Author: Dr. Douglas Holmes


Unprecedented?

I hesitate to add to the cacophony surrounding the corona virus, but these are ‘unprecedented’ times, or so that’s what I’ve heard and read a thousand times.

If I ever see that word again it will be too soon.

Challenging? Yes

Unusual? Of course

Unprecedented?Aabsolutely not. And not even unpredicted.

This pandemic was preceded by H1N1 flu virus (1918 flu pandemic, 2009 swine flu), SARS (2003) and MERS (2012), both corona viruses.

The 1918 flu pandemic killed 50 million people worldwide, with 675,000 Americans. With Covid-19 to date about there are 338,000 deaths worldwide, with 96,000 in the US.

It is partly through experience and lab work with SARS and MERS that we know what we do about corona viruses.

So any novel viral outbreak in the world (not to mention Ebola (2014-2016), and current outbreaks as we speak) has the potential with our world wide travel to cross continents and the world in days to infect every human.

Such is the reason for official surveillance organizations, such as WHO and threat organizations in the US. But recent funding cuts have decimated their abilities to research and communicate.

And even when the siren call went out, it went unheeded. Disregarded, quashed even, because “There will be no bad news on our watch!!!! It might affect the stock market and even worse chances for re-election”.

As far as combating the virus, every nation was on their own, and in our nation every state was on their own. No UN, WHO or other coordinated international effort. No national plan for supplies or resources to address the most needy areas. Not even leadership that demonstrates proper behavior and responsible use of medication.

To combat an international problem requires international cooperation, not name calling or finger pointing. National problems require a national plan to limit damage and death as much as possible.

This will pass, or so they say. But this will not be the last novel virus. History will judge our response to this one, and God help us to be prepared for the next. Cause it’s coming.

Big Cancer Cases

“You’re a bad ass” he said as I walked into his hospital room, making post op rounds from the previous day’s surgery.

Yesterday I spent five hours excavating this huge tumor from his neck. A local spread from a poorly differentiated squamous cell skin cancer previously removed from the back portion of his neck, just behind and below his left ear.

These poorly differentiated cells are the worst; wild cancer cells running amok in the lymphatic system, multiplying and invading locally, infiltrating into surrounding muscle and skin.

Pre op exam revealed an 8 x 5 x 3 cm mass, firm, fixed, right up under his ear. Big and stuck!

I told him there were no options other than cutting that monster out, and he gave a big thumbs up.

In the OR, I placed a nerve monitor with subcutaneous electrodes about his eye and mouth, just in case I needed to dissect around his facial nerve. We prepped and draped his neck for a big procedure.

I excised the scar from his previous skin cancer removal, cut in front and below his ear and looped the incision into his neck below his jaw line, raised skin flaps, and started dissecting the mass from surrounding tissue, including many lymph nodes in the neck below it and in front of it (technically what we call a supraomohyoid neck dissection). It had invaded the sternocleidomastoid muscle and totally compressed his jugular vein. Both of these structures needed to be removed along with the mass. I carefully preserved his carotid artery and vagus nerve (to the vocal cords), dissected the hypoglossal nerve (motor to the tongue) and the parotid gland from the superior extent of the tumor. I went through the deep fascia into the levator muscles which support the cervical vertebrae. Any further removal would have left his neck weak and unstable. This level of invasion could never be handled with surgery alone, and there was no surprise that microscopic remnants of the cancer were seen in the pathology specimen. Post op radiation therapy should be able to kill the residual tumor cells.

I put in a drain to collect tissue fluid post op for a few days, sewed him up nicely, using his own expanded skin from the tumor mass to cover the area excised, and then on to recovery. All nerves working fine, eating and drinking well with a good night, and then the next morning: “you’re a bad ass.”

So I had him clarify that statement. He had been seen at the VA, and referred to me, because “No one else there wanted to handle this. And you could, and you did!! I feel so much better with that goose egg thing out of my neck”. Actually more like an ostrich egg.

