Time Lapse: Pacemaker Implantation Table Setup

Oh, the wonders of Apple's iOS8!  Now there's no excuse for slow room turnovers:



Yeah, I can see all kinds of applications for time lapse photography, especially when it comes to improving my productivity...

-Wes

On Folding

Every surgeon has been there at some time in their career.

It's a horrible, exhausting feeling.

Yet one we all must come to grips with: knowing when to stop.

There you are, six hours into a case, legs rubbery, mind racing, and barely conscious of the world outside the narrow view of the operative field. A life, literally in your hands, asleep now, but hoping (with you) for the best of outcomes on this last try.

"Maybe if I just..." you think, and a new idea is tried to no avail.

"Now, let's look at that again," you ask your techs. "Which electrogram's earlier? That one is CLEARLY earlier...right?" as you try to convince yourself that another choice is better. "What about here?" You go back and recheck once more, just to be sure...

So you do.

And it's still a dangerous spot to burn.

"Maybe it's on the left side?" So you cross to the left side and repeat the process. Everything maps back to the spot your dreaded before.

"Maybe if I give just a little energy here...." You hold your breath.

No effect.

"But if I burn here, I risk giving the patient a pacemaker. We never talked about a pacemaker," you think.

Yet the tachycardia persists, as if laughing at you and your inability to locate its origin.

* Bruuuuhaaaahhaaaahhaaaa... *

"Bastard!" you think. "I can get this!"

So you map above, below, left and right, forward and back...

* Bruuuuhaaaahhaaaahhaaaa... *

Like stubborn mule, you fail to give in. Again.

And again...

Until finally...

... you quit. A white flag raised. It beat you. Yes, you lost.

The supporting team with you, ever helpful, feels the patient's loss with you. They are relieved, though, for a pacemaker will not be in the offing. Like you, they know there will be another day, another arrhythmia: another victory to quell the sting of this defeat.

And while the Defeated hangs his head low to talk to the family, you then realize the the family is just as exhausted and concerned as you.  They thank you for trying.  They understand.

That's when you know you did the right thing.

-Wes

Can I Watch?

It's one of the more common questions I hear from family members before I take their loved one into a procedure: "Can I watch?"

For me, the answer is simple: no.

Fortunately, when I explain my rationale, most people come to understand why this isn't such a good idea:

• First, the doctor performing the procedure has enough to think about without having to be a tour guide to a family member. Even something as simple as a pacemaker battery change can go very wrong if an operator is distracted long enough to accidentally reverse the atrial and ventricular leads when they are reattached to the new pacemaker pulse generator.
• Second, if something should occur that is unexpected during a procedure, a doctor needs to focus on the problem at hand without having to deal with the physical and psychological well-being of a family member also.
• Third, the operating room has all kinds of unusual sights, sounds, and (often unexpectedly) smells to which many people are not accustomed. If a family member becomes lightheaded, nauseous, or hits the deck as a result of these powerful stimuli, it can make for a very long (and embarassing) day indeed.

-Wes

Keepers

When fishing, you never seem to remember the fish you threw back because they were too small, but you would always remember the "keepers."

Surgeons, too, have keepers, they just don't always show them to you.

But today, courtesy of one of my patients, I got to see some "keeper" gallstones (one of which measures about 2.5 cm in size) that were recently snatched from her belly and are now offered solely for your edification:







Boy, makes your mouth water, doesn't it?

-Wes

A Piece of Equipment Every Electrophysiology Lab Needs

File this under the "totally cool" file.

I've written several posts on this blog about close entomological encounters that occasionally occur during pacemaker implants. No doubt others have experienced similar moments in other operating rooms or procedure rooms around the world.

Now, thanks to clever military engineers working to eradicate malaria, a new approach is being tested on mosquitoes that would have applicability in every operating room across the country to keep the flying foreign bodies at bay: using a LASER to fry the buggers' wings (See the third video at the link).

Awesome.

-Wes

Blogging from Haiti

Dr. Mike Howard - one of our plastic surgeons, is live-blogging from Haiti. Here's a sample:

Looking at the historical course of cases here has been quite interesting. The quake occured on 12 January. Most amputees relate their first operation was not until 19, 20 or 21 January. Most ex-fixes went on between 22 Jan and 3 Feb. There will be a huge need here in 3-4 weeks just taking off exfixes. The scene is bad now 6 weeks out; I cant imagine the traumatic, mangled extremity scene the first week post quake. Thousands of crushes untreated for days.

