Gloves and surgery… (Day -243)

Bristol Vet School Glove Perforation Study

Something that many take for granted is once you put the sterile operating gloves on, unless you do something stupid you remain sterile. This is even more important when it comes to pet guardians who when entrusting their animals to us take it for granted that a vet will do everything possible to ensure a good outcome.

A good outcome here is there being no Surgical Site Infection because the surgeon has worn gloves, and taken all steps to reduce the risk.

However a recent study published in July this year has shown that perforations (holes) occurred in gloves during 43% of orthopaedic surgeries (you can read the study here). This followed an earlier study looking a glove perforations in general surgery which identified perforation in 26.2% of surgical procedures. The latest study confirms that perforations are more likely in orthopaedic surgeries.

This is concerning as in a human study the risk of surgical site infection doubles when there is glove perforation. When dealing with orthopaedic surgery especially the effect of an infection can be devastating especially when there is an implant or metalwork involved. Anything that can be done here to lower the risk of infection is therefore extremely important.

Unfortunately though as surgeons the ability to detect a glove perforation can be extremely difficult. The studies I read here have detection of a perforation at between 7-31% – in human surgery it is only 37%.

So as with most problems there is a solution, and in this case it is wearing a pair of sterile indicator gloves under the surgical gloves. These indicator gloves are made exactly the same as the surgical gloves with just the addition of a dye. Therefore when the outer glove is perforated and liquid contacts the inner glove a colored spot will appear on the glove at the site of perforation to alert the surgeon that it has occurred.

With the use of indicator under gloves the detection rate of glove perforation by surgeons increased to 90%.

Whilst from this it would be logical to say that every single surgeon should use indicator undergloves there are the practical concerns of veterinary medicine to consider. Currently there is no study on the ability to perform surgery to the same level and dexterity in veterinary surgery so whilst double gloving may decrease the risk of infection in 26.2% of all cases (43% in orthopaedics), in the other cases it may increase the risk of surgical mistakes when a glove slips for example.

Then there is the economical impact – indicator undergloves will increase the cost of the surgery. And already pet guardians commonly complain about the cost of veterinary medicine. So adding £10 to the cost of every surgery in case gloves break so that the surgeon can recognise they have broken may not for many owners be acceptable.

However when doing orthopaedic surgery like a joint replacement where a surgical site infection may result in removal of the implant and in some cases amputation then £10 becomes very little indeed.

I would love to hear your thoughts and comments as it is definitely one that needs consideration…

Genius on the Edge – The Bizarre Double Life of Dr. William Stewart Halsted (Day -255)

Genius on the Edge – The Bizarre Double Life of Dr. William Stewart Halsted

After reading the biography of Dr Harvey Cushing I was very excited to start reading this book as Dr Halsted is where modern surgery comes from.

The size of the book is relatively thick, however there is a large font used throughout with a relatively large text spacing make it easy reading. Unfortunately this is one of the only positives about this book.

The author jumps backwards and forwards through time almost randomly. It is a constant struggle to know just what stage of Dr Halsted’s life is being discussed, and there is no logical order to the flow.

This is compounded by the inclusion of many other people within the book – I would guess that if you removed all this stuff about other people the book would be half its size. This disappointed me as I wanted to learn about Dr Halsted – and instead of this found very little about him here. I am not sure whether this is because there is so little known about him, however with the way the author kept jump to random other people it felt like they were just trying to make their word count. Often I had to search backwards and forwards just to find out where in time I was supposed to be.

I guess that something I really liked about the Harvey Cushing biography was the inclusion of historic documents including letters and medical reports. These are not included in much detail within this book on Dr Halsted.

All in all, I would not recommend this book for someone wanting to learn more about the contribution of Dr Halsted to surgery. I will be continuing on my search to find out more about this great man.

Harvey Cushing – A life in surgery – A Review (Day -266)

Dr Harvey Cushing - A Life in Surgery

As the first biography I have ever read cover to cover this book was absolutely gripping with me wanting to find out what happened next.