Years of study at Univ of Iowa, doing big tumor work. Years of experience taking care of federal inmates referred cross country with their large, growing tumors, had put me in a great place to help out this Vet.

Cut and sew right, preserve the vital important structures, and all will be well. Great anesthesia, experienced nursing crew. My team was ready, and we performed.

Shingles, or another virus demanding attention

While we are focusing so much attention on the coronavirus, we mustn’t lose focus on our other healthcare needs.

The need for my wife and me this week was our second shingles vaccine. That very nasty shingles attack is caused by the chickenpox virus (varicella zoster, a type of herpes virus different from the cold sore or genital type) that lives dormantly in our nerve roots, just waiting for who knows what conditions to break out along that nerve’s distribution and cause awful pain, blisters, loss of nerve function with facial paralysis (if it happens along the facial nerve), and possible post eruption pain (post herpetic neuralgia). That means when the virus attack resides and the blisters heal, you’re left with terrible pain along the area affected. It’s an anti gift that keeps on giving. Like that unwanted relative who is always coming for dinner or your neighbor who attacks his landscaping with any loud engine based device at any time (esp Sat and/or Sun at AM, or wine on the back porch time near dusk). But much worse, not just uncomfortable, I mean excruciating pain.

But, like with most viruses, there is a vaccine!!!! Several years ago (2006) a vaccine was developed that unfortunately was only about 50% effective. So another has been developed (2017) that is a 2-time shot, separated by 2 to 6 months, but 90% effective. Age 50 is the start date for this vaccine.

I like those numbers much better.

The problem is this: those 2 shots kick your butt, with about 36 hours of feeling lousy, really lousy, headache, muscle pain, sore arm at the injection site, and ready to do nothing but stay in bed and take some Motrin. With the first shot, I was uninformed (even as a doc) and had a full day the next day. I made it through, but it wasn’t easy. So this time we planned a Friday evening shot, picked up comfort food from a local restaurant, and went home to chill. 36 hours later we are resurfacing to the living world.

Shingles stinks. The shingles vaccine stinks. But shingle stinks a whole lot more. Just be prepared to weather the prevention. Try a good book, it was Hamilton for me.

COVID-19 Policies & Thoughts

For urgent or compelling needs, our office is open for face-to-face (with a mask), hands-on (with gloves) good old fashioned in-person office visits and examinations for the most accurate diagnosis and the most effective treatment. If and when you need us for urgent issues, we will take your temperature, have you wear a mask, and gel your hands. And when you leave the exam room it will be disinfected with 70% alcohol. Dr. Holmes is seeing patients with urgent needs in the office on Monday and Wednesday mornings and afternoons as well as Friday mornings. Please call 919-782-9003 to schedule an appointment.

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In these COVID-19 days, it is very challenging being an ENT or any surgical subspecialist. The conditions of the virus are limiting patients coming to see us and patients having needed procedures.

What most surgeons do is necessary of course, but most is also elective, meaning it can wait a few weeks. Now breathing problems, bleeding, or pain move these issues to the front of the line.

To preserve masks and other PPE, operating rooms and hospitals are limiting surgery to only urgent cases, defined as needing to be done in next 30 days or there will be harm to the patient’s health.

A special nuance of this virus is that it lives in the lining membranes (mucosa) of the nose and sinuses, as does any respiratory virus. This one then goes down into the lungs. Any procedure done in the nose or sinuses can potentially release the virus into the air and infect any unprotected healthcare worker in the room. We have learned this the hard way in China, Italy, and France with many ENT docs getting severe infections and dying. For this reason, most of the nasal and sinus procedures we do routinely are being delayed until this crisis is over. If urgent or emergent, the patient must undergo testing that shows that they are COVID-19 free. And just now rapid tests have been developed. We will see how long it takes to produce and disseminate them. So far I haven’t had an emergency case, but I do have an urgent case this week and will wear appropriate N95 mask.

