Saturday, September 24, 2011
In which we see how hands are restored and what our cast thinks of TV doctors
The patient is asleep and draped on the OR table. He is a 42 year old male, right hand dominate, married, father of two, a computer and electronics repair man who works in his own wood working shop on weekends. He is here in the OR because he had an unfortunate encounter with a table saw and his right hand. Table saws are responsible for more hand injuries than any other power tool. In the music industry, the annual award is the Grammy, a miniature gold gramophone. If there was an annual award for hand surgery, it would be a miniature gold table saw. The patients right arm is extended out at a right angle to his body on an attachment to the OR table just for hand surgery. It is about two feet wide and three feet long. Seated around the hand table on stools are: Dr. Lamb, hand surgeon, Dr. Oriel, a hand fellow (a fellow is a fully qualified surgeon, who has completed a residency and passed his board exams, and is doing an additional year of training in a sub-specialty), and Debs, an OR Tech. Anne is the circulating nurse. Behind the sterile sheet raised to separate the patients head from the sterile field is Dr. Spiro, anesthesiologist. This raised sheet is referred to as the “ether screen”, the term an anachronism from the days when ether was used as an anesthetic agent. Lamb and Oriel are wearing loupes, glasses that have magnifying telescopes sticking out of the lenses, giving them highly magnified views of the field, while allowing them to look around the telescopes for an unmagnified view.
Lamb: OK, I think you have done a good job of exploring the injury, tell me what you have found, and what you plan to do next.
Oriel: Well, there are fractures in the proximal phalanges (the first bone outward from the knuckle) in the index and long fingers. There are injuries in the vascular and nerves as well as severance of the flexor tendons. The ring and small fingers seem to be just superficially injured, maybe a flexor tendon in the ring finger. I want to first get the fractures reduced and stabilized, then repair the veins arteries and nerves in the first and second digits. The tendons can be last. The ring and small fingers can wait until the others are finished. The core of the problem here is that the most important fingers for strength and precision are compromised, and this patient needs both to do his work. The ring and small fingers are not nearly as important, but have minor injuries.
Lamb: That’s exactly how I see it. The fractures are clean cuts, so pinning them with K-wires should be sufficient, no need for plates and screws.
Debs had already reached this conclusion herself and had prepared the pin driver with an .045 K-wire, and now extended it to Dr. Oriel. He begins to drive the pin.
Spiro: Anybody see “House” last night? It drives me crazy the way they always start a patient on some drug before they confirm a diagnosis, and big surprise, the patient gets worse!
Anne: He brings in a patient, makes at least three wild guesses at a diagnosis, orders treatments for each wild guess, the treatments nearly kill the patient, then gets inspired by some random visual cue to make the correct diagnosis! And as many professionals have noted: “It’s never Lupus!”
Debs: And House and his team seem to be the only people working in their hospital. No nurses, no lab techs, no radiology techs. No Radiologists, Pathologists either. They do it all themselves!
Lamb: As if any of us would know how to run the lab equipment or what reagents to use for a given test! And where do they find the time to do all that? It must be great to only have to deal with one patient at a time.
Oriel: And what hospital would ever put up with the way that House treats everyone, patients and staff? No way.
Anne: Not like the old TV medical shows. Remember Marcus Welby, Ben Casey, and Dr. Kildare? They were these saints who not only cured your illness, buy reconciled your dysfunctional family, took care of your bankruptcy, and helped you to find God, even.
Debs: I could swear that the AMA had control of the scripts back then.
Oriel: OK, bring in the C-arm.
A C-arm is a fluoroscopic device that lets you see an x-ray image as a still or video picture. It has an emitter on the top of a “C” shaped steel rail, and a drum shaped collector on the bottom. The “C” is attached to a console with a TV monitor on top where the Image is viewed. The “C” shaped part is draped with a large clear sterile plastic bag. The hand is placed on top of the collector and a foot pedal activated by the surgeon produces an image on the monitor.
Lamb: Looks good. Turn it over. You won’t get approximation better than that. (Approximation is the lining up and joining the two ends).
Oriel: just need a second K-wire to stabilize it.
Spiro: I used to laugh at Ben Casey. Old Dr. Jaffe would always watch his procedure from way up in this gallery, where you couldn’t possibly make out the small delicate things that go on in brain surgery. Then after the procedure he always without fail tells Dr. Casey “Your technique is excellent”.
Debs: Anyone here ever actually see one of those galleries in an OR? They are such a staple on TV.
Unanimous answer: No!
Lamb: I’ve been in many, many hospitals and I have never seen one. I never could see the point. You can’t see anything that would matter from such a place.
Oriel: I always wanted to hear Dr. Jaffe say to Casey “Your diagnosis is mistaken and your technique is faulty”.
Oriel: C-arm again. Looks good. Now the long finger.
Debs: Also known as the “flip” finger.
Anne: I think Grey’s Anatomy is probably the worst offender of all. Such an incredible bunch of sex crazed drama queens.
Lamb: C-arm again. Good.
Oriel: Bring in the micro scope. How are we doing for tourniquet time?
