What A Fallen Snickerdoodle Taught Me About Ganglionectomies

“Are you really going to eat that?”  

“Of course I am. That’s a damn snickerdoodle, hot out of the oven and it was only on the floor for a few seconds,” I answered my germophobic friend Vinny.

Quickly, I deposited the hot cookie into my mouth, chewing and savoring the cinnamon flavor and the neurointoxicating sugars, while mentally laughing because his question caused me to remember that joke about Jeffrey Dahmer asking Lorena Bobbitt the same question. 

“You can’t be serious, dude,” he responded in a John McEnroe-like tone. 

So it got me to thinking about germs and other things. Why do we think and do things the way we do them? What is it that establishes our paradigms? Is it training or scientific truth? In an ideal world, our training would be updated to incorporate scientific truth but dudes don’t read, and our schools stick with the same old curriculum decade after decade despite new discoveries that are scientifically true. 

Now we all know about the five-second rule. Right? Well if you don’t, then do something other than read this blog because you need to connect to the sanctity of microbiological doctrine.

That damn cookie hitting the floor for less than a couple of seconds had no more potential to hurt me, in fact much less, than the neurotoxicity of the sugar contained in it. That is the beauty of neurotoxins. We take in those that are just subtly toxic by the gallons and pounds year after year to become the fattest nation on the planet. However, add a little dab of ricin and there is no more thinking about it.

It is all about context really. Now if the floor that I picked up the snickerdoodle from had just been covered with chicken juice I recently sloshed from my leaky marinade bag, there would be no chance I would eat the cookie. Context you see. Same floor but now with salmonella-laden goo on it. No dice. Not going do it.

Same thing with the kitchen sink. Dirty little bugger. Something falls in that, dude, and it is not going to get into my boca. Of course, my friend Vinny has no problem pulling out a fat wad of cash to give the waitress a generous tip and then sticking his dinerofied digits into his mouth. (According to Myth Busters — and who can doubt them? — paper money contains far more germs on it than my clean kitchen floor or, for that matter, the dry toilet seat.)

Now that we have gone through all that, what is the point here? Context and belief. Take ganglionectomies for example. How has everyone in the world who surgically takes these out been trained? They were trained to try to keep the ganglions intact and find the stalk. Most of the time, the ganglions would burst, even with the most meticulous and careful dissection. Yes, sir. That is the way to do it.

Really? About a year ago, I popped the sac just as I had gotten through the patient’s dermis and had canned ham jelly all over the place. After a couple of expletives (that is why I like general anesthesia), I grabbed the shriveled sac. Guess what? I was able to easily dissect it away from all the remaining normal tissues and right down to the sacred stalk. Less dissection. Faster. There was much less chance of a small nerve injury and it was very easy to find the origin of the beast.

So now, for more than one year, guess what my new technique is for ganglions? Get through the dermis, identify the most superficial aspect of the cyst and then just pop that sucker with abandon. You can choose what instrument of destruction you like. I like my little Stevens tenotomy scissors. Squeeze the jelly out and begin the dissection. Oh, you will be surprised how much easier this is and how quickly and reliably you will be able to find the origin of the little devil. Tie it off, send the sac to your favorite pathologist and whammo, you are done. You likely did a better job and did not have to suffer the ignominy of all the OR staff exhaling “Oh!” in unscripted unison when you pop the ganglion. You also saved some very valuable OR time and, in the future with declining reimbursements, that is meaningful.

Better outcome, less time. Hey, that could be a good tagline for a new neurotoxicant. Only things to add: fewer calories and fat free.

I have two quick shout-outs.

1. Read the book Sugar Crush by Rick Jacoby, DPM. It is a good book that will help you and your patients.
2. Go to the Association of Extremity Nerve Surgeons (AENS) Annual Meeting this November in Denver. This meeting will change your life and your practice, and the chances of hearing the word “osteotomy” are less than one in 1,000 at this great conclave. Visit  www.AENS.us .

Disclaimer: I am the current president of AENS but have no financial interest in getting you to the meeting. If it really does change your practice and life, I will accept random donations sent in unmarked bills.