"Surgery- the fine art of removing diseased parts with the expectation that the patient will be better."



Learning Surgery can be a daunting task, but thankfully the days of trying to read Schwartz's Principles of Surgery, what I generally refer to as trying to read the unofficial "Encyclopedia of Surgery," are behind us.  A great web resource can be found at Surgical-Tutor, a British site.

There is considerable depth to this site, and looks like something for everyone.  Students and junior residents will benefit from the numerous Clinical Tutorials, which go over common cases, illustrated with images.  There are also banks of radiology images, and pathology as well.  I especially enjoyed the Journal Club section, which had important articles, all nicely summarized by topic.

Also notable is that the high quality content is all free, so this is one site to bookmark.



Decompressive Craniectomy in Diffuse Traumatic Brain Injury

In the patient with a severe traumatic brain injury (TBI), it is of the utmost importance to control intracranial hypertension, and to maintain cerebral prefusion.  There are several strategies to accomplish this, but a secondary therapy is a decompressive craniectomy.

The New England Journal did a randomized trial on 155 adults with severe TBI and diffuse injury, looking at decompressive craniectomy versus best medical therapy.  On the one hand, the craniectomy had a shorter ICU length of stay, less overall procedures and less time of elevated intracranial hypertension (ICH).  While achievement of these results is important, other endpoints paint a different picture.  These include that the overall mortality did not change, and the GCS scores at 6 months (the so called extended Glascow Outcome Scale), were worse in the craniectomy group of patients.

Unfortunately, this study reinforces why this procedure is so infrequently performed.

N Engl J Med 2011; 364:1493-1502


Quote of the Day

 "Specialists know more and more, about less and less, until they eventually know everything... about nothing."


Dexamethasone To Reduce Hospital Stay

I have to say that the addition of a steroid, to a patient with an active infection often feels like an oxymoron.  After all, just when the patient is battling a severe illness, why would we want to shut it down?  Of course, I am not talking about those cases of relative adrenal insufficiency, where the steroid becomes a treatment for this, and is not functioning primarily as an immunomodulator.  Anyway, in the recent study from the Lancet, the steroid used was dexamethasone which has minimal mineralocorticoid effect anyway.

Meijvis and colleagues randomized 304 patients with community acquired pneumonia (CAP) to receive dexamethasone 5 mg IV daily for 5 days, or a placebo in a double blind fashion.  This was done in 2 emergency departments, and those in need of immediate admission to an ICU were excluded, which implies that there were few, if any, critically ill patients included in this study.

At any rate, there was no mortality difference, and the dexamethasone patients had a mean length of stay (LOS) of 6.5 days, which was a day shorter than their control counterparts.  However, there was a price to be paid as there was a significant increase in hyperglycemia in the steroid group.

Lancet. 2011 Jun 11;377(9782):2023-30. Epub 2011 Jun 1.


Not Too Old For Surgery

My general philosophy is that age alone is rarely a contraindication to surgery. In fact, elderly patients generally have less physiologic reserve, and often do better with an early surgical approach to most problems.

While many elderly do fine with traumatic brain injury, and require only observation, with little to no intervention, a recent study in the Journal of Neurosurgery shows that patients over 80 years old, did as well as their younger counterparts after surgery for intracranial hematomas.  While the length of stay increased as well as the complications in the elderly group, the overall mortality and return to functional status did not differ.

More info


Yales Goes With iPad

I remember the note service in medical school, and it was a royal pain in the butt. All those notes, and after a few weeks, there were piles of paper everywhere, and the night before the test you would realize you were missing some transcript. So then I got organized, and put them in these humongous binders, that before too long were about to explode.

Now Yale is taking a new approach. They are using an iPad, and a top of the line, 32 GB 3G with a Bluetooth keyboard at that. Add in that they can now load a full year worth of notes, and I am seriously sold at this point.

Just don't tell me it is a computer...




I have no idea what they are saying, but it looks like they are looking at the aortic arch. It would be nice to be able to see the CT images without leaving the operating room table. Will iPad's become standard OR equipment?


The Multidisplinary Team

It has been shown several times that having an intensivist in an ICU is associated with better outcomes. However, they shouldn't get all the credit. Taking care of the critically ill is never for one person alone to do. At least one of factors for the better outcomes is due to having a multidisciplinary team making rounds, at least according to the Archives of Internal Medicine. So, next time you see a crowd of folks making rounds in the unit, just realize that they are making a difference.

Arch Intern Med. 2010;170(4):319-320.


Check & Double Check

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I have to say that the video doesn't mention that small things can easily be lost in the retrocardiac region. I have heard that some centers don't even count the 7-0 prolene needles because they are so small, and easily lost. While the patient may have numbness, AFAIK there is no way that a bulldog clamp left in that area could cause hand numbness.

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Laparoscopic Surgery Not Better For Surgeons

While there are many benefits for patients of minimally invasive surgery, it is not at all ergonomic for the surgeon. I know some surgeons that argue that using the Davinci robot system is the safest way to avoid it. However, not all surgery will be done that way as that is a 2 million dollar device. In the meantime, the wrist can certainly be affected by the reptitive motion of laparoscopy.


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King Tut Died of Leg Fracture, Malaria

The abstract in JAMA can be found here.

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