Some patients may develop headaches, nausea or dizziness after a general anesthetic, but this is all treatable with medications and rapidly passes away.
For those patients who do not need or want a general anesthetic, the anesthesiologist can give a heavy sedation in combination with the surgeon injecting a local anesthetic like marcaine or xylocaine. Many surgeons do hernias, breast biopsies, removal of skin tumors, and many other general and orthopedic surgeries under combined general sedation and local anesthesia.
A third method of anesthesia is the regional block. In this type the anesthesiologist injects local anesthetic agents around specific nerves to block or temporarily deaden the area. The patient feels no pain, although he may still retain a sense of pressure or vague touch.
Still another type of block is the spinal or epidural, another location near the spinal cord, such as used in delivering babies or even to do abdominal or lower extremity surgery. This is usually augmented by some sedation, again to decrease the anxiety during the surgical procedure.
In many medical centers, the anesthesiologists are giving what is called a continuous epidural block, which involves placing a very fine tube in the epidural space in the back and delivering a set amount of medication, such as morphine, even after the surgery is completed. This takes away most of the discomfort after a major abdominal or lower extremity surgery and can be kept in place for several days. It's certainly the way I want to go if I have to have any major surgery, but it takes a specially trained physician to place the tube and to monitor it carefully afterward.
The anesthesiologist and pain management specialist has a large number of procedures he can do to permanently block sensory nerves in individuals with severe pain from chronic diseases and from cancer. There is practically no situation where pain cannot be alleviated, and these specialists are the ones a surgeon will turn to when that expertise is needed. But, remember, it is necessary and important for the patient or the family to be “proactive” and ask about all these types of procedures.
Chapter 23
BURNS
Somehow, with whatever happens inside,
We can retain some personal pride.
Because when our faces and smooth skin are left
We're somehow not completely bereft.
The tragedy with burns appears to be
They can harm our personality,
We can tolerate an inner pain, you'll discover,
But destroy our looks, and we may not recover!
Today most major burns are handled in comprehensive burn centers, with dedicated nurses, internists, and surgeons familiar with this subspecialty. Some estimates indicate that there are more than 200,000 major burn victims in the United States each year, and more than a third require hospitalization. Burns are graded as first, second, and third degree, depending on their depth of penetration and injury to the skin. Most of us are familiar with first degree burns, which are essentially like sunburns, causing redness, pain, and occasional swelling. This type of burn may result in superficial peeling but does not cause any permanent scarring.
Second degree burn is a more extreme extension of this with blister formation, severe pain, and partial sloughing of the outer layer of skin. It takes regular cleansing and care not to get infected, and yet it will heal on its own without skin grafting. However, depending on the depth and location, it will probably leave some scarring and deformity.
Third degree burns indicate full thickness destruction of the skin and are often initially not painful because the skin and its nerves have been destroyed. If the area involved is more than a small percentage of the body surface area, there can be severe loss of fluids and the body chemistries called electrolytes, high chance for infection locally and throughout the body, a shock-type state with possible damage to the lungs and kidney. The involved skin will never recover, and these areas have to be covered with eventual skin grafts or rotation of skin from adjacent or other areas of the body. These situations will result in severe scarring and disfigurement, often very difficult to correct with plastic surgery.
The treatment for advanced burns in a burn center consists of cleansing the areas, debridement and removal of dead tissue in what is often a painful process because of the live skin remaining next to the dead skin, vigorous fluid and electrolyte replacement, antibiotic therapy, and a very strong psychosocial support program.
The skin is the largest organ in our bodies and, if you didn't already know it, it is a vital organ, keeping infection out of your body and keeping fluids, heat, and chemicals inside. Loss of even a small amount of skin can, therefore, be very dangerous, requiring intensive treatment. In spite of this many burn patients die. The problem is more severe in children because they can deteriorate very quickly and don't have the body “reserves” of fluid to withstand such a major insult.
Often, the survivability of a burn patient is dependent upon two factors: the percentage of the body burned and the amount of second and third degree burns. The following diagram shows the percentage of body surface areas and is used by a doctor in determining these factors.
RULE OF NINES
| REGION | PER CENT |
| HEAD AND NECK | 9 |
| UPPER EXTREMITIES (ARMS) | 18 (9 X 2) |
| LOWER EXTREMITIES (LEGS) | 18 (9 X 2) |
| FRONT OF BODY | 18 |
| BACK OF BODY | 18 |
| GROIN (PERINEUM OR GENITALIA) | 1 |
| TOTAL | 100 |
DIAGRAM 2
Also important is whether the patient has sustained lung damage, thermal or heat damage, and whether there is damage to the kidneys. Underlying other conditions, such as diabetes mellitus, heart disease, kidney disease, and lung problems, such as emphysema from smoking as well as advanced age and poor general physical condition, may cause an increase in the mortality rate.
Burn care is a very complex problem of management, and my best comment is to insist that any significant burn should be treated in a burn center by specialists. It's better to take all burn victims to the experts at once, rather than a day or two after the incident when complications have already started. It is no longer a condition that a family doctor or general surgeon can manage with anywhere near the acuity of specially trained nurses and doctors in a burn facility with the needed isolation units, debridement tanks, special large holding tanks for bathing and debriding, and specially trained anesthesiologists to control the pain management. The plastic surgery required for even the most basic reconstruction is beyond the expertise of the average plastic surgeon.
When confronted by a severe burn think only BURN CENTER!
Chapter 24
SUTURES, STAPLES, AND DRAINS
Sutures, staples, and drains, I contend,
Are all a means to a surgical end.
And to dispel any bizarre surgical rumors,
They're just to close wounds and drain evil humors.
The choices we have to close wounds are as varied
As the tomb you can choose if you want to be buried.
You