The Journal of the American Medical Association Internal Medicine has a really interesting essay they've published in full online. It's written by Anna Petroni, a 77-year-old California woman who recently decided against undergoing surgery on her ankles and knees to correct recurrent foot abscesses and arthritis. It's a short, simple piece — just Petroni recounting the story about why she made the decision she made — but serves as a jumping-off point, I think, for several different important discussions about the way we do medicine and the way we make medical decisions.

A couple of things particularly stood out to me. First is the relationships we have with doctors, especially specialists whom we see once or twice and who don't know us very well. Petroni's story suggests that bedside manner is about more than just making somebody feel nice — it can also affect their overall health if the doctor makes decisions related only to their specialty without taking into account the patient's whole story. The second thing I think is really important here is the idea of there often not really being one right answer when it comes to medical decisions. Doctors can say, "we can do this" or "we can fix that", but there's a responsibility on the patient (one we're not usually prepared for or coached through) to decide whether the trade-offs of intervention outweigh the side-effects. And those decisions can vary widely from patient to patient.

I guess I was so shocked when the orthopedist told me I needed to have 4 surgical procedures, I didn't even think about the fact that he did not ask about my cardiac history. But I sure did afterward. I only went in to have my tendons checked. He did not ask how I felt about anything. He just told me what needed to be done.

About a month later, I received a call from the receptionist who asked if I had decided on a date for surgery. I said that I had decided not to go ahead with it. When I feel I can no longer tolerate walking without tendon surgery, I will reconsider my options. Until then, I want to live the best I can with what mobility I have.

Read the rest

Pierre Bouhanna is a Paris-based surgeon who, for the past five years, has been performing increasing numbers of mustache implants. He says the majority of his patients come from the United Arab Emirates, Iran, Lebanon and Turkey, with men traveling to France to have the surgery performed.

"My impression is more and more they want to establish their male aspect," he said. "They want a strong mustache."

Mustache Transplants on the Rise in the Middle East [KTLA] (via JWZ)

(Image: James and Matthew, with fake moustaches, a Creative Commons Attribution (2.0) image from jonevans's photostream) ]]> http://boingboing.net/2012/12/03/mustache-transplants-on-the-ri.html/feed 46 http://boingboing.net/2012/09/24/an-atlas-of-horrible-things-th.html http://boingboing.net/2012/09/24/an-atlas-of-horrible-things-th.html#comments Mon, 24 Sep 2012 15:01:56 +0000 Maggie Koerth-Baker http://boingboing.net/?p=182837 Today, he's known as "Wound Man", but once upon a time this illustration was just one part of a standard medical or surgical text book.]]>

Today, he's known as "Wound Man", but once upon a time this illustration was just one part of a standard medical or surgical text book. You'd get your basic illustrations of anatomy. Then you'd get your Wound Man, to show you all the different, awful things that could happen to that anatomy. A 2009 blog post from the Wellcome Library explains:

Captions beside the stoic figure describe the injuries and sometimes give prognoses: often precise distinctions are drawn between types of injuries, such as whether an arrow has embedded itself in a muscle or shot right through. (The latter is better – the arrowhead can be cut away and the shaft withdrawn smoothly, whilst the embedded arrow will tear the muscle with its barbs when pulled out.)

The other interesting thing about this illustration: It's also an example of how the early printing industry worked. According to the Bernard Becker Medical Library at Washington University, there were several different versions of the Wound Man, but the same version would show up in multiple books — a result of surgeons and printmakers literally carrying the same wood blocks from one printing press to another.

Read more about surgery and medicine during this time period by visiting the excellent history of science blog: The Chirurgeon's Apprentice

This is absolutely wonderful, and absolutely not for the squeamish.

Defective Heart Girl Problems is a blog where physicist Summer Ash has blogged her experience with finding out that she has a defective heart valve and getting treatment to deal with that defect. The image above shows her scar from her recent surgery.

Ash went through surgery to repair her heart on July 18th. Here's how she explains the problem:

I recently discovered that I was born with a congenital heart defect known as bicuspid aortic valve disease (BAVD). It’s not a disease, per se, so much as a defect. Most people (roughly 99% of them) are born with a tricuspid aortic valve. I am the lucky 1% born with a bicuspid valve. (I am the 1%!)

