Surgery Without Wires

Surgery is messy... and I don't mean in terms of blood and guts...

What I mean are wires, cables, tubing, etc.

Let's take a routine tonsillectomy and adenoidectomy for example...

1. Electric cord for the operating table
2. Electric cord for the anesthesia machine
3. Electric cord for the surgeon's headlight
4. Light cord from the surgeon's headlight to the lightbox
5. Breathing circuit tube from the patient to the anesthesia machine
6. Carbon dioxide outflow tube from the patient to the anesthesia machine
7. Suction tubing from the surgical table to the vacuum canister
8. Vacuum cable from the vacuum canister to the wall socket
9. Electrocautery cable (along with electric cord to power the machine)
10. Coblation cable (along with electric cord to power the machine)
11. IV fluids lines from patient to IV bags
12. EKG lines
13. Grounding pad cable
14. All the wires and cables that go with running a computer
15. etc etc etc

It's an "organized" chaos of cords, tubes, electric wires, etc all emanating away from the patient like a Man-of-Wars jellyfish.

Pictures shown on the internet as well as movies are "staged" and appear to be neat and orderly, but believe me (as someone who has had pictures taken), surgeons and nurses take the time to "tidy" things up before the picture or video is recorded giving a false impression of neatness.

99% of the time, everyone knows where everything is, so it's not a problem. However, when an unanticipated emergency happens, things get confusing and in fact dangerous to not only the patient, but the staff (I recall one incidence of a nurse running to get a surgical tray, tripping on one of the numerous cords mentioned above, falling, and breaking her hand).

When something stops working... we literally have to trace the cord from source to origin to figure out why something stopped working. With all the cords present, this tracing needs to be done by hand and eye (analogous to an entertainment system with all the wires in the back, one would trace out the cords by hand and eye).

IS there a better way???

Of course the operating room staff takes the time to bundle and organize the various cords, but the fact remains that the cords are there.

What about wireless technology to power instruments or relay information?

Well, NPR reported on August 23, a young 22 year-old entrepreneur Meredith Perry, who has invented and patented a way to transmit power over the air without the need for wires using ultrasound. Yup... the same ultrasound used to look at a human fetus in the womb.

Her ingenious idea is to use ultrasound to "vibrate" the air which than vibrates a piezoelectric transducer contained within nearby devices. The vibration of the piezoelectric transducer will than generate an electric current which can be stored in a battery and used to power anything that requires energy.

I acknowledge that it may take time before such wireless power is available to power large surgical devices, but one can always hope!

Read the NPR story here.

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Why Are You Looking in My Mouth When It's My Ear Hurting?

One June 20, 2011, NPR aired a great story about how a person may not "see" a person getting beat up on the side of a jogging path when they are focused on a task (pursuing another jogger)... even if they pass RIGHT BY THE FIGHT!!!

In fact, only a third of the subjects reported seeing this mock fight when the experiment was conducted at night. Even more surprisingly, broad daylight didn't improve the statistics (only 40% noticed the fight).

Though the situation and circumstances do not exactly correspond, there is a lesson to be learned here that applies to a medical visit.

As an ENT, I often see patients for a very specific complaint...

"My right ear hurts."
"I have a bad cough."

No matter what the complaint, unless it is for a specific task (there is earwax... can you remove it), I most always still do a complete ear, nose, and throat exam no matter the complaint.

Why???

Because often the symptoms are "the jogger" in the example above which is noticed to all exclusion when "the fight" is the more important event that should have been noticed.

Let's go to the examples stated above...

"My right ear hurts."

Though a patient may wonder why the heck I look in the mouth when their ear is the main complaint, it's mainly because there are other things that can cause ear pain... some of it life-threatening.

Tonsil cancer can cause ear pain (without any other symptoms) as well as a base of tongue abscess. Obviously, giving antibiotics to treat the right ear pain totally misses the fact that there was tonsil cancer that got missed or the tongue abscess which requires an emergency trip to the operating room followed by a few days in the intensive care unit.

"I have a bad cough."

This statement is pretty self-explanatory. Why bother looking in the ears??? A loose hair in the ear canal can cause a persistent dry cough. Why look in the nose if the cough is coming from the throat? Severe allergies and nasal polyps can lead to post-nasal drainage leading to a chronic cough. Why would an ENT than ask about my blood pressure medications? Because ACE inhibitors like lisinopril cause a chronic dry cough as a side effect.

