byvillar

SQUARE BREAST VS ROUND BREAST

Mon, 22 May 2023 10:57:25 GMT

I just came across a rare photo of James W May Jr. He was my Chief Resident as a Junior surgical resident on the Massachusetts General Hospital plastic surgery service.

Tall, handsome, brilliant, bow tie, Brooks Brothers, consummate gentleman and master technician. Totally unassuming, modest, generous, and an unquenchable thirst for knowledge.

My first day on the plastic service, I was assigned to assist Brad Cannon, a senior master surgeon. We were performing a breast reduction. As the case proceeded, the breast seemed kind of square to me. I asked, “Why does the breast look square?” Brad explained, “when you pull the flaps down, they all come out square”. At that point the scrub nurse fainted and started to fall. I wheeled around and got my gloved hand under her head before it struck the floor. I lifted her legs and she recovered. We had both broken scrub and had to leave the room to re- scrub. Brad continued the surgery as if nothing happened. “Get me a new scrub” he calmly ordered.

I returned immediately, scrubbed, and gowned to finish the case. It was my first reduction. The breasts looked square.

The original scrub nurse returned just as we were finishing. “What happened dear? ” asked Brad. “ It must have been the square breasts sir, ” she smiled behind her mask with a wink to me.

My second case that day was a breast reduction with James. We called him Jim. He was performing an inverted T reduction. I noticed that the breasts came out nice and round. After the case, I inquired, “ I just did one of these with Brad and the breasts came out square. Yours came out round. Why?”

Jim came up and put his arm around my shoulders. He was tall and leaned over conspiratorially in a soft whisper as if this was to be a deep dark secret between us, “ IF YOU CUT THEM SQUARE, THEY COME OUT SQUARE. IF YOU CUT THEM ROUND, THEY COME OUT ROUND “. He smiled that James May Jr. smile.

This was perhaps my first and most important lesson in plastic surgery!

TWO MINUTE BALLET #3

Sat, 06 May 2023 14:10:15 GMT

I had just come down from Boston to Nassau County Medical Center on Long Island, New York.

I did not yet have a dorm room assigned, so I slept in empty hospital beds of opportunity.

I had to go back to Boston in two days to pick up and move my belongings down.

The medical intensive care unit (MICU), was adjacent to the surgical intensive care unit (SICU), separated by an open through passage. I was wandering about, getting the lay of the land and checking out the nurses, when I noticed the medical team resuscitating a patient in the late afternoon. He would arrest and they would get him back. This occurred numerous times over a few hours. Then they posted a chest X-ray on the backlit frosted glass x-ray reading boxes along the wall across from the patient cubicles filled with blinking and beeping machines punctuated by the slow crescendo swish of ventilators, separated by curtains.

From afar, I noticed the heart silhouette was massive. I moseyed up to the x-ray box, studying the x-ray. The Chief Medical Resident approached and asked who I was. “Just down from Boston to be the first 5th year Chief Surgical Resident”, I responded. Surgical residencies had been four years long. But with the historic advances in Medicine in the 70s, the programs were being lengthened to 5 years.

“What do you think?”, he asked knowing the answer. “That silhouette suggests a cardiac tamponade (that is when fluid fills the sac around the heart under pressure, and the heart cannot expand to refill its ventricles with blood, cutting down output). Would you like me to tap it?” ( remove the fluid with a big needle so the heart can expand again), I offered .

“Sure”, he said just as all hell broke loose!

The patient went flat line again, but this time did not respond to medication or defibrillation. I asked the Chief Resident if he wanted me to cut his chest open to restart his heart. His eyes widened in disbelief, “can you do that”? “Sure, nothing to lose. CPR on that heart will do nothing”. (With tamponade, you cannot get compression of the ventricles with CPR).

I called for a surgical blade from the surgical nurses in the adjacent SICU before he could say “a tap and CPR will be too little too late.” The patient was already intubated, and a Swan-Ganz line in. This was a thermo-dilution catheter placed through a vein into the right ventricle up into the pulmonary vein and wedged into the alveoli vessels by balloon. By injecting cold D5W (5% sugar water) of a known temperature into a proximal port in the right ventricle and measuring the temperature drop at the distal wedge port, you could calculate the cardiac output. We pioneered this technology in my trauma fellowship in Boston, programming our own primitive computers and building a portable cart from parts found in the hospitals basement. We were responsible for every septic patient on both the surgical and medical floors. My fellow Fellow and I dropped so many catheters that toward the end of the year we could guess the cardiac output of many septic patients before placing the the device, just on clinical evaluation. Of course the cardiac output of this patient was a no brainer. It was zero!

A surgical blade without a handle was handed to me and the two minute ballet began with gloveless hands. Count the ribs down from the clavicle like a pianist. Two sweeps of the blade to get through the ribs avoiding the lower margin where a groove accommodates the blood vessels. Pull the ribs apart with a cracking sound. Push the lung away and cut the pericardium open expecting a gush of fluids and squeeze the heart to pump blood hoping it will restart on its own.