Spiro: Twenty-eight minutes.
Oriel: Let us know when we get to an hour.
Anne moves the C-arm out from the hand table and moves in the microscope, a binocular Zeiss with three sets of eyepieces. It also is draped with a clear plastic sterile drape. Anne removes the foot pedal for the C-arm and places the foot control for the microscope. Anne removes the loupes from Lamb and Oriel. The microscope affords them even more magnification than the loupes, but an un magnified view of the field is not available.
Lamb: They get so far-fetched on Grey’s. I get patients all the time with the most incredible ideas they get from that show. Very misleading.
Anne: The doctors are so caught up in their own dramas that they totally lose sight of the patients.
Debs: Those old shows with the saintly doctors stayed away from the doctors lives entirely. The focus was always on the patients, one good point for them.
Anne: Don’t even get me started on how they have portrayed nurses.
Oriel: Give me a double small vein approximator. (Two small clips attached to a small rod on which they can be slid back and forth. By use of the approximator the ends of the vessel can be brought together and held in place for suturing.) (Veins are almost always repaired before arteries in hand surgery. It sees counter intuitive, but the real problem is getting blood out of the injured finger, not into it. Like when you put a rubber band tight around your finger, it swells and gets purple colored and throbs in time with your pulse. There is pressure behind the arterial blood so it still gets in, but the venous blood can’t get out, causing the purple color, the swelling and the throbbing.)
Oriel: 9-0 nylon.
Debs: Here you go.
Debs places the Castro-Viejo micro needle holder with the suture loaded into Oriel’s right hand in the position it will be used, then guides his hand under the microscope until it is in his field of view. This is so that he will not have to look away from the eyepieces of the microscope. She places a jeweler’s forcept into his left hand. She then places jeweler’s forcepts and a micro scissors into Lambs hands, guiding thm into the field of view. Then she looks into her own set of eyepieces. She has a syringe filled with a solution of Heparin at the ready. Heparin is an anti-coagulent, and will prevent clotting until after the repairs are complete.
Oriel starts suturing the vein. Debs spreads a white towel out on the field. The 9-0 suture and needle are so fine, that if it should be dropped it could only be found with great difficulty on the blue sterile drapes. They show up well against white however.
Spiro: Yeah, always standing at the nursing station with perfect hair and makeup, holding a chart. Meanwhile, the doctors are doing all the things that nurses do. And they are always the ones that find when something is going wrong, not the nurses who are the ones who are actually with the patients.
Anne: Or else they are saintly paragons of virtue and self sacrifice, except when they are mentally deficient sexpots. I remember an episode of Trapper John, MD that had a nurse who was a stripper on the side.
Lamb: The classic naughty nurse fantasy. White thigh length high heel boots with spurs.
Oriel: (looking away from the microscope and making an exaggerated wink) You thinking of taking up a side job Anne?
Anne: You wish, you pervert!(Her eyes sparkling with mirth)
Debs: I forget which show, but they had a nurse that was a dominatrix.
Anne: Honestly, that’s about as likely as a physician doing those things on the side.
Spiro: Remember “ER” with George Clooney? I gave up on that one after they had the nurses stealing the resident’s coffee. In my experience it’s always the other way around.
Anne: Amen to that!
Oriel: I will give “ER” and “St. Elsewhere” credit for showing gritty inner city hospitals and taking on some tough story lines like AIDS. But again, too much on the doctors weird personal lives. But at least there was this thing that the exaggerations were just that, exaggerations for comedic effect. They were not presented as if they were serious. That show “Scrubs” is like that. They punctuate with sound effects to make the absurdities plain. Although a lot of the time when they use medical sounding dialog, it's just gibberish.
Lamb: That looks good. Let’s go for the money shot. How are we on tourniquet time?
Spiro: Fifty eight minutes
Oriel: Let’s let it down for five.
Spiro: OK. Tourniquet down.
Oriel: See the artery here? No leaks. And I don’t see it in the long finger. Looks like we got lucky with that one.
She extends the Doppler probe towards Dr. Oriel. The Doppler picks up and magnifies the sound of blood moving through a vessel. By the quality or absence of the sound, the presence and quality of blood supply can be established.
Oriel: Good idea, thanks.
He takes the Doppler probe, and extends the end with the contact plugs to Anne over the patient’s chest. Anne plugs the leads into the Doppler box and switches it on. Debs extends a small plastic cup filled with a clear jell to Oriel who dips the end of the Doppler probe into the jell. The jell increases the contact of the probe providing a better signal, just like the jell used for ultrasound examination of fetuses in a pregnant woman. He then applies it to the index finger. No sound is heard, as expected. He then applies the probe to the end of the long finger. Aloud pulsing, whooshing sound comes from the box Anne is holding. A swishing sound would indicate diminished flow. No sound would mean no flow.
Lamb: good pulse there.
Oriel applies the Doppler probe to the ring and small fingers, resulting in more of the pulsing whooshing sounds.
Oriel: All the rest are good.
Spiro: I really hate the way they portray ERs. Like every person coming in has some big life threatening situation. Reality is that 99.9% of ER admissions are just routine stuff from people with no other access to health care providers, so they turn to the ER.