As a bonus, being born with this genetic mutation also means the lower part of my aorta, the part that connects to the aortic valve and helps channel the flow of oxygenated blood into the arteries, has less fibrillin-1 – a protein that helps to maintain the structural integrity of the aortic wall. This means that my aorta is prone to “stretching out” and even the normal stress of blood flow coming out of the heart and being channelled to the rest of the body is enough to cause it to start ballooning outward.

The nominal course of BAVD usually entails the aortic valve calcifying and stiffening later in life (60s – 70s), ending in valve replacement surgery. Some people will also need the root of their aortas replaced at this time, some may not. My problem is that my aorta is jumping the gun; it’s already stretched out to the point where it’s considered an aortic aneurysm. I like to imagine it as a hipster, dilating before it’s cool to do so.

On July 29, she posted the full story of her surgery, including photos of her visible heart and really clear, well-written explanations that describe what her surgeon's did while they were rooting around in her chest cavity. It's graphic. And it's not for everybody. But it's also extremely powerful storytelling about both medical science, and the experience of having something go wrong with your body that you can't control. Highly recommended.

Read Summer Ash's description of her surgery

(Via Jennifer Ouellette)

Sometimes, it's a little mind blowing when you remember just how recently medicine passed from the world of art/magic/tradition and into the realm of science. There's plenty of reason to argue that the transformation still isn't complete today, but I'm really mesmerized by stories from the 19th century, when every surgery was something of an experiment and the same, cutting-edge doctor could vacillate between modern techniques and medieval bio-alchemy in his treatment of the same patient.

Until that time, the prevalent method of cataract treatment was “couching,” a procedure that involved inserting a curved needle into the orbit and using it to push the clouded lens back and out of the line of sight. Warren's patient had undergone six such attempts without lasting success and was now blind. Warren undertook a more radical and invasive procedure—actual removal of the left cataract. He described the operation, performed before the students of Harvard Medical School, as follows:

"The eye-lids were separated by the thumb and finger of the left hand, and then, a broad cornea knife was pushed through the cornea at the outer angle of the eye, till its point approached the opposite side of the cornea. The knife was then withdrawn, and the aqueous humour being discharged, was immediately followed by a protrusion of the iris."

Into the collapsed orbit of this unanesthetized man, Warren inserted forceps he had made especially for the event. However, he encountered difficulties that necessitated improvisation:

"The opaque body eluding the grasp of the forceps, a fine hook was passed through the pupil, and fixed in the thickened capsule, which was immediately drawn out entire. This substance was quite firm, about half a line in thickness, a line in diameter, and had a pearly whiteness."

A bandage was applied, instructions on cleansing the eye were given, and the gentleman was sent home. Two months later, Warren noted, inflammation required “two or three bleedings,” but “the patient is now well, and sees to distinguish every object with the left eye.”

That's from an amazing essay on the history of surgery published last month in the New England Journal of Medicine.

The article is absolutely fascinating. I recommend reading it all the way through. If for no other reason than to get a better understanding of the fumbling way medical innovation happened. It wasn't like everybody woke up one morning and decided to adhere to the scientific method and the germ theory of disease. Instead, there were debates, and failures, and horrible things that happened as doctors tried to expand the number of illnesses they could treat before they necessarily had the tools (or the mental paradigms) to solve those problems. But, it was through making all those mistakes that the actual solutions started to form.

Among the more-interesting points in this piece: The advent of anesthesia didn't just make surgery more pleasant for the people experiencing it. It also enabled surgeons to slow down and practice surgery with a great deal more care. For instance, prior to anesthesia, a good surgeon could successfully amputate a leg in less than a minute. That's the surgery you can see being performed in the image at the top of this post.

Read "Two Hundred Years of Surgery" at the New England Journal of Medicine

Billboards for weight loss surgery provider "1-800-GET THIN" were ubiquitous around LA freeways until recently; the company has since come under scrutiny by the FDA, consumer affairs watchdogs and Consumer Reports for sketchy business practices. Now, the Los Angeles Police Department is investigating the firm over the recent death of a patient. Snip from LA Times report:

In a civil lawsuit, two former surgery center workers alleged that a series of medical gaffes contributed to [55 year old patient Paula] Rojeski's death. That lawsuit, filed in January, said an intravenous line was not properly inserted into Rojeski's arm during surgery, causing solution to pool on the floor of the operating room. Former surgical technicians Dyanne Deuel and Karla Osorio also said in the lawsuit that the anesthesiologist forgot to turn on the oxygen tank before surgery.

