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  Surgical scissors commonly used in the ED and the OR fall into two basic types: tissue scissors and suture scissors. A surgeon who cuts too many sutures with his tissue scissors will set himself up for a rap on the knuckles by the operating assistant who is responsible for the instruments, as that tends to dull the relatively delicate tissue scissors rapidly. The tissue scissors come in four basic forms, most of which are made in OTL in both straight and curved versions, with the curved versions allowing for cutting closer to the body. The Metzenbaum scissors most often seen in the curved form, and the iris scissors most often seen in the straight.

  Mayo scissors are blunt tipped, symmetrical scissors that are used for heavy work such as cutting the thick connective tissue around muscle bundles. The handles of a pair of Mayo scissors are only about twice as long as the length of the blade. Metzenbaum scissors are lighter scissors, again with blunt tips, where the handles are often more than twice as long as the blades. While they are used for cutting, one of the more important uses is to insert the tip of the closed Metzenbaum scissors into tissues and then spread the tips. This splits the tissues along the natural planes without cutting blood vessels or nerves in a technique known as blunt dissection.

  Iris scissors are very finely pointed scissors initially developed for eye surgery, but this instrument has also found favor in plastic and hand surgery.

  Lastly, there are so called "sharp and blunt" scissors that are midway between the Mayo and Metzenbaum scissors in weight, and have one sharp point and one rounded point on straight blades. These are often used as suture scissors in the OR, but can also be used to trim ragged tissue edges.

  Suture scissors tend to have shorter, heavier blades than most tissue scissors, and often have a "hook" on the bottom blade and sometimes, fine serrations to prevent the slick suture material from slipping out. Wire-cutting scissors have even shorter blades, often as short as 15mm, with comparatively long handles to provide the extra advantage needed to cut stainless steel wire. They also frequently have a notch in both the top and bottom blades near the pivot point, which provides even more security to cut heavier wires.

  Bone saws are already common in the 1600s, because amputations were the last chance to save someone’s life when gangrene threatened. The big improvement in the saws will be using first metals and later autoclavable plastics for the handles of the instruments, rather than the bone or wood, which was common up to the 1880s in OTL. A smaller, but significant improvement will be the Gigli style wire saw, which will make some types of brain surgery possible down-time, and does an amazingly fast job of cutting through a femur, when used by an experienced surgeon. Interestingly, one of the major uses of Gigli saws started in WWII, when the saws were inserted into bootlaces worn by aviators for use during escape attempts. Similar saws are included into tactical survival kits to this day in OTL.

  There are a number of other cutting implements in use, primarily in orthopedics. Bone cutters (rongeurs) have sharp edges on scoop shaped mating jaws, allowing the surgeon to nibble the harsh edges of cut or broken bone to allow for the closure of an amputated stump. Several types of diagonal cutters are available for trimming wires and pins after they have been inserted into bone. Simple hand drills, again made with metal instead of wood grips, are used to place pins to align bone, or to start holes in the skull to pass the Gigli saws so that a flap of skull can be removed. Manual cast-cutters may bear a distinct resemblance to compound metal snips or to an arboralist’s tree limb lopper, save for having a blunt shovel tip like bandage scissors.

  There are a wide variety of different types of "clamps," so called because they generally have a ratcheting locking mechanism, which allows a variable amount of pressure to be maintained by the clamp after the surgeon has released the handles.

  Hemostatic clamps or forceps fall into two classes: crushing and vascular (atraumatic) clamps. The difference is simple: the vascular clamps are used when the surgeon wishes to preserve that blood vessel for later reattachment, while the more common crushing clamps are used when the surgeon plans to ligate (tie off) the blood vessel.

  These hemostats are also used for blunt dissection, where their smaller tips may be more effective in delicate dissections. Most of the crushing clamps were devised between 1880 and 1940, with the rise of the vascular clamps after 1940 as vascular repair became practical, and intricate cardio-thoracic surgery became possible. Because of the worldwide progress of medicine, it is not unusual to find similar clamps named after widely separated surgeons, doing the same function. For example, there are the Crile and Halsted mosquito clamps, invented by G. W. Crile and W. S. Halsted respectively, which differ only in how far along the jaws the serrations are carried.

