Dr. Joel Aronowitz - Real Patients Real Stories: Pediatric Lip Laceration Repair in the Plastic Surgery Operation Room
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| Dr. Joel Aronowitz |
Dr. Joel Aronowitz: “Now, we have a pediatric patient with laceration, two-year-old, with a lip laceration through the vermilion border. This is a good example of the kind of laceration that in most cases should be repaired by a plastic surgeon. And we have a sad young man here who's worried, and that's great. Thank you so much. And we are going to, because he's two, he can't really cooperate. A three-year-old and above can. Between three and five, about half and half will be able to cooperate, and half will need to be papoosed. And I'm going to show you how we papoose a small child that is a child under three, or sometimes older children that can't really cooperate with us. And the whole purpose is to immobilize the patient so that we can do our job and not cause further trauma. And the alternative to papoosing is to sedate the patient, which I would prefer to not sedate the patient and subject the child to the risk of anesthetic complications rather than simply papoosing the child physically. So, here we go. So, we're going to do a little papoosing here. There we go. We're going to put your head right here, and then we're going to make you into a little burrito, okay? Can we make you want to do a little burrito? Do you like the burrito? So, first thing is we need to have the arms down at the sides, completely out straight, and then we need to bank that nice and snuggy, snuggy, and holding hands down. So, when we put this strap on, that's all completely straight. And then that little burrito is so nice and snug, and then we want this one to be over the knees so we can't bend the knees. So, we don't want to be able to bend the knee or bend at the elbows, because then we can do things. And then we want to make sure that we're not going to go anywhere, and we have the whole burrito stays on the plate. So, the next step is to tape everybody down, and we can do the whole thing with a sheet and tape if we don't have a papoose board, right? Right? And we're going to tell you everything we're going to do so you don't have to be scared. So, the next step is going to be to put a little guard over your eyes. I'll need you to put on gloves, please. And if you would be kind enough, before you put on the gloves, to open the 6-0 crowling. And then we're going to put this big, scary light on in just a minute. And I find that it's very helpful to talk about our pets, because everybody likes pets, like I have a cat. And do you know what a cat says? Does a cat say, ruff? Or does a cat say meow? You think I'm crazy, don't you? I think he thinks I'm crazy. And, but I'm just trying to distract you a little bit. And it's always better to not have mom or dad back here, because then if the child hears mom or dad, then the child's going to be in more distress.
Assistant: “Hey, bud!
Dr. Joel Aronowitz: “And the, I mean, the child's going to be in more distress, but the parent is going to be in distress. We're going to put some barrel blue towels on, like so. Oh, this is so great. This is so great. And I have an assistant, so I don't have to do all by myself. And now we're going to put this on your eyes so that it guards your eyes. We're going to put the light on there. And then we're going to washy washy a little bit here. Washy, washy, washy.”
Assistant: “Hey, bud.
Dr. Joel Aronowitz: “There's the little.”
Assistant: “You're doing so good.”
Dr. Joel Aronowitz: “Now, if you take that earlobe and just pull on that earlobe a little bit.”
Assistant: “What's this?”
Dr. Joel Aronowitz: “Yeah. No, hold that earlobe. There you go.”
Assistant: “What's that?”
Dr. Joel Aronowitz: “Oh, yeah. Oh, yeah. That's a boy. That's a boy. Yeah. Are you pulling on that little earlobe a little, little, little, little, little bit? That's it. Okay. Now, what a good boy you are.”
Assistant: “You're doing so good. What a good boy you are.”
Dr. Joel Aronowitz: “And the kitty cat says. What does the kitty cat say, Sarah? Meow? Meow? Meow? Her? Go ahead with the distraction with the earlobe. Now we're going to clean this up a little bit. Oh, yeah. You're doing so good.”
Assistant: “Look at that.”
Dr. Joel Aronowitz: “Look at that. I see it.”
Assistant: “What's in there?”
Dr. Joel Aronowitz: “I see what you're doing. That's so good.
Assistant: “Good job. That's good.”
Dr. Joel Aronowitz: “Now it's nice and clean. And what we're going to do is we're going to put.”
Assistant: “Look at you.”
Dr. Joel Aronowitz: “We're going to put this back together. What we want to do here is the vermilion right there. And we're going to go back this way.”
Assistant: “Look at that.”
Dr. Joel Aronowitz: “And we want to line this up perfectly.”
Assistant: “Good job, bud.”
