Tuesday, June 26, 2007

96 Tears....or Stitches, or whatever

People are funny --- ya just gotta love 'em! I have to laugh every time I hear a variation of this question:

"How many stitches did they have to put in?"

Of course, the question is always directed at me --- you know, the guy who just carefully placed all of the sutures --- but somehow the question is always asked in regards to some nebulous "they." In any event, folks are always interested in knowing just exactly how many sutures were placed to close a patient's wound. Gee, how does one answer that question? Was it a subcuticular running suture? Interrupted single sutures? Horizontal mattress sutures? Vertical mattress sutures? Or, horror of horrors, skin staples?

And another thing -- what does this question imply? Is it simple curiosity, or are folks wanting to know if I made an ugly scar? Or maybe is there a subtle critique involved, that somehow I used too few or too many sutures. Sort of like the fabulous exchange between the Emperor and Mozart in Amadeus:
Emperor Joseph II: Your work is ingenious. It's quality work. And there are simply too many notes, that's all. Just cut a few and it will be perfect.
Mozart: Which few did you have in mind, Majesty?


What is almost never asked, of course, is what happened on the inside of said wound.


Surgery is in many ways like making chocolates --- the customer/patient wants the outside to look nice and pretty, but it's what is inside the chocolate that counts. Nothing is better than selecting a chocolate at random from a pretty box and tasting a little bit of heaven. But surely everyone has bitten into a chocolate confection, only to find it contained something that tastes like year old mold with a hint of orange? Well, unfortunately, surgery can occasionally be a lot like that. My job is to make sure that the "insides" of my "chocolates" are, if not necessarily tasty, then at least well made.

So, whenever I get asked about "how many stitches" were used, or "how big is the scar?," I have to act a bit like Carl Spackler --- "I have to laugh, because I've outsmarted even myself." The surgical "artwork" that I may accomplish on any given day may represent the finest display of the craft of surgery available, worthy of a Netter drawing.....but it can't be put on display like a scar. What surgeons do, and take great pride in, is more than skin deep, and if everything goes according to plan will never see the light of day!

Sunday, June 24, 2007

The worst book ever, and a few alternatives

So, if you read the last post, you have realized that by age 45, I don't appear to have accomplished a hill of beans when it comes to reading all of the great books that I should have by all rights long since finished. OK, so I'm a slacker. However, in my defense, I was forced, with the threat of penance hall with Fr. Rivoire, to read some awfully bad alternatives during high school and college. And the whole reason of this post is one of them, the worst book ever foisted on high school students passed off as great literature (or, just the worst book ever passed off as great literature (TWBEPOAGL), for short). If you haven't gotten my hint, I really loathed this one, and I think it should be banished from required reading lists forever.

Just off the top of my head, I can think of several excellent substitutes for the worst book ever passed off as great literature :

  • Lonesome Dove by Larry McMurtry -- I generally can't stand westerns, but the character development in this book is second to none; plus, it doesn't contain the driveling, whiny complaints of a teenage boy like TWBEPOAGL
  • Atlas Shrugged (or its cousin, The Fountainhead) by Ayn Rand -- hardly "great writing," but it certainly is a great source of ideas which need to be discussed by young people: self-reliance, integrity, and an understanding that it is the people of this country that make it work, not the government
  • A Confederacy of Dunces by John Kennedy Toole --- you want quirky? You got quirky! Once the reader gets past the humor (and there's plenty of it), this book carries a warm humanity, gently prodding us to look at our own quirks, failings, and inconsistencies
  • Tinker, Tailor, Soldier, Spy by John le Carre --- fabulous characters, a wonderful sense of drama, and it is a good way to introduce today's students to the Cold War and the evils of communism
  • Crime and Punishment by Fyodor Dostoyevsky --- yes, it's hard to read. Yes, it requires patience and an active discussion in the classroom. And yes, reading can be one of the most rewarding experiences in a young person's life. A fabulous dissection of right, wrong, conscience, and consequences.
  • Perelandra by C.S. Lewis --what would have happened if free will had not been introduced to the garden of Eden? As always with C.S. Lewis, well-written and thought provoking
  • One Day in the Life of Ivan Denisovitch by Aleksandr Solzhenitsyn --- I can describe this no betther than with the Amazon.com review: Solzhenitsyn's first book, this economical, relentless novel is one of the most forceful artistic indictments of political oppression in the Stalin-era Soviet Union. The simply told story of a typical, grueling day of the titular character's life in a labor camp in Siberia, is a modern classic of Russian literature and quickly cemented Solzhenitsyn's international reputation upon publication in 1962. It is painfully apparent that Solzhenitsyn himself spent time in the gulags--he was imprisoned for nearly a decade as punishment for making derogatory statements about Stalin in a letter to a friend.
  • The Hitchhiker's Guide to the Galaxy by Douglas Adams --- a mid-semester fun book about nothing and everything, just to take the tension off. The test covering this book should consist of one question: What is the meaning of life, the universe, and everything? (If you don't know the answer, you need to read all of the books in the series).
  • The Bonfire of the Vanities by Tom Wolfe --- fun, with a wildly different style of writing than high school students will have been exposed to, and carrying an introduction to "modern" hubris that needs to be absorbed ("I'm a Master of the Universe!")
  • QB VII by Leon Uris-- no, it's not about football. It is a British courtroom drama involving libel....and quite a bit more than that. For a teacher who wants to introduce students to the Holocaust from an oblique angle, and have his/her students read a very well written book, this is an excellent choice.

