46%. The paper concludes by advocating that CT of the cervical spine replace plain c-spine radiographs as the preferred initial test to exclude blunt cervical injury.

This is a classic case of where the data has finally caught up to what actually happens in real life. (Got that, you CER disciples? Science isn’t as accomodating or as quick as we would like. The proof of what is already apparent in clinical practice can lag years behind.) I cover trauma at a level II center and I’ll be honest; I don’t spend a lot of time looking at plain films of the neck. They’re always sort of suboptimal and don’t consistently show all the vertebrae you need and if there’s a question, you’re just going to get a CT cervical spine anyway. So I go straight to the CT films.

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Good of you, Buckeye. I agree completely.

The Head CT protocol for trauma victims in my department uses a helical scan plan that goes from the mandible to the vertex. This covers at least up to the fifth cervical vertebra in most patients.

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[The green box represents the area to be scanned]

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[Midsagittal MPR image showing Cervical vertebrae up to superior endplate of C6]

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[VR image - left lateral view showing normal skull, facial bones, mandible and cervical spine. Bonus point for identifying the structure caudal to the mandibular ramus]

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[VR image - RAO view. Bonus points for identifying the fractures and the anatomical variant]

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Usually the films and my report would be confined to describing the findings (if any) in the brain, skull and facial bones if no spinal injury is found. This being India, where the vast majority of healthcare spending is from the patients’ pockets (my friend George has a great term for it OOPS = Out Of Pocket Spending), cost concerns are supreme and there is no additional charge for the inclusion of the facial bones and/or cervical spine related information in the Head CT report.

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via medGadget - Artificial Heart Inspired by a Cockroach and built like an Onion & The Telegraph -  An Indian artificial heart.

[Image Credit]

Finally, there could be an artificial heart with a Made-in-India tag. Nearly 40 years after the West invented a crude, pneumatic-powered device that could pump blood quite like a normal heart, Indian biomedical engineers are trying something similar, but one which is more efficient and reliable. The artificial heart, or biventricular pump as its inventor Sujoy K. Guha of the Indian Institute of Technology, Kharagpur (IITK), calls it, consists of two identical artificial ventricular pumps, made of a series of interconnected diaphragm chambers. A battery-driven motor controls the compression and expansion of the chambers.

The device, which was the main draw at a recently concluded event — called IndAc 2008, that showcased new technologies developed at IITK — draws inspiration from the heart of a cockroach which has a fail-safe mechanism. A cockroach’s heart has as many as 13 chambers, unlike the four in a human heart. As a result, failure of a single chamber in the former does not become life threatening unlike in the latter, says Guha. Moreover, the pumping of blood in a cockroach’s heart happens in a staged manner, which reduces the build up of pressure, often experienced in the human heart.

“The inventiveness of our work lies in recognising the merits of the cockroach’s heart and adapting them to the needs of the human system,” said Guha. Guha’s team, which has already tested the device on frogs, has recently sought permission to test it on goats. A patent application has also been filed for it. “The technology is ready for clinical trials,” said Guha. “A series of diaphragms divides the load of the pump, thereby increasing its longevity,” he added. The internal flow is designed to prevent excessive blood recirculation, stagnation and mechanical trauma. An obvious advantage of such a device would be to lower the need for heart transplants. “With increased understanding of the heart’s functioning and continuing improvements in prosthetics, computer science, battery technology and fuel cells, a practical artificial heart may be a reality in the 21st century,” said Guha.

Read more here & here.

Way to go IIT-K

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I was called to do an urgent bedside ultrasound scan of the abdomen for a trauma victim.

The patient was a young man of twenty-four who had been involved in a road traffic accident (RTA = MVA in US medical terminology). He had been brought - without any kind of basic life support - after sustaining a major trauma at a village about two hours away. The intensivist in the ICU told me that he was in severe hypovolemic shock on admission with a GCS of 4. Preliminary examination and radiographs had shown a comminuted fracture of the right femur (thigh bone) with a large hematoma and some facial bone fractures. After initial assessment and resuscitation in the casualty, a CT scan was done. He had a fracture in the frontal bone and a few small contusions in the brain, that raised the possibility of Diffuse Axonal Injury, nothing that could explain a GCS of 4 though. The assumption was that it was all due to extensive blood loss and hypovolemia. He was shifted straight to the ICU after the CT scan and I was called to do an ultrasound scan to check for hemoperitoneum (ie, abdominal injury and blood loss).

The scan was normal. As I was doing the scan, the intensivist was busy trying to put in a Subclavian central line. He secured the line just as I finished my scan, which incidentally was normal. As I was stepping away from the bed, the patient had a cardiac arrest, as evidenced by sudden bradycardia on the monitor. I moved out of the way as the intensivist, orthopaedic surgeon and ICU nurses went through a full resuscitation protocol. After a while, even I realized that it seemed like a futile exercise.

I was not particularly busy, so I peeped into to the Cardiac ICU next door as there seemed to be some commotion there. My cardiologist colleague, a normally friendly soul was peering intently at a very fast heart rhythm on a monitor over the bed of a young girl of about six or seven. There were a couple of nurses injecting something slowly into an intravenous cannula in the kid’s forearm.  In passing, I noted that the kid was very calm and seemed very interested in what the nurse was doing. I stepped close to my friend and asked what was up. He turned, gave me a quick nervous smile and said he was trying to revert an SVT (supraventricular tachycardia, a very nasty fast heart rhythm). Honestly, I had never seen an SVT in someone so young, so I asked him what was the history. He told me the kid was brought by her mother to his outpatient clinic a short while ago because she complained of palpitations (I forgot the exact description used by the kid, but it was quite descriptive). My friend said he was sure it was an SVT after a quick examination in the clinic, so he rushed the kid upstairs to the Cardiac ICU, connected her to a monitor, confirmed the diagnosis and had ordered Adenosine IV stat for reversal. He maintained his intent survey of the monitor as he recounted the story and the nurse continued her slow IV injection. At one particular point when the line on the monitor became particularly squiggly, he shouted, “STOP!” and the nurse stopped injecting.

