The Post-Op Hug

Who said hugs aren't nice. . .sometimes?

Cataract surgery has turned out to be a truly gratifying experience - and I think it's so for both the surgeon and the patient. In the academic and VA world, patients with cataracts have usually been walking around with them for quite some time. So by the time they present to us for the discussion about taking them out, they are usually fairly advanced. They have long lost their 20/20 vision, their sense of the color white is forgotten, and they can't remember the last time they were able to drive at night. It's different in the private world where patients have money and time and ability to keep regular eye appointments and cataracts are discovered and operated on early - though sometimes too early.

At any rate, for my patients, the difference between their preoperative vision and their postoperative vision is usually quite large. I've had some who couldn't even see the big "E" on the chart who now see 20/20 without any glasses. And even if we don't get to that perfect target, the vision is still far better, clearer, and brighter than before. Sometimes they are so thrilled, they can't help but hug me. I don't know that anyone ever hugs the surgeon who takes out an angry appendix; but cataract surgeons are frequent receivers of the post-op hug.

And that defines gratifying if nothing else does.

What I See in an Ambulance

As a medical student and even as a medicine intern the things I thought when I saw an ambulance were quite different from the things I think of now. It used to be we just affectionately called the ambulance a "whaambulance" in reference to it's most common passenger: someone without a real medical emergency.

Now, and especially the days I am on call, I will be driving home on the highway and see an ambulance headed the opposite direction. All I can think is, I hope that's not a trauma with facial fractures and an open globe. This may not be the best way to think of them, but I do.

Adjusting My Volume

Get the reference??

Something quite humorous happened to me in clinic the other day. I am currently seeing patients on a daily basis at the VA - the hospital for the veterans, for those who don't know. This is largely a population of patients 60 years old or older, usually with a list of medical problems with accompanying medications longer than the LOTR roll call.

At any rate, one day I seemed to get a particularly long stream of near-deaf patients in my chair. So over and over again I was doing nothing short of yelling at my patients, probably driving the patients and physicians in neighboring rooms to question my ability to establish good rapport. The patients in my room, however, knew no different. In fact, for some of them, I was doing little more than whispering.

Then a patient with normal auditory function stepped in. But I didn't know this at first. I had found myself stuck in volume-to-eleven mode and began yelling to him.

"HOW ARE YOU TODAY, SIR?"
"Fine. By the way, I may be near blind, but I'm not deaf."

I couldn't help but look at the floor and silently laugh. It's not like he could see me anyway. (Actually, he was nowhere near blind).

Some Basic Anatomy, Doc

Most of the people I come into contact with in a medical setting, at least on the doctor-to-doctor front, know their basic eye anatomy. Most nurses as well know at least the information on this here diagram. Now, I know the exposure to ophthalmology type stuff in most medical school curricula is limited. But this is basic anatomy - first and second year student material. Most learn this to a limited degree well before medical school even starts. Allow me to say that I would never expect the primary care doctor to know the eye and orbit anatomy as well as my mentors (I can't say "me" because I'm still learning). But something must happen when certain people graduate - any knowledge of the eye just leaves.

The example is when I was recently consulted to see a patient in the pediatric emergency room. I was told over the phone that the iris was lacerated from a stick injury.

"Okay, so you're telling me there's an open globe, then?"
"No, Bradley, the iris is just lacerated."
"That by definition, Dr. Wuposnockee, is an open globe."
"But. . ."
"What's the vision?"
"Well it's 20/20."
"You're telling me the patient had a stick go through the cornea, lacerate the iris, and yet the vision is perfect? The patient doesn't have an open globe, or an iris laceration."
"Well than what is it?"
"I'll tell you after I see the patient. . ."

The cornea had a scratch on it. Yep, he did just fine. I once had an open globe myself, and as minor as it was, I had nowhere near 20/20 vision. My iris was not even lacerated, by the way.

Call Before You Send it My Way

There are a lot of things that get sent to us from other areas of the state to take care of. A good deal of it occurring on nights and weekends does so because some local eye doctor is not available (or more commonly doesn't want) to take care of it. But that is for another discussion entirely. There is another group of things that get sent to us because others just don't know what to do about them.

I am happy to help take care of anything that someone else may have a question about. But there are certain times when that help should more appropriately be provided over the phone. There are clearly times when the patient just needs to be sent to us - the trauma patient, the patient with the orbital abscess, etc. But here are a few that don't

The shingles patient. A patient shows up to your emergency room or your office with shingles involving the same dermatome as that involving the eye. Does this patient need an eye exam - yes. Does it need to be done three hours from home in the middle of the night - absolutely not. This has happened more than once. The patient got sent inappropriately for an eye exam in the middle of the night. Had someone taken the five minutes to call me and ask about this, the trip could have been avoided. Because, guess what? This is not an eye emergency - I could have told them to come the next day. Or better yet, see someone local after the sun came up.

The conjunctivitis patient. This can always wait until the next day. To top it off, never, EVER, send these patients by ambulance or helicopter (which has been done!!) for a viral illness we will treat with over the counter artificial tears.

Above all else, if you're sending a patient to me specifically for specialized eye care, it's common courtesy to let me know about it ahead of time.

Please Don't Shake Your Baby

One of the less-than-satisfying tasks of being an ophthalmologist is getting that call from the pediatric intensive care unit after a child suspected of being abused is admitted. One of the routine exams performed in such a case is a dilated eye exam. Certain findings in the retina used to be a gold standard in making this diagnosis. But, thankfully, lately it has been more widely realized that such findings are only a single piece of the puzzle. They don't rule anything in or anything out; other than that the retina sustained a significant injury. It is not our job as eye doctors to make conjectures in these cases as to what happened.

But when we do see it, it's sad nonetheless. Any more, by the time we are getting called to do the exam, a pretty extensive history has already been undertaken and there is something there that made somebody suspect abuse. This, more than anything else, is probably most useful information that can be gathered. Interacting with parents or the accused during the process is extremely uncomfortable. We walk in the room and there is usually one of two responses.

The first is the catatonic response. The parent that doesn't want to interact much with me, or even the child. Are they guilty or simply in shock at the accusations? The second is the "Oh my God, what do you see, is he gonna be all right?" parent. These are hard to interact with simply because I don't know how much to divulge or to whom. That's when I become the catatonic one.

Just save it. Don't do it in the first place.

The Role of Teaching

As we each progress through residency we learn a large amount of material. I remember as a fourth year student I was quite amazed at just how much stuff there was to learn about two little eye balls and their surrounding milieu of tissues. As I have slowly picked up some of these things, and some of them have actually stuck, I now find myself with a unique responsibility.

Now in my second year, there are three residents now affectionately called "the first years." Although, one of them is a prior trained ophthalmologist from another country. So the likelihood that I could possibly impart anything other than knowledge of how to navigate the local university system is low - I may go to her for ophthalmology questions. As for the other two, I was very recently in their shoes, and I remember well what it was like to know little. Now in my current shoes, and for any other no longer first year, the task of helping to teach the new people is upon me.


This has only reaffirmed, I think, that I want to be involved in an academic setting when I finally grow up. I rather enjoy teaching most days.

Everything Becomes Relatable to Cataract Surgery

I briefly mentioned recently how cataract surgery serves as the bread and butter foundation for eye surgeons. We no longer do it like the guy in the red over there. The steps are much more humane now and the results much more satisfactory.

As I am learning to do cataract surgery, weekly refining different steps along the way, I have noticed something funny. Not uncommonly I will think of some very every day things in a new light - as how they compare to something done during routine cataract surgery. Brushing my teeth is like polishing the capsule - gentle but brisk. Routing the kitchen's trim is like grooving through a nucleus - shave it away until the desired shape is reached. Opening what should be an unopened envelope is like making a good capsulorhexis - don't let any tears go astray.

Making your wife mad is like having a case go poorly - you don't want to have to face up later.

ReReading

A good residency program comes with at least a decent didactics program. I interviewed at several programs where there was no organized lecture time and it's hard to imagine how any accountability is given to the residents. At any rate, we have a very organized schedule. Of course, recent studies suggest it works only moderately well.

Our lecture series, and the board exam as it were, is based on a set of books published by the American Academy of Ophthalmology; all in all a few thousand pages of stuff. We read through the entire series each new year. So, all that said, this being the second year of residency, I am going through the entire set of books a second time. At first I thought this would make the reading easier to sit through. Easier to stay awake during.

It's not panning out so far.

The Maiden Cataract Extraction

One of the rights of passage for an ophthalmology resident is cataract surgery, kind of like for otolaryngologists it's the ear tubes, for the general surgeons the appendectomies, and for the urologists the cystoscopes. One could argue it is much more technical that many of the other surgeries we do, but nonetheless, we start early with them.

The whole surgery is a conglomeration of small steps, none of which individually take very long, which together accomplish the removal of a cataract and placement of an artificial lens. Some of these steps are easy to learn and others take time and time again to get them halfway correct.

But the very first one, the one in which anything can go wrong, is one to sweat and clench through. A good cataract surgeon can enter the eye with the first step and be done in 10-15 minutes. A maiden case takes often an hour, or more. Thankfully, mine went well, and they have done so since then. And patients frequently don't care if it takes so long - they can almost all see better afterwards and are incredibly grateful. Kids are less so after ear tubes - they don't typically know the difference.

Oh That Propofol

The first part of our routine cataract surgeries at the VA involves giving a retrobulbar injection of local anesthetic. As expected, not too many people are very fond of witnessing a long needle coming towards their eye. Really, they wouldn't even need to look at it, but I'm sure it doesn't feel good either.

At any rate, the way we deal with this is to put the patient to sleep for a few short minutes while we do it. One of the best IV medications for the job is propofol - a fast acting, though short-lived injectible. The effects on the patient are nothing short of often comical. You can imagine trying to talk to someone right as they're falling asleep - s/he won't fully comprehend the question, nor even the answery s/he is trying to give. Of course, this is how we know the near full effect is achieved - we ask them questions. When the answers become garbled, quite frequently coupled with big, fat yawns, it's time to inject.

To make the experience more humorous for us (okay, not really, it's for the patient to look at), there's a large paper butterfly taped to the ceiling above the patient's head. So not uncommonly, their final words may be:

"Gargle mmsnuff sshbipner. . .buttterrrfflyyyy. . . ." Nothing like starting eye surgery with a giggle.

The Ophthalmic Hazards of Dentistry

I recently had a patient come into the clinic after what was apparently an eventful dentist appointment. While sitting in the grand chair of dentistry, he had his mouth wide open. The possible implications of this are many, but suffice it to say, we all generally have our mouths open while in the chair of dentistry. He was having some drill work done in his mouth when suddenly he felt as if there was something in his eye. Naturally it didn't want to come out and it is unlikely the dentist looked for it.

So he comes to the eye clinic with this complaint (BLOG!!, I thought). After a thorough exam of the redundant forniceal tissue, I found this little dark chunk. Was it enamel? Was it a chip off the old drill bit? Was a lasting memory of last week's polenta lasagna? Well, I didn't send it for further analysis.

At the end of the day, we all learned one more task during which to wear protective eye wear: being a dentist's patient.

Whether to Publish

One way to beef up an application for fellowship big time is to have publications on board. But not just any - specialty-relevant publications would be nice. I have one online journal publication (ophthalmology based) and one peer reviewed article published on which I am a secondary author (not ophthalmology based). Where does this leave me? Fairly deep in the ground.

I have this research project on which I spent several hours gathering and manipulating data. Then several hours more building a presentation around it. The big question for me lately has been whether to take all of this to publication. The "information" I found was not ground breaking or likely to change the way in which anyone practices medicine. It mere takes something which has not been extensively studied in the past and fails to come up with a concrete answer to anything - just recommendations. And while they may be reasonable or even correct, they aren't deeply grounded. I just don't know that anyone would publish the rubbish.

Then there are a couple case reports I have sitting around I would work on. But even those are getting harder to publish it seems.

A Piece of History

Recap from yesterday: I collect old medical stuff. So I guess in a way this is a continuation of yesterday.

This little (heavy-ass solid cast-freakin'-iron) thing is called an ophthalmometer. I can't say it's something I've ever seen used, nor had I ever seen one prior to acquiring this as a birthday present from my parents. I am somewhat familiar with its close relative, a keratometer. A keratometer is used to measure the curvature of the cornea. This does very much the same thing, though differently. And as a young eye doctor, I have no idea how.

One thing I've been trying to do is figure out when it was made. There are some models out there quite a bit older that this. And those that are much newer are all electronic. All of the mounted manual ones in clinic are also newer, but again, are known as keratometers.

I've got some research to do on this one. But I don't think it will be publishable.

What People Used to Think

For those of you who may not be aware, I am a collector of old medical texts and equipment. This little gem you see here has brought me some real joy by looking at it from time to time. It was written circa 1900 (title pages didn't seem to be a requirement back then) by a very cocky, self-proclaimed expert.

I don't say this because of the statements made about treatments for ocular conditions - things were definitely very different then. He refers to cataract surgery as very barbaric, and back then, it certainly was. It was a big surgery full of complications only to leave you needing coke bottle glasses. But there are many other things stated in this book which are absolutely ridiculous. He has ascribed a "Mild Medicine Method" to all illnesses of the eye and ear. Phsssh. Taken from the text:

"There is barely a hint of agreement, among medical authorities, as to the cause of cataract, but it is pretty generally recognized that among the common causes are overworking and straining the eyes, reading or doing needle and fancy work with insufficient light, injuring the eyes by a blow or by a pressure or rubbing with the hands."  Um, what???

On astigmatism, "For it is not a thing to be cured by the mere use of glasses. It may lead to a permanent injury of the sight, to cataract, or other dangerous afflictions of the eye." I think even most (real) eye doctors then didn't feel this way.

And the best part:
"If your eyes are tired, or if they ache and smart on account of their intemperate use, you should write to or personally consult me. I will give you advice and treatment that will undo the evil you have caused through your own carelessness and neglect. In the schools the sight of hundreds of children is impaired every year by the over-use of the eyes. Teachers should be very careful in this matter. Children had better devote a little less time to the books and preserve their eyes for use in the after life than to have them fail just enough to lead their parents to rush off to an ignorant oculist who may finish the work of destruction already begun." Where was this guy when I was in school?

Of course he finishes the book by telling you how to get to his office and why he was so damn brilliant in placing his office in Kansas City.