Dr. Joel Aronowitz: “OK. Now hopefully we got that right. We'll know in a minute. Now just keep your hand on his temple. Yeah. Hey, now, do you know the song that never ends? You want to hear the song that never ends? That's a good one. This is the song that never ends. Just keep his temple down. That's it. It just goes on and on. My friend, somebody started singing. Yet I think it was Nathan. And now we're all still singing it forever. Just because this is the song that never ends. And Sarah is not going to be a dancer because she has no rhythm. The poor girl can't dance. And now we're all still singing it forever. Just because this is the song that never ends. Now I'm going to check and make sure I've got this first stitch in the right place here. Look carefully. So far, so good. So, let's put another one right here. And then we'll check again. Make sure our vermilion is lined up because otherwise we get what's called a notch deformity. Right, Sarah? We don't want a notch deformity.
That's good. Okie dokie. I'll tell you, if you're not cute when you're two, you're never going to be cute. You are never going to be cute. Are you actually a good dancer, Sarah? I actually think I am. You are? Okay. I didn't want to criticize your dancing ability based on the... I guess your dancing to my singing is probably... The world out there can see my great dancing and your lovely singing.”
Assistant: “So just more entertainment for the world.”
Dr. Joel Aronowitz: “Yeah, I don't know how entertaining my singing is.”
Assistant: “You are doing such a good job, bud. You're going to look so pretty.”
Dr. Joel Aronowitz: “I don't know if he wants to look pretty. He's a tough boy. He's a tough boy, aren't you?”
Assistant: “Okay.”
Dr. Joel Aronowitz: “Sarah's doing a good job. It's that little distraction. Okay, so far so good.”
Assistant: “You are doing so good. Better than Dr. A would do.”
Dr. Joel Aronowitz: “That is for sure. That is absolutely for sure. I need to admit that. Absolutely true.”
Assistant: “Okay.”
Dr. Joel Aronowitz: “So this suture is called chromic because it used to be chromatized cat gut. Of course, it's not made out of cat intestine anymore. But originally that's what it was made out of. And it holds up for about four or five days, which is just long enough and then it will start to dissolve and fall out by itself. So, we don't have to take it out. But the other sutures, we are going to, the blue ones are permanent sutures, so those will need to be removed. And there's just a little piece of mucosa here that, let's see, just take that off. Okay, one more little stitch here and we are done. And we will take a little band-aid in a minute. And just a second, I will show you the anatomy of the injury here. So here is the vermilion line. And you can see the cut goes across the vermilion and over this little V. And this is probably a result of his own tooth. And this is the, that is this lateral incisor. And that's probably what cut him or the incisor down below, which are just small sharp teeth. And they are named incisors. Do you know why they are named incisors, Sarah?”
Assistant: “What does incise mean?”
Dr. Joel Aronowitz: “Cutting. Cutting. Or incising.”
Assistant: “Exactly.”
Dr. Joel Aronowitz: “Exactly. So, if you have a little band-aid, you can put a band-aid. Sure. If you could get me a little band-aid.”
Assistant: “Do you want just like one of the small circular ones? You also could have.”
Dr. Joel Aronowitz: “Let me have a little band-aid.”
Assistant: “Sure.”
Dr. Joel Aronowitz: “Now, do you want a band-aid that hurts or the kind that doesn't hurt? You want the kind that doesn't hurt?”
Assistant: “I probably want ice cream. You want ice cream?”
Dr. Joel Aronowitz: “I'd like ice cream.”
Assistant: “You want regular ice cream? Look at this. What kind of hair here?”
Dr. Joel Aronowitz: “Should we go to Mommy? Should we go to Mommy? Okay. No. We'll do that. We'll do that.”
Assistant: “Okay.”
Dr. Joel Aronowitz: “All righty. All righty. There's Kirk. You want to go with Kirk? You want to go with Kirk?”
Assistant 2: “Hi.”