Many people may have heard of Cushings Syndrome or Disease which is where the pituitary gland often has a tumour which increases the amount of hormone released from it. This increased secretions has a big effect on the rest of the body and was defined by Dr Harvey Cushing. However in addition to this Dr Cushing was also the founder of modern brain surgery.

Back in 1887 when Cushing looked to train as a surgeon there was no such thing as neurosurgery – actually there were no requirements other than money for the fees to get into medical school. The medical schools were run by practicing doctors from the local area that did it to supplement their income. Surgery back then however was only an emergency last attempt – there was no elective surgery – and when it happened the odds of the patient surviving were tiny. Not just from the actual surgery itself which was often only amputations but from the infections that occurred afterwards.

Dr Cushing started his studies at Yale before moving to Harvard and in 1896 was planning to travel to Europe to study when instead he was offered a place to study with Dr Halsted at the new John Hopkins Hospital after being initially denied. Learning from Dr Halsted the techniques of haemostasis, good surgical dissection and aseptic surgery.

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When the skull was opened here the patient in most cases suffered from something called fungus cerebri which is infection of the brain. In 2016 there are neurosurgeons that have had entire careers without seeing such a thing. This is largely thanks to the careful use of aseptic technique that Dr Cushing had learned from Dr Halsted.

Something that really interested me was the use of dogs within the surgery training courses at these medical schools. Initially they started as just using dogs for trying out new techniques, then for the training of new surgeons, however these training centres evolved into the first veterinary hospitals with human doctors treating dogs for surgical diseases not treated before. Some of the research that evolved from dogs has been instrumental in developing modern neurosurgery.

For example the Cushing reflex which says that when the pressure inside the skull raises, then the blood pressure will rise as well to compensate and keep the brain oxygenated. Dr Cushing investigated this by opening a dogs skull and replacing a section with glass so that he could see the vessels of the brain as he increased the pressure in the skull. He noticed that as he increased the pressure the vessels initially became compressed, however then the blood pressure of the body increased to force blood back into these brain vessels.

The thing that Dr Cushing is most known for however is that of Cushings syndrome or disease which is where a tumour on the pituitary gland at the base of the brain causes excess hormone release into the rest of the body causing clinical signs. Dr Cushing did a range of experiments here both on dogs and with human patients looking for a way to treat those suffering from acromegaly which is increased growth. At the time the function of the pituitary gland was unknown, so this work was ground breaking.

I would highly recommend that anyone interested in the history of surgery reads this book.

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The crazy killer cows… (Day -267)

Cow reproductive management

Growing up in London I had very little experience with farm animals. So starting my vet school journey I had an open mind with a willingness to work with them, to try and understand them. To follow advice and instructions of those more experienced with working with them.

Sure accidents can and will happen, big animals may step on your feet or crush you against a wall. These are things we are taught to recognise and avoid. However together I met my first cow that actually meant to injure humans.

Talking about intentions when it comes to behaviour is generally a very massively frowned upon thing to do.

As background it is common to try and form a channel to move cows from one place to another. Sometimes humans are used to block paths as most cows will do anything to avoid a human… So we were using a channel into the crush with no problems.

In this cows case however I am not under any illusion that the cow was attacking us humans. It used its head firstly on one of my colleagues, knocking her to the ground, and then when she tried to escape crushing her to a wall. Then the cow turned around and head butted a farm worker who tried to close the gate after the cow had the left the area we were in to protect. Not just the once, but once the worker was falling the cow head butted him against the gate.

This is the first time that I’ve seen an incident like this occur with cows. It’s not nice to be the target of a 500kg animal, and it is rather scary. Whilst I have always thought cows would never cause intentional harm I realised that this a wrong thought to have. Normally I have no problem helping with the movement of a cow or calves, or blocking a path to help form a channel for the cow to move along to where she needs to be.

After this incident I chose not to act as a human barrier to close a path off. I think this is the first time where I have actively refused to do something for fear of injury or harm during my entire time at vet school. My judgement here was proven correct when the farm worker that took my place had to climb the fence to escape from the next cow through.

I know now that I will never been working with cows ever again once I finish my ruminants state exam.