Many of our current surgical cases are dealing with complications of prior surgeries. It is at first tempting to say "what were they thinking, doing that?" But, stepping back, imagining the scene and realizing that there was no way of knowing if they or the patient would ever get another chance. It was essentially 4 weeks of damage control surgery. It is amazing that the first groups in, did so much, so well. For the most part.

Case in point: one of my wound patients was admitted, seizing, 4 weeks ago (about 14 days post quake). In the ER, Dr. Ken was about to give him some ativan when a nurse injected the contents of another syringe into the patient. Penicillin. The guy survived his full blown tetnus (Ed's note: types like me) episode and looks great.

And from Wednesday's post:

Got an email last pm from a friend saying, "wow, it must be depressing."

Quite the opposite.

Yes, there is an amazing amt of destruction. The death toll is staggering. The poverty is everywhere. People living in the streets with nowhere to go or tents in front of their houses, afraid to go back inside. Corruption rivaling that of Chicago - maybe worse. The trauma fresh on the peoples faces and bodies. A generation of amputees in a country with zero handicap accessibility.

But, in the midst of all that, the sun is shining beautifully, the orphans at our hospital are truely smiling. The Haitian people are so friendly and appreciative. The volunteers are coming from everywhere, some alone, some by the bus load.

Health care doesn't get better than this. Nice work, Mike.

-Wes

The Risks of Hospitals Live-Tweeting Surgeries

Should hospitals send twitter "updates" on patients undergoing complicated catheter ablation procedures using "pre-approved" scripted story lines?

In a far corner of the operating room Thursday, a Web producer and a cardiac expert with St. Vincent’s huddled over a laptop. They chronicled the procedure largely from a script that Oza had signed off on a day earlier.

The procedure uses radio frequencies to scar parts of the heart. The scars block signals sent from a quartet of veins in the left atrium, signals that cause the heart to go haywire. The entire procedure is done using a catheter inserted into a patient’s groin while the patient is anesthetized.

Given several hours of time to fill and only a page and a half of script, Candy Bowen, the Web producer, sprinkled in descriptions about atrial fibrillation and gave health tips. Meanwhile, in the waiting room, Peacock’s family watched the updates on a wide-screen television.

“It’s some reassurance that everything’s going well,” Melissa Peacock said.

A few minutes before 6 p.m., this message popped up on Twitter: “Mr. P says Hi, and is responsive.” And then a minute later: “Mr. P has been informed that his family has been updated. And he’s smiling.”

I'm all for education using social networking, but when doctors and technicians tweet live (even if it's scripted), they risk appearing more concerned about their marketing efforts than the patient's well-being. If a complication ever arose in such a situation, what would happen? Would the world be updated? What about the family watching the tweets on television as a doctor returns to explain what really happened during the procedure?

One only has to look back at the problems a formerly anonymous doctor blogger encountered when his identity was revealed in court during a malpractice trial and the contents of his blog than might have been used against him in court. He settled.

As trendy as tweeting "live" surgical procedures might seem, I fail to see how this benefits the patient undergoing surgery at all. Education of a surgical procedure can always occur before or after a procedure. If a complication were to arise during a live-tweeted or scripted-tweet surgery, the responsible doctor and hospital might ultimately find themselves in the very uncomfortable position of having to explain their actions to a jury.

-Wes

Wide Awake Open Heart Surgery

Click image to enlarge

Why someone would want to do this, I haven't a clue.

Swaroup Anand, 23, from Bangalore, is fully conscious as he undergoes open-heart surgery. An epidural to the neck, administered at the city’s Wockhardt Hospital, has numbed his body. Dr Vivek Jawali pioneered the technique ten years ago and has recently released a tutorial on DVD which gives a step-by-step guide to the procedure – sorry, but you can only get a copy if you’re a surgeon or an anaesthetist.

Seems there would be considerable risk of respiratory compromise is the epidural went too high. But according to this video, over 400 cases have been performed, including a bypass with aortic valve replacement!

I don't know... I'm not sure I could stomach the sound of the bone saw or, worse, if the surgeon said "Oh, crap..."