The LA Times report goes on to list four additional patient deaths. (photo: LA Times)]]> http://boingboing.net/2012/04/10/lapd-probing-lap-band-surgery.html/feed 20 http://boingboing.net/2012/01/09/wide-awake-during-brain-cancer.html http://boingboing.net/2012/01/09/wide-awake-during-brain-cancer.html#comments Mon, 09 Jan 2012 20:13:17 +0000 Xeni Jardin http://boingboing.net/?p=137942 This fascinating video from the Mayo Clinic explains how 28-year-old Mary Meixner went through "awake surgery" during which surgeons used an intra-operative MRI to target her brain tumor.]]>

This fascinating video from the Mayo Clinic explains how 28-year-old Mary Meixner went through "awake surgery" during which surgeons used an intra-operative MRI to target her brain tumor.

At the end of the operation, she slept. Then, she says, "I woke up and I was so excited, and I was like, yes! I'm not dead! I can talk! I can think! Because you never know, right?"

Transcript here (PDF).

(via @thespeachgal)

This is a really fascinating entry in The Guardian's multi-video package about heart health and medicine. Bruce Martin, a British anesthesiologist, talks about his job, anesthetizing patients for heart surgery. If this doesn't make your job seem less stressful by comparison, then you're probably a fighter pilot or something.

]]> http://boingboing.net/2011/12/02/an-anesthesiologists-view-of.html/feed 13 http://boingboing.net/2011/10/06/man-undergoes-extensive-plastic-surgery-to-look-like-superman.html http://boingboing.net/2011/10/06/man-undergoes-extensive-plastic-surgery-to-look-like-superman.html#comments Thu, 06 Oct 2011 14:56:04 +0000 Cory Doctorow http://boingboing.net/?p=121957
A Filipino man named Herbert Chavez has undergone extensive surgery to make himself look like Superman: a nose job, a chin implant, collagen in his lips, and (randomly) hip implants.

Pinoy goes under knife to look like Superman

(via Neatorama) ]]> http://boingboing.net/2011/10/06/man-undergoes-extensive-plastic-surgery-to-look-like-superman.html/feed 26 http://boingboing.net/2011/10/05/how-to-remove-a-bladder-stone-in-the-days-before-anesthesia.html http://boingboing.net/2011/10/05/how-to-remove-a-bladder-stone-in-the-days-before-anesthesia.html#comments Wed, 05 Oct 2011 12:24:32 +0000 Maggie Koerth-Baker http://boingboing.net/?p=121817 The Chirurgeon's Apprentice is an entire blog dedicated to eye-witness accounts of surgery in the days before anesthesia. Oh, Internet. Thou art wonderful and horrible.]]>

The Chirurgeon's Apprentice is an entire blog dedicated to eye-witness accounts of surgery in the days before anesthesia. Oh, Internet. Thou art wonderful and horrible.

Collected by University of London medical historian Lindsey Fitzharris, the stories come from well-documented sources, from the 17th century onward. Part of the goal here is to follow the path of surgery as it really started to become its own profession ... separate from that of barber. Yes, this is going to be every bit as gory as you imagine. I'll start looking for a unicorn now.

If you visit the Gordon Museum at Guy’s Hospital in London, you will see a small bladder stone—no bigger than 3 centimetres across. Besides the fact that it has been sliced open to reveal concentric circles within, it is entirely unremarkable in appearance. Yet, this tiny stone was the source of enormous pain for 53-year-old Stephen Pollard, who agreed to undergo surgery to remove it in 1828.

Although the operation itself lasted only a matter of minutes, lithotomic procedures were painful, dangerous and humiliating. The patient—naked from the waist down—was bound in such a way as to ensure an unobstructed view of his genitals and anus [see illustration]. Afterwards, the surgeon passed a curved, metal tube up the patient’s penis and into the bladder. He then slid a finger into the man’s rectum, feeling for the stone. Once he had located it, his assistant removed the metal tube and replaced it with a wooden staff. This staff acted as a guide so that the surgeon did not fatally rupture the patient’s rectum or intestines as he began cutting deeper into the bladder. Once the staff was in place, the surgeon cut diagonally through the fibrous muscle of the scrotum until he reached the wooden staff. Next, he used a probe to widen the hole, ripping open the prostrate gland in the process. At this point, the wooden staff was removed and the surgeon used forceps to extract the stone from the bladder.

