Ephraim McDowell: the qualities of a good surgeon.

OBJECTIVE: To identify those personal qualities which enabled Dr. Ephraim McDowell to be successful as the first surgeon in the world to remove a large ovarian tumor. SUMMARY BACKGROUND DATA: Dr. McDowell, in 1809 and before anesthesia or antisepsis, removed a large ovarian tumor from his patient, Jane Todd Crawford, who then survived 33 years. METHODS: Existing histories and accounts of Ephraim McDowell's life and operations were sifted for his personal qualities. A visit to the McDowell House and family 200 reunion in Danville, Kentucky, added details. RESULTS: Qualities of confidence, compassion, courage, commitment, communication, courtesy, and especially cleanliness have been identified. CONCLUSIONS: Those qualities attributed to Ephraim McDowell perhaps were instrumental in his successes. Those basic qualities are still important for surgeons today.

Serum amylase and lipase alone are not cost-effective screening methods for pediatric pancreatic trauma.

BACKGROUND: Injury to the pancreas is rare in pediatric trauma. Identification of pancreatic injury relies on clinical, radiographic, and laboratory data. Serum screening for pancreatic injury frequently is used but has not proven to correlate well with pancreatic injury. This study investigated utility and cost effectiveness of serum assessment of amylase and lipase. METHODS: A retrospective study of 1,821 pediatric trauma patients over 64 months was conducted. A total of 293 (16%) of these patients suffered trauma to the torso 195 (11%) of whom had confirmed intraabdominal injury. Eight pancreatic injuries (4% of abdominal injuries) were identified; 5 underwent surgery for pancreatic ductal injury. One patient not operated on had a pseudocyst that required late drainage. RESULTS: Serum amylase or lipase levels (AMY/LIP) were measured in 507 (28%) patients. A total of 116 (23%) had elevated AMY/LIP levels. Six of 8 with proven pancreatic injury underwent AMY/LIP testing; 5 had elevated values. Forty-eight percent of patients with elevated AMY/LIP levels had no evidence of intraabdominal injury. Seventy-four of 116 (64%) with elevated AMY/LIP levels underwent abdominal and pelvic computed tomography (CT) scanning, yet 38 (51%) of these had completely normal scans. Many patients with elevated AMY/LIP levels (cost, $6 per test) underwent screening CT scans (cost, $592 per test) based on AMY/LIP alone. No patient with elevated AMY/LIP levels but without clinical suspicion was proven to have pancreatic injury. Cost data are presented. CONCLUSIONS: Serum amylase and lipase determinations may support clinical suspicion in the diagnosis of pediatric pancreatic trauma but are not reliable or cost effective as screening tools. Costs incurred from routine serum amylase and lipase or from imaging tests subsequent to elevated serum values may be significant and unjustified.