-Wes

h/t: Slashdot

Reference:
Chakravarthy MR, Jawali V, Patil TA, Srinivasan KN, Manohar M, Khan J, Jayaprakash K, Das JK, Mahajan V. "High thoracic epidural anaesthesia as the sole anaesthetic technique for minimally invasive direct coronary artery bypass in a high-risk patient." Ann Card Anaesth. 2003 Jan;6(1):62-4.

Frontloading Surgical Performance

I must say, in all the years I have been practicing medicine, I have never seen a "thank you" gift delivered before surgery, but recently, our team got delivered this:

Click image to enlarge

Needless to say, I was floored.

But then I read the note, which was priceless:

Click image to enlarge

Fortunately, all ended well, and no "oops" were had.

But talk about the pressure to perform well!

:)

-Wes

The Academic Surgical Model Strained

It seems the requirement for surgeons to be part of academia (and therefore, have to contribute to a medical school's "dean's tax" for the priviledge of their academic title), caused surgeons to bail in West Virginia:

“The construct of this relationship historically has dictated that all of the surgeons in the program had to be academic full-time faculty in the School of Medicine. So, I think one could argue, and it was certainly Mon General’s perspective that by only having one model under which cardiac surgeons could work in this market constrained the recruitment process,” McClymonds said.

These days, money talks. Declining Medicare payments coupled with declines in the surgical workforce are permitting many academic surgeons to rethink classic payment models.

-Wes

The Drawbacks to a 48-hour Work Week

In England, it seems bureaucratic work limits might have drawbacks:

The survey showed significant under-reporting of hours worked by trainees as NHS Trusts struggle to meet the new restrictions.

It found only 25% of surgeons think their human resource departments accurately reflect their actual working hours.

And 85% come in to do surgery on their days off.

More than two-thirds reported a deterioration in the quality of training and operative skills as a result of the new working patterns.

When we adopt this policy, just make sure I get the day shift, okay?

-Wes

The Sights and Sounds of Open Heart Surgery

Here's some nice footage of open heart bypass surgery.

(Warning: the heart contains blood.)

In medical school, I was always impressed that the sounds and smells of the operating room never accompanied pictures I'd see in text books. For the unititiated, these can take one by surprise. Although the smell of electrocautery cannot be captured in this video, the sound of the bone saw as it cuts through the sternum is recorded... loudly.

-Wes

Surgical Schmear

The surgical scrub sink is being replaced with schmear.

The days of slathering povidone iodine or chlorhexidine solution over your hands and scrubbing your hands for 3-5 minutes with a soapy watery mess dripping from your elbows as you enter the procedure room or operating room no longer flies. Instead, you get to don “emollients” that stick like gooey glue to your hands and provide continuous “kill” to the bacteria throughout the surgical case. It seems there’s some industry-sponsored research that proves its improved bacterial kill rate. Just wipe in on your dry hands (yes, doctor, they must the dry), let the alcohol evaporate, and slide on those gloves! Total prep time – about 15 seconds. Fast, efficient, effective and relatively cheap.

What could be better?

But it was shocking to find this little orange dispenser next to the scrub sink (arrow) and my usual water-based soap dispenser removed:



Now, I look at our poor scrub sink. Lonely, cold, dull stainless steel. Who will love it when water no longer flows there? Instead, I now look down at my hand after squirting a bit of this slime there and wonder about its uncanny resemblance to… oh, never mind…



All in all, it’s been a paradigm shift in the way I prep for cases. Yes, it's faster. But there's never enough of this stuff to cover your hands and arms with one little squirt. And I ask myself, is it better for the patient? I'm not sure - it's just too early to tell. But one thing's for sure: the residue that remains bound to my hands at the end of each case is most disconcerting - bound for eternity to my dermis so that super-resistant organisms grow on my keyboard.

Why do I know this?

Because I no longer have any regular soap available to wash this stuff off.

-Wes

Ref: Guidelines for Hand Hygiene in Health-care Settings (pdf): Recommendations of the Healthcare Infection Control Practices Advisory Committee and the ICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force, Morbidity and Mortality Weekly Report. October 25, 2002 / Vol. 51 / No. RR-16.