Unfortunately for Stephen Pollard, what should have lasted 5 minutes ended up lasting 55 minutes under the gaze of 200 spectators.

Via Ed Yong

I used OsiriX, a well known open source medical imaging package for mac OS to open the CT scan images and produce a surface render (mesh of points) and export it in a format I could manipulate and make compatible for the printers at Shapeways. I exported the files as .obj files and opened them in a recommended manipulation program called MeshLab. This, another free open source application for mac osx. The aim of this application is to close any holes in the meshes and to delete any artifact produced in the scans. These were then exported as .stl files ready for printing.

I uploaded them to Shapeways through my account and they were almost instantly verified as printable and Shapeways began processing the images. The total cost for both bones in white flexible plastic only came to a tiny £77. The bones were in our hands in 7 days to the UK. The resultant models were amazing! We verified them and found them to be virtually identical copies of the bones on the CT scans. The white plastic was a great material to machine and use our normal orthopedic drills and saws and screws on to practice the operation.

The majority of people reading this sentence will, at some point in their lives, undergo a medical treatment that requires general anesthesia. Doctors will inject them with a drug, or have them breathe it in. For several hours, they will be unconscious. And almost all of them will wake up happy and healthy.

We know that the general anesthetics we use today are safe. But we know that because they've proven themselves to be safe, not because we understand the mechanisms behind how they work. The truth is, at that level, anesthetics are a big, fat question mark. And that leaves room for a lot of unknowns. What if, in the long term, our anesthetics aren't as safe for everyone as we think they are?

The only way to know for sure is to figure why anesthetics cause unconsciousness, and how one drug differs from another. Roderic G. Eckenhoff, MD, is a professor at the University of Pennsylvania's Perelman School of Medicine. He's one of the people trying to figure out what general anesthetics really do inside the human body, and how we can use that information to discover even safer drugs than the ones we already rely on today. How does he study that? By drugging tadpoles.

This week, Chemical and Engineering News published a profile of Eckenhoff and his work, written by journalist Carmen Drahl. That piece inspired me to call up Eckenhoff and find out more about what we think we know about anesthetics, why it's taking medical scientists so long to understand such a commonly used class of drugs, and why tadpoles make an ideal model animal.

Roderic G. Eckenhoff, MD: The real simple answer is that we don't know. We don't even know what class of macromolecule, for certain, underlies the effects of general anesthetics. And anesthetics don't just do one thing. They produce a myriad of effects ranging from hypnosis, to amnesia, to pain relief and a range of other effects that are much less desirable, like hypothermia, nausea, and vomiting.

But most of us think about the primary effect, which would be unconsciousness, and the answer is still we don't know for sure. But there has been a gradual shift in the field to thinking that protein targets are the likely candidates for this interaction. The main reason is selectivity. Even though "unconsciousness is unconsciousness" the whole spectrum of what the unconsciousness looks like aren't always the same from drug to drug. Some patients are more dysphoric afterwards, for instance. There are components of the electroencephalogram that look different from one drug to the next. That leads us to believe that there's some selectivity.

That's a bit of a surprise, actually, that the drugs aren't all working the same. In the last 5 years or so that's come more to the forefront. A very, very small molecule like halothane, which isn’t used in the United States anymore, might act differently than a drug that's more popular today called isoflurane. There's surprising selectivity to these drugs and we're only now starting to appreciate. And when you talk about selectivity, you're talking about proteins because they have the most diversity in terms of structure.

Ion channels [A type of protein—MKB] are also important because they transduce most communication and signaling in the central nervous system. If we think the drugs affect synaptic transmission, for example, then there's a host of ion channels that could be candidates. They are prime targets simply because of what they do. The evidence to date looking at ion channels in vitro strongly supports that notion.

RE: That gives you some insight into how difficult the problem will be. A large group of people has been working on this for a long time and we barely know what class of macromolecule underlies the effects. That's remarkable at this stage, given the millions of dollars that have been poured into the problem. It’s taken so long because we've been searching for the single target or just a few ... but it's probably a bigger problem than that.

