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 Jacob O. Levitt
Joseph F. Sobanko
Editors

Safety in Office-Based
Dermatologic Surgery

123
Safety in Office-Based Dermatologic Surgery
Jacob O. Levitt • Joseph F. Sobanko
Editors

Safety in Office-Based
Dermatologic Surgery
Editors
Jacob O. Levitt, MD, FAAD Joseph F. Sobanko, MD, FAAD
The Icahn School of Medicine at Mount Sinai University of Pennsylvania
New York Philadelphia, PA
USA USA

ISBN 978-3-319-13346-1 ISBN 978-3-319-13347-8 (eBook)

DOI 10.1007/978-3-319-13347-8
Springer Cham Heidelberg New York Dordrecht London

Library of Congress Control Number: 2015931091

© Springer International Publishing Switzerland 2015

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this
legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically
for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work.
Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
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While the advice and information in this book are believed to be true and accurate at the date of publication, neither
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Printed on acid-free paper

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To my patients, who have patience with my students. To my students, who
cannot grow without my patients. To my mentor, Dr. Mark Lebwohl, who
continues to guide my own growth as a dermatologist. And, of course, to my
mother, the beauty queen, my father, the genius, and my sister, the beautiful
genius.
–Jacob O. Levitt, MD, FAAD
To my family (especially my “moms”), whose love and continued support
strengthen me in all aspects of life. To my patients, for the fulfillment they
provide in allowing me to help in their care. And to all my mentors and
trainees, who inspire and motivate me to continually improve – “call the crib,
same number same hood, it’s still all good.”
–Joseph F. Sobanko, MD, FAAD
About the Authors

Dr. Levitt is Vice Chairman, Residency Director, and Associate Professor of Dermatology at
the Icahn School of Medicine at Mount Sinai. Dr. Levitt has created a website (http://bit.ly/
dermedu) for dermatology education that contains videos on how to perform many of the pro-
cedures discussed in this book. He has produced a New England Journal of Medicine Video in
Clinical Medicine [1] on how to perform a punch biopsy. He has also authored articles on the
instruction of venipuncture [2] and a survey of safety during dermatologic procedures per-
formed by residents [3].
Dr. Sobanko is Assistant Professor of Dermatology and Director of Dermatologic Surgery
Education at the Hospital of the University of Pennsylvania. His practice focuses on cutaneous
oncology and complex reconstruction. Dr. Sobanko is the senior author of a two-part continu-
ing medical education article in the Journal of the American Academy of Dermatology
on surgical techniques [4, 5].
Drs. Levitt and Sobanko bring over 15 years’ combined experience in training residents and
medical students to this book. They developed a surgical safety focus session at the American
Academy of Dermatology (AAD) annual meetings, in which many of the key points in this
book were introduced. The session has become a fixed part of the AAD meeting curriculum.

References
1. Levitt J, Bernardo S, Whang T. Videos in clinical medicine. How to perform a punch biopsy of the skin. N
Engl J Med. 2013;369(11):e13.
2. Pan M, Harcharik S, Luber A, Bernardo S, Moskalenko M, Levitt J. Instructional video for teaching veni-
puncture. Clin Teach. 2014;11(6):436–41.
3. Goulart JM, Oliveria SA, Levitt J. Safety during dermatologic procedures and surgeries: a survey of resident
injuries and prevention strategies. J Am Acad Dermatol. 2011;65(3):648–50.
4. Miller CJ, Antunes M, Sobanko JF. Surgical technique for optimal outcomes. Part I. Cutting tissue: incising,
excising, & undermining. J Am Acad Dermatol (in press).
5. Miller CJ, Antunes M, Sobanko JF. Surgical technique for optimal outcomes. Part II. Repairing tissue: sutur-
ing. J Am Acad Dermatol (in press).

vii
Preface

We frequently observed that unfamiliarity with procedures increases the likelihood of

occupational exposures. Learning to perform a procedure correctly early in training will rein-
force safe habits moving forward. We observed many ways that injuries occur with office-
based procedures and have evolved our techniques on the basis of these observations in order
to prevent injury. Rather than struggle through trial and error through numerous potentially
unsafe techniques, we have composed this textbook to propose safer methods for many
office-based procedures
This textbook is intended for use by any healthcare provider who participates in office-
based procedures, such as injections, biopsies, excisions, and laser surgery. Common unsafe
practices in office-based surgery are highlighted in this textbook. Chapters are divided into
individual procedures for easy referencing by students, trainees, as well as seasoned practitio-
ners. Figures attempt to illustrate how seemingly innocuous actions and procedures can result
in dangerous exposures to healthcare workers. Hazardous scenarios are presented as
“Accidents,” which are followed by one or a series of safer “Solutions”. To prevent confusion,
we avoided including the accident and solution in the same photo. Injuries are indicated with
a red star (“the boom-pow”).
We elected to use nonhuman substrates for many of our photos to provide the clearest depic-
tion of our points and did our best not to compromise realism. Where appropriate, we used live
patients. The emphasis of the book is on accidents that harm the provider while performing a
procedure; however, we highlight some situations that can harm the patient. When pertinent,
we describe proper procedural techniques to maximize practitioner safety. It is our belief that
raising awareness of unsafe techniques in office-based surgery may allow for improvement in
surgical safety and reduction in occupational exposures.
While we have attempted to be comprehensive in our description of “Accidents” and
“Solutions,” it is possible that you implement safe “Solutions” not found here. We encourage
you to share this information with those that work with you in order to promote a culture of
safety. We also encourage you to analyze the situation surrounding any personal injuries asso-
ciated with procedures to identify the reason why it happened and to modify circumstances and
techniques to prevent its recurrence. We welcome your thoughts and suggestions via email and
hope you enjoy the book!