Subspecialist Shortages and the EMR

The growing pay gap of non-procedurally-based subspecialties is threatening acute shortages of physicians in those fields:

A discipline built on spending time with patients to gather clues for a diagnosis, neuro-ophthalmology could become another casualty of a medical payment system that favors high-tech procedures over low-tech exams. The median income of a neuro-ophthalmologist at a teaching hospital is $200,000, according to the North American Neuro-Ophthalmology Society. That's a third less than most general ophthalmologists, who undergo less training but can see more patients, and do more pricey procedures, in a given day.

Many in health-policy circles have focused on how the current health-care payment system is helping create shortages among primary-care doctors, internists and others on the front lines of medicine. But often lost is how the system is endangering some of the country's most highly trained specialties as well.

Endocrinologists, rheumatologists and pulmonologists -- specialties that also don't involve performing many procedures -- face acute shortages. Many of the severest deficits affect children. Though nearly 300,000 children in the U.S. are diagnosed annually with juvenile arthritis, lupus or other complex rheumatic diseases, there are fewer than 200 pediatric rheumatologists to take care of them, according to the U.S. government's Health Resources and Services Administration.

And while this is concerning, it is only the beginning of the story.

New pressures are mounting on proceduralists (like gastroenterologists, cardiologists, radiologists and orthopedic surgeons) to increase procedural volumes. In multispecialty groups, the Medicare reimbursement system which devalues time with patients through its arcane and toxic documentation requirements shifts the burden of revenue generation to specialists to support other subspecialties that are less profitable. High-productivity specialists are now urged to do more to cover short-falls in revenue by their business managers. Even small fluctuations in practice volumes are seen in real-time thanks to electronic billing and the Electronic Medical Record (EMR).

The EMR has become not only the administrators' friend, but the proceduralists' as well. Thanks to text-generating "macros" (sometimes called "dot-phrases") the burden of the pre-op history and physical has been all but erased. If a patient has one cataract done thirty-two days ago (outside JCAHO's 30-day requirement), well then, no problem, just hit a few "dot-phrases" and presto! Away we go! "Dot phrases" can load up an empty history and physical form faster than you can say "operation."

But this push to increase procedural volumes, so easily tracked by the electronic medical record, puts additional burdens on today's procedural specialists and creates new patient-care conflicts. Increasingly, there is a push to tie physician compensation to "productivity." Productivity, then, becomes king. And for the patient who desires careful analysis of procedural options, careful decision making becomes clouded as salaries are increasingly tied to productivity.

So for doctors, the dark underbelly of the EMR for patient care is surfacing: despite its marvelous communication capabilities and efficiencies, the EMR has now become the quintessential business oversight tool and might just threaten the doctor-patient relationship as we've known it.

-Wes

HeartNet for Heart Failure

Heart failure occurs then the heart pump is unable to meet the body's metabolic needs. It typically occurs from two basic pathologies: (1) dilated cardiomyopathy, where the force of contraction of the pump is diminished and the wall tension stretches the chamber dimensions of the heart or (2) restrictive cardiomopathy, where is heart pump works normally, but the heart is restricted from receiving blood, either because it's muscles don't relax to fill adequately or because the heart is encased in a non-compliant shell that restricts filling.

To me, I just don't see how the HeartNet device, a nitinol wire mesh that encases the heart and will ultimately be surrounded in fibrous tissue, won't just convert the pathophysiology of a dilated cardiomyopathy into that of a restrictive cardiomyopathy...

A 6-month trial seems much too short to test the long-term safety of this device. After all, the wire mesh puts a whole new meaning to "a porcelain heart."

-Wes

Reference: Early, industry-sponsored results.

Virtual Surgery - is Wii for Me?

It seems there's real push these days for ways to train our future surgeons without having to get their hands wet. By playing a few Nintendo Wii games, surgical residents improved their performance on a laparoscopic simulator compared to their non-practiced counterparts. I'm not sure why practicing with a Wii to improve upon another virtual experience is big news, but hey, I don't make the rules.

But maybe I should try this. After all, it sounds fun. I could stay up all night gaming and come in to the operating room all bleary-eyed, with Wii-tenosinovitis and be unable to pick up my instruments.

And why stop there? Why not simulate all of medicine? I mean we have SimMan and SimBabies. Heck, why not use SimDolls to simulate overcrowded ER's (sorry, I slipped with this one).

But before I go out on a limb and say too many more disparaging comments, there might be some benefits to all of this, if surgical simulators could be developed from a surgeon's perspective. For instance, Johnnie Chung Lee of Carnegie Mellon University's Human-Computer Interaction Institute has demonstrated simple adaptations of the Wii that could be implemented into virtual surgery simulators, like head-tracking, finger tracking, or even manipulating surgical fields with your hands just like manipulating an electronic white-board. Imagine using these ideas with the anatomy of Argosy's Visible Body. Although the tactile look and feel of real surgery will be hard to replicate, the visual experience could be made very dramatic.

-Wes

Addendum @ 08:30AM 18 Jan 2008: Hmmm. On second thought, now that the video game industry earns $18 billion a year, maybe they're on to something...

Maiden Voyage

“Hey, you wanna see an operation?”

“Uh, sure.”

“Look, when we go in, just tell ‘em you’re a ‘fourth year.’ They’ll think you’re a fourth year medical student, rather than a senior in college.”

“Really? You sure that’s okay?”

“Hey, these guys are cool and they’re doing a really amazing case today. Some guy needs a repair of a huge descending aortic aneurism.”

“Cool,” I said, not really knowing what a descending aortic aneurism was at the time.

“Alright, follow me.” We walked through a labyrinthine series of halls and institutional doors. A few buttons were pushed on a door lock, and the heavy door was pushed aside to reveal the inner sanctum of a men’s locker room. It didn’t look too different from the locker room of my high school: lots of vertical lockers with little padlocks securing the handles and the artificial fluorescent lights that gave a pale green glow to your face.

One particular shelf had his interest as he sorted through some pale blue garments.

“Here, these look like they’ll work. Try these.”

“Can I wear my t-shirt?”

“No! You can take that off and hang it over here with your pants,” as he pointed to a series of hanger hooks perched above a large plastic bin marked “Soiled Linens.”

So I took off my clothes and put on the pale blue pants and shirt. The pants where held in place by a flimsy red draw string, the shirt was large, but felt comfortable with a deep v-neck exposing my upper chest.

‘What shoes should I wear?”

“Oh, those’ll do fine. Just put these over them,” He handed me this ridiculously small shriveled ball of paper with an elastic band attached and said: “One size fits all.”

So I sat on the bench in the locker room, put back on my tennis shoes and stretched the ridiculous elfin shoe cover over each shoe.

“You gotta put on these, too.” And I looked at his hands which held another pale blue paper ball with elastic attached and a surgical mask. It seemed the next elastic paper item was to be stretched over your hair, and the surgical mask had all of these strings attached.

“This is perfect!” he whispered. “Here, let me help you tie that mask.” And he proceeded to tie one pair of ties behind my neck and the second pair over the crown of my head. “There! Check it out,” as he pointed to the mirror.

I looked and saw myself looking every much the part of a surgeon. Regal. Mysterious. Or maybe like a bandito about to rob a train. I smiled as the thought came to me, but he couldn’t see.

“You ready?”

“Sure.”

So off we went, out of the locker room through another door that opened into a long hall of the hospital. Like classrooms attached to a main hall, I could see through windows revealing other rooms packed with equipment, but most were empty. It was a Saturday after all. He waved me on in excitement.

“Here.”

And he opened to door.

I was completely unprepared for what I saw. Worse still, what I heard and what I smelled.

It was an electric kind of smell. Pungent, unfamiliar, like someone burning wood blended with steak and torched with an arc welder. It’s hard to describe. Except that it was unpleasant. No, that’s too kind. It reeked.

The light over the blue-draped table was incredibly bright – and cast a white-orange tint to the drape over the object on the work surface. Several surgeons stood on stools to get a better look wearing funny black-rimmed nerd glasses. A trail of smoke rose from the table each time a high-pitched musical tone could be heard. One of the surgeons held a thin garden hose full of (Holy sh--!) foamy blood. The hose was attached to a large container with a second clear tube attached to the wall. I could hear slurping. Again and again. Sschlluuurrrrrpppppp. Sscchhllluuurrrppppp. Then the tone and smoke and scccchhhuurrrrrppp again.

“Why don’t you stand over here?” he said to me, pointing to the area where the anesthesiologist was standing. “You can get a really good view from there.”

So I hesitantly walked over as he introduced me to the anesthesiologist. “Hi, Joe, this is my brother, he’s a ‘fourth year’ from Duke.”