This is when things went terribly wrong! There was no gush of fluid! When I grabbed the heart , it did start beating but my thumb almost went right through the heart into the left ventricle! I have no words to describe that feeling of utter surprise and pure relief that my finger nails were well manicured.

This was not a pericardial effusion, it was a massive left ventricular aneurism and the bubble was the size of a baseball only millimeters thick. The dead muscle had thinned out like a massive bubble on an old inner tube! I was going to be up all night with a dead man.

With my hand cradling this time bomb of a heart and hot blood from the incision pouring down my scrubs filling my shoes, the nurse held a phone to my ear in an attempt to notify the cardiac surgeon. He was tied up in surgery! So they got the Chief of General Surgery, Anthony DiBenedetto on the line.

Anthony DiBenedetto was the most respected surgeon on Long Island. He had just hired me to be the first 5th year Chief Resident on the recommendation of my mentor at Massachusetts General Hospital, John F. Burke, the man who had pioneered growing skin for our patients at the Shriners Burn Institute. John saw me as a trauma surgeon and suggested I complete 5 years of general surgery and give it a try, before committing to plastic surgery. Hell, what’s a few years more to a young man?

We developed an instinctual bond on the interview, but our life long bond of mutual respect was yet to bloom. I called him “Chief” from the start.

I explained the predicament I was in and that the heart surgeon was tied up. “Good job, get him to the operating room, I am on my way”. I hope he knows something about heart surgery, this is going to be a long night, I mused as we rushed to the operating room with my hand on his heart. Being drenched in hot blood was exciting for a young trauma surgeon in those days before HIV. But by the time we got to the OR, it was cold, sticky, and uncomfortable.

Within minutes, the Chief was in the room with the current Chief Resident, Al Adamo. The Chief was in the hospital 7 days per week. He was a master clinician. He could listen to your lungs with a stethoscope and tell you what the x-ray would show. Due to my lack of musical ability, I never mastered that. In addition to my intercostal incision, we split the sternum and placed the patient on bypass. (That is when you place tubes in an artery and vein and a machine circulates the blood, bypassing the heart.) To my surprise, the Chief had been a cardio-thoracic surgeon, and one of the best.

Once he was on bypass, the Chief told me to to get a quick shower and change with haste. He and Adamo prepared for a mind blowing procedure that rocked my world!

At the General in Boston, we called Mecca (the Harvard Surgical Service at Massachusetts General Hospital), we pioneered in open heart surgery with a magnificent survival rate.

On my rotation at University of Maryland Hospital cardiac surgery 1973, our survival rate was a dismal 2 out of ten! The next year at MGH we saved 9 out of 10!

“What are we doing different”, I asked the Chief of Cardiac Surgery William Gerald Austen. He put his feet up on the desk revealing worn holes in the ball of his shoes (on interviews he would do this to intimidate candidates), leaned back, and folded his hands behind his head.. “They are waiting until the patients have damaged most of their muscle before taking them to surgery. We are intervening early to re-vascularize while we still have viable heart muscle”, he explained. Open heart surgery was in its infancy then. In the 1960s you would die with a major heart attack or arrhythmia. We were in a brave new world in the early seventies, and not all hospitals are created equal, I learned first hand. I had experienced every known heart procedure and even got to sew in part of a heart valve at the General. But I had never experienced what was about to happen!

When I returned, the heart had been stopped and the Chief told Adamo to cut the aneurism (giant bubble) out of the left ventricle! That was 60% of the left ventricle! Then he said, “Suture it closed” and showed him how. I was flabbergasted, but this was a dead man anyway. By the time the heart was closed, the young heart surgeon arrived after finishing his case. “OMG Chief, there is nothing left of that ventricle! You better put him on a balloon pump.” (This is a mechanical device placed in the femoral artery with a balloon that pulsates to circulate blood taking pressure off the heart.). “No”, the Chief said, “ this one will come off fine”. We all looked at each other in disbelief.

We took the patient off bypass and defibrillated the heart. It started up on the first discharge! The spiraling contractions with no leakage and the remaining left ventricle expanding to accommodate its new role was a beautiful and impressive sight.

Adamo and I spent the rest of the night repairing the sign of Zorro incisions. Dr. Anthony DiBenedetto was about two inches shorter than I am, but in my mind he was well over six feet tall from that day on.

The next day, I took off for Boston to retrieve my belongings. I was away for a week and when I returned, the patient was no longer in the hospital. I assumed the obvious.

Three weeks later, I was in the outpatient clinic. Down the corridor sitting on a table was a patient with unusual scars on his chest. As I wondered, “could this be?”, an elderly woman approached me. Are you the boy that opened my husband. I still had not developed manly facial hairs and everyone thought I was a boy.

