Wednesday, September 14, 2011

In The Usual Sterile Fashion

Dennis settled in his chair, the scent of cauterized tissue lingering in his nostrils. Stacks of medical texts loomed on the wood desk. One of the texts, a neurosurgical tome, was splayed open at his chest. Beside that, a dictaphone with mini-cassette.

He lifted the handset, began dictating the operative report.

Surgeon: Dennis Falconcliff, MD

First Assistant: None

Preoperative Diagnosis: Large left sided post-traumatic subdural hematoma

Postoperative Diagnosis: Left subdural hematoma

Procedure: Left fronto-parietal craniotomy, evacuation of subdural hematoma, hemostasis, placement of subdural drain, duraplasty, cranioplasty, closure.

Surgical Procedure:  The patient was taken to the operating room and placed in supine position. Anesthesia was administered. The patient’s head was bent to the right, exposing the left fronto-parietal region. The hair was clipped and removed. Using anatomical landmarks, a straight incision was marked on the left fronto-parietal scalp from front to back.  The area was prepped and draped in the usual sterile fashion. A mixture of 0.25% marcaine and 1% lidocaine with epinephrine was used as local anesthetic. A 10 mm scalpel was used to make the skin incision down to the galea and periosteum. Hemostasis was obtained using bipolar electrocautery as well as Raney clips. Retraction system was applied. The periosteum was lifted from the skull using a periosteal elevator. Good exposure was achieved and the area was irrigated. Two burr holes were placed on the anterior and posterior aspect of the incision using Midas Rex perforator. The dura was separated from bone. The craniotomy bone flap was elevated between the two burr holes.  The dura was well visualized and appeared blue and taut, under significant pressure. Hemostasis was achieved using gelfoam in thrombin and electrocautery….

Dennis shifted in his seat, leaned a bit, recalling each detail. The next part brought great satisfaction, reinforcing his decision to pursue medicine.

…….A #15 blade scalpel was used to make the initial incision on the dura. As soon as the dura was opened, a large amount of subdural fluid rushed out of the subdural space under pressure. The remaining dura was opened using Metzenbaum scissors in cruciate fashion. A large amount of semi-clotted subdural fluid was released. The dural leaflets were secured to the surrounding tissues using 4-0 nylon stitches in order to achieve adequate exposure. The area was irrigated copiously. There was a subdural membrane along the cortex which was opened. The brain was visualized and appeared healthy and expanding appropriately. The entire subdural membrane was evacuated using suction and irrigation. There was some bridge vein oozing in the subdural space. This was cauterized. Surgiflo and thrombin was used for further hemostasis.  After evacuation there was clear irrigating fluid. A #7 JP drain was placed in the subdural space. The dura was approximated. A piece of Duragen was applied to the surface as duraplasty…..


Dennis set the microphone on his desk alongside the open surgical text. Shook his head in disgust. Squinted to keep his cool.

“Whaaaaaat?” He had to yell. She was upstairs. In a wheelchair. A blessing for him. It sucked living with your elderly mom. But heck, she made dinner every night.

“What’re ya doin?!”

“Studying to be a doooooctooor, Maaaa! You know it!”

“Ahhh! You ain’t never gonna be no doctor, Denny! You lucky you take care a yur own flesh and bones decent!”

“You’ll see!”

“That feller still there? Yur friend? He eatin too?”

Dennis looked over at the feller. Still paralyzed. Coming around. Hanging IV bag. Endotracheal tube jutting from lips like a fat stogie. The secondhand respirator whooshing and wheezing. Blood streaked face, liquid pooling on the table, dripping. A dark puddle on concrete. Half head shaved. Eyes darting. That made Denny laugh. It reminded him of a goldfish.

“Naaaaaah!!!” Dennis yelled. “Had to go!!”  Yup. Nice cranioplasty. He was proud of the job, no mind what Ma says. Evacuating the hematoma, getting it all back together like a top neurosurgeon.

“Then get on up heres!”

Dennis could hear Ma’s wheelchair creaking on wood planks. A clanking dish.

“Don’t worry, feller.” Basement doctor voice now. “After supper, I’ll be back. We’ll try something else.” Dennis flipped pages in the surgery text. “How about a nephrectomy? Ain’t done one a those yet.”