Tonsillectomy: Useful But Not Without Risk

I’ve been fascinated by the case of Jahi McMath, who is the girl who suffered surgical complications after a tonsillectomy and has been left brain dead. I’ll be discussing other aspects of this case next week but I thought I’d invite fellow medical musketeer and ENT physician, Dr. Richard Mabry, by to discuss the risks/benefits of this procedure.

I happily endorsed Richard’s forthcoming novel Critical Condition. It’s a great story and gives insight into that elusive area of the hospital– the OR. I hope you’ll check it out when it’s released in April.

Welcome back, Richard!

Any resident physician in otolaryngology (ear, nose and throat) can tell you that tonsillectomy is not a benign procedure. It’s very useful when indicated, but strict criteria for its consideration have been developed.  These include recurrent documented infections as well as sleep-disordered breathing. Attention to these criteria is important before tonsillectomy is considered.
Prior to the procedure, parents should feel free to ask questions or seek clarification of any points they don’t understand. Most physicians have instruction sheets that are given to help prepare families for the procedure.
The procedure itself is typically short—30 to 60 minutes—after which the child is observed in the recovery room until they are fully awake and stable. The child may be discharged later that day if they’re doing well, but sometimes complications necessitate an overnight stay.
The risk associated with a general anesthetic administered by competent personnel is tiny. Probably equally or more important is the possibility of complications occurring after the procedure. 
Undoubtedly, the number one risk is post-operative bleeding. If the child expectorates clots or large amounts of bright blood, parents should seek medical attention immediately. They are also warned to watch for and report fever, persistent vomiting, or difficulty breathing.
The tonsils receive their blood supply from branches of five different arteries, so bleeding—at surgery and afterward—can be a problem. To deal with this possibility, various methods—primarily application of caustic chemicals, use of ligatures, or various types of cauterization—have been traditionally been used. In recent years, surgical methods other than sharp dissection have become more popular. These include partial tonsillectomy and use of lasers to remove tonsil tissue. Thus far, the perfect solution hasn’t been found.
What are the risks associated with tonsillectomy? According to a recent journal article, the risk of dying from the operation ranges from 1 in 10,000 to 1 in 35,000 cases. Although mortality (i.e., dying) is rare, morbidity (i.e., complications) still occur. The most important, of course, is bleeding after the surgery. In one study, the incidence of bleeding was reported at from 2% to 3% of cases. The two most common times for post-tonsillectomy bleeding to occur are immediately after the surgery and after about a week, when scabs separate.
Does that mean that all parents should shy away from a tonsillectomy for their child? Not at all. It’s a very beneficial procedure when indicated and performed by a competent physician. But it behooves every parent to ask questions, learn what to watch for, and participate in the care of their child while they recover from the surgery.
Richard Mabry is a retired physician, past Vice President of the American Christian Fiction Writers, and author of “medical suspense with heart.” His novels have been a semifinalist for International Thriller Writers’ debut novel, finalists for the Carol Award and Romantic Times’ Reader’s Choice Award, and winner of the Selah Award. You can follow Richard on his blog, on Twitter, and his Facebook fan page.

Hostages: Episode 8 Analysis 1/3

Seriously, medically speaking, the CBS drama Hostages is becoming that car accident I can’t avert my eyes from. This episode had me doing some serious eye rolling– one of my eyes may have actually rolled away from me at one point. I have since recovered it so don’t worry.

During episode 7– the husband is left alone with the primary hostage taker and his primary goal is to do him in. What remains in the house is the “colorless, non-traceable, fast-acting poison” that was contained in a lipstick holder for Ellen to give the President during surgery.

Hubby finds it, a needle and syringe and draws up the medication. At the end of this episode he manages to put it into his chest and pushes in a little of the medication.

Enter the hero doctor who is now convinced that he must live or all of her family will die.

She asks him, “What is the poison?”

He says, “A rapid-acting paralyzing agent.”

At this point, I’m going to beg the producers of this show to either get a new medical consultant or hire one. Because, whoever is advising them doesn’t know anything about WHY this wouldn’t kill the president during his operation.

Paralyzing agents don’t stop your heart from beating. I’ve blogged here before about the unique characteristics of heart cells. They have their own automaticity. Paralyzing agents work at the neuromuscular juction to stop the muscles from being able to contract. Your heart muscle is different from this system but your diaphragm is not which is the primary muscle used for breathing.

The reason a paralyzing agent will kill you is that it stops the contraction of your diaphragm muscle and therefore you stop breathing. Obviously, if you’re not breathing you’re going to die so to save your life we have to provide rescue breathing and preferably oxygen.

In surgery, especially the type of surgery the president is having which is a lung surgery, he is already going to be intubated and bagged with oxygen to keep him alive. The injection of a paralyzing agent (of which he may already have some on board to get him intubated) would have a net ZERO effect.

You can read more about neuromuscalur blocking agents here

So– it is fiction people and someone in the military wants him gone. You can’t invent an odorless, rapid-acting, undectable poison and give it a cool name?

Part II we’ll continue with the good doctor’s treatment.

Medical Question: Brain Surgery

Today, Amitha concludes her thoughts on surgery with some specifics about brain surgery.