  Before the development of electrocautery (actually, an offshoot of radio experimentation) in the 1930s in OTL, much time had to be spent providing a "dry" operating field by individually ligating (tying) all of the little bleeders in the skin, subcutaneous fat and the muscles of the abdominal wall before an abdominal operation could proceed. This was done in OTL with the use of upwards of twenty mosquito hemostats being placed along the length of the incision, and then lengths of suture material being used to ligate those small bleeders. Silk and cotton threads were most commonly used, and were tied using one or two-handed "free tie" techniques most commonly associated with Dr. Halsted. A well-coordinated surgeon and first assistant can ligate all of those little blood vessels and remove those hemostats in a remarkably short length of time, but this is far longer than the same team can affect the same process using an electric cautery.

  Fortunately for Sharon Nichols, Sanchez was both slender and probably in early shock, both of which tend to reduce the amount of bleeding she had to deal with during his operation.

  Small vessels are tied off with fine thread, usually of silk or cotton in the early part of the twentieth century, replaced for hemostasis with either electric cautery or synthetic absorbable sutures after the 1980s. Larger vessels are secured with wide tape, which may be held in place with one of the hemostats, or with one of the vascular clamps if available. This helps prevent excessive damage to the lining of the blood vessel, reducing the formation of blood clots inside the vessel lumen.

  True vascular surgery will have to wait for several milestones:

  the (re)development of polymers strong and flexible enough to be pulled as hair fine monofilaments for sutures

  the (re)development of "swaged on" suture and needle combinations and

  the (re)development of polyester and PTFE (Teflon® and Gortex ®) for large diameter grafts (because veins are only suitable for small diameter arterial grafting).

  Until those milestones are reached, ligation rather than repair will be the rule for vascular injuries.

  An interesting hemostatic device, called a "bulldog clamp," is very useful for surgery of the head and neck, particularly of the scalp. These areas are so richly supplied with blood vessels that achieving a bloodless field is difficult, and the surgeon often finds the need to tie blind. These clamps resemble small binder clips, with the folding handles being replaced by a tong shaped applicator. Once a ring of these clamps stop the bleeding of the scalp edges, the surgery can be completed easily. As the clamps are removed for wound closure, individual bleeding vessels can be tied off as needed, with the final closure and a firm dressing providing a final stop to the bleeding.

  Another group of clamps is used to close off various types of hollow organs such as the bowel or the bile duct, preventing the contents of that organ from contaminating the abdominal cavity. As with the vascular clamps, there are a number of different but similar clamps, invented by widely separated surgeons, which do the same job. For example, Drs. Emil Kocher (Switzerland) and Alton Oschner (USA) invented similar clamps used in the removal of the gall bladder.

  Other locking clamps are designed to hold tissue gently but securely so that the surgeon can reattach edges together. The jaws of these clamps may be smooth, have grooves along or across their width, an
d may or may not have teeth at the tips.

  The last general type of clamp is a simple long, locking clamp with looped ends. Called sponge forceps, these are used by placing a folded square of gauze in the looped ends of the clamp. The gauze "sponge" is used to swab on fluids or medications or to swab blood from the depths of a wound (or occasionally, sweat from the surgeon’s nose).

  Thumb forceps, by contrast, are tweezers, often writ large, ranging from 6 to 12 inches (15 to 30 cm) in length. The tips of the thumb forceps will usually have grooves across the width of the tips, and most forceps used to manipulate tissue have some type of interlocking teeth at the ends. Dressing forceps, on the other hand, have relatively smooth tips to avoid snagging on the loosely-woven fabric. Two special kinds of thumb forceps that have proven very handy to me in the past include the Brown-Adson tissue forceps and the Russian or “bear paw” forceps. The Brown-Adson forceps have two rows of a half dozen teeth on each tip, which interlock to hold tissue over a wider area than other tissue forceps, allowing for a firm grasp with less pressure, and therefore less damage to the tissue. The Russian forceps have circular tips with interlocking teeth, allowing the surgeon to easily manipulate a suture needle deep in a body cavity. This both reduces the size of the cavity needed, and reduces the chance that the surgeon (or the assistant) will end up stuck with the bloody needle.

