Author: Ross Fisher

What’s our vector, Victor?

Posted on by Ross Fisher
what’s our vector Victor

What’s our vector, Victor?   

 

Most surgical trainees look at their Chief and think, “Damn, you’re old,” because, in the middle of something important or complex the chief will say something random like, “what’s our vector, Victor?” The anaesthetist who is also as old as Mehtusulah will smile and this will prove to one and all that the Chief is a child of a bygone age. She really isn’t, she is just subtly trying to teach you about tying surgical knots properly, and why you should push into the wound not pull out of the wound. Vectors can be the difference between life and bleeding out horribly. Your Chief is wise.

 

“What’s our vector, Victor?” comes from an old (sic) film called “Airplane.” You should watch it, if only to understand why old people randomly say things like, “Surely you can’t be serious?” (I am. And don’t call me Shirley!) In terms of surgical knot tying understanding, vectors is everything. If you don’t you won’t understand why your knots are causing your Chief to sweat like Ted Striker. If you get vectors wrong, bad things will happen.

what’s our vector victor

This post is not about how one throws a knot. That will be found elsewhere. It is about how one tightens a knot and uses vectors to both secure the knot and stop the tissue being ligated from being ripped out of a deep dark, soon to be filled with blood, hole. A vector is a quantity made up of force and magnitude; the amount you pull and the direction you pull in. 

 

If you throw a knot and pull up on both ends in two separate directions, out of the wound, the resultant vector (red arrow) will cause tearing of the underlying tissue upwards, away from whatever essential structure is in the deep. Worse, the knot will not be fully locked either.

what’s our vector Victor

what’s our vector victor

If however, you hear your Chief’s voice in your head saying, “What’s our vector, Victor”  and then rotate one of the treads to push down on that, in completely the opposite direction from the pull out of the wound, the resultant vector will be a balance of both of these forces, ideally zero (red dot). Nothing will move with the exception of the knot locking and your Chief being impressed. (They won’t say they are impressed, they expect this.) But if you can achieve this, somewhere, deep inside, something will change, all because of vectors. What’s our vector, Victor? Roger, Roger.

Epigastric hernias don’t need surgery

Posted on by Ross Fisher
epigastric hernias don't need surgery

Epigastric hernias don’t need surgery. They are asymptomatic protrusions of pre-peritoneal fat through a tiny mid-line defect in the linea alba. They are irreducible. The reported prevalence is over 10% and epigastric hernia repair represents approximately 4% of hernia surgery. This is in the face of no evidence whatsoever of complications related to the problem itself. Epigastric hernias in paediatric surgical practice are an excellent area to consider the influence of evidence and experience. Epigastric hernias don’t require surgery.

Operative experience (sic) reveals a defect between interweaving fibres of the linea alba with variable protrusion of pre-peritoneal fat. The defect is never greater than a millimetre but the rest of the herniated fat may spread out to a diameter of 20mm. This is the “bulge” noted by parents, palpated by practitioners, perceived (truly) as irreducible and the causation of referral, even as an emergency conflating the words hernia and irreducible. The description of the lesion by the family is almost pathognomonic, “you need to see it in the right light Doctor, with leaning just off to one side…” The symptomatology of the lesion, however, is harder to clarify despite various attributions of localised pain, tenderness, difficulty with extension and change in bowel habit. The fat has no sensation, is never seen as infarcted or even inflamed. Bowel is never present in a paediatric epigastric hernia and attribution of symptoms, therefore, becomes challenging.

The literature reflects many of the issues discussed above. The pathogenesis is unclear but probably relates to the weave of crisscrossing fibres. The symptomatology is confused. One of the very few review articles published in 2000 suggested that “little is known about their presentation and natural history in this age group” dismissing a paper from 1960 that proposed a conservative approach to the matter. The “symptoms” described, however, the “mass” as being reducible, enlarging or tender. This is entirely contrary to my personal experience. I cannot think why this centre and many others that charge money for such surgery might have such a divergent view of the value of the intervention.

It is clear that the surgery involved in repairing such a tiny defect will be more significant than the defect itself. Fantastical minimally invasive approaches are also described to fix this issue that has no symptoms or complications. The astute surgeon should carefully assess the patient, the history described and the risks and complications of the surgery proposed and offer the appropriate choice to the family. Epigastric hernias don’t need surgery. Caveat emptor.

 

 

Caveat emptor (Latin) let the buyer beware.

 

References

Ponten, J., E. Somers, and H. Nienhuijs. “Pathogenesis of the Epigastric Hernia.” Hernia 16.6 (2012): 627-33

Coats, Richard D, Mary A Helikson, and Randall S Burd. “Presentation and Management of Epigastric Hernias in Children.” Journal of Pediatric Surgery 35.12 (2000): 1754-756

FOAMed

Posted on by Ross Fisher
FOAM

 

FOAMed is Free Open Access Medical education. Medical teaching has been around since Thgg showed Gthh how to treat an infected sabre tooth cat wound, back in the Stone Age. However, Mrrr wasn’t around as he was away hunting and so he never learned. Mrrr died a few weeks later of an infected sabre tooth cat wound. Teaching cannot always take place at appointed times and that affects patient care. Ask Mrr.

The essential knowledge in paediatric surgery should not be locked in a facility or charged for but should be globally accessible, crowd-sourced, an educational adjunct providing inline (contextual) and offline (asynchronous) content to augment traditional educational principles. This is the concept of FOAM. This is the stimulus to develop this resource and share links and input from around the world.

 

FOAMed initially started in Emergency Medicine and Intensive Care in 2012. Around the world a community of like-minded groups were created, each constantly evolving, working collaboratively and interacting such that education resources in Melbourne might be used in Manchester, shared in New York, refined in Cape Town and finally distributed on the web to make the world a better place and improve the care of our patients, everywhere. FOAM is independent of platform or media — it includes blogs, podcasts, tweets, online videos, text documents, photographs, Facebook groups, and according to the scientific literature, a whole lot more. This is FOAM and these are some of our friends.

St Emlyn’s is an Emergency Medicine site. We share the same virtual campus with them at Virchester.  One of our staff is also on faculty there. St Emlyn’s produce internationally acclaimed content regarding all aspects of Emergency Medicine but also has a strong suit in the concepts of education and learning theory. They recognise clinicians are not machines and so have multiple resources crafted to support us in our psychological and physical welfare.

St Emlyn's

In the paediatric sphere  Don’t Forget the Bubblesis an essential site and we have worked with them giving presentations at their amazing conferences. They are internationally renowned for developing knowledge related to emergency and general paediatric care and even for some of their “research.”

Don't Forget the Bubbles

One of the principles of FOAM is the generation of evidence, rather than eminence-based medicine. The idea scientific literature should guide care more than old professors shouting loudly. The SGEM is a leader in this, continually striving to shorten the knowledge gap of new practice evolving through research and then become part of established practice. Visit this site and start to understand the true implications of the literature we read.

The Skeptics Guide to emergency Medicine

If you start searching you will find the volume and availability of education available are truly overwhelming. Over at RebelEM our friend Salim Rezaie explains how we might consider using this amazing and initially overwhelming resource.

RebelEM

Lastly, the field of pediatric surgery (and pediatric surgery too) is pretty barren when it comes to FOAMed. It is interesting to consider why this might be but the leader currently in our field is our friend and colleague Todd Ponsky. His global cast podcasts can even be accessed through their own app “Stay Current,” available wherever you get your apps.

Global Cast MD

There is so much opportunity and so much information available in FOAMed, none of us can know it all. It is said that in the past we used to expect clinicians to carry all the knowledge with them as a library. To be honest that never worked. What we can do now is to be the librarian and know where to find that information. If you have thoughts or links that you use, please let us know in the comments section and we can spread the FOAMed further.