“Nice to meet you. Wanna stand up here to see?” as he pointed to a small black stool barely 4 inches high. Next to him was a daunting array of machinery with some sort of bellows rising and falling with manometers and electronic gadgetry attached to this thing beneath the drapes. I looked down and saw hair for the first time. There was a body beneath the drape, lying on its side, with a white tube in its mouth and eyes taped shut. I peered over the wall-like drape separating the anesthesiologist from the surgeons and noticed what was happening for the first time. There, to my amazement, was the chest cavity, held open by a large rib-spreader, and a balloon like purplish-red organ rising and falling to the soft sounds of the machine: Shhhhhhhh. Gaaaaaaaa. Shhhhhh. Gaaaaaa. With each “Shhhhhh,” the balloon rose. With each “Gaaaaaaaa,” the balloon fell. It was his lung. Cool.

But there was bleeding. Lots of it. Seems the aneurism was leaking.

Shhhhhllluuurrrrrp. Tone. Smoke. Shhhhhlllluuuuurrrrrrrrrrpppppp. Tone. Smoke. Electronic smells pierced my olfactory bulb. I looked around. Everyone so focused.

“Mets.” I heard the surgeon say as he held out his hand and a scrub nurse slapped a pair of scissors in hid hand. “Hold here. Bovie.” He glanced up at me. “So you’re at Duke?”

“Yeah.”

“Know Dr. So-and-So?”

“No, can’t say I’ve met him.”

“Good guy. Head of Cardiothoracic Surgery. We trained together. Hey, don’t hold that like that, hold it this way. Suck!”

Our conversation was over, thank God. He returned to the operation.

Shhhlluuurrrrpppp. Really long tone. Lots of smoke.

I’d been standing of the stepstool for a while and noticed a sudden wave of nausea hit me. I felt cool. Clammy.

Schhhllluuuurrrp. Sccchhhhhhllluuuuuuup. Gurgle, gurgle. More smoke: like the smell of napalm in the morning. Shhhhhhhhhh. Stink. More smoke. Sccchhhlluuurrrrrp. Bleeps. Gaaaaaaa.

By now, I was feeling really nauseous. The thought of blowing chunks all over the operative field entered by mind. Maybe this is why I was wearing the mask over my face – to prevent such a moment. I noticed the medicinal smell of the mask and noted the little fibers tickling my nose as if to coax me into projectile vomiting.

“Uh, is there a bathroom nearby?”

My brother looked at me. My face was as white as a sheet. Maybe green is a better description. He’d seen that color before, I think, on someone dead.

“It’s just out the door to your left,” pointing me the way. I managed to make it back to the bathroom and just felt like hell. I sat on the toilet, unsure of what would happen next. I wanted to puke, but couldn’t. I put my head down, panting. I just wanted to die I felt so bad. So nauseaus. Oh, pleaaaasssse, just puke and get it over with! But it was not to be.

A few minutes later, my brother came back to the bathroom.

“You okay?”

Never wanting to sound like a wimp to my brother, I proclaimed, “No, I’m okay, I just need a few minutes” from the bathroom stall. My nausea finally seemed to be improving a bit. Slowly, gradually, I was coming back from the dead. Finally, I emerged from the stall, smiling.

My brother looked on in horror as he saw his brother emerge from the bathroom still looking like hell warmed over. He was nice enough to not say anything.

“So what ‘d ya think?”

“Awesome.”

-Dr. Wes

Image credit.

Close Encounter

Disclaimer: My spousal consultant, in the interest of retaining my current place of employment, has insisted that I take a moment to note that this case occurred at a previous location, that will go unnamed, although I suspect it has happened elsewhere.

It was a case like every other Friday afternoon - a lady in her 80's who needed a permanent pacemaker after falling at home and arriving to the Emergency Room with a heart rate of 30.

After a careful evaluation of her situation and agreeing that a pacemaker made sense, I discussed the risks, benefits and alternatives to a permanent pacemaker implantation with her, and she agreed.

She was brought to the pre-operative holding area and her left upper chest was prepped with an antiseptic solution for 5 minutes. She was pre-medicated with an antibiotic to avoid infection, and after wheeling her into the electrophysiology laboratory, her chest area was prepped twice more with antiseptic solution.

