Wednesday, December 18, 2013

"Stealing" the thyroid gland


Here's a story about a technique of thyroid surgery that is no longer being done

During one summer of my college years in the mid-1960s, I worked as an orderly at a community hospital in my hometown. There are no orderlies anymore. I guess the closest thing would be a "patient care technician." Orderlies used to push patients around on gurneys, help the nurses change beds, clean up poop, run errands, and do whatever no one else wanted to do. It was common for premed students to do at least one summer of orderly work to demonstrate their commitment to becoming a doctor. I suppose it's analogous to today's premed students' doing a summer of research cleaning test tubes.

Anyway, back to the story. A woman was admitted with thyrotoxicosis, a hyperactive thyroid gland resistant to whatever medications were being used to suppress thyroid function at the time.

She was scheduled for a total thyroidectomy, but the stress of anesthesia and surgery was known to induce a potentially fatal condition called a "thyroid storm." A thyroid storm can still occasionally occur in patients with untreated hyperthyroidism. Some symptoms of thyroid storm are fever, rapid heart rate, agitation, delirium, tremor, and low blood pressure, among others.

In the early 1900s, the threat of this problem prompted a famous early thyroid surgeon, George Crile, to devise a plan for "stealing" the gland.

Following Crile's script, what we did with our hyperthyroid lady was to visit her every day dressed in our surgical scrubs. The anesthesiologist would fiddle with her IV and talk to her. The OR nurse and I would chat with her too. All of this was done so that she could become accustomed to our presence. The idea was to one day anesthetize the patient in her bed and take her to the operating room for her thyroidectomy. Since the patient did not know on which day her surgery would occur, she was not so anxious.

A few days went by. One day we were told, "Today's the day." When we went into the room, the anesthesiologist, instead of just fiddling with the IV, injected some sodium pentothal, and the patient fell asleep. Off we went to the OR, and the operation was done.

These days, it's a good thing that hyperthyroidism can be treated with more effective medication. I doubt that insurance companies would pay for a three or four day preoperative hospital stay so that the thyroid gland could be stolen.

13 comments:

Ganesh Puttu said...

do you still prefer to do total thyroidectomy or do you leave some of the tissue behind? (as some modern theorists advice us to do? ) also do you remove parathyroids along with the total thyroidtectomy? jus curious

Anonymous said...

What a great story. Unfortunately, I once had a patient, young 20'ish year-old female, who had thyroid storm in the recovery room. She hadn't been taken her medications pre-op. I learned a valuable lesson that day. Thanks for the story.

Skeptical Scalpel said...

Ganesh, when I did that type of surgery. I left a little portion of the thyroid gland in place in hope that it would be sufficient to maintain the patient in a euthyroid state. Some surgeons advocate a total thyroidectomy which minimizes the risk of recurrent hyperthyroidism but increases the risk of complications.

One tries to leave all four parathyroid glands in place during any thyroid surgery. Removing all the parathyroid glands is a serious complication leaving the patient chronically hypocalcemic, which can be difficult to treat.

Skeptical Scalpel said...

Anon, thanks for commenting. A thyroid storm can be an impressive and scary thing to see.

Les said...

I laughed a little while reading this. We used a similar habituation technique with lab rats before doing any experiment involving the hypothalamus-pituitary-adrenal axis when I was a graduate student. I hope her nose wasn't twitching or anything.

Skeptical Scalpel said...

Les, I can't recall if her nose was twitching or not. It might have been.

Libby said...

I'm sure if it was tried now someone would question the ethics of it...definitely a paper trail of consent forms would be needed. I know a few people who would sign up for a 'stealing' of whatever was going to be removed just so they don't get all worked up prior to going under.

Korhomme said...

That's a new one to me. I've heard of a thyroidectomy under local anaestheia to minimise the risks of a thyroid storm, but never I've never seen it done. Thanks.

Skeptical Scalpel said...

Libby, I agree that it would be impossible to do today due to the paperwork, patient ombudsman, ethics committee and others.

Korhomme, I don't think you'll ever see someone steal a thyroid either.

Ian M. said...

Thank you for sharing this. I love hearing about the surgery of the past.

Skeptical Scalpel said...

I'm glad you enjoyed it.

bigjimricotta said...

When I was in college in the mid 70's I volunteered at a NYC hospital ICU basically stocking shelves. One day, a resident or junior attending asked me(a college junior) to help him place an internal jugular line on an intubated ICU patient. He had me put sterile gloves on and I held one end of the guide wire while he placed the needle and then the wire etc. It seemed like it took an hour and as if we were doing brain surgery. Imagine the controversy today if a volunteer helped a resident place a central line!!! As far as thyroid storm, I think it is the anesthetic itself rather than patients anxiety that you have to worry about. I had one 30 year old male with acute appendicitis have thyroid storm post op. Once in a lifetime was enough for me. He survived but it was pretty frightening. I wonder sometimes why medicine costs so much more today, when we are so much more efficient in many ways. In the old days a hernia, varicose vein, breast biopsy etc came in the day before surgery. In house colon preps for 2 days, hemorrhoidectomies stayed 4-5 days, open cholcystectomies stayed 5-7 days. I guess now we have robots that cost 2 million dollars that may actually be doing more harm than good, multiple eighth generation antibiotics, and lets not forget electronic medical records--which I call "where's Waldo" because there is so much useless and wrong information you get lost trying to figure it out. In the old days, the medical student wrote the 5 page note, then the intern resident and attending wrote progressively shorter notes. Now, the attending has to document a hole bunch of crap to satisfy some bureaucrat. I remember some of my old attendings who were great clinicians---they often wrote a 3 or 4 line note--very succinct, that was all you needed to know.

Skeptical Scalpel said...

Big Jim, nice comments. We did some things back in the 70s that would curl the hair of a risk manager today. I agree with you about the EMRs and have written about that topic. Here are two links among others http://skepticalscalpel.blogspot.com/2011/04/emr-follies.html and http://skepticalscalpel.blogspot.com/2011/04/emr-follies-part-2.html

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