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Beware of the treadmill!

Parents, beware that awesome new holiday gift that you got.

You know, the treadmill?  The thing you got so that you can run indoors when it’s bitterly cold or when the inversion is awful?

Probably not an ideal use of your new gift...
Probably not an ideal use of your new gift…

(Photo credit to normanack)

That treadmill, which we all want to believe is a great tool for improving health, is a hazard for little hands.  Some of the earlier research on this came from our group almost 10 years ago, when we demonstrated that the 48 injuries that we saw over a 6 year period that almost half of treadmill friction injuries in children required skin grafts.  The children involved in these accidents are typically 3-5 years old, and while the injuries are typically small and limited to the hand surgery is required for half of more.  Further, long-term issues with scarring may complicate the care of these children.

A 2012 publication shows that this is not a uniquely American issue, with similar findings reported in the UK.  A more recent examination of US data looking at all home exercise equipment re-confirmed the specific relevance of treadmills and the impact they have on children under age 4.  Perhaps most importantly, when I speak with parents of children who have sustained a treadmill injury, they simply had no idea that this is a relatively common occurrence.  They weren’t told about it when they were sold the treadmill, nor was information about the risk of treadmills to little hands anywhere in the box.

As a burn surgeon I struggle with these injuries because I believe they are almost entirely preventable with good education, but with bad care they can have devastating functional outcomes.  I’m not going to tell you to haul your treadmill out to the curb if you have a preschooler in your home; that would be a Draconian response to something that is largely manageable.  Remember that for the many treadmill injuries that we see in our clinic every year, there are many, many more treadmills that are safely used in homes.

How can you equip your home for safe treadmill use if you do have a preschooler?

  • If your treadmill has a key that is required for it to work, remove it when you’re not using the treadmill and put it somewhere that little hands can’t get to it.  Trust me, your 3-year-old is smart enough to use the key if they find it.
  • Make sure that your preschooler isn’t nearby when you’re using the treadmill.  Preschoolers are by definition a curious lot, and they don’t necessarily respond to being told not to touch something (sometimes it’s more of an incentive, rather than less, based upon my experience).  About 1/4 of documented injuries in two different studies occurred when a parent was on the treadmill, which means that it’s best to separate the treadmill and your preschooler.
  • The treadmill should be in a location where the operation of it can be supervised OR it should be in a location that can be preschooler-proofed against entry.
  • Be aware!  Reading this was already a first step for you.
  • And finally, we’re here if you need us.
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“Flesh-eating bacteria!”

It’s honestly a bit impressive how much we hear about “flesh-eating bacteria” in the news.  Truth is, in the United States in a given year there are fewer than 3000 cases; our estimates aren’t very good because Necrotizing Soft Tissue Infections (NSTIs) are not a common disease.  NSTIs are just common enough that almost every physician will see a case at some point in their career, but they are not common enough for most physicians to develop true familiarity.  This lack of familiarity represents a true diagnostic challenge for many physicians when they evaluate a patient with cellulitis or a complex soft tissue problem that is not an NSTI- while they don’t want to inappropriately ask for help from the surgeon-specialist, they also don’t want to miss a disorder that is life-threatening in the face of inadequate management.  We do know that the reported incidence of NSTI has increased over the last 20 years.

So, what is an NSTI?

An NSTI is an aggressive soft-tissue infection that results in the skin and tissue below it dying.  This infection may be cause by a single type of bacteria or by multiple types of bacteria.  NSTIs are often life-threatening, and they require early and extensive removal of the infected tissue.  Patients with NSTIs also require post-operative care that can be quite complicated and usually have wounds from the tissue removal that require specialized care.

Who gets NSTIs?

Sometimes we can’t predict this; I have taken care of completely healthy women in their 30s who have an NSTI.  However, most patients who get an NSTI have some known health problem.  Our group’s study using NSQIP data showed that obesity, hypertension, and diabetes are all more common in patients who develop an NSTI.  Similar findings were generated by analyzing the NIS, which showed that obesity, diabetes, and liver disease were associated with NSTIs.

What does an NSTI look like?