The point being with these examples is that medical doctors are trained to not just focus in the exact symptom the patient is complaining of, but the entire picture. It doesn't do the patient any good if a doctor gets tunnel-visioned to the point where they don't notice what may be a very obvious thyroid mass or the large nasal polyp.

SO... next time you see a doctor for a specific complaint, humor us, and answer fully all questions about your medical history, surgical history, medications you are taking, and the physical exam we will perform on you... even if you are there for just a "simple" earache.

Read the NPR story here and the police beating that triggered this inattention experiment.

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The Diane Rehm Show on NPR Examines the Human Voice

Diane Rehm who hosts an NPR show of her name, suffers from a voice disorder called Spasmodic Dysphonia. On April 18, 2011, she hosted a show on vocal issues with expert guests addressing what makes a healthy voice. The experts range from physician laryngologist Dr. Nazaneen Grant to voice coaches.

Listen to the show here!

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How is Love Like Dizziness? Medically Speaking...

I watched this touching video of what it is like to fall in love... that very moment when you see the love of your life for the first time... and the world falls away. Time slows down. That feeling of elation, passion, love overwhelms. Time stands still. Everything else blurs out except for him/her...

Nuit Blanche from Spy Films on Vimeo.

Now from a medical perspective, how can we test this? If "love" is considered a disease, how can we positively "diagnose" this? How can a doctor touch, see, feel, measure "love" and the severity of this affliction when all the symptoms are felt on the inside?

The simple answer is you can't. Similarly, dizziness is a problem that like love, can't be seen, touched, measured by the doctor very easily. Unlike tonsillitis where all a doctor has to do is look in the mouth and "see" the infection, we can't do the same for dizziness.

The way a physician approaches a sensation that is only felt by the patient, but no other is via several steps.

A good history. That's why when a patient with dizziness comes to a doctor's office, we ask a lot of really picky questions as it helps narrow down the possibilities. This step is just like when a friend asks exactly what you felt when you first saw the love of your life.

- What does the dizziness exactly feel like? Spinning, fainting, rocking, drunk, etc???
- Exactly how long does an episode last for? Seconds, minutes, hours, days, weeks, months???
- Can it be triggered? Turning, bending, walking, etc???

Click here for a dizziness flowchart based on answers to these and other similar questions.

Based on the history, additional testing may or may not be required. If a doctor was trying to decide if a patient was afflicted with "love", a good history may be all that is required. However, if the doctor is not quite sure, he/she may want to get an EKG to measure the pulse to ensure no supraventricular tachycardia arrhythmia ("When I see John, my heart races"), MRI scan to ensure no brain tumor (causing symptom of time standing still), ophthalmology exam ("Everything else seems to blur out except for John"), etc.

Just like for "love", a similar type workup needs to be pursued for dizziness depending on how the dizziness exactly felt like and may include audiogram, EKG, bloodwork, ENG, cardiac ECHO, 24 hour holter, 30 day cardiac event monitoring, pulmonary function tests, carotid ultrasounds, MRI/CT scans, EEG, chest-x-rays, allergy testing, tilt-table test, etc. As such, one may need to have an evaluation by a neurologist, cardiologist, ENT, pulmonologist, endocrinologist, etc to uncover the cause of your specific dizziness.

Once the cause is determined, treatment is based on addressing that specific diagnosis. As one can see, the human body's sense of balance is actually extremely complex making dizziness one of the most difficult symptom to diagnose and treat.

"Love" would be similarly difficult to diagnose with absolutely certainty if it was considered a disease as well. Based on symptoms alone (without history), love could potentially be confused with fear, anger, hate, etc.

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Can Placebo Be Used to Help People Instead of Drugs?

On my way to work On December 23, 2010, I heard a great story on NPR regarding how placebos can potentially be used to help people... EVEN if they know it's a placebo!

Based on research done at Harvard, they found that a placebo helped patients with irritable bowel syndrome 59% of the time compared to a similar group that received nothing. Of greater significance... the treatment group with placebo KNEW they were getting a placebo.

Given that many medications have similar (and even lower) improvement rates, that's quite amazing.

Why does placebo work?

My own personal belief is that this is truly a case of mind over matter.