For these very important reasons, ENT docs in the country are closing or severely limiting their practices to prevent viral spread. We, at ENT & Audiology Associates, are open for urgent appointments, in other words, it just can’t wait.

Back in 1918 when the flu was pandemic, most docs were general practitioners and were overwhelmed with patients. But in 2020, unless and until we are needed to staff COVID-19 hospitals (like what happened in China), we ENT docs
and other surgery specialists (neurosurgery, orthopedics, plastics, urology, ophthalmology, etc) are wondering when this will end and what will be the status of our practice and our employees (nurses, receptionists, billing, etc.) when the dust clears.

So, bottom line is we will be there for you if necessary. Call first if you have cough or fever or shortness of breath or recent loss of smell (due to virus zapping your smelling nerves), so we can advise you properly. Please note that we will take your temperature upon arrival, and that all staff will be wearing masks, and we’ll ask you to put one on also.

Also please note that audiology support is the bare minimum.

Stay at home if you can, stay safe always.

Book Club, or Docs Read

One of the challenges of practicing medicine today is the relative isolation of doctors from other doctors, especially referral sources and recipients of those referrals.

In times past, a new doctor in town would join the local medical society to meet the other community docs, and express their desire to join into the medical community (primary care and specialists alike). The specialists would present their availability for consultations and referrals, while the primary care docs would pull shifts in the emergency room (now emergency department) to make their presence known and gather unassigned (those without a doctor of their own) to recruit to their new office.

And many of the doctors in the community would round on their inpatients and see each other in the physician lounge. Or take part in grand rounds (lectures, talks, medical education) to meet and greet.

And the third avenue for collegiality was the local medical society dinner meetings with one’s spouse. I assume many practices did business on the strength of the relationship of the spouses (most likely women suiting the era, who may or may not have had professional careers of their own).

But of course, times have changed. Many aspects of medicine have changed. Forever altered by hospitalists (relegating most docs to their office only and never coming to the hospital), emergency physicians (a specialty of their own), change of demographics with many more female physicians and of course doubly employed spousal partners (and the rise of the male medical spouse).

This leaves the local medical society to find relevance. Many have not and have folded. Some have embraced the need for docs to meet together and sponsor quality quarterly educational meetings.

Our local Wake County Medical Society has decided that one of its major missions is to create venues for conversation and collegiality and communication between docs, and their families. Hence the many social programs of exploring the many cultural opportunities Raleigh and Wake County afford.

And then there is the BOOK CLUB!!! Ta da!!! Trumpet call please!!!

We have a solid group of docs, around 10 or so, that faithfully read the offering and bring insight, opinion, personal experience, enlightenment to a quarterly meeting, with a humble meal, comfort food.

Fiction and nonfiction.

Medical and anything but medical.

Purview the list:

Dopesick, Beth Macy
Underground Railroad, Colson Whitehead
Kids These Days, Malcolm Harris
The Immortal Life of Henrietta Lacks, Rebecca Skloot
Things That Matter, Charles Krauthammer
Astrophysics for People in a Hurry, Neil deGrasse Tyson
The Beekeeper of Aleppo, Christy Lefteri
The Great Influenza, John Barry

A quarterly meeting with a simple dinner, breaking bread and discussing themes and motif. And trust me all have read the book, it is after all a type A kind of club.

I have been inspired after reading Tyson’s book to study astronomy further with an online course from UNC, astronomy 101 with lab. Got an A in both.

The flu pandemic of 1918 puts our current Coronavirus in perspective, and begs us to ponder what is next, even as we struggle with this virus.

Dopesick, about the opioid crisis, which has taken a back seat to the virus.

Henrietta Lacks, whose breast cancer cells have advanced all forms of medical research.

Underground Railroad, facing our ugly past, personalized it seems, like no other portrayal of the beast of slavery.

Reading together and coming together, supping, and dissecting a book TOGETHER.

Such power, such meaning, such connection.

I look forward to every book and can’t imagine missing these times.

One day I will leave the office practice and the OR, and I will retire and not actively practice medicine, but I so look forward to continuing the exploration of literature and writing with my physician colleagues.