  The most important device that prevents the surgeon from being stuck is the needle driver. Using a similar locking ratchet mechanism to the hemostatic clamps, the jaws of the needle driver are shorter and stouter, with a definite crosshatch pattern, rather than the simple unidirectional ribbing of the clamps. The drivers range from 4 inches (10 cm) to 12 inches (30 cm) long, but the jaws remain constant at about 10-15 mm long. Someone skilled in the "instrument technique" of suturing can place neat stitches deep in the belly or another body cavity through a surprisingly small incision.

  One major problem with surgery in the early 1630s will be the strictly limited supply of up-time suture material, something that will take years to replace. Fortunately, there are some old-fashioned and down-time alternatives that will suffice for most uses until materials science in general and polymer technology in particular catches up with the needs of surgery.

  One last piece of equipment that the field medics and many of the ED nurses will carry will be a leather holster that has slots for two hemostats, a regular pair of Lister bandage scissors, a pair of trauma shears, and a lock-back folding knife. A loop for a pen light will be included, but not filled until the battery and bulb technologies get to the point of providing the small lights again. The floor and ICU nurses will carry a lighter version, with room for only one pair of scissors, one or two clamps, a penlight and a pen.

  In Part 2, I’ll discuss the basics of aseptic surgery and anesthesia.

  Notes

  [i] The Trauma Attending is a board certified General Surgeon with extensive experience in trauma and critical care.

  [ii] A Trauma Fellow is a surgeon who has completed a seven to ten year residency, and who is now acquiring extra experience in trauma and critical care prior to taking the general surgery boards.

  [iii] Personal communication with the ATLS coordinator at the American College of Surgeons.

  [iv] Some of us go so far as to become ATLS instructors, but there is nothing in canon to indicate that any of the physicians have done that.

  [v] The C4 program is open to any nurse, dentist, PA, or NP who has completed their training, and to any physician who has completed at least their first year of postgraduate training (the internship year). Reserve and Guard members can use the program to fill all or most of their Annual Training requirement. I took mine during an elective block in my second post graduate year, as soon as I was eligible. Mary Pat would not yet have been eligible, and Beulah McDonald and the older physicians would have completed their service before the program was in place. CW3 John Sullivan (MOS 18D- see below) might have taken the course as part of his military training,

  [vi] In a communication from Danita, she indicated that the nursing degree would be a BSN rather than the BN that has occasionally appeared in Bar discussions.

  [vii] Grantville Gazette Volume 16: “The Galloping Goose”

  [viii] In 1946, DeBakey and Simeone wrote a landmark paper entitled "Battle Injuries of the Arteries in World War II; An Analysis of 20,471 Cases". This paper, published in the Annals of Surgery, looked at two distinct groups. In the larger group, soldiers underwent ligation of their injured arteries, and 49% of those individuals who survived went on to amputation. In a much smaller group of 81 patients, primary suture repair of the injured vessel was performed, and the amputation rate in this group was 35%, and was "deemed significantly better" by the authors. With the institution of "routine" primary vascular repair by Spencer and colleagues during the Korean conflict, and the progressive decrease in times from injury to definitive care in Korea and Vietnam, amputation rates dropped to around 10%, and the current civilian experience with isolated arterial injuries now has documented an amputation rate of less than 5%.

  Quoted in a Trauma-L correspondence with Ron Gross, MD, FACS, COL, MC (ret)

  [ix] 1634: The Galileo Affair Chapter 43

  [x] Grantville Gazette, Volume 9: "Tool or Die" Feb 1632

  [xi] Grantville Gazette, Volume 4: "'Til We Meet Again" January 1634

  [xii] Grantville Gazette, Volume 14: "The Galloping Goose" November 1634

  [xiii] "An Invisible War" ibid

  [xiv] Trueta, Joseph, TREATMENT OF WAR WOUNDS AND FRACTURES WITH SPECIAL REFERENCE TO THE CLOSED METHOD AS USED IN THE WAR IN SPAIN. London 1940, PRINCIPLES AND PRACTICE OF WAR SURGERY WITH REFERENCE TO THE BIOLOGICAL METHOD OF THE TREATMENT OF WAR WOUNDS AND FRACTURES. St. Louis 1943