The human body is literally a pharmaceutical manufacturing company able to naturally produce all sorts of chemical compounds. Pretty much every drug that you can take in pill form, the human body already produces within to some degree. Drugs in essence augments what the body is already able to naturally produce.

The placebo effect is (in my opinion) when the human mind is able to boost the production of the appropriate drugs the body is already able to naturally produce.

The REAL key to improving the human health condition and avoid all the drugs and their potential for side effects is to somehow figure out how to enable the placebo effect on command.

Read the NPR story here.

Reference:
Placebos without Deception: A Randomized Controlled Trial in Irritable Bowel Syndrome. PLoS One. 2010

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NPR on Endoscopic Sinus Surgery

NPR published a story on Oct 4, 2010 describing endoscopic sinus surgery using image guidance. The NPR story is actually quite balanced with accurate portrayal of what sinus surgery can or can't do.

Just like in the NPR story, our office performs the same high-definition endoscopic sinus surgery using BrainLAB image guidance (which provides the real-time 3-dimenstional guidance).

Prior to sinus surgery, a patient must fail medical management first (unless nasal masses like polyps are found) including allergy control.

Read the NPR story here.

Read more about sinus surgery here.

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NPR: Injuries To Kids From Swallowed Disc Batteries Are No Joke... It Is An EMERGENCY!!!

In fact it is a STAT emergency... NPR published a story on Sept 20, 2010 regarding Chuck E. Cheese's recall of two toys (a light-up ring and glasses) due to a disc battery used to power them.

These disc batteries can be access by small children if they smash apart the toy. The Consumer Products Safety Commission says two kids have had problems with batteries; one swallowed it and the other stuck it up his nose.

The danger is that when a disc battery is inserted into a nose (for example), a localized electric current is created between the positive and negative poles of the battery within the nose. This electric current basically "electrocutes" the lining inside the nose leading to tissue damage and ultimately necrosis (tissue death) within an hour. The same applies even if the battery is swallowed or put into the ear canal.

Treatment is IMMEDIATE removal... as soon as possible. Regardless of the day or time. STAT...

In the last 10 years, 13 deaths related to swallowed batteries have been reported, 12 of which are due to disc batteries (20 millimeter lithium cells).

Small children should NEVER be able to access disc batteries.

Read the NPR story here.

Read about the recall itself here (also from NPR).

Reference:
Preventing Battery Ingestions: An Analysis of 8648 Cases Published online May 24, 2010
PEDIATRICS (doi:10.1542/peds.2009-3038)

A Review of Esophageal Disc Battery Ingestions and a Protocol for Management Arch Otolaryngol Head Neck Surg. 2010;136(9):866-871. doi:10.1001/archoto.2010.146

Images of the toys that have been recalled...

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New Reason for Chronic Cough... Playing the Trombone!

NPR published a story on Sept 8, 2010 regarding a trombone player whose chronic cough for over 15 years was ultimately found to be due to a mold called fusarium as well as mycobacterium (cousin to TB) found growing inside his trombone. Each time he inhaled while playing the trombone, these germs inside his trombone was causing an allergic reaction, which led to hypersensitivity pneumonitis, a severe inflammation of the lungs.

The doctor who figured out the problem went on to investigate other wind/brass instruments of other players and found them all contaminated with germs. His results have been published in the journal Chest.

Though the NPR story was on this particular trombone player (whose cough improved once he started cleaning his instrument regularly), the problem is NOT new...

Here's a report on a saxophone player.

There is also this one company called MaestroMD that claims to help with musical instrument sterilization.

This issue was so concerning in Massachusetts, that a law is being passed to require sterilization of musical instruments in schools! Read more here.

I even wrote a blog article about this problem back in January 7, 2010.

In any case, how does the trombone player featured in the NPR story now clean his instrument? He uses a rod with a cloth and alcohol — rubbing alcohol or isopropyl alcohol which he pours down into his instrument after playing.

References:
Trombone Player's Lung: A Probable New Cause of Hypersensitivity Pneumonitis. Chest. 2010 Sep;138(3):754-6.

Hypersensitivity Pneumonitis Due to Molds in a Saxophone Player. CHEST September 2010 vol. 138 no. 3 724-726.

A microbiological survey into the presence of clnically significant bacteria in the mouthpieces and internal surfaces of woodwind and brass musical instruments.

Horn with nasty microbes.

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