Common signs and symptoms include redness, swelling, and tenderness of the infected area.  Unfortunately, these signs and symptoms are essentially identical to the clinical findings with cellulitis, which is not a surgical disease- it simply needs treatment with antibiotics for a full recovery.  A patient with an NSTI may present with an elevated white blood cell count and a decreased sodium level, but this is not always true.  The LRINEC score has been used to estimate the likelihood that a patient has an NSTI by giving point values for various laboratory values, with a score >6 having a 92% positive predictive value and a 96% negative predictive value.

What are the risk factors for mortality with NSTIs?

First, it’s important to understand that mortality from NSTI seems to be decreasing; two different recent analyses showed mortality rates of 9% and 12%.  This is likely attributable to better recognition of the disease, allowing for more aggressive early intervention, as well as improvement in critical care and wound care.

Patient age is clearly related to mortality, but severity of illness at presentation also plays a role.  Two different studies using NSQIP data have shown that emergent surgery is a risk factor for morality.  Last year, our group created a risk calculator for mortality consequent to an NSTI; the biggest flaw in our calculator is simply that it caps at an 85% probability of mortality.

Should I worry about my patient having an NSTI?

Usually, no.  These are rare infections.  I do say that with some hesitation because I know a disproportionate number of NSTI survivors…but that’s a product of what I do in my work.  Distinguishing the patient with an NSTI from a patient with “just” cellulitis is a genuine diagnostic challenge, particularly for those who don’t care for these patients often.  The important thing is that if the idea that something might be an NSTI enters your head, it’s worth it to talk to an expert.  If they do have an NSTI, the sooner they get to surgery, the better they are likely to do clinically.

Bonus information: Our SlideShare about the mortality calculator from the 2012 Western Surgical Association meeting.

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Does surgeon = jerk?

For those of you who follow me on Twitter, you’ve seen my feed the last few days filled with thoughts and comments from the AAMC Mid-Career Women’s Professional Development Course (#MidWIMS- storify from the meeting coming next week!).  The opening talk on Saturday was given by Julie Lien Wei, Professor of Otolaryngology and Division Chief at UCF.  One of her statements during her discussion of her career trajectory resonated deeply with me.

“I thought that becoming a surgeon was synonymous with being a (((jerk))).  One woman surgeon changed that.”

I’ll confess that I entered medical school with the image of surgeons as being less kind, less humanistic, and definitely less well-rounded than other physicians.  I was also very determined when I started medical school that I wouldn’t be a surgeon when I finished.  Fortunately during my 3rd year I came under the influence of a pediatric surgeon who epitomized a happy, enthusiastic, kind surgeon.  As a result of his influence and that of a couple others here I am, almost 20 years to the day from my acceptance letter to Texas A&M College of Medicine, happily ensconced in my career as a surgeon.  More importantly, I want to believe that I didn’t sell my soul to get here, and that I am every bit as kind, humanistic, and perhaps more well-rounded than my colleagues in other fields.

Even with the 20 years that have elapsed since my own decision-making, as surgeons we still have an image problem.  When I tweeted Dr. Wei’s statement, I had a student respond, “They are jerks.  The woman was an exception.” Ouch.

So this is all the further we’ve come?  As recently as 2010, one study showed that medical students enter with a negative perception of surgeons (good to know I wasn’t alone in that!). The perception that physician/ patient relationships are lower quality is a negative influence on selection of a career in surgery.  And we know that personality fit plays a role in specialty selection, meaning that if students consistently see behaviors that they perceive as incongruent with their values, they’ll vote with their feet.  However, the surgical clerkship appears to offer an opportunity for mitigation of these negative impressions.  Nevertheless, the perceptions appear to return to baseline within a year of the clerkship.

Clearly we aren’t yet where we should be.  We’re definitely not where I want us to be, and I’m basing that on information I see from my own students about how some of my colleagues and our residents behave at times.  Caveat:  I’m not saying I’m perfect every day because I’m not…but I try hard to be a good example, and if I sense I’m not being one I’ll own it.  I’m also generous with apologies if I’ve dropped the behavior ball.

Here’s my request for you, fair reader.

-If you are a medical student, what is your perception of surgeons?  How can we improve it?

-If you are not a surgeon but work with us, what do you see that we could change?

-If you are a surgeon, what do you see behaviorally in our specialty?  I know that bad behavior is significantly influenced by environmental tolerance (blog post for another day), but what else do you observe?

The bottom line, what I really want to resolve, is how do we fix our image so we’re not scaring off folks who would be incredibly talented?