Dr. Joel Aronowitz: “That's your buddy. Kirk is your buddy. Yeah. Oh, hi. Kirk is your buddy. Okay. Some tips for treating small children. Tip number one is to separate the parent from the child. There's going to be a lot less net suffering in the world if the parent and the child are apart. The parent should not, in my opinion, be made to hold the child. That's very tough as a parent. And needless suffering on the part of the parent. The child doesn't understand why the parent wouldn't help them. Needless suffering and anguish on the part of the child. Number two is that I don't think that most children need to be sedated. I think that it's an unnecessary risk of the anesthetic to sedate the child when you could simply papoose the child. Mobilize a child who's under three. They rarely, if ever, remember it anyway. And it doesn't have to be a traumatic experience if you talk the child through it. If you're honest with the child, tell the child what you're doing and why. And distract the child while you're doing the painful part, for example. If I'm pulling on the patient's ear while I'm injecting very, very gently with a small gauge needle. Very slow speed of injection. Inject through the actual cut instead of through the intact skin. Don't distend the tissues very aggressively. Then the actual injection doesn't hurt very much. The other trick with the injection is to neutralize the acidic pH of the lidocaine so that the lidocaine doesn't burn. So just a couple little tips. Immobilization. Three points of fixation. One is the temple. So, if my head is up against the flat surface, I can't move. It takes very little force against the temple to hold the head down. Doesn't interfere with the airway or anything. Doesn't require a lot of force on the head. Keep the elbows straight and the knees straight and I can't really get anywhere. If you let me bend at the elbow or bend at the knee, I can push off with my foot. I can push off with my elbow and I can get loose. But if the elbows and the knees are kept very straight in the papoose, then it's fairly easy to control almost any size person. So, a couple little tips for pediatric lacerations and hope that helps a little bit. So, we'll go talk to the mom now and we'll plan on suture removal in this trial in about four or five days. Thank you.”
Assistant: “Hey, bud!
Dr. Joel Aronowitz: “And the, I mean, the child's going to be in more distress, but the parent is going to be in distress. We're going to put some barrel blue towels on, like so. Oh, this is so great. This is so great. And I have an assistant, so I don't have to do all by myself. And now we're going to put this on your eyes so that it guards your eyes. We're going to put the light on there. And then we're going to washy washy a little bit here. Washy, washy, washy.”
Assistant: “Hey, bud.
Dr. Joel Aronowitz: “There's the little.”
Assistant: “You're doing so good.”
Dr. Joel Aronowitz: “Now, if you take that earlobe and just pull on that earlobe a little bit.”
Assistant: “What's this?”
Dr. Joel Aronowitz: “Yeah. No, hold that earlobe. There you go.”
Assistant: “What's that?”
Dr. Joel Aronowitz: “Oh, yeah. Oh, yeah. That's a boy. That's a boy. Yeah. Are you pulling on that little earlobe a little, little, little, little, little bit? That's it. Okay. Now, what a good boy you are.”
Assistant: “You're doing so good. What a good boy you are.”
Dr. Joel Aronowitz: “And the kitty cat says. What does the kitty cat say, Sarah? Meow? Meow? Meow? Her? Go ahead with the distraction with the earlobe. Now we're going to clean this up a little bit. Oh, yeah. You're doing so good.”
Assistant: “Look at that.”
Dr. Joel Aronowitz: “Look at that. I see it.”
Assistant: “What's in there?”
Dr. Joel Aronowitz: “I see what you're doing. That's so good.
Assistant: “Good job. That's good.”
Dr. Joel Aronowitz: “Now it's nice and clean. And what we're going to do is we're going to put.”
Assistant: “Look at you.”
Dr. Joel Aronowitz: “We're going to put this back together. What we want to do here is the vermilion right there. And we're going to go back this way.”
Assistant: “Look at that.”
Dr. Joel Aronowitz: “And we want to line this up perfectly.”
Assistant: “Good job, bud.”
Dr. Joel Aronowitz: “OK. Now hopefully we got that right. We'll know in a minute. Now just keep your hand on his temple. Yeah. Hey, now, do you know the song that never ends? You want to hear the song that never ends? That's a good one. This is the song that never ends. Just keep his temple down. That's it. It just goes on and on. My friend, somebody started singing. Yet I think it was Nathan. And now we're all still singing it forever. Just because this is the song that never ends. And Sarah is not going to be a dancer because she has no rhythm. The poor girl can't dance. And now we're all still singing it forever. Just because this is the song that never ends. Now I'm going to check and make sure I've got this first stitch in the right place here. Look carefully. So far, so good. So, let's put another one right here. And then we'll check again. Make sure our vermilion is lined up because otherwise we get what's called a notch deformity. Right, Sarah? We don't want a notch deformity.
That's good. Okie dokie. I'll tell you, if you're not cute when you're two, you're never going to be cute. You are never going to be cute. Are you actually a good dancer, Sarah? I actually think I am. You are? Okay. I didn't want to criticize your dancing ability based on the... I guess your dancing to my singing is probably... The world out there can see my great dancing and your lovely singing.”
Assistant: “So just more entertainment for the world.”
Dr. Joel Aronowitz: “Yeah, I don't know how entertaining my singing is.”