–>>Note: If you’re squeamish stop reading here!<<–

As far as what would exactly happen during the brain surgery, it’s hard for me to say because I don’t really know what kind of surgery your fictional patient is having. But most basically, the surgeon first cuts into the patient’s scalp, exposing the skull. They drill open and remove a portion of the skull, then cut into the dura (a membrane surrounding the brain) to expose the brain. Then the surgery is performed (depends on the type of surgery). At the end of a craniotomy, the skull is reaffixed using screws or other techniques (though in a “craniectomy” it is not replaced).

This website: goes into some specifics about what’s involved during different brain surgeries. Make sure to scroll down to the bottom for some nice images.

Search YouTube for craniotomy:

If you have an idea what specific kind of surgery your fictional surgeon is performing, there’s probably a video of it on YouTube.

But as far as things that would make your story believable, I think this video of an awake craniotomy is excellent. You get views of the room, the equipment they use, the patient, the doctors and others in the room, and the surgery itself.

This video isn’t quite as self-explanatory, but shows a surgery where the patient isn’t awake and where a special microscope is used during the surgery.

When writing, I’d try not to get too bogged down in research and details. You’ll bore yourself and your readers to tears. I’d focus on getting the overview of things right. What people are wearing. What people are doing—rather than specifics of the surgeries.

It’s the simple things that will make your reader question your credibility as an author. For example, knowing that your surgeon will already have her face mask and hair coverings on before she enters the OR and that she’d keep these on the entire time she’s in there is something that anyone who has seen a surgery would notice. Whereas, choosing the wrong type of scalpel, or the wrong kind of anesthesia, would be overlooked by most people.


Amitha Knight is a former pediatric resident turned writer of middle grade and young adult fiction. She’s also a blogger, a book lover, an identical twin, and a mom. Follow her on twitter @amithaknight or check out her website:

Medical Question: Surgical Timeline

I’m pleased to have Amitha Knight back who will be hosting a medical question today and tomorrow about surgeries. Today, she covers the general surgical timeline and what the patient’s process is through the OR. On Friday, she’ll cover more in depth about brain surgeries.

RB asks:

In the book my one lead character, a Brain surgeon, will be performing two major surgeries during the life of the book, one on (an animal), and the other she will be performing a radical operation on the male lead.

Could you, in as short as possible, give me an overview of what happens during such a surgery. The big picture and any suggestions you could give me that would make the scenes believable.

Even if you can point me at a website where I can read up about brain surgery – any videos would help as well, I am not squeamish about blood etc… so don’t worry about that side (more fascinated by the whole process).

Any help would seriously be appreciated.

Amitha says:

While I saw lots of surgeries during my 12-week surgery rotation in medical school, ranging from cholecystectomies (gall bladder removal) to liver transplants to cardiac surgeries to breast implants, I didn’t see any brain surgeries. I especially didn’t see any veterinary surgeries so I can’t comment on that part of your question.

The reason I didn’t see the brain surgeries was that the surgeons wanted you to be there for the entire surgery and brain surgeries can take a long time. For example, I heard of one brain tumor removal taking 6 hours. A quick search of the web reveals people who report their brain surgeries having taken more than 12 hours–not sure if they’re counting recovery time. Performing and assisting surgeries for long periods of time requires stamina, dedication, and patience. Alas, our hospital didn’t have a surgical theatre like on Grey’s Anatomy where people could eat lunch, gossip, and come and go as they please while watching surgeries.

While I haven’t seen a brain surgery, the very basic timeline of surgeries are generally the same:

  • The patient is wheeled into the sterile operating room (OR) and transferred to the operating table. Everyone in the room (besides the patient) is required to wear a face mask, a hair covering of some kind, scrubs, and shoe covers.

  • The anesthesiologist sedates the patient (sometimes this is started in the pre-op area). During some brain surgeries, the patient is kept awake for portions of the surgery (so they can monitor the patient’s brain functions by having the patient do different things during surgery) while in others, the patient is intubated and kept under general anesthesia the entire time.

  • The patient is positioned appropriately for the surgery. Parts of the body that aren’t being operated on are covered up. The patient’s head is shaved (or at the very least the part that they are operating on I should think).

  • Meanwhile the surgical team “scrubs in” (i.e. they go to a separate room attached to the OR to thoroughly clean their hands/arms up to the elbows and then return to the OR where they are helped by surgical technicians and nurses into sterile gowns and gloves, all the while making sure not to touch anything that isn’t sterile). Sterile coverings (which are usually all blue) are draped everywhere so that people who are “scrubbed in” don’t accidentally touch non-sterile things. People who aren’t “scrubbed in” aren’t allowed to touch anything in the sterile field. Keeping things sterile and clean is key.

  • The surgical area is “prepped” (i.e. cleaned).

  • Surgeons and surgical techs do a “time out” and double check the patient’s name and the procedure being done and the area being operated on.

  • The first incision is made.

  • The surgery is performed. Tools are all counted by the surgical tech. (During long surgeries, this may happen several times throughout.)

  • The surgical site is “closed” i.e. stitches are put in, the wound is dressed.

  • The patient is wheeled to the post-operative area (“post-op”).
Have you ever written a scene that involved the operating room?

Amitha Knight is a former pediatric resident turned writer of middle grade and young adult fiction. She’s also a blogger, a book lover, an identical twin, and a mom. Follow her on twitter @amithaknight or check out her website: