04/19/15
Endless Novella

An Endless Array of Broken Men

Endless Novella

Click book image to go to Amazon page

 

An Endless Array of Broken Men
A novella of Civil War surgery by Edison McDaniels

“It requires a man with a steel nerve and a case hardened heart to be a Army Surgeon…”
—An anonymous soldier of The Civil War

For Josiah Boyd, hell is twenty-four sleepless hours, every one of them scalpel in hand, standing under a cross in a nameless church atop a dusty hill after a pointless battle. For too many good men, this is where the world ends.

The surgeons in this place work at their unpleasant task with a fever matched only by the fervor of those that have inflicted their wounds. This camp of wounded is filled with men of both sides and the surgeons use these men, Johnny Reb and Billy Yank alike, making no distinction as to the color of a man’s uniform—the life-blood being all the same. The men wait their turn with an eerie patience, as if their fate has already been decided and it is the duty of those present in this time and place to carry it out. Arms and legs are parted from each in turn and the pile of disarticulated flesh grows at a hideous pace—eight or ten feet high. The men move on and off the tables with nary a word, except for the occasional groan that can’t be suppressed. Indeed, there is little to be said at such times, each participant in the drama knows his place and the universal language of blood speaks for all.

On this sleepless morning, Josiah Boyd is the embodiment of exhaustion. The blood and sinew that soil his front apron are now a full day old, and he hasn’t had so much as a latrine break in hours. The muck on the altar floor is two parts blood, one part shit from exploded bowels, and one part tobacco juice; Boyd spits frequently. The mothy taste of the chewed tobacco obscures the overwhelming stench of broken bodies and rotted flesh, allowing him to keep working in this seething hell.

Except for the ever present hum of flies (they are everywhere, a constant distress), it is mostly quiet; no sounds of battle breaking the dawn stillness, only an occasional random shot. Outside the church-turned-hospital, those who have survived the night await their turn at the surgeon’s table. They are a quieter lot now, having seen the two extremities of their fate in those that have gone before them.

They will live or die—it is beyond their making now…

This novella is available for 99¢ right now for Amazon Kindle

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04/19/15
MatriarchCover2

The Matriarch of Ruins

Coming this summer from Northampton House Press, the five star follow-up novel to Not One Among Them Whole, the acclaimed story of the surgeons at the battle of Gettysburg…

MatriarchCover2

 

Husbands and wives.

Sons and daughters.

Soldiers and surgeons.

Men and slaves.

Widows and ghosts.

The living and the dead come alive in this epic novel of a widow struggling to keep her family together amid the carnage of the Battle of Gettysburg—and the memories of her dead husband. A story of ordinary folks caught in the maelstrom of an extraordinary time.

It is 1863 and the war has come home to the Gamble farm in Southern Pennsylvania. With her husband buried under the willow tree in the back yard, and only four months in the ground, the widow Purdy Gamble must cope with losing him all over again when a rebel surgeon conscripts her farm—and Purdy’s growing respect despite herself. Hannah Gamble Griel, Purdy’s daughter, disappears into the chaos of war to chase her own ghosts, both imaginary and real. And then there are the twins Loli and Coal, just fourteen. One, struck dumb by a mule kick at age five, will find a disturbing peace amid the flames of war. The other will twice save a man’s life, unburying a horrid family secret in the process—a secret at once as alive as warm flesh and as dead as cold bones mouldering under the earth. 

The Matriarch of Ruins is a haunting story of lost love, moral dilemmas, and psychological traumas amid the ruins of war, by the author of Not One Among Them Whole, which told the story of the surgeons at Gettysburg. This is a vivid, suspenseful tale, told with heart-breaking empathy and stunning detail.

Available this summer for the Amazon Kindle & soon in paperback as well. From Northampton House Press.

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03/24/15
back is killing me

9 Reasons Back Surgery Might Help

9 Reasons Your Back Pain Might Improve With Surgery—Or Not

back is killing me

Back pain is a fact of life—if you are a human being (and presumably if you are reading this you are) sooner or later you will have back pain. That’s the bad news.

The good news is that for most of us, it will run its course and we will be none the worse for it. Most of us will have a single bout, perhaps two, lasting a few hours to several days, and that will be it. Some of us will have more, and sometimes that will be recurring pain (every few months or once every few years as an example), or chronic low level discomfort that’s just enough to interfere with life’s enjoyment but not at all incapacitating.

Others will be saddled with incapacitating pain, though even then most folks will find a happy medium and be able to function with certain accommodations, as with any other chronic illness (diabetes, heart disease, kidney failure) or condition (rheumatoid or osteoarthritis, fibromyalgia, emphysema).

But for an unlucky few, and unfortunately the masses of people on this earth mean the numbers work out to hundreds of thousands each year, back pain just might be an indicator for back surgery. This sort of back pain typically doesn’t get better without surgery—or at least doesn’t get better quickly enough for we busy humans. That’s the bad news.

The good news is that for these few, back surgery is overwhelmingly successful.

Here are nine reasons your back pain might need to be treated with surgery.

1. If it’s associated with leg pain.

Back pain that’s associated with leg pain may indicate a pinched nerve. Although even then most of these won’t need surgery, if the pain becomes unrelenting or lasts more than two months, see a physician. This kind of pain generally responds well to surgery, especially if the leg pain is worse than the back pain.

In the overall scheme of things, back pain that is purely and truly back pain is rarely an indication for surgery, though there are always exceptions. There are hundreds of ligaments, bones, and nerves in the back and any one (or group) of them can be a pain generator. This sort of pain might be from a stress fracture, a pulled ligament, a small muscle tear, or any of a thousand other sources—most of little consequence in the long run and most of which will heal and resolve on their own, though it will almost always take longer than you would like or expect.

2. If it’s off the midline to one side or the other.

Back pain that’s off the midline may indicate a pinched nerve or arthritic joint on one side of the back. If it’s always in the same place, it might respond to fusing the joint, deadening the nerve, or decompressing (unpinching) a pinched nerve.

3. If it’s always in the same place and does not roam around.

Pain that will respond to surgery does not roam around. The intensity may vary, and frequently does, but the location of the pain is a constant. Usually it is one sided and off the midline of the spine.

Roaming back pain rarely responds to back surgery and seems more likely related to muscle strain or spasm, or perhaps has no relation to the back at all. 

4. If it’s associated with leg weakness as opposed to pain or numbness.

One of the most frequent back problems is a pinched nerve, and while these don’t always require surgery they certainly can. Leg weakness with back pain is one indication of a pinched nerve and generally indicates that surgery should be strongly considered, especially if it is severe or not getting better with time. In general, if weakness is present, see a physician sooner rather than later.

5. If it’s been present for more than 6-8 weeks and doesn’t seem to be getting better.

Most back pain is self-limited and improves even without therapy, though it takes time since something is wrong and that something takes time to heal. Sometimes pain itself is a diagnostic tool though, and pain that isn’t obviously improving after two months is such a tool and should be thoroughly investigated. 

By the same token, chronic back pain that has been present for more than 2-3 years and is stable is generally unlikely to have a surgically treatable cause, even if severe at times. However, such pain should be thoroughly investigated at some point (at least once) since exceptions do exist.

6. If it’s always present in the morning and does not improve as the day advances.

Back pain that is worse in the morning after just getting out of bed and improves with activity rarely responds to surgical intervention. This is often age related. There’s a reason professional athletes retire around age forty. 

On the other hand, if you have back pain from the time you get up and it consistently does not improve (or even worsens) with activity, you should see a physician if it persists over weeks or months.

7. If the pain increases with walking—until you MUST sit down or else.

Pain that consistently worsens with activity to the point of intolerability, especially if just sitting down for a few minutes improves or alleviates it (sitting for five or ten minutes, not an hour or two), may indicate narrowing in the spinal canal—a condition which responds very well to surgery.

8. If the pain is associated with trouble walking—and you can improve the walking by leaning over a shopping cart.

This is known as a positive shopping cart sign and is so suggestive of a problem that can be fixed that if you have noticed this you should discuss it with your physician. Note that the trouble walking may be pain or weakness or both. Sometimes patients complain of “rubbery legs.”

Typically a person notices these symptoms when grocery shopping—they have to both push the cart and lean forward over it in order to shop. Just hanging on to the cart has no effect, the uncomfortable pain persists. Typically, those with a surgically treatable problem get great relief leaning over the cart as they move around the store. In fact, leaning over the cart becomes a must and is the difference between being able to do their own shopping or not being able to shop at all.

As the severity of the condition progresses, even leaning over the cart becomes ineffective and patients stop doing their own shopping. They become homebound.

9. If the “back pain” is really buttocks and leg pain.

In general, the more leg pain one has, the more likely their problem is to be treatable with surgery. Surgery for back pain alone is, in general, a disappointing experience (except in cases of fracture, tumor, infection, or perhaps scoliosis), but back pain associated with leg pain is a different story.

To understand why, one has to consider the generalized nature of back pain, which makes it difficult to narrow down an exact cause and thus limits what surgery can do. However, the occurrence of leg pain often indicates a pinched nerve and since each nerve has a stereotypic course, the location of the leg pain often marks which nerve is pinched—and hence the location of the back problem—with more or less precision. Surgery can then unpinch, or decompress, the nerve.

Neurosurgery101—TheBlog. About life’s harder or more interesting moments…

Search Edison McDaniels at Amazon for great fiction—Ordinary folks in Extraordinary situations! Intense. Available on Kindle.

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03/5/15
Killing King

Saving King

Saving King

Click the image to go to the Amazon Kindle page to purchase this work.

A seminal work on a moment that changed the world. Stunning.

The Rev. Dr. King was shot at 6:01 pm on April 4th, 1968. He was pronounced dead 64 minutes later, after a struggle that included an emergent tracheostomy and open heart massage. In Saving King, McDaniels dramatically recreates these events in graphic detail, providing an almost minute by minute account of the first responders at the scene, followed by the action as it appears to have taken place in the emergency room. This account is based on a close reading of eyewitness reports, King’s autopsy, and the 1978 House Select Committee on Assassinations’ investigation into the MLK assassination.

Saving King is a clever work of creative nonfiction which not only dramatizes the action in heartbreaking detail, it showcases the US trauma system at work in 1968—and in 2013. One of the most interesting portions of the monograph (which runs about 8,000 words and is an intense read by any measure) comes near the end, when McDaniels goes the extra mile and shows how such a grievous injury might be handled today.

In fact, one of the things Saving King does so well is to inform the lay public about the US trauma system. In this regard it is informative and educational without seeming to be. It reads more like a novella than a monograph, and very definitely has a story to tell.

The story opens with King on the balcony of the Lorraine Motel one minute before he is shot, and doesn’t end until he is pronounced dead 65 minutes later. Along the way, we watch as the first responders (a modern term) are overwhelmed by the bleeding and essentially just scoop and run. It is a tense 15-20 minutes later before King’s airway is finally established via an emergent tracheostomy—and his breathing finally restored to something reasonable. We learn too about the incredible coincidence that led to a delay in calling an ambulance—it turns out King wasn’t the only fatal casualty that day.

The author is himself an accomplished writer, and more than qualified to write such an authoritative work. Edison McDaniels is a board certified neurosurgeon with an extensive surgical experience, including more than a little bit of trauma. He is the author of several novels, including the acclaimed Not One Among Them Whole: A Novel of Gettysburg, which  has been described as a magnificently harrowing trip into the bloody horrors of the Battle of Gettysburg. It’s about surgery in a time when every wound was potentially fatal and every operation was a minor miracle, according to the author himself.

McDaniels’ strength in writing, which comes across loud and clear in Saving King, is his unusual ability to make the intricacies of medicine and surgery understandable to the masses. This is at least in part owing to his unique combination as an experienced surgeon, a talented writer, and a passion for both. And, in his case at least, the parts sum to more than the whole. Indeed, Taylor Polites, author of The Rebel Wife, has called him “An amazingly talented writer…”

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03/4/15
SixWordStoryEPM

Six Word Stories

 

—Other stories from the mind of Edison McDaniels—

The American Civil War Series

Not One Among Them Whole — A magnificently harrowing trip into the bloody horrors of battlefield surgery at Gettysburg in 1863. A vivid, steep descent into insanity.
An award winning novel available in trade paperback and eBook (Kindle, Kobo, Nook).

The Matriarch of Ruins (coming soon) — A widow woman struggles to keep her family together amid the onslaught of battle in 1863.
The sequel to Not One Among Them Whole. A novel.

An Endless Array of Broken Men — A surgeon struggles to save his son’s life at a battlefield hospital.
An award winning, vivid & engrossing FREE story available right here at surgeonwriter.com.

 

Thrillers Well Calculated to Keep You in Suspense

The Touched — Dr. Isaac Weed had it all, until his daughter died. Then he discovers a door to the afterlife, one never meant to be opened. Sometimes, healing can go too far.
A far surpassing supernatural medical thriller, a novel available on Kindle.

Juicing Out — Think you know how a surgeon’s thinks? Think again.
A tale of suspense, a novella available on Kindle.

Blade Man — A chilling tale of life on the road.
A twisted thrill ride, a novella available on Kindle.

The Weight of Potter’s Field (coming soon) — When an operation goes horribly wrong, a patient returns from the grave to haunt his surgeon. But it isn’t revenge he’s seeking…
A terrifying tale of things that go bump in the night at an old county hospital. A soon to be published novel.

 

Others Stories of Note

The Bottom of the Fifth — The miracles surrounding a little boy on opening day of the little league baseball season.
A short story available on Kindle.

Saving King — Dr. King struggled for 64 minutes after being shot. This is the story of that struggle.
Creative nonfiction, available on Kindle. Not for the faint of heart.

The Crucible — A brain surgeon works to save the life of a little boy on his operating table in 1951.
A gripping & empathetic short story. FREE. Available HERE.

Send to Kindle
03/4/15
Gutenberg Review

gutenburg

Gutenberg Review

—Other stories from the mind of Edison McDaniels—

The American Civil War Series

Not One Among Them Whole — A magnificently harrowing trip into the bloody horrors of battlefield surgery at Gettysburg in 1863. A vivid, steep descent into insanity.
An award winning novel available in trade paperback and eBook (Kindle, Kobo, Nook).

The Matriarch of Ruins (coming soon) — A widow woman struggles to keep her family together amid the onslaught of battle in 1863.
The sequel to Not One Among Them Whole. A novel.

An Endless Array of Broken Men — A surgeon struggles to save his son’s life at a battlefield hospital.
An award winning, vivid & engrossing FREE story available right here at surgeonwriter.com.

 

Thrillers Well Calculated to Keep You in Suspense

The Touched — Dr. Isaac Weed had it all, until his daughter died. Then he discovers a door to the afterlife, one never meant to be opened. Sometimes, healing can go too far.
A far surpassing supernatural medical thriller, a novel available on Kindle.

Juicing Out — Think you know how a surgeon’s thinks? Think again.
A tale of suspense, a novella available on Kindle.

Blade Man — A chilling tale of life on the road.
A twisted thrill ride, a novella available on Kindle.

The Weight of Potter’s Field (coming soon) — When an operation goes horribly wrong, a patient returns from the grave to haunt his surgeon. But it isn’t revenge he’s seeking…
A terrifying tale of things that go bump in the night at an old county hospital. A soon to be published novel.

 

Others Stories of Note

The Bottom of the Fifth — The miracles surrounding a little boy on opening day of the little league baseball season.
A short story available on Kindle.

Saving King — Dr. King struggled for 64 minutes after being shot. This is the story of that struggle.
Creative nonfiction, available on Kindle. Not for the faint of heart.

The Crucible — A brain surgeon works to save the life of a little boy on his operating table in 1951.
A gripping & empathetic short story. FREE. Available HERE.

Send to Kindle
03/4/15
Writers World

Writers World Passage

Writers World

—Other stories from the mind of Edison McDaniels—

The American Civil War Series

Not One Among Them Whole — A magnificently harrowing trip into the bloody horrors of battlefield surgery at Gettysburg in 1863. A vivid, steep descent into insanity.
An award winning novel available in trade paperback and eBook (Kindle, Kobo, Nook).

The Matriarch of Ruins (coming soon) — A widow woman struggles to keep her family together amid the onslaught of battle in 1863.
The sequel to Not One Among Them Whole. A novel.

An Endless Array of Broken Men — A surgeon struggles to save his son’s life at a battlefield hospital.
An award winning, vivid & engrossing FREE story available right here at surgeonwriter.com.

 

Thrillers Well Calculated to Keep You in Suspense

The Touched — Dr. Isaac Weed had it all, until his daughter died. Then he discovers a door to the afterlife, one never meant to be opened. Sometimes, healing can go too far.
A far surpassing supernatural medical thriller, a novel available on Kindle.

Juicing Out — Think you know how a surgeon’s thinks? Think again.
A tale of suspense, a novella available on Kindle.

Blade Man — A chilling tale of life on the road.
A twisted thrill ride, a novella available on Kindle.

The Weight of Potter’s Field (coming soon) — When an operation goes horribly wrong, a patient returns from the grave to haunt his surgeon. But it isn’t revenge he’s seeking…
A terrifying tale of things that go bump in the night at an old county hospital. A soon to be published novel.

 

Others Stories of Note

The Bottom of the Fifth — The miracles surrounding a little boy on opening day of the little league baseball season.
A short story available on Kindle.

Saving King — Dr. King struggled for 64 minutes after being shot. This is the story of that struggle.
Creative nonfiction, available on Kindle. Not for the faint of heart.

The Crucible — A brain surgeon works to save the life of a little boy on his operating table in 1951.
A gripping & empathetic short story. FREE. Available HERE.

Send to Kindle
03/3/15
Cervical Fracture Cartoon

Cervical Fracture Explained

Cervical Fracture Cartoon

Cervical Fracture Explained

This graphic details a lateral x-ray showing a C4/5 fracture/subluxation, but there’s no bony fracture! How is that possible?

The injury here is through the disk space between the fourth and fifth cervical vertebrae (C4/5). The force of the injury ripped through the soft tissue disk and tore the ligaments front and back at this level. This is a devastating injury for two reasons.

First, with such great disruption of the ligaments, surgery is absolutely necessary to stabilize the bones. Ligaments hold bone to bone and when they tear, there is nothing to check the movement of the bones. In contradistinction, with a bony fracture, the bones will generally knit back together if immobilized in place (with a cast or pins).

Second, and perhaps more important, with such severe disruption and unstable movement of the bones, the spinal cord has been injured. The spinal cord does not heal well; such an injury is likely to result in permanent paralysis.

Think of the spinal cord as a vast cable with millions of wires. The wires carry messages between the brain and body. Compare it to the transatlantic cable, with all its wires. Imagine the cable is damaged, cut in half for instance, midway between the US and England. Imagine all of the wires are the same color and you are tasked with splicing them back together. Ten thousand feet underwater. While holding your breath.

This is the task of the neurosurgeon in repairing a damaged spinal cord (though the cord is rarely transected; it is usually bruised beyond repair). We can’t see the individual nerve fibers in the operating room (we actually don’t even expose the spinal cord in such as injury as experience has proven the cord recovers better if we don’t disturb it), and even if we could we wouldn’t be able to tell which fiber connects to which other fiber—it all looks the same and though we might use a microscope, that’s more for illumination than magnification. No way we could magnify things enough to see the individual cells, or even bundles of cells.

Fortunately, as noted above the cord is rarely transected. What this means is that it is still anatomically intact (though physiologically disrupted). Because it is anatomically intact, in at least some cases there may be potential to regenerate the appropriate connections between damaged fibers. There is much research directed to this end, though success is still many years away. But as long as the cord is anatomically in one piece, the less we manipulate it the better. It might heal—emphasis on MIGHT—but not if we disrupt it still further. Hands off is the order of the day.

In the mean time, the best we can do is realign the bones and replace the ligaments with screws and rods to stabilize everything. This decreases the amount of pain, minimizes any chance of ongoing spinal cord injury, and gets the patient up and about earlier—which minimizes peri-operative complications. Mobilizing a patient as soon as possible after such an injury is key to returning them to a viable lifestyle, both mentally and physically. It also helps to prevent DVT, pneumonia, muscle wasting, nutritional depletion, infection, etc. In short, surgery to stabilize and realign the bones is crucial to optimize the environment around a damaged spinal cord in hopes of getting some eventual healing, or at least in preventing further injury.

Bottom line. The best treatment for a spinal cord injury is not to injure the cord in the first place. NEVER DIVE HEAD FIRST INTO A BODY OF WATER. NEVER.

 

 

 

 

 

 

 

 

 

 

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07/10/14
BrainVeins

Veins of the Brain

BrainVeins

A Neurosurgeon’s Perspective on the Veins of the Brain

The most curious thing about the veins of the brain is how seemingly innocuous they are, until you mess with them. They can get you in trouble in a hurry. Thin walled, they can be very stubborn and persistent in their oozing (and oozing is what they do, this is largely a low pressure system). They don’t hold stitches well, so often if damaged they have to be sacrificed. That may or may not turn out well. In general, if a vein has a name (vein of Labbe, vein of Trolard), it was named for a reason. Probably somebody in the past messed with it, usually with poor consequences.

For instance, the vein of Labbe is the largest vein draining the temporal lobe into the transverse or sigmoid sinus. Sacrificing it often results in a stoke of the temporal lobe—so much so that one rarely violated rule is ‘don’t fuck with Labbe!’ The vein is Trolard is a less constant vein, usually draining the parietal lobe up to the superior sagittal sinus.

Sinuses differ from veins in that they are designed not to collapse. They carry great volumes of blood under low pressure, but they don’t like to be occluded (stopped up). They bleed copiously and when stoppered, even for a few seconds, the brain behind them swells dangerously. Not good.

Click to see JUICING OUT on Amazon.

Click to see JUICING OUT on Amazon.

In my stories, I have written several fictional scenes of a neurosurgeon dealing with venous bleeding. Here’s one, from my novella JUICING OUT, which is just 99¢ for the Amazon Kindle (though the price is going up soon):

He looked pale. Like instead of a bullet to the brain he’d taken a vampire to the neck. His blood pressure was ninety over thirty one moment and sixty over fuck the next. If he had been awake and not anesthetized, he’d have passed out. He would have fainted and never awakened. Yes sir, he looked like a forty percenter to me.

Bobby, he drinks some but he ain’t no bad guy you know. He hardly ever do me when I don’t want it. I thought Bobby’s days of doing her were just about over.

I stole a glance at the scrub tech. She was frantically trying to get the instruments laid out and ready. I glanced at the table, saw a scalpel and a mess of hemostats, scissors, clamps, and sponges. I thought it probably wouldn’t be enough. I thought it had to be enough. Jesus Mother Mary. You wait any longer, I told myself, you’ll be operating on a cadaver.

“I can’t wait,” I said. “Help me with this, Joe.”

Together we unwrapped the diaper and the crown of his head came into view. He was mostly bald, middle-aged or better I thought. I hadn’t asked his age in the confusion, not that it mattered much now. His age would be on his tombstone after all. No confusion about that.

The skin at the back of his head was torn and bruised. I saw that much. Then Joe pulled the diaper off the hole in Bobby’s skull and the damn burst wide. A sea of dark blue, almost black, blood. For an  instant, it poured out like somebody had diverted Niagara freakin’ Falls into that broken head. Acting with twenty years of experience behind me and without really thinking, I stuffed a wad of cotton into that opening. It might make things worse, might even kill him on the spot if there was a clot inside half as big as the wad of cotton outside. That clot would press the brainstem and then, in the words of Josie’s grammie, he’d go to ground quick. But I didn’t think that would happen. Blood finds it’s own level, and, like water, is always looking for a way out, any way out. I hadn’t seen a clot on the scan (which at twenty minutes old was, admittedly, now ancient history) but the man had looked too good right up until a minute before. So I pressed that wad of cotton against the hole in his skull, against his brain, and bought us a few more precious minutes. “Get that blood, goddammit.” I hadn’t even had time to wash my hands or put on a gown.

“Getting frequent PVC’s over here.” Back flips again. The beeps filled the room, going up and down like a radio signal you couldn’t quite tune in. Bobby’s heart was losing the race. “We need blood for christ’s sake.”

The door opened just then and a pimply faced kid came in carrying a picnic cooler. If he had a clue he was carrying the man’s life in his hands, he didn’t show it. “Hey who do I give this to?”

The blood was hanging within one minute. One of the anesthesia folks (I couldn’t keep straight who was doing what and didn’t try) was squeezing the blood bag between his hands. When the first was finished, he squeezed in a second. He was on his third bag before I pulled away the cotton.

A large piece of lead floated out of Bobby head, followed by dark chunks of what could only be pieces of Bobby’s brain.

The torrent started up again. It flowed steady rather than pulsed with his heart. I knew from that, and from the amount of blood, that it was that mofo vein bleeding. And probably more than a small tear if the amount of blood was telling. I thought there had to be a hole the size of Montana in that thing. “Jesus Mother Mary” I said, then “Stitch!”

The scrub tech slapped a needle holder into my palm, a curved needle and silk stitch clamped into the end of it. I might have closed my eyes—I’ve been told I do that sometimes in surgery when I’m trying to visualize something—though if so I don’t remember doing it. I took that needle and aimed it into the pool of blood. “Suck here Joe, right here,” I said, and when I thought I could see something, something gray and not black red, I plunged the pointy end of the needle through whatever the visible tissue was and looped it out again. I cinched it down and tied it quick, then repeated the maneuver again after adjusting slightly for lighting, sweating, my own bounding heartbeat, and the regret I wasn’t wearing my own diaper. We’re losing.

An image of Josie came to me then. Josie in her Howard Johnson’s maid’s outfit, her weight in the upper limits of the couch potato zone, her unhealthy ruddy complexion. She sucked a cigarette and smelled of pinesol from the toilets she cleaned. The blue beneath her eye had coalesced somehow and now she had a decidedly black eye. Bobby, he drinks some but he ain’t no bad guy you know. He hardly ever do me when I don’t want it. I know he love me.

I fished out another piece of lead. Either the blood was slowing or whatever was left in his veins was thinning, I couldn’t say which at that moment. But I thought maybe I could see better, that Joe was doing a pretty damn good job moving that sucker here and there, sucking away the blood and oozing brain so I could work. Looking at that broken mess, looking through that thinning blood, I suddenly saw what needed doing, how there was not but one thing to do.

I saw that if I oversewed that mofo vein, it would probably kill him within a few minutes. That’d be like plugging a hose at its business end while water still flowed in from the faucet. In a few seconds that hose would rupture at its weakest point. Bobby’s weakest point was somewhere deep inside his skull, somewhere I hadn’t a prayer of getting to, and when it burst—game freaking over.

But I had no other choice. He was like a pig on a stick otherwise. I could watch him bleed out right now, or I could oversew that mofo vein and wait a few minutes for his head to explode.

He hardly ever do me when I don’t want it. I know he love me.

I thought, So that’s true love then This is for you, Josie. It’s all I got left to save your ain’t no bad guy. And I began to oversew that mother-fucker. When I was nearly done, I looked up to see Bobby’s color was better and, more important, his heart sounded a steady beep throughout the room. More important still, the puddle of blood at my feet had stopped growing and the flow out of his head had thickened and trickled. A few final throws and it stopped altogether.

“Damn fine job, Sam,” Joe said. “You can cut on me anytime.”

Want more? JUICING OUT, a kindle novella for just 99¢ over at Amazon. Give it a read today. Thanks.

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06/28/14
FirstGSWSpineLogo

The First Clinical Xray

FirstGSWSpineLogo

 

This is an historic image.

On January 1st, 1896, Wilhelm Rontgen presented the first ever xray, an image of his wife Anna’s left hand. Later that year, a young doctor by the name of Harvey Cushing—who would go on to become one of the most prolific surgeons in history and the father of modern neurosurgery, produced this image, the first clinical x-ray (they called them rontgenograms back then)—a gunshot wound to the neck and spine.

There are actually two images here, one from the front (on top) and one from the side (on bottom). Each image took an incredible thirty-five minutes to expose.

The xrays show the bullet frgament (the dark blob) either within or overlying the C6 vertebra. So which is it—within the bone or in front of it?

It’s worth recalling that x-rays are 2-D representations of 3-D space. Consider a regular photograph. Everything visible in the frame of a regular photo will be condensed to a single plane, with only the items in the forefront visible. Everything behind will be hidden. With an x-ray however, everything in the frame will be condensed to a single plane including the items in the background. What?

If I take a picture of my hand over my face, my face is hidden by my hand. You can’t see how big my nose is or how many teeth are missing, because they are in hidden by my hand. But if I take an xray of my hand over my face, you’ll see not only my hand bones, but all the bones, teeth, and various soft tissues of my both my hand and face. In fact, that’s the hallmark of an xray—it looks through what’s on top to show what’s behind.