Anne: And doctors hanging out at the ER doors just waiting for an emergency to come along! As if!
Spiro: Time up. Tourniquet back up?
Oriel: OK, tourniquet up.
Lamb: Now let’s get that artery.
Debs extends an arterial approximator to Oriel. The difference between the vein approximator and the arterial one is in the strength of the clips. Arteries have thicker walls and a muscle layer so that they can constrict and dilate according to the bodies reflexes. The arterial clips must exert more pressure. Oriel applies the approximator and lines up the ends of the artery. Debs hands him a Weck spear, a small triangular cellulose sponge on the end of a toothpick size stick. Oriel uses it to clear the small quantity of blood on the ends of the artery so that he can see better under the microscope. She hands him another 9/0 suture, and jeweler’s forceps. She passes the forceps and scissors to Lamb. She readies a neuro patty (a ¼ by ¼ cotton felt pad) soaked in 2% Lidocaine solution. Because of the muscle layer in arteries, they often go into spasm. The Lidocaine will relax the spasm.
Spiro: I, of course, take offense at the portrayal of anesthesiologists on TV. Most of the time they just sit there doing nothing, just being another part of the furniture. On Grey’s they had one who fell asleep during a procedure, and they started calling him McSleepy.
Anne: You guys are the only ones who get even less respect than nurses.
Lamb: Give us the Lidocaine patty.
Debs: What kills me is how they do CPR on TV. Too slow, with elbows flexing, so that the compressions are worthless.
Anne: And the monitor alarms when it goes flat line, (asystole) instead of a wavy line that would indicate ventricular fibrillation. Monitors only actually alarm when there is a malfunction. Then they proceed to defibrillate even though the patient is in asystole, not a shockable rhythm.
Spiro: I remember an episode of “Medical Center” where Chad Everet, Dr. Gannon, defibs a guy in a parking lot with jumper cables from a car battery. Hah!
Oriel: And on “Gray’s” I even saw them defib a guy that was conscious and talking!
Lamb: How about how they do a surgical scrub? With no mask up, and talking to someone in street clothes!
Anne: They go into OR’s all the time in street clothes. But it drives me crazy how they are talking about all their deep personal tribulations while they are doing all of this.
Debs: And I have never seen them get gowned and gloved in any way that was actually sterile.
Oriel: OK, I think that does it for the artery. Let’s bring down the tourniquet again and get everything freshly perfused.
Spiro: Tourniquet down now.
Debs passes the Doppler probe and jell. A satisfactory whooshing sound is produced. The artery doe not leak. She has prepared the items that will be needed next for repair of the tendons. While they are waiting, they dab the wound with sponges and inspect their handiwork.
Oriel: OK, let’s have the tourniquet back up. Take the microscope away.
Anne pulls the microscope back, then gets the loupes and places them over the surgeon’s heads and in place on their noses. Debs places needle holders in Oriel’s right hand. The needle holder is armed with a 4/0 Dacron suture. She places a pair of DeBakey forceps in his left hand. She places a pair of suture scissors in Lambs right hand. They begin the repair of the tendons in all the fingers.
Anne: Can you believe the miraculous recoveries they have on TV? The patient can have just been defibrillated, and they are talking!
Debs: It’s even worse if they have been in a coma. In reality, they would be demonstrating Aphasia (they inability to retrieve words and generate speech. And they probably would have disphagia (inability to swallow). All that requires a lot of time and therapy to get over.
Spiro: Not to mention that their hair and makeup are in perfect condition.
Oriel: OK! I want to check with the Doppler one more time before we start closing the skin. Then we will need a plaster splint and all the dressings. Debs, great work as usual. You too, Anne.
Spiro: What about me? See? No respect here either. I might as well sleep through this.
Anne: Have any of you seen the new Nurse shows? They are even worse! This “Nurse Jackie” takes the flawed hero/anti-hero, breaking all the rules, up against the establishment, fighting for the patient non-sense that has become the standard for the doctor shows to new heights of depravity. In the show that I saw, she commits three huge felonies; forging a driver’s license, seducing a pharmacist to obtain drugs to feed her addiction that makes House look like a kid on candy, and flushes a patient’s ear down the toilet.
Lamb: Yeah, how do any of these characters keep their licenses let alone stay out of jail?
Debs: Well, at least they aren’t blowing things up, and shooting their way through dens of terrorists, torturing middle easterners on the way to truth like Jack Bauer.
Anne: They are the terrorists.
Oriel: Let me have the Doppler one more time. I think we are going to have a good result here. The fractures did not involve the joints, so there should not be any loss of mobility, we have good circulation. The only problems I see will be connected to the nerve repair. He may have areas of numbness or hypersensitivity; I expect that he will have cold intolerance. But he should have a fully functioning hand.
Lamb: It will take a year or more to see what recovery there is from the nerve damage. All will now depend on good physical therapy. I think he will be a good compliant patient.
Oriel: It is surprising how many patients we get that do not complete therapy, and then complain that they have less than optimum results.