I can go on and on. I am sure that everybody that reads this (all two of you!) can easily name one or more books that would be great additions to the standard high school reading list. I read some great books with some fabulous teachers --- the poems of Shelley, Lord Byron, and Yeats; the Iliad and the Odyssey; the Aeneid (in Latin, no less); and Crime and Punishment with the late, great Mr. Joe Kratville, which was an experience I remember with great fondness and clarity.

To be honest, I read some real dogs too --- The Good Earth comes to mind --- but none comes close to the book that shall not be named --- what a waste of paper, what a non-stop, overwrought description of a whiny, wimpy teenager. I wish I could convince a few English teachers that it needs to be tossed in the trash bin and replaced with something -- anything! -- better.

Friday, June 22, 2007

Books......and more books

I love to read, and the older I get the more I realize that I will never be able to read everything that I want to --- too many books seem to pile up on my Amazon wish list, similar to the stack in my office and on my bedside table. I have always been a heavy reader, but time constraints of school, residency, and practice (ok, and bloggging!) have taken a heavy toll on what I can reasonably expect to get to. A few months ago, I heard a great discussion on Hugh Hewitt's program about what "classics" should be on every college student's reading list; it's an enjoyable 30-40 minutes that's worth listening to. That piqued my interest, because I feel that I had the opportunity to read some great books in high school and college, but had a slew of trash thrown in there as well.

First, the list from Mr. Hewitt's show; the one's in purple I have read, my "comments" are in red:

The Bible pretty obvious, but not for everyone
Plato's Republic
Plato's Dialogues
Homer's Iliad
Dante's Divine Comedy
Miguel de Cervantes Don Quixote
Charles Dickens David Copperfield
Fyodor Dostoyevsky The Brothers Karamazov
Evelyn Waugh Brideshead Revisited
Aleksandr Solzhenitsyn The Gulag Archipelago
Homer The Odyssey
Aristotle Ethics
Plato The Republic
Sophocles Oedipus Rex
St. Augustine's Confessions
John Locke Second Treatise on Government
Virgil
Aeneid
Abraham Lincoln's Gettysburg Address and his Second Inaugural Address
Plutarch's Lives of the Noble Grecians and Romans
Winston Churchill History of the English Speaking Peoples
Charles Dickens A Child's History of England
Paul Johnson The Birth of the Modern
The Declaration of Independence & The Constitution of the United States
The Federalist Papers
Alexis de Tocqueville Democracy in America
Adam Smith The Wealth of Nations
Marx & Engles The Communist Manifesto
Charles Darwin Origin of Species
Friedrich Nietzsche The Geneaolgy of Morality
Sigmund Freud Civilization And Its Discontents
C.S. Lewis The Abolition of Man
James Joyce Ulysses oh, Lord, not that one; what a waste of paper
Aeschylus Oresteia
St. Thomas Aquinas Summa Theologica
Blaise Pascal Pensees
Jane Austen Pride and Prejudice
Oscar Williams Immortal Poems of the English Language
Herman Melville Moby Dick
Michel de Montaigne Essays
Edmund Burke Reflections on the Revolution in France
Geoffrey Chaucer The Canterbury Tales
Niccolo Machiavelli The Prince
Edmund Spenser The Faerie Queene
John Calvin Institutes of the Christian Religion
The Song of Roland
Lewis Carroll Alice's Adventures in Wonderland and Through the Looking Glass
William Shakespeare not surprisingly, these professors had several picks from old Will's pen:

King Lear
MacBeth
Henry V
Julius Caesar
As You Like It
Twelfth Night
Henry IV
Winter's Tale
The Tempest
George Bernard Shaw's Shakes Versus Shav
John Milton
Paradise Lost
Ancius Boethius
The Consolation of Philosophy
Cicero On Friendship and On Duties
Thomas Hobbes Leviathan
Leo Tolstoy Anna Karenina and War and Peace
T.S. Eliot Collected Poems I've read some, but certainly not all
Whittaker Chambers Witness
Flannery O'Conner's Complete Stories
Norman Mailer Of A Fire on the Moon
Walker Percy Lost In The Cosmos

That's quite an ambitious list, and I must admit there are a few there that I would probably use as door-stops before ever taking the time to read them. In my next post, whenever I get to it, I will list the books that I read in school that were either spectacular or spectacularly awful, including the worst book ever foisted on high school students passed off as great literature. I would also like to list perhaps a few alternatives, books that never will be studied in an English class but which would be well worth the to teach.

Fixin' Funyun Trauma

Jes fer fun, try something --- take one of those terrible-for-your-heart Funyuns (yes, I know you've had them at some point), hold it between your index finger and thumb, and then squeeze. When it breaks and sprays crumbs all over the place, it will never break in only one place. It's a ring, and unless force is applied in an outward fashion, rings break in at least two locations. Unfortunately, in an automobile accident, your pelvis acts not unlike that cracking Funyun --- it's a ring, albeit one containing a fair amount of expensive real estate and a treasure trove of blood vessels.

Without getting too involved in the how and why of what happens with pelvic fractures -- the bony and ligamentous structure disruption in anterior-posterior and lateral shear -- suffice it to say that they range from relatively mild to very severe. Significant disruption of the pelvic ring can result in significant bleeding, which is almost exclusively venous in nature. Since veins don't have much in the way of any ability to constrict like arteries, and since there is no "limited space" compartment that would fill up and allow the bleeding to stop and develop a clot, patients with big pelvic fractures can really empty themselves of a substantial amount of blood in a short period of time.

We have learned that the best way to slow that bleeding down to a trickle in most cases is to put Humpty Dumpty back together again into a more normal configuration. A good way to do that is to put on a pelvic fixation device ("external fixator"), which resembles nothing so much as a set of Tinker Toys drilled into the iliac crests anteriorly with bars across the anterior pelvis. This technique works pretty well in most instances, and has been utilized widely for years.

The one little problem with placing an "ex fix" is that it takes time --- time to get the orthopedist to the hospital, to locate all of the Tinker Toy sets to place it, and to get the patient to the operating room where it is almost always placed. In a patient who may be bleeding not only from pelvic fractures, but possibly has a splenic injury, a femur fracture, etc., ongoing blood loss is not the best possible scenario. Uncontrolled hemorrhage leads to acidosis, consumption of coagulating factors in the blood, temperature loss......and then if not reversed, more bleeding that can't be stopped. A multiply injured patient can seem at first to be sailing rather smoothly on relatively rough seas, but in reality is a boat slowly circling the edge of a gigantic whirlpool. They can get "sucked down" and "circle the drain" quickly, and it takes a whole lotta work to get them pulled back out.

Other, quicker options to reduce the pelvic fracture started popping up, such as using MAST trousers (didn't work well) or towel clipping a sheet around the pelvis (quick, easy, but doesn't apply uniform pressure). So, some Smart GuysTM devised a string-and-velcro device to accomplish the same thing (there are actually a few on the market). The T-POD device allows rapid placement, easy access to the patient, and uniform circumferential compression of the pelvis. Here are a few photos from their web site:

But, does it work? Do these types of devices deliver superior (or at least comparable) results to external fixation? A nice study from the University of Tennessee Health Science Center in Memphis tried to compare apples to apples. Although it was a retrospective study, the authors did find the pelvic orthotic device (POD) to

  1. decrease 24 and 48 hour transfusion requirements
  2. decrease hospital length of stay
  3. decrease ventilator associated pneumonia rates (likely due to decreased transfusion needs
in comparison to external fixation. Even given the problems interpreting retrospective data, this was a good study that showed that this rapid, inexpensive technique has the potential to do some serious good in the trauma suite. Not too shabby for a simple device that resembles a corset (and don't think I would put a picture of a corset up here; this is a family blog!).