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A Vital Measure: Your Surgeon's Skill // NYTimes

It has been clear for nearly 30 years that not all surgeons produce the same results. The reasons, however, have remained elusive. Most studies on surgical quality have focused on what surgeons do before and after surgery, practices that are easy to measure and analyze, like giving antibiotics to prevent surgical wound infections and administering blood thinners to guard against the development of blood clots.

But even with the most compulsive adherence to these pre- and post-operative protocols, and much to the chagrin of many a well-intentioned health care expert, payer and policy maker, significant disparities in patient outcomes after surgery have persisted.

The reason, observers have postulated, may be the one, obvious thing that most of these initiatives have scrupulously avoided: what goes on in the operating room.

Now an innovative collaboration between researchers, payers and weight-loss surgeons, the Michigan Bariatric Surgery Collaborative, has addressed that-which-could-not-be-named. And their findings have confirmed what patients have long suspected and trainees have long known – the dexterity of a surgeon’s hands can account for much of the differences in how well patients do. (» more)

It’s just an operation doctor…

Ok, does anyone else come across this odd attitude that people have when coming into ER/A&E as regards having or getting operations?

People seem to think that having an operation is an easy thing. I usually get told: “That it’ll be all ok because I’ll have an operation” or the most common comment “but it’s just an operation”! I also get asked to “just put me to sleep” for the tiniest wound that I might need to suture in A&E.

People do not seem to understand that one of the risks for ANY operation is death. Yes. Even those really simple operations. Of course, the risk is small and I don’t want to scaremonger too much but there is always a risk! Not so much from the surgery, but more from the anaesthetic. We do these things everyday, but medicine is not 100% predictable. Things happen and might go wrong. Patients might react differently and suddenly to different medications. It’s like riding a bucking bronco. Anything can happen!!

So remember, operations and anaesthetics are serious business.

Night shifts are over! Whoohoooo

Ok so I was asked if anyhting interesting happened on my night shifts. to be fair, nothing really. It was alittle like waiting for the storm to arrive, but nothing did.

However I did learn one thing.


I was asked by a surgical reg to go and assess a lady that they wanted to do a laparotomy on. These are the details:

  • 92 years old
  • admitted under medics 4 days earlier with abdo pain
  • treated as an UTI
  • now becoming hypotensive, tachycardic and tachypnoeic
  • ?perforation
  • deteriorating conditions at home
  • minimal function

I assessed this lady and was extremely concerned that she would not survive any operation! But the surgeons still wanted to operate :O My boss was in and even came to see this lady herself. We spoke to ITU and decided that she would have 100% mortality if we anaesthetised her. In fact she had 100% mortality in the next few hours/days anyway. She would not leave the hospital. We spoke to her family and informed them of this, they were happy to leave it in our hands as they realised how sick she was. The operation was cancelled.

I found out from the medical team that this lady passed away 5 hours later.

So the lesson to be learnt is:

A good surgeon knows when to operate.

A great surgeon knows when not to.


¿Where is the trauma?- Patient that was being crash by a car. 

Ouchy!! I’ve seen these injuries many times in both A+E and in the forensics lab. Pedestrian vs Car. The tibial fractures are secondary to the bumper.

But if you get faced with this in A+E/ER - do ABCDE first, but be aware that you may have to deal with catastrophic haemorrhage from the legs if there are bleeding arteries. Immobilise! This patient (if they are alive) will be heading for bilateral external fixators!

Be prepared to deal with stuff like this in A+E/ER!


A) you could tell me this isn’t cool, but I would disagree COMPLETELY
B) I like that metal hand holding down the hand

It is cool, the pulleys in the fingers holding down the tendons are stunning!! Know these for A+E/ER. Very useful in tendon damage and lacerations to fingers and hands. Learn your ANATOMY!!

As for the metal hand - its lead, very malleable and brill to play with (not that I ever did!) ; )

(Source: vvarcrimes)


Man Walks Again After Surgery to Reverse Muscle Paralysis

After four years of confinement to a wheelchair, Rick Constantine, 58, is now walking again after undergoing an unconventional surgery at University of California, San Diego Heath System to restore the use of his leg. Neurosurgeon Justin Brown, MD, performed the novel 3-hour procedure.

“Following a car crash, Mr. Constantine had a brain stem stroke that caused paralysis on the right side of his body.  His leg muscles became so severely spastic that he could not walk,” said Brown, director of the Neurosurgery Peripheral Nerve Program at UC San Diego Health System. “Our team performed a delicate surgery to reduce input from the nerves that were causing the muscles to over contract to the point of disability.”

“After my injury, I was told I would never walk again. All I could to was move from my wheelchair to my bed or a chair,” said Constantine, a former NASCAR crew member. “After surgery with Dr. Brown, I could put my foot flat on the ground to walk. With physical therapy, everything just gets better and better. I’m a firm believer in never giving up.”

Prior to surgery, Constantine underwent botox treatments and physical therapy in an attempt to restore the use of his leg. The results were positive but minimal. An additional nerve conduction study, called an electromyogram (EMG), identified the muscles causing the dysfunction.

“When all other options did not produce satisfying results, we opted for surgery,” said Brown. “With the EMG, we identified the over-excited nerves that needed to be downgraded. Mr. Constantine had surgery on a Friday and within days was in physical rehabilitation. Two weeks later he was walking without a walker and has even completed a 1-mile race without assistance.”

The surgery, called a selective peripheral neurotomy, is a procedure performed under a microscope.  Brown makes an incision behind the knee to reach the tibial nerve. He then selectively trims back the troublesome nerve branches by up to 80 percent.  Cutting the nerve reduces the “noise” being relayed back to the spinal cord which causes the spasticity.

More here

Patient of the day

26 yo male post lap chole.
No one in recovery thought something might be wrong, when the drain bottle needed to be changed (they are 500mls).
Only the wonderful scrub nurse who has a fab head on his shoulders went “woah!! Check the patient!!” After being asked for another drain bottle! O_O

BP 70/30
Very weak distal pulses
Cold and very clammy!
More confused!

Hmm, hypoxia secondary to hypovolaemia?

Straight from recovery into emergency theatre. Loads of clots, but no obvious bleeding point!

Lesson from today-
If the drain bottle is full, get the surgeons!! There is a bleed!

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