“I am not sure ma’am, was his surgery three weeks ago?” “Yes, they cut a big piece of his heart out.” “Can I ask you a question?”, she said in a conspiratorial whisper. “When can we have sex?”, she whispered looking around with embarrassment. “Soon, but not just yet”, I said feining no surprise, which was a theme quote in GLADIATOR (a piece of movie trivia). “Soon, but not just yet”.

I approached the patient with cautious disbelief. There was the sign of Zorro, in freshly healing wounds. He was alert and had no brain damage. He had no recollection of his chest being cut open without anesthesia. He was feeling great and had been discharged three days after surgery in stable condition! We chatted at length, but I made no mention of his wife’s request. Too early for a new heart attack!

The doubts I had from saving the body but not the brain in Lynn, Massachusetts years ago were answered. That had been a stepping stone, a learning curve, to this right time, right place, right skills moment.

TWO MINUTE BALLET #2

Fri, 05 May 2023 14:07:49 GMT

As a Junior Surgical Resident at Massachusetts General Hospital we had a rotation through Lynn Hospital.

I had just come up from my Shock Trauma Internship at the University of Maryland. A 55 year old male presented to the Emergency Room with a severe heart attack.

Back in the early 70s, people routinely died from heart attacks in community hospitals. There were no cardiac catheterization services, CAT scans, MRIs, sonograms. There was only one trauma center in the entire country! I just came from it, at the University of Maryland. Open heart surgery was in its infancy. During my rotation in open heart at University of Maryland in 1973, mortality was 80% and worse at other times!

CPR failed, the medical crew could not stabilize him and when he went flat line, I performed the two minute ballet with no gloves as a last chance. Time was of the essence. Count down from the clavicle like a pianist. Two sweeps of a #10 blade staying away from the lower margin of the rib which has a groove containing the blood vessels. Push the lung aside and open the pericardium. Upon squeezing the heart, it started right up giving us time to administer medications and oxygenation. Then off to the operating room to close the wound.

At first I was so excited! I had saved a life in no uncertain terms. I beat the Grimm Reaper! I pulled off the two minute ballet flawlessly. I was hot shit!

After a few days it became evident that we saved the body, but not the brain. The patient could not remember his wife or the past. It gave me pause. Was it worth it? Should I have let nature take its course? I left that rotation without ever knowing the long range outcome of that reflex decision. It was sobering. It shook my foundation.

This skill set, however, served me well in the Emergency Room and Operating Room over the next years of residency. Dozens of gunshot and stab wounds to the heart and pulmonary arteries and veins received a second chance in life by fast and decisive treatment.

Then finally, late in my surgical training, those skills and expertise intersected my date and time with destiny. But that is another story.

Part two of three.

NOT ALL DOCTORS ARE CREATED EQUAL

Thu, 04 May 2023 14:06:01 GMT

How I learned NOT ALL DOCTORS ARE CREATED EQUAL.

Case #1 Two Minute ballet

During my first week as Intern at St Frances hospital in Baltimore a 50 year old male presented to the emergency room with a gunshot to the heart. He was leaving a restaurant with his wife. A man demanded his wallet. He gave it without resistance and was shot through the heart.

His pupils were fixed and dilated, but his heart was still fibrillating. I intubated him and started large bore IVs with fluid resuscitation. But what next? I called the Chief Resident. “I have a gun shot to the heart, fixed a dilated. Can you show me what to do if he came in still salvageable?”

“Keep resuscitating”, he commanded. “On my way”.

I feigned resuscitation on his brain dead body until the Chief Resident arrived.

He flew into the room. His fingers glided down the left chest starting at the clavicle like a grand pianist counting ribs. “Knife” he calmly requested with outstretched hand. In two swift deliberate strokes he was through the ribs avoiding the lower margin where the blood vessels run along in a groove. With gloveless hands, he pulled apart the ribs with a cracking sound.

He pushed the lung aside and cut the pericardium (the sack surrounding the heart) open. “Suture”. Without hesitation he placed a figure of eight suture in the front hole. He flipped the heart over and placed a figure of eight in the exit wound.

Less than two minutes! I had witnessed a ballet of fluid, graceful, purposeful, efficient movement. It was love at first sight. Me and trauma were destined for a long love affair.

Like WWII aces remembering a dogfight, this memory is etched in my mind and gets played over and over in slow fluid motion.

Months later I witnessed another emergency thoracotomy at the main hospital. The attending asked for a tray (instruments). He then meticulously prepped the patient with Betadine. He laid sterile towels. He proceeded to daintily cut the skin until he finally entered the chest. He asked for a retractor to spread the ribs. He pushed the lung aside and asked for a retractor to hold it out of the way. He cut the pericardium and reached the heart. Eight minutes. The patient did not survive.

I learned a valuable lesson. NOT ALL DOCTORS ARE CREATED EQUAL !

I was determined to be the ballerina.

I got to perform the two minute ballet a number of times In my career, but that is a story for another time.

First of three part series.