  [xv] Grantville Gazette, Volume 14 "Doc"

  [xvi] From communications with Jose Clavell and Danita

  [xvii] Grantville Gazette, Volume III “If the Demons Will Sleep”

  [xviii] Ibid

  [xix] Ibid

  [xx] Grantville Gazette Volume 26: “Advice and Counsel”

  [xxi] I’ve never understood this one. Why didn’t Jefferson get her MSN as a Midwife or a Nurse Practitioner? "A Matter of Consultation," Ring of Fire

  [xxii] Grantville Gazette, Volume 29: "NCIS: No Greater Love"

  [xxiii] 1632

  [xxiv] Grantville Gazette, Volume 10: “The Prepared Mind”

  [xxv] Grantville Gazette, Volume 23: “Loose Canon”

  [xxvi] Grantville Gazette, Volume 15: "The Whippoorwill" I base this statement on the salvage of Hatfield’s arm, rather than an amputation, which I would have expected most down-time surgeons to do because of the damage. This goes along with the statements in "Doc."

  [xxvii] "Doc" ibid

  [xxviii] Grantville Gazette, Volume 11: "A Gift of Blankets" Spring 1632

  [xxix] http://en.wikipedia.org/wiki/Burke_and_Hare

  [xxx] Moore, Wendy The Knife Man (Broadway Books, 2005)

  [xxxi] http://en.wikipedia.org/wiki/Anatomy_Act_1832

  [xxxii] http://www.teleflexmedicaloem.com/pdf/KMAD-4_General.pdf

  [xxxiii] http://www.icrc.org/Web/Eng/siteeng0.nsf/htmlall/p0446/$File/ICRC_002_0446.PDF

  [xxxiv] http://www.icrc.org/Web/Eng/siteeng0.nsf/html/p0516

  [xxxv] Suggested by Danita

  [xxxvi] Including at least one Special Forces (18D) medic and another 91C LPN (John and Anamarie Sullivan), pointed out to me by Caper2. They are currently claimed by Kerryn, and he has slushed a story where they are now a BSN (John) and a DO (Anamarie) respectively.

  [xxxvii] Endoscopes are used to "look inside" the body. These include devices to peer into the throat and voice box (laryngoscope), the lungs (bronchoscopes), the stomach and upper part of the small intestine (gastroscope) and the large intestine (proctoscopes (very short), sigmoidoscope (longer) or colonoscope (very long)). http://en.wikipedia.org/wiki/Endoscope

  [xxxviii] A mild acetic acid (vinegar) wash is used to turn precancerous cells
white, and is followed by an iodine wash which turns normal cells a mahogany brown, making the white cells stand out.

  [xxxix] The culposcope is used to examine the back of the vagina and cervix for cancerous changes.

  [xl] http://en.wikipedia.org/wiki/Electrosurgery

  [xli] http://en.wikipedia.org/wiki/Hyfrecator

  [xlii] Oddly enough, finding a diathermy machine hiding in one of the older doctor’s attics would go a long way to helping redevelop the microwave oven, as the older machines would be easier to copy than the more compact kitchen microwave units.

  [xliii] Grantville Gazette, Volume 28, "On His Majesty’s Secret Service" the first down-time produced movie

  [xliv] Grantville Gazette, Volume 17, "Feng Shui for the Soul" HDG has developed film sensitive enough for Kirlian photography by the end of 1634. HDG is producing commercial quantities of the developing chemicals by this time.

  [xlv] http://www.teleflexmedicaloem.com/pdf/KMAD-4_General.pdf

  [xlvi] Again, I was a bit atypical. I purchased a small steam sterilizer and four decent suturing sets, including high quality carbide insert scissors and needle holders when I first started in practice in 1990.

  [xlvii] Personal experience as a sterile instrument technician

  [xlviii] Grantville Gazette, Volume 31: "Me fecit Solingen Nicht"

  [xlix] Grantville Gazette, Volume 5: "Burmashave"

  [l] http://en.wikipedia.org/wiki/Scalpel