My bias, which is somewhat speculative, but evidence supported, is that we're talking about interactions with as many as 10, 20, or even 50 different protein targets. That constellation of small effects disrupts the extraordinarily well-timed signaling in the central nervous system to produce the final common pathway of unconsciousness.

What we’ve seen is that people have their favorite targets that they work on in vitro and when they work their way back up to an intact animal they find that this target has only a very small contribution to the overall effect, in contrast to in vitro work. That's been reproduced time and time again. The model that seems to work best is a small-effects-at-multiple-targets model. How does one achieve selectivity then? What you’re probably seeing is each drug affecting different but overlapping mix of targets.

RE: The first question is about safety. We started with two principle drugs in 1850, chloroform and diethylether. Those two grew up together and the latter is a very safe anesthetic, but it’s explosive and flammable. So it doesn't mix well with today's electronics. Chloroform is unsafe, in the sense that it's metabolized into reactive products in the liver and causes liver toxicity. It also has bad cardiovascular effects. So both drugs have gone by the wayside and the safety profile of the drugs we do use has continuously improved. But it’s not because of us knowing how they work. It's all been empirical, trial and error stuff.

Today, we have drugs that are safe in the short term, but we’re worried about long lasting effects, especially cognitive effects in the vulnerable brain, for example the elderly and children. Effects could last well beyond duration of administration. That's gotten people worried. That's why we're trying to come up with other chemotypes that don't do these things.

RE: Because we get away with it. Worldwide, it's estimated that over 200 million general anesthetics are given each year. In this country alone it’s something like 40 or 50 million per year. Really, only 30-40% of people make it through life without experiencing a general anesthetic. Based on the safety profiles, the bad things that happen and are directly attributable to anesthetic are very rare. But that's just the tip of the iceberg. We don't know what else we're doing long term. We're just not set up to know that yet.

RE: I wouldn't give that to any human. Aminoanthracene is strictly a lab anesthetic that helps us to understand what the microscopic and molecular targets might be. It's only advantage is that it’s fluorescent. If you do reading on 1-aminoanthracene you know they aren't good molecules to have in you for any length of time. Probably carcinogenic.

We have two arms to our research, finding the targets and trying out new drugs. Aminoanthracene has helped in both arms. One arm of the project is discovering new drugs — we've done a large screen of half a million compounds and are now sorting through the hits to find a new class of general anesthetic. The other arm tries to identify what the molecular targets might be. Finding the targets helps us to direct drug development a bit more.

RE: The mechanism of local anesthetics for things like epidurals, spinals, local anesthesia, we think we understand that a lot better. They're bigger molecules and there’s a good relationship between selectivity of the molecule and its size — local anesthetics are more selective about what they affect. And part of the safety also comes from the fact that we only give a little bit in a very selective place, to begin with. By the time it disseminates into the rest of the body the concentrations are so low that it does nothing. Dose matters. For example, if you give enough local anesthetic intravenously, they can cause seizures and cardiovascular collapse. But in small doses it’s safe.

RE: Basically, this sounds kind of primitive, but the basic endpoint used in anesthesia is that when a surgeon cuts the patient, they don't move. I'm serious. It's very, very crude, but it's the coin of the realm. The bottom line is that when you do something that ought to hurt the animal, it doesn't respond. In a tadpole that means trying to elicit a startle reflex by tapping their dish, or tapping the tadpole itself. If it doesn’t do anything, it’s considered anesthetized.

That behavior, loss of movement, we see in animals going all the way down to the fruit fly or the nematode. Any animal that can move can be an anesthetic model. But what I really mean by “mimic” is that concentrations required to produce that endpoint are almost the same, within 10 or 20% or so, of those required to achieve the endpoint in humans. And that’s right across a large number of common anesthetics.

The ability to be anesthetized is a very conserved response. I wrote a paper a few years back on “Why can all of biology be anesthetized?” The response even extends to plants!

RE: I have a theoretical, protein-based argument — that proteins have small hydrophobic cavities that are essential to their movements and function. If you fill those holes with a small hydrophobic molecule, like anesthetics, you're going to inhibit or change the function of the protein in some way. It may be such a small change that it doesn't matter, or it can matter a lot. But all proteins have these cavities, so all of biology should be affected.