Put another way, in a photo only the visible foreground information is used to generate the image. By contrast, in an x-ray, all of the information in the frame (hidden or not to the naked eye) is used to generate the image. 

So how do we know if the bullet is in the bone or in front of it? The answer, of course, is we have to have two images in different orientations. Fortunately, Harvey Cushing intuited this even back in 1896. The image on top is an AP image—an exposure taken from the front. The dark spot overlying the C6 vertebra is the bullet. C is the skull and D is the ribs and lungs. The image is severely underexposed, so the soft tissue does not show well (including the lungs). Of course, since it was the first x-ray of its kind, we can forgive the underexposure.

The lower image is a side view. It shows the bullet overlying the C6 vertebral body as well. Since both the AP and side (lateral) xrays show the bullet overlying the bone, it must in fact be within the C6 vertebral bone itself—and not just in the soft tissue in front of or alongside the bone.

FirstGSWSpineDetail

On the lateral image, A is the spinal canal (where the spinal cord itself lives, here it has been colored in for clarity). B is the so-called pre-vertebral space, the soft tissue in front of the spinal column. There isn’t much detail here compared to today’s imaging, but there’s enough for us to say there is no fracture of the bones despite the presence of the bullet in the body of the C6 vertebra. The body of any vertebrae lies in front of the spinal cord, and very often a bullet may be lodged there without damage to the cord itself (especially if it is a low velocity missile image, as it likely was here). 

At other times, severe spinal cord injury (paralysis) may result from a gunshot wound to the spine, even one that completely missed the spinal cord itself. This is caused by blast effect, a sort of shock wave that goes through the tissue as a result of the kinetic energy of the gunshot wound as it passes through and disrupts the anatomy. Think of it as the ripples emanating from a pebble thrown into a quiet pond of water.

Of course, it’s possible the bullet passed through the spinal cord before it came to rest in the C6 body. That’s doubtful here though, since there’s no apparent bony fracture and such a path would very likely have disrupted bone. More likely, this bullet entered the front or side of the neck and came to rest just in front of the spinal cord, within the C6 vertebral body. From a stability standpoint, such an injury is very stable (that is, it does not compromise the spine’s ability to hold the head up—the patient would not need to be externally braced). We would not operate to remove such a bullet today, unless CT showed a blood clot compressing the spinal cord. Even then, the primary goal would be to remove the blood clot; retrieving the bullet would be secondary. Of course, there might be a non-neurosurgical reason to operate, such as damage to the trachea, etc.

Occasionally, serial imaging will show the bullet’s position is not stable, that is, that the bullet is migrating around. In such a case, removal may become necessary. There is a famous case in the neurosurgical literature of a very heavy bullet migrating through brain tissue. Imagine the damage that could cause!

Was this patient paralyzed? No way to tell from the images and his or her clincial fate is lost to us.

What about Harvey Cushing, the enterprising young doctor who made the x-rays? As noted, he went on to become the father of modern brain surgery. Almost single handedly he reduced mortality in brain surgery from a wopping 70-90% to much more tolerable though still astounding 10% (today it’s well below 1%).

Harvey Cushing operated on over 2,000 brain tumors. After he lost a patient in surgery as a medical student (he was responsible for anesthetizing the patient while the professor repaired a hernia during a lecture—when the patient died, the operation proceeded anyway!), he developed the anesthetic record, being the first to use serial recordings of heart rate and breathing. Blood pressure was added later after he discovered the BP cuff on a trip to Italy and brought it back to the United States with him (standard of care is to record all of these vitals and much more in modern day surgical anesthesia).

He made numerous advances in our understanding of the pituitary gland (Cushing’s disease, a dysfunction of the pituitary gland, is named after him).

Along with William Bovie, he developed electrocautery, which is used in 99% of operations today to minimize bleeding. Without it, modern surgery would not be possible.

He also won the 1926 Pulitzer Prize for his biography of Sir William Osler (considered by many the father of modern medicine, and one of the founders of Johns Hopkins Hospital). By the way, Cushing, who manned a military hospital in France during the last year of WWI and made many contributions to military medicine and surgery as well, was present when Osler’s son Revere died of his war wounds in France.

Cushing, a chain smoker, died of heart disease in 1939 at age 70. An autopsy showed he had a benign form of brain growth called a colloid cyst—which might well have been operated on using today’s standards.

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