NY, USA Jacob O. Levitt, MD, FAAD

PA, USA Joseph F. Sobanko, MD, FAAD

ix
Acknowledgments

We wish to thank Aurélie Graillot (www.aureliegraillot.com) for her artful photo editing,
which has contributed greatly to the clarity of the photography.

xi
Contents

1 Occupational Exposures: Epidemiology and Protocols . . . . . . . . . . . . . . . . . . . . 1

Joseph F. Sobanko
2 The Surgical Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Joseph F. Sobanko
3 Working with a Surgical Assistant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Justin J. Leitenberger
4 Injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Jacob O. Levitt
5 Shave Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Jacob O. Levitt
6 Punch Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Jacob O. Levitt
7 Excision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Joseph F. Sobanko
8 Hemostasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Joseph F. Sobanko
9 Suturing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Joseph F. Sobanko
10 Venipuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Jacob O. Levitt and Lauren L. Levy
11 Curettage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Jacob O. Levitt
12 Cryotherapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Lauren L. Levy and Jacob O. Levitt
13 Incision and Drainage (Abscesses, Acne, and Milia) . . . . . . . . . . . . . . . . . . . . . . 119
Mark E. Burnett and Jacob O. Levitt
14 Paring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Mark E. Burnett and Jacob O. Levitt
15 Nail Clipping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Lauren L. Levy and Jacob O. Levitt
16 Earlobe Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Joseph F. Sobanko

xiii
xiv Contents

17 Laser Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

Vasanop Vachiramon and Joseph F. Sobanko
18 Personal Protective Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Vasanop Vachiramon and Joseph F. Sobanko
19 General Safety Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Jacob O. Levitt and Joseph F. Sobanko

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Contributors

Mark E. Burnett, MD Department of Dermatology, New York-Presbyterian Hospital/

Weill-Cornell Medical College, New York, NY, USA
Justin J. Leitenberger, MD Department of Dermatology, Oregon Health and Science
University, Portland, OR, USA
Jacob O. Levitt, MD, FAAD Department of Dermatology, The Icahn School of Medicine
at Mount Sinai, New York, NY, USA
Lauren L. Levy, MD Department of Dermatology, Yale University, New Haven, CT, USA
Joseph F. Sobanko, MD, FAAD Department of Dermatology, Perelman School of Medicine
at the University of Pennsylvania, Philadelphia, PA, USA
Vasanop Vachiramon, MD Division of Dermatology, Ramathibodi Hospital,
Mahidol University, Bangkok, Thailand

