Certain individuals may be scar formers with development of thickened, unsightly scars at the incision site,called hypertrophic scars or keloids. These can sometimes be lessened by the injection of a steroid substance such as Kenalog into the wound, but it usually does not completely eliminate the problem. If you have to have elective surgery, discuss the location of the incision with the surgeon, and he may be able to place it in such a way that it won't ruin your social life!
Chapter 22
ANESTHESIA
Though this profession has its class,
These Docs are known for passing gas.
But you won't know it cause they keep,
All their patients fast asleep.
Actually, that statement is only partly true. Anesthesiology is a profession requiring several years of training after medical school, and these physicians have a whole armamentarium of ways to keep you from experiencing pain during a surgical procedure.
The advent of practical anesthesia in the mid-eighteen hundreds opened the doors for tremendous advances in surgical technique that were impossible in awake or sedated patients. In the last fifty years the advances have progressed to safer and more esoteric methods of dealing not only with eliminating consciousness and pain during surgery, but also to a subspecialty of pain management that allows them to help patients with chronic pain from benign or malignant disease.
The anesthesiologist will take a history from the patient, review the records and do a limited, appropriate physical exam. If you are having a surgical procedure, he will discuss with you the various options, including full general anesthesia, where you are put to sleep, heavy sedation plus local anesthesia, or some type of spinal or regional anesthesia. Except for the completely local anesthetics, most anesthesiologists will need to have an IV started for administration of medications, and he or a nurse will start this in the preop area. Once you have gone into the operating room, you will be hooked up to an EKG monitor. Depending on the seriousness or location of the surgery, he may want to place an arterial line, an IV line in an artery to better monitor your blood pressure and a place to draw blood samples, if needed, and give antibiotics. After you are asleep, he could place a nasogastric tube through your nose into your stomach and a Foley catheter in your bladder to measure urine output. While the surgeon is called the captain of the ship in the operating room, the anesthesiologist is certainly the second captain and manages the patient's vital signs and any non-surgical problems that might arise during the case. This includes a host of medical problems, including heart abnormalities, respiratory problems, paralyzing the patient when needed, and looking for any untoward reactions to the abnormal state of anesthesia.
The patient is usually sedated prior to entering the operating room to allay anxiety, and some of the drugs, like Versed, may cause total amnesia from the time it is given until you wake up in the recovery room. Once in the operating room, the anesthesiologist administering a general anesthetic will give more medications by vein, followed by a combination of intravenous medications and gases, the last of which are given either through a mask held or strapped over the patient's mouth and nose, via an endotracheal tube inserted into the trachea, or a special laryngeal tube fitted into the throat. The anesthesiologist may either breathe for you, if you are completely paralyzed, or connect you to a machine which will breathe for you at a fixed rate and give you a fixed volume of oxygen mixed with several anesthetic agents. We don't need to discuss the specific agents except to say that ether and chloroform, two old standbys, are no longer used.
Some patients may develop headaches, nausea or dizziness after a general anesthetic, but this is all treatable with medications and rapidly passes away.
For those patients who do not need or want a general anesthetic, the anesthesiologist can give a heavy sedation in combination with the surgeon injecting a local anesthetic like marcaine or xylocaine. Many surgeons do hernias, breast biopsies, removal of skin tumors, and many other general and orthopedic surgeries under combined general sedation and local anesthesia.
A third method of anesthesia is the regional block. In this type the anesthesiologist injects local anesthetic agents around specific nerves to block or temporarily deaden the area. The patient feels no pain, although he may still retain a sense of pressure or vague touch.
Still another type of block is the spinal or epidural, another location near the spinal cord, such as used in delivering babies or even to do abdominal or lower extremity surgery. This is usually augmented by some sedation, again to decrease the anxiety during the surgical procedure.
In many medical centers, the anesthesiologists are giving what is called a continuous epidural block, which involves placing a very fine tube in the epidural space in the back and delivering a set amount of medication, such as morphine, even after the surgery is completed. This takes away most of the discomfort after a major abdominal or lower extremity surgery and can be kept in place for several days. It's certainly the way I want to go if I have to have any major surgery, but it takes a specially trained physician to place the tube and to monitor it carefully afterward.
The anesthesiologist and pain management specialist has a large number of procedures he can do to permanently block sensory nerves in individuals with severe pain from chronic diseases and from cancer. There is practically no situation where pain cannot be alleviated, and these specialists are the ones a surgeon will turn to when that expertise is needed. But, remember, it is necessary and important for the patient or the family to be “proactive” and ask about all these types of procedures.
Chapter 23
BURNS
Somehow, with whatever happens inside,
We can retain some personal pride.
Because when our faces and smooth skin are left
We're somehow not completely bereft.
The tragedy with burns appears to be
They can harm our personality,
We can tolerate an inner pain, you'll discover,
But destroy our looks, and we may not recover!
Today most major burns are handled in comprehensive burn centers, with dedicated nurses, internists, and surgeons familiar with this subspecialty. Some estimates indicate that there are more than 200,000 major burn victims in the United States each year, and more than a third require hospitalization. Burns are graded as first, second, and third degree, depending on their depth of penetration and injury to the skin. Most of us are familiar with first degree burns, which are essentially like sunburns, causing redness, pain, and occasional swelling. This type of burn may result in superficial peeling but does not cause any permanent scarring.
Second degree burn is a more extreme extension of this with blister formation, severe pain, and partial sloughing of the outer layer of skin. It takes regular cleansing and care not to get infected, and yet it will heal on its own without skin grafting. However, depending on the depth and location, it will probably leave some scarring and deformity.
Third degree burns indicate full thickness destruction of the skin and are often initially not painful because the skin and its nerves have been destroyed. If the area involved is more than a small percentage of the body surface area, there can be severe loss of fluids and the body chemistries called electrolytes, high chance for infection locally and throughout the body, a shock-type state with possible damage to the lungs and kidney. The involved skin will never recover, and these areas have to be covered with eventual skin grafts or rotation of skin from adjacent or other areas of the body. These