Great care was used to drape her first in sterile towels, then this was covered with an antiseptic-impregnated plastic film that was draped over the surgical site. Next the sterile final drape was carefully exposed over the operative field to shield all other contaminated areas from affecting the surgical site. A plastic cover was placed over the image intensifier of the x-ray tube, and finally, her face exposed to the nurses on the other side of the bed.

A local anesthetic was infiltrated beneath the skin:

"You'll going to feel a pinch and a bit of burning as we numb up the area here, Mrs. Smith."

She jerked slightly, but soon tolerated the anesthetic. After all, this was the necessary step to avoid the discomfort of the pacemaker implantation. She tolerated the anesthetic administration remarkably well.

A bright light shown from my forehead, an operative light strapped there to permit the light to move where my visual field traveled. It illuminated the surgical area remarkably well, causing the patient to question, "What it that light I see flashing?" she asked.

"Oh, it's just a bright light I use to see into the surgical area, Mrs. Smith." She silenced as the sedation took effect.

A small silver scalpel blade was then pressed against the skin and passed to the subcutaneous tissue in one smooth stroke. Bleeding was managed with gentle pressure and a cauterization unit stopped the flow of significant bleeding.

Suddenly, a small flurry of activity occurred in the back of the laboratory. I was unaware at first. It was just a minor scuffle. But soon one of my technicians could be seen standing on a chair waving a towel.

"What the...? Can I help you guys?"

"No, thanks. Just keep working."

"How the hell can I keep working when you guys are dancing on chairs around the EP lab?"

"Well, it just... well... this...."

"Whaaaaatttt???"

"... this... this... fly."

"What the hell are you talking about? You mean we have a fly in here?"

"Yes, sir."

"Turn off my headlight, guys! I don't want that sucker over here!"

The light was dimmed. We stood motionless, waiting for any hint of motion from the little tiny black contaminated object.

Nothing.

We waited.

My technicians had a vague idea where they had seen it last. They approached one corner of the operating suite. Suddenly, like a Komikaze pilot aiming for the sterile surgical drape, the fly turned perilously close to the surgical field but veered off at the last moment toward the room light above. My technician, armed with a medium sided towel, hurled himself toward the critter, but as he turned to address the flying foreign body, his head collided with the xray monitors dropping him to the ground like a giant sequoia. He rose quickly, determined to capture the maggot with wings, blood dripping from his brow. The fly, impervious to the damage below, circled above. I stood scrubbed, helpless.

By now, the nurses, too, had joined the chase. The fly had become Public Enemy Number One. Nothing could proceed until we were assured of its demise. The contol room technician and industry rep, too, helped identify the location and trajectory of the defiled detritus with wings.

"In-coming," I said as the fly approached the surgical field.

A maze of hands attached to towels swooped in to prevent the flying refuse residue from entering our "no-fly" zone. But his velocity exceeded their swipes. As he approached the surical field, they withdrew. The fly made a close pass, but hurried past to the corner of the operating room. There, it made one critical error: it landed briefly.

By now, my blood-stained technician, fire burning from his eyes, descended on the critter with such might, it looked like a scene from Apocalypse Now, and the fly was flattened. He raised his hands, victorious.

We all breathed a collective sigh of relief but stood stunned at what had just transpired. Soon, my headlight was illuminated once more.

"Well alrighty then... Anybody got some valium for the doctor?"

-Wes

Photo credit.

CT Surgeons as Virtual Heroes

Has the CT Surgery market become so compromised that they need to turn to virtual surgery games for training?

-Wes

Surgical FlashLites

Found this at the Heart Rhythm Society meeting, and finally had a chance to download a few pics from my camera. Check out this little flashlite that uses a small adhesive disk to attach to surgical gloves or an electrocautery pen:


It might just help bail someone out of a surgical "hole" when you can't find that bleeder in the back of a sugical pocket. The sterile mini-flashlite seels for $19 each and uses a small LED lite bulb. I suspect the glove or electrocautery pen should be dry before attaching, so you might have to change gloves before applying one of these. Here's a closer view:


The device, called SiteLight® is made by Pressure Products, Inc., which makes lots of little gizmos for the electrophysiology surgical suite. We also saw sterile laser pointers for teaching, too, although I could not find either of these devices yet on their website, yet. The shelf life of the packaging is about three years, we were told, due to sterility issues.

This might also be useful for folks in the ER. It's almost like this small company is becoming the Sharper Image or Brookstone of electrophysiology surgical products.

-Wes