Assistant: “You are doing such a good job, bud. You're going to look so pretty.”
Dr. Joel Aronowitz: “I don't know if he wants to look pretty. He's a tough boy. He's a tough boy, aren't you?”
Assistant: “Okay.”
Dr. Joel Aronowitz: “Sarah's doing a good job. It's that little distraction. Okay, so far so good.”
Assistant: “You are doing so good. Better than Dr. A would do.”
Dr. Joel Aronowitz: “That is for sure. That is absolutely for sure. I need to admit that. Absolutely true.”
Assistant: “Okay.”
Dr. Joel Aronowitz: “So this suture is called chromic because it used to be chromatized cat gut. Of course, it's not made out of cat intestine anymore. But originally that's what it was made out of. And it holds up for about four or five days, which is just long enough and then it will start to dissolve and fall out by itself. So, we don't have to take it out. But the other sutures, we are going to, the blue ones are permanent sutures, so those will need to be removed. And there's just a little piece of mucosa here that, let's see, just take that off. Okay, one more little stitch here and we are done. And we will take a little band-aid in a minute. And just a second, I will show you the anatomy of the injury here. So here is the vermilion line. And you can see the cut goes across the vermilion and over this little V. And this is probably a result of his own tooth. And this is the, that is this lateral incisor. And that's probably what cut him or the incisor down below, which are just small sharp teeth. And they are named incisors. Do you know why they are named incisors, Sarah?”
Assistant: “What does incise mean?”
Dr. Joel Aronowitz: “Cutting. Cutting. Or incising.”
Assistant: “Exactly.”
Dr. Joel Aronowitz: “Exactly. So, if you have a little band-aid, you can put a band-aid. Sure. If you could get me a little band-aid.”
Assistant: “Do you want just like one of the small circular ones? You also could have.”
Dr. Joel Aronowitz: “Let me have a little band-aid.”
Assistant: “Sure.”
Dr. Joel Aronowitz: “Now, do you want a band-aid that hurts or the kind that doesn't hurt? You want the kind that doesn't hurt?”
Assistant: “I probably want ice cream. You want ice cream?”
Dr. Joel Aronowitz: “I'd like ice cream.”
Assistant: “You want regular ice cream? Look at this. What kind of hair here?”
Dr. Joel Aronowitz: “Should we go to Mommy? Should we go to Mommy? Okay. No. We'll do that. We'll do that.”
Assistant: “Okay.”
Dr. Joel Aronowitz: “All righty. All righty. There's Kirk. You want to go with Kirk? You want to go with Kirk?”
Assistant 2: “Hi.”
Dr. Joel Aronowitz: “That's your buddy. Kirk is your buddy. Yeah. Oh, hi. Kirk is your buddy. Okay. Some tips for treating small children. Tip number one is to separate the parent from the child. There's going to be a lot less net suffering in the world if the parent and the child are apart. The parent should not, in my opinion, be made to hold the child. That's very tough as a parent. And needless suffering on the part of the parent. The child doesn't understand why the parent wouldn't help them. Needless suffering and anguish on the part of the child. Number two is that I don't think that most children need to be sedated. I think that it's an unnecessary risk of the anesthetic to sedate the child when you could simply papoose the child. Mobilize a child who's under three. They rarely, if ever, remember it anyway. And it doesn't have to be a traumatic experience if you talk the child through it. If you're honest with the child, tell the child what you're doing and why. And distract the child while you're doing the painful part, for example. If I'm pulling on the patient's ear while I'm injecting very, very gently with a small gauge needle. Very slow speed of injection. Inject through the actual cut instead of through the intact skin. Don't distend the tissues very aggressively. Then the actual injection doesn't hurt very much. The other trick with the injection is to neutralize the acidic pH of the lidocaine so that the lidocaine doesn't burn. So just a couple little tips. Immobilization. Three points of fixation. One is the temple. So, if my head is up against the flat surface, I can't move. It takes very little force against the temple to hold the head down. Doesn't interfere with the airway or anything. Doesn't require a lot of force on the head. Keep the elbows straight and the knees straight and I can't really get anywhere. If you let me bend at the elbow or bend at the knee, I can push off with my foot. I can push off with my elbow and I can get loose. But if the elbows and the knees are kept very straight in the papoose, then it's fairly easy to control almost any size person. So, a couple little tips for pediatric lacerations and hope that helps a little bit. So, we'll go talk to the mom now and we'll plan on suture removal in this trial in about four or five days. Thank you.”
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