The Tools We Hold: The Allis Clamp

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Today I used an Allis clamp in the operating room.  Like so many surgical instruments, it is a thing of beauty.  It’s a balanced, well engineered tool designed to hold without crushing.  And it has been used by surgeons all over the world since it was first first created.… in 1883.

1883-fashions-71-woman-austrian-customeWomen’s fashion in 1883

Imagine if you will the operating room of 1883… it’s still the beginning of modern anesthesiology and the concept of antisepsis in surgery had been published by Lister less than 20 years before.

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Surgeons in 1883 performed operations which were gory and painful. Patients routinely died, if not from the actual procedure then from the infections afterwards. Operating on the bowel in the 1880s was particularly dangerous with a mortality rate of 30-40%.

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But despite the mortality (not to mention the morbidity and outright suffering), bowel obstructed by cancer or necrotic from strangulated hernias still needed to be resected. Faced with these outcomes and this suffering, surgeons in 1883, like we do now, studied, discussed, performed experiments and tried new techniques to improve the treatments they offered their patients. ( For a great review on the history of bowel anastomosis, click here.)

One of those surgeons was Oscar Huntington Allis.

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Dr. Allis was born in 1836 in Holley, New York.  He attended Jefferson Medical College and did an internship at the Philadelphia General Hospital.  Like many surgeons of the era, he spent several years studying in Europe. Upon his return, he worked as a general surgeon at Presbyterian Hospital in Philadelphia. Dr. Allis died of a cerebral hemorrhage in 1921.

Here is Dr. Allis’ account of developing and using the Allis clamp (referred to as “toothed forceps”), which was delivered to the College of Physicians of Philadelphia in 1901. As you read this, remember that he was using a straight needle, much like a tailor would use.

My operation was performed in the following manner:  If the reader will divest himself of his coat and place the cuffs parallel, he can look down into the sleeve ends as into a double-barrelled gun. The inner surfaces of the sleeves correspond to the mucous surfaces, and the outer surfaces to the serous surfaces of the gut ends. Now, if the reader will sew the two proximal edges of the coat sleeves together, by a suture that passes entirely through them, he will find that he can readily sew fully half their circumference together. If now he will turn in the remaining borders, he will find that he can readily complete the circuit by sewing the outer surfaces. It was precisely in this way that I finally successfully approximated the intestines in Case 2. The fact that the mucous membrane could be safely included in a suture emboldened me to repeat the operation; and finding by experience that my fingers could not always accomplish my purpose, I have added to my case two instruments that I have found very convenient not only as special aids in anastomoses, but also in general surgical work. 

screen-shot-2016-10-25-at-7-06-27-amThe first may be called tenaculum forceps (Fig. 1, a). I use them very much as women use pins and basting thread to secure their work temporarily while they are sewing it more securely. It does not matter what stitch is used–the whip stitch, through-and-through stitch, or over-and-over. All that is essential is that the approximated bowels should be securely united. Having firmly approximated one half the circumference, I remove the forceps, and, turning the partly united structures half round, I seize the seam with my tenaculum forceps, and with a pair basting the work a little further on (Fig. 3), the through-and-through suturing can be continued almost entirely around the entire circumference.

screen-shot-2016-10-25-at-7-04-49-amWhen near the end of the approximation I have found toothed forceps (Fig. 1, b), with serrations on the edge, convenient for turning in the mucous edges, adjusting the serous, and holding them approximated until sutured (Fig. 4)

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How to Choose Your Medical Specialty

At lunch last week with my clinical students the topic turned to which specialties they were considering for their future career.  The senior resident (PGY6) on our service walked by and we asked her to join us.  “Come sit down… we’re talking about how you choose a specialty.”  She responded “You mean how a specialty chooses you.”

I believe that picking your specialty has far more in common with picking a spouse than anything else.  All of us, at some point in our lives made a list of attributes we would like in our significant other… but… when we actually meet the person and fall in love, it’s almost a sure bet that who they are doesn’t really match the list… at least not entirely.

The wrong way to pick a specialty should be obvious – pick an “easy” specialty (or  because the residency isn’t as demanding),  or pick a specialty just because of what your income will be, or because it’s what you always said you would do.   Just like picking who you will marry, choosing your specialty is not a choice that is made with lists of pros and cons.  Some of the unhappiest doctors I know picked a residency because it was easy or because they thought the specialty would give them a better lifestyle… and then they were miserable because they hated the work.

 

Wear the White Coat

Almost every year I end up talking to a student who from the very first day of medical school was absolutely sure that he/she was going to be a surgeon.  In choosing their rotations, they put surgery last – thinking that it would mean a better grade, better letters and a better chance for a good residency.  They cruise through their other rotations superficially – interested enough to get decent evaluations and good grades – but never really engaged in the specialty.  And then the unthinkable happens… they start their surgery rotation…. and they realize they don’t want to be a surgeon.

I tell students at the end of basic science that as they enter the clinics they should “wear the white coat”.  When you are on pediatrics, be a pediatrician.  When you are on internal medicine, be an internist.   Don’t just think about it, try it on.  When your attending asks you what field you are thinking about for your career, tell them that you are really interested in _____   (fill in the blank for the current rotation).  It’s the truth…. you are interested.  Show up every morning with the thought that this is the specialty you will be practicing the rest of your life.  At the end of the rotation, you’ll have an honest understanding of the field… and you’ll be able to know for sure if it’s a good fit for you or not.

One other important thing to remember:  there are more specialties out there than you will be exposed to…. The link below is the list of all boarded specialties in the United States.

http://www.abms.org/Who_We_Help/Physicians/specialties.aspx

Learn about specialties that sound interesting, meet physicians who practice them, and ask questions.  You don’t have to be on a rotation to spend some time with a doctor in practice; most of them are delighted to have someone interested in the field spend some time with them.  Email them and tell then you are interested and want to shadow them for a day or two.

 

How to Pick Your Specialty

I’ve watched the process enough to have a theory about how we pick our specialties.  Here’s how I think it happens.    The first thing that happens, as you go through your rotations, is you discover that you are more “medical” or “surgical”.   I will warn you that it’s not predictable!  Remember – somewhere over 70% of medical students end up in a field different from the one they predicted when they started medical school.    The field of medicine needs both surgical and medical doctors.  The two halves make up the whole, like the classic Yin-Yang symbol.  And, like the symbol, every surgeon must have a little internist in them and vice versa if they are going to be a master in their field.

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Once you are comfortable with your “medical” or “surgical” leanings, the next step is whether or not you want to care for the entire patient (e.g. general surgery, general medicine, family practice) or a part of the patient (e.g. ophthalmology, dermatology).  Again, there is no judgment implied here – all the specialties are necessary and important.  There’s one more branch in this decision tree… whether or not you want to work with children, adults or both.  These are things you learn, not things you decide.   I think my senior resident was absolutely right.  The specialty chooses you.  So how do you let it choose you?  Listen. I don’t mean listen in the usual sense.  Watch for the moments when you feel the tug to care for a certain kind of patient, notice when a role model makes the field seem appealing, pay attention when you get up in the morning and you can’t wait to get to the hospital.   I don’t know of any better way to pick your specialty…. or let it pick you.