Sunday, January 13, 2019

What if Pathologists Performed Surgery?

A pathologist's Mayo Stand.  " Pass me the hack saw, nurse."

Delay of game is not limited to football. Action in the operating room can be subject to breaks in the action too. Waiting for a frozen section report to come back from the pathologist  or a time out while the circulating nurse scrambled to flash sterilize an esoteric instrument that the surgeon just had to have were common interrupters of what had been feverish goal oriented action in the tiled temple.

I liked to busy myself with buffing surgical instruments until they shined in the overheads or wrestling with wiry twisted chromic suture in a vain attempt to get the kinks out during these postponements. Dr. Slambow did not like my heightened activity during these surgical layovers. One of his life lessons was to take a break whenever you have the opportunity, and as an oldster, I've put that lesson into practice way too many times.

As the intense intraoperative activity ground to a halt, he dropped his usually tense voice  an octave or two as  he admonished, " Take a break Fool, and rest those oversize lunch hooks of yours, I've got a little joke for you; In a perfect world the English would be police officers. The Germans would be engineers, and the French would be the cooks. In a more ghastly universe things would be different. The English would be cooks. The Germans would be law officers and the French would be engineers." Ha..Tee..Hee.

Every scrub nurse knows the obligation to laugh at the surgeon's jokes and make a comment about his clever wittiness, but my mind sometimes wandered and thought about what would happen if physicians other than surgeons performed surgery, just as the characters in his joke switched roles. Standing at my Mayo stand in a post joke moment, I came up with an off the wall  idea that made the notion of German police officers sound like a good thing.

What if pathologists performed surgery? The instruments they would bring to the table are enough to shiver just about anyone's timbers. I had never heard of a #60 knife blade because it's exclusive to the morgue. This monster blade made a meat cleaver seem like small potatoes. It's the only scalpel blade I'm aware of that has an edge sharpened along it's entire length. This blade eschews attachment to an ordinary scalpel handle and prefers mating with an autopsy handle that resembles the throttle of a Harley Davidson Electra Glide. This sabre like snickersnee  reduced cutting to it's most barbaric level. In surgery millimeters mattered. A pathologist's  mindset was calibrated in meters. Monster incisions were OK in the morgue, but wouldn't make for a happy ending in the OR.

A pathologist is experienced with slicing through chilled skin that doesn't bleed. I wonder how the novel experience of dealing with those little bright red bursts erupting from the yellow subcutaneous fat would be dealt with. I wonder if a foul smelling liquid like formalin would cauterize a bleeder. There certainly is an abundance of that nasty stuff in a morgue, but surgery is no time for foolhardy experiments. I suspect they would have to learn how to use a Bovie like everyone else.

That's just about enough of my foolish ramblings. I don't want to even think about those giant hedge pruner implements found in a morgue would be used for. Pathologists are conditioned to simply cut structures  out of the way to expose anatomy. Could they adapt to using retractors for accessing organs?

I pondered that last notion while sipping bean soup for my midday sustenance. Glancing down at my fasciculating fingers and realizing I forgot to take my Sinemet, the thought suddenly occurred to me. Dr. Slambow was right, I do have oversize lunch hooks for hands.

Thursday, January 3, 2019

When the Human Body Works Like a 3D Printer

Here is a case of human reproduction that does not involve a gamete, egg, or mitosis. I would have mentioned "ploidy" too, but I'll be darned if I can remember what that involves. A 35 y/o man who was critically ill had a vigorous  coughing fit which was so  productive that he hacked up this blood clot which formed in his right main stem bronchus; a near perfect anatomic reproduction of the airway cast in blood.

Hemoptysis in the extreme, which formed a perfect casting demonstrating 5 branches of the bronchial tree. The clotting cascade was a real challenge to memorize and about the only thing I can remember  is the cross linking of fibrin forming the framework for the clot. It certainly out performed it's intended purpose in this case.

 The right main stem bronchus is like a grease trap in a fast food restaurant because almost anything that goes down the trachea winds up here. It's the first bronchial segment to branch off and has a larger lumen than the left main stem bronchus. It's also more perpendicular making it the perfect exit ramp for just about anything coming down the trachea. Anesthetists always checked for bilateral breath sounds because it was so easy to selectively intubate the right main stem bronchus. An absence of left sided breath sounds?  Time to pull the endotrach tube out a bit to clear the right bronchus.

It's difficult for me to understand how a clot of this size could form because the most likely scenario would be a clot occluding the upper segment and blocking the filling of  the middle and lower branches.  This perfect cast of the bronchus jolted my memory and brought to mind another memorable anatomic replica produced by the human body.

Fecal impactions were a miserable experience for all parties involved and were common in old school hospitals as a side effect of prolonged bed rest combined with opiate analgesia. With the passage of time, pressure from the upstream accumulation of stool in the sigmoid colon  numbed the nerve endings of the internal sphincter. The end result was a massive hardened bowel movement firmly lodged in the sigmoid colon.

Removing these forbidding fecal accumulations was no easy task because the stool hardened to a consistency of Sakrete concrete. The first step in the unpleasant (to say the least) removal process was the rectal installation of warm mineral oil  in an often times futile attempt to soften the painful putrid plug. The final step was similar to a Roto Rooter operation whereby the mass was manually extracted.

One of my colleagues, Ann, was especially proficient at removing fecal impactions. Her fingers were lithe and she had the unique ability to curl the distal metacarpal at a right angle to the rest of her finger resulting in a hook. Her fecal impaction removal technique involved twisting her index finger much like a boring brace to gain entrance to  the tenacious turd. Having bored inside the monstrous mass much like an African dung beetle  she hooked her finger and gently increased traction until the massive mess slid out.

After the patient's  screams of agony subsided, the oows and ahhs began as attending staff members marveled at a perfect sculpture in brownish stool  of the sigmoid colon. The distal part of the colon is lined with haustral markings which delineate colonic saculation.  As the stool hardened a perfect colonic cast was formed.

Most nurses chipped away at fecal impactions which resulted in a hodge podge collection of fecal shreds. Ann's technique of rmoval in toto resulted in an anatomic model not  unlike the cast of the bronchus. Simply amazing!