29 DEC 2007 No surprises

I was asked a few questions after my last posts, and I thought I'd share them here:

Q: Would you have any suggestions about what those of us who can't bring steaks to you could do to show our support and concern?

A: As for what to do for us, honestly, we do have every convenience we could ask for on this base. There are many organizations that help to get care packages and supplies to troops who are in rougher conditions than I am. As for me, simply an email of support and good wishes is enough to let me know that I am remembered and brighten my day a little! As an American, I think the best thing you can do for the troops is to honor them by exercising your freedoms, being sure that the no one, including our government, takes them away, and speaking up to make your opinion known to fellow citizens and leaders. Lastly, if you are so inclined, you could consider helping out with a very important cause: injured and disabled veterans. Fisher House Foundation ( http://www.fisherhouse.org ) gets an A rating as a charity because nearly 100% of their funds get put to use. It doesn't maintain a large balance of idle unspent funds and has an extremely low ratio of funds spent on fundraising.

Q: It's good that you were able to use the supplies meant for the boy - do you have enough supplies for all the burn victims? What would have happened to the girl if you didn't have the supplies left over from the boy? Just curious.

A: We do have enough supplies for burn victims. We are responsible for many US troops who are in the area, so we have to be sure that we have a stockpile ready for large numbers of casualties at any time. If any supplies get depleted, we have an incredibly strong supply chain that could replenish us in a short time. Burn care is very resource intensive, both emotionally and with regard to supplies. However, there are many, many ways to treat a burn, and in this situation it seemed like I would save this little girl some pain and suffering by using the artificial skin that we happened to have available. If it hadn't been there, we would have found a different way to care for her.

Q: We don't do burns where I am at so it's good to know about the artificial skin. Is it Alloderm or something else?

A: There is such a variety of products available for burns. I have used Alloderm (cell-reduced cadaver skin) in the past, but in this case I used Biobrane (collagen protein coated silicone/nylon mesh) to cover her burns. The burn is a multiple attack: there is the stress from the insult of the thermal trauma, there is the presence of dead tissue that needs removal, and then there is the breech in the skin's defenses against heat loss, moisture leakage, and infection. All of these problems must be dealt with. A skin replacement can temporarily do the jobs that the missing skin has left untended. The skin replacement will cover the bare area until new skin grows or is grafted in from another part of the body by a surgeon.

29 DEC 2007 No surprises

Today again started cold, but ended up a very mild afternoon. Much of the OR staff migrated to the roof to enjoy the sinking sun, have a drink, or puff on a cigar. The rooftop lounge is nearly complete and bears the initial coats of paint and varnish. We have been meaning to rig up a slingshot for some time. Today I tried to fashion one with a long elastic strip called an Esmarch's bandage. Freidrich von Esmarch designed it in the 19th century to help control blood loss during battlefield amputations. Fortunately, we haven't had to do an amputation for a few days, so I decided to put one to a different use in a purely scientific interest in ballistics. I was able to fling an orange, but no further than 40 feet or so because it kept rolling out of the strip of bandage when released. I'll have to add a pocket sling to the middle or switch to the traditional slingshot of two passes of surgical tubing. If I can get enough distance, I might even be able to hit my hooch from the hospital. This is what happens when a surgeon doesn't have a trauma victim on whom to operate. I'm thankful for these moments when we aren't seeing a tide of casualties roll in. I got to enjoy a good phone call with my parents.