Anyone up for poetry?

Sinus Balloon Procedure

Sinusitis  101

It is uncommon for sinus infections to spread outside of the sinus into the eye or brain, but certainly the possibility exists and must be treated urgently.

This week I was called to assess a patient with infection spreading into the eye and causing thrombosis (clotting) of the veins draining the eye. All from a sphenoid sinusitis. The sphenoid is located smack in the middle of your head, right below your brain and between the area that the optic nerves and eye blood vessels enter and exit the skull.

The eye was extremely swollen and could not move well in the socket.

The treatment was to drain the sinus by enlarging the sinus opening with a balloon, under image guided conditions. Watch this video!!

We went to the OR for anesthesia, and I carefully led a balloon catheter into the sinus (sort of like using in heart vessels) using previous CT scans which allowed me to know that the balloon had entered the sinus. After inflating the balloon, I then looked with an endoscope and suctioned out infected material. In the recovery room the eye pressure and headache from the infection was immediately greatly improved.

Techniques such as balloon sinuplasty, used routinely on an elective basis (not urgent or emergent), have become quite useful to these emergency conditions.
The more routine balloon cases performed, the more prepared is the surgeon is to handle these more challenging cases.

I use sinus balloons often, and am ready for any challenge.

Glomus Tumor Case

In the OR, working through a speculum with an opening the size of a BIC pen, I surgically raised up the right ear drum to view the middle ear, and there it was.

A rather large impressive bright red tumor, sitting on the bony medial wall of the middle ear, creating pulsating sounds that brought the patient to me.

“Doctor, I can hear my heartbeat in my right ear”.  Examination showed the reddish mass behind the translucent ear drum (tympanic membrane or TM for short).  Only surgical excision would relieve this condition, and only surgery would stop it from expanding and growing.

It would need excision, with laser ablation of its feeding vessels, all under microscopic dissection, with intense concentration and coordinated movements between surgeon, anesthesia, and OR tech.  (too much drama, but of course it does, all procedures do!!!)

But this is special. It’s really neat.  To flip up the TM and stare the beast in the eyes.  Large, red, full of blood and bleeding potential, this is why God made me a doctor.  (ok, a bit more drama).

In any case, this is exciting surgery.  Remove the vascular mass.  I was first introduced to these vascular anomalies while a medical student, on neurosurgery rotation, assisting in removing an AVM (arteriovenous malformation) in a teenaged girl.  It looked like a big red spider on the surface of the brain.  But that was a big open procedure, with a big bone flap removed and later replaced.  Nothing like ENT ear surgery (we ENT’s are the best, most delicate, etc, the saying should be: “it’s not ENT surgery”, no lie or exaggeration here).

So I introduced the CO2 laser fiber into the middle ear and coagulated feeding vessels from above and below, but there might also be some feeding the mass that I couldn’t see, underneath the mass.  The only thing to do was to remove the mass with cup forceps and deal with the bleeding.  And so I did.  But that’s not the additional lesson here.  Most younger surgeons in the face of bleeding here would have sucked and lasered and sucked and lasered without effect, but the senior surgeon (like me) would place a cotton ball with some type of vessel constrictor like epinephrine or Afrin ( I use afrin, it is safer) to initially stop the bleeding and then go back and laser.  So what does the surgeon do while waiting for the cotton soaked ball to work?  Absolutely nothing, and that is the hardest part!

I learned from my wonderful mentors during ENT residency at the University of Iowa, especially chairman Dr. Bruce Gantz, that there is great benefit to pushing back from the scope and taking a few moments to compose oneself, take a few deep cleansing breaths, and then carry on.

And that’s what I did to great success. After removal of the afrin cotton ball, all bleeding had stopped and the tissue was ready for further coagulation and ablation with the laser.

TM replaced intact, case closed.

Now for some coffee (none yet to prevent caffeine tremors under the magnification of the microscope), talk with the family, and a little post-op EMR computer work.