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It was almost magical.

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The squiggles became a recognizable cardiac rhythm, albeit very fast - about 160 to 170 beats per minute. My friend called out to one of the superfluous nursing attendants and asked them to get the kid’s mother inside. A very anxious young lady who had obviously been weeping was led in. My friend showed her the monitor and explained to her that the nasty rhythm had been made to behave itself or something to that effect and told her that the kid was out of any imminent danger.

Happy with the positive outcome, I strolled out to be confronted by a wailing family, including two young girls, maybe a year or two older than the calm kid inside, who had just been told that their older brother who fell off his motorbike was dead.

It was past my work hours. I went out and had a drink and reflected.

Such is life.

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The latest edition is up in Q & A format at Vagus Surgicalis, by Jeffrey Leow.

SurgeXperiences 225 ⪻ Vagus Surgicalis.

Welcome to the 25th edition of SurgeXperiences – the one and only Surgical “Grand Rounds”, where the best surgical-related posts are gathered into one succinct post every 2 weeks. Thank you for dropping by, and because i’m in exam mode, i shall present this edition in a Q&A fashion; enjoy!

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The next edition

SurgeXperiences 226

which happens to the the 50^th edition

will be hosted by me in this blog on June 28, 2009.

Deadline for submissions is midnight on Friday, June 26. Suggested theme is surgical practices in different parts of the world.

Please send in your submissions early 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 SurgXperiences editions for your reading pleasure.

If you wish to host a future edition, please contact Jeffrey who runs the show (& is the host of the current edition) here.

…

Start Slide Show with PicLens Lite

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Note: This is the third (and final) case in a short series of CT images of extra-axial intracranial hemorrhages.

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Diagnosis: Subarachnoid Hemorrhage.

Subarachnoid hemorrhage (SAH) implies the presence of blood within the subarachnoid space from some pathologic process. SAH causes approximately 5% of all “strokes.” The common medical use of the term SAH refers to the nontraumatic types of hemorrhages. The most common cause of nontraumatic SAH is ruptured intracranial aneurysm or arteriovenous malformation (AVM). A relatively uncommon but important cause of non traumatic SAH is the entity known as nonaneurysmal peri mesencephalic subarachnoid hemorrhage (pnSAH).Headache is most common symptom. Frequently reported as severe (”worst headache of life”), of abrupt onset, reaches maximum intensity within seconds (”thunderclap headache”).

The initial imaging study of choice is an urgent CT scan without contrast. Acute hemorrhage is most evident 2-3 days after the acute bleed. Sensitivity decreases with time from onset. Studies traditionally report 90-95% sensitivity within 24 hours of onset of bleeding, 80% at 3 days, and 50% at 1 week. Acute SAH appears as high-attenuation material that fills the normally hypodense subarachnoid spaces, which include the basal cisterns, especially the suprasellar cistern; the Sylvian fissures, interhemispheric fissure, the sulci over the convexities of the brain. A clue to identifying SAH during the subacute period (days to weeks after acute bleed), is decreased visualization of the normally “black” fluid within the sulci and basal cisterns and enlargement of the ventricles from communicating hydrocephalus. A false negative CT scan can result from severe anemia or small-volume SAH. False positives may occur by mistaking normal visualization of the falx cerebri and tentorium cerebelli for SAH. Distribution of SAH can provide information about the location of an aneurysm and prognosis. Outcome is worse for patients with extensive clots in basal cisterns than for those with a thin, diffuse hemorrhage.

Multidetector CT angiography (MDCTA) of the intracranial vessels is now a routine examination that has become fully integrated into the imaging and treatment algorithm of patients presenting with acute SAH in many centers. Digital-subtraction cerebral angiography (DSA) has been the gold standard for the detection of cerebral aneurysm, but CT angiography has gained more popularity and is frequently used owing to its noninvasiveness and a sensitivity and specificity comparable to that of cerebral angiography.

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Axial NECT section shows hyperattenuating acute SAH in the Sylvian and interhemispheric fissures (yellow arrows). Third ventricle and atria of the lateral ventricles are mildly dilated.

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[Click on the image to open a labelled image in a new window]

Axial NECT section cranial to the previous image shows hyperattenuating acute SAH in the Sylvian fissures (yellow ovals) and interhemispheric fissures (yellow arrows). Third ventricle and atria of the lateral ventricles are mildly dilated. Small amount of intraventricular hemorrhage is seen in the dependent occipital horn of left lateral ventricle (red arrow).

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References & Further Reading:

1. Diagnostic Neuroradiology: A Text/Atlas by Anne G. Osborn, MD.
2. Subarachnoid Hemorrhage. eMedicine article by Rami C Zebian & A Antoine Kazzi [Registration required. Free]
3. CT in Head Trauma - Tutorial by Andrew Downie, from SRS-X, the Scottish Radiological Society’s Educational Resource.
4. SAH - LearningRadiology.com 
5. MedPix - SAH.

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55-year-old man with swelling in the right groin.

Ultrasonography was done.

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[click on the image to open larger version in a new window]

What is the diagnosis?

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Answer: Here.

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