The girl with the burns on her back is doing well. The nurses have done a wonderful job of teaching her father to change the dressing on her hand. She does wail so for that small dressing so I'm glad that the artificial skin on her back can sit there undisturbed for a while. I'm always so impressed when parents can participate in the care of their own children. I would be so timid if I had to use any of my skills on my own children. I just think that my worry would overcome my reason. M. would probably handle it much better than me! Once my son had a laceration on his ankle that I closed up with some butterfly strips. It was a little scratch, and he stayed so calm for me while I applied them. Still, I was anxious and relieved when it was over. It is just harder on my own child to distill off the worry and reach the calm place I need to do the best job.
About two weeks ago, I operated on a boy who had been injured by an explosion in his back yard. We had operated to remove his injured intestines, but as he healed he became blocked up by internal scars. His intestines have finally begun working again. He is able to eat and is making healthy bowel movements in his colostomy bag. Now that he can get good nutrition and hydration, he is up and about, behaving like a normal 12-year-old boy. He is kicking the butts of the translators and nurses on the Wii video game that is on the ward. Soon he should be able to return home to his family. It is such a relief to see the body's natural healing accelerate and take over all of the functions that it should.

I helped on one operation this morning. It turned out to be a surprise and exciting. If you are familiar with the inside of an operating room, you know that both of those terms are unwelcome. It is best when surgery is scheduled and boring. Boring surgery is good surgery. A man who had received shrapnel wounds to both his legs was going to the operating room to have his wounds washed out. Orthopedic PA J. asked me to take a look at his tracheostomy site, which was bleeding a little. Orthopedic Surgeon H. also said to stop by because the man just looked a little funny. He couldn't put his finger on it, but you have to learn to trust those instincts that something is wrong. It is like Spidey-sense. It starts tingling when something is askew, even before you can really identify it. I washed his trach site and we replaced the tube through his neck with a breathing tube through his mouth. I saw some signs of infection and cauterized a few spots that oozed, but thankfully there wasn't damage to the large vein that runs through that area.

I had finished my part and we were about to prepare the patient for the cleansing of his wounds when Anesthesiologist C. noticed that his heart rhythm wasn't normal. His heart rate had accelerated to faster than normal, and the electrical pattern was strained. Anesthesiologist C. gave him more oxygen, and I kept a finger on the pulse in his neck to see how well the heart was doing its job of pumping the blood around with the impediment of this abnormal rhythm. The pulse was fast, but present. We gave some medications to stabilize the electrical activity of the heart, and prepared for any emergency. As we waited, I noticed that the pulse weakened, became irregular, and then disappeared altogether. I started compressing the man's chest with the heels of my hands while Anesthesiologist C. timed breaths of oxygen-laden air. O.R. Nurse R. applied the electrical defibrillator paddles to the man's chest and shocked him after ensuring that all staff had dropped contact with the table to avoid being zapped. His arms jerked forward. His heart took on a new rhythm of disorganized flopping of the heart muscle. We gave doses of emergency medications to try and ameliorate any mineral deficiencies and continued the CPR. Again we shocked him at a higher energy level and his heart rhythm abruptly reverted to a quick but normal pattern of pumping. I felt his neck and found a bounding pulse. We got some blood tests, and abandoned the operation to return the man to the intensive care unit. I'm sure this little episode has thrown the man's system for a loop. But since he has survived, now we have the luxury of methodically discovering why it happened and making sure that it doesn't happen again. I'm so lucky that I get to be part of this expert team. Everyone moved together on instinct like a finely-meshed machine. I'm sure that this man is still alive because of their smooth expertise.

As usual, my thoughts often turn to the next meal. It is the fortune of our little band to ring in the New Year together here in Balad. Last night, two little piggies arrived from Germany. They will be roasting on a spit behind our hospital as the clock chimes midnight. We ran into some trouble when one of the aircrews refused to fly a pig to a Muslim country. We had to gently remind them that our DFACs on base serve bacon, sausage, ham, pork chops, deviled ham, pork tenderloin, chopped pork, pork ribs, pork barbecue, and pork Mongolian barbecue, so it probably wouldn't make the sky fall. I've signed up for a watch to hand-crank the spit near the end of the 24 hour roasting because It is my suspicion that there will be some prime pig-pickin' to be had at that hour. A chef has to make sure and check the meal! Mmm.

Love life, be mello, and have fun!

CC