xv
 Occupational Exposures:
Epidemiology and Protocols
Joseph F. Sobanko
Why Is This Information Important?
• Up to 800,000 needle sticks occur to healthcare workers
in the United States each year [1].
• The healthcare workers most susceptible to blood expo-
sure injuries are physicians-intraining (residents), nurses,
and medical students [2].
– Lack of training, fatigue and the sense of being rushed
are frequently reported explanations by physician
trainees for being stuck while suturing [3].
• One of every ten US health care workers has a needle
stick exposure each year [4].
• HIV, Hepatitis B and C are the pathogens most likely to
be transmitted via an occupational exposure.
• Percutaneous injury is the most efficient mechanism of
transmission of occupational blood-borne infections
(HIV, HCV, HBV).
• A person receiving a needle stick with known-HIV con-
taminated blood has a 0.3–5 % of acquiring the virus [5].
The risk of acquiring HIV through unprotected sexual
intercourse is 0.3–3.0 % [5].
• The risks of acquiring HBV or HCV through a needle
stick are 5–35 and 3–10 %, respectively [6].
• 40–50 % of suture needle sticks occur while suturing [7, 8].
• 2/3 of suture needle sticks are self-inflicted [8].
• Outpatient procedures most prone to result in an exposure
are injection, suturing, and excision [9, 10].
J.F. Sobanko, MD, FAAD
Department of Dermatology,
Perelman School of Medicine at the
University of Pennsylvania, Philadelphia, PA, USA
e-mail: joseph.sobanko@gmail.com
J.O. Levitt, J.F. Sobanko (eds.), Safety in Office-Based Dermatologic Surgery,
DOI 10.1007/978-3-319-13347-8_1, © Springer International Publishing Switzerland 2015
1
Can Exposures Be Avoided Completely?
• Despite the best attempts at prevention, occupational
exposures in the form of needle sticks and splashes do
occur.
• It is essential to be familiar with your office/institution’s
individual protocol for reporting such incidents. If you are
unfamiliar with the protocol, you must immediately report
the incident to your supervisor in the event of an
exposure.
• Most occupational exposures go unreported – PLEASE
REPORT YOUR INJURY.
• The action taken after an occupational exposure will often
depend on the exposure risk (Table 1.1).
Table 1.1 Features of a “high-risk” occupational exposure [11]
Exposure to a larger quantity of blood or other infectious fluid
Prolonged or extensive exposure of non-intact skin or mucous
membrane to blood or other infectious fluid or concentrated virus in
a laboratory setting
Exposure to the blood of a patient in an advanced disease stage or
with a high viral load
A deep percutaneous injury
An injury with a hollow-bore, blood-filled needle
1
2 J.F. Sobanko
What Do I Do in the Event of an Occupational
Exposure (Fig. 1.1)?
• Any employee who receives a stick during a surgical
procedure should step out of the field and avoid fur-
ther contact with the patient to prevent potential trans-
fer of blood-borne pathogen from healthcare worker to
patient.
• Dispose of the instrument that has punctured the skin
(i.e., suture needle, syringe) rather than reintroducing it to
the patient.
• Those with a needle stick should wash the affected area
thoroughly with soap and water as quickly as possible
after the exposure [13].
– It is not necessary to use alcohol or other caustic agents
such as bleach to clean the affected area.
– The practice to “milk out” more blood is controversial
and not recommended by the Centers for Disease
Control (CDC).
• Irrigate splashes to the eyes or mouth with water or saline
as quickly as possible after the exposure. Do not use caus-
tic agents such as antiseptics or disinfectants.
• Report the exposure immediately [12].
Dispose of Wash the
Step out of Report the
the affected
the field incident
instrument area
Fig. 1.1 Four simple steps to follow in the event of an occupational
exposure [12]
How Do I Report the Incident (Table 1.2)?
• If the source patient is known then the patient should be
tested for HIV/HBV/HCV (pending informed consent).
– The CDC recommends that if the source patient cannot
be tested then the medical diagnoses, clinical symp-
toms, and history of risky behaviors should contribute
to the decision regarding post-exposure prophylaxis
(PEP) [12].
• When the source patient is not known then the likelihood
of high risk exposure must be evaluated and used to guide
further action (i.e., community infection rate, demograph-
ics of patients seen at site, etc.).
– It is not recommended to test the discarded needles for
bloodborne pathogens since the reliability of testing is
unknown.
• Baseline testing of healthcare practitioners should be per-
formed for all occupational exposures.
– Those exposed to HIV should receive repeat HIV-
antibody testing at 6, 12, and 24 weeks following
exposure [14].
– Those exposed to HCV should have repeat tests for
anti-HCV IgG and liver enzyme (ALT) at least
4–6 months after exposure.
Table 1.2 Necessary information when reporting an occupational
exposure
Details of the incident (type of bodily substance involved, the route
of exposure, the severity of exposure, time exposure occurred, etc.)
Details of the exposure source, if known (e.g., source material or
patient HIV/HBV/HCV positivity)
Details of the exposed healthcare provider’s history (e.g.,
vaccination status, pregnancy status, medical conditions, etc.)
1 Occupational Exposures: Epidemiology and Protocols
Should I Take Post-Exposure
Prophylaxis (PEP)?
• HIV
– The recommendation to initiate antiretroviral prophy-
laxis is determined by the factors noted above, in addi-
tion to balancing the risk of HIV with the known risks
of PEP medications [15].
– PEP rapidly loses its effectiveness if delayed. The goal
should be to swallow the first pill within the first
24–36 h after exposure. Some reports note that if it is
started more than 72 h after exposure then it is not
effective [16].
– PEP regimens continued for less than 4 weeks are also
considered less effective [5].
– The specific medication regimen will vary according
to each institution. Two-drug regimens appear appro-
priate for low-risk exposures while three-drug regi-
mens may be recommended for higher-risk exposures.
These regimens change as new medications become
available and as local resistance patterns change. Keep
abreast of what the current recommendations are from
Infection Control departments in the health care set-
tings in which you work.
– Baseline laboratory studies should be performed (e.g.,
CBC, CMP, HIV test, Hep C ELISA, Hep B sAg, Hep
B sAb) if PEP is initiated.
– Nausea and fatigue are the most commonly reported
side effects of PEP medications. These symptoms may
be relieved with promethazine and loperamide.
– If the source patient’s HIV test is determined to be
negative then PEP may be discontinued. Although
HIV testing can be negative while a person is in the
“window period” between infection and the presence
of detectable antibodies against HIV, no case of trans-
mission involving an exposure source during the win-
dow period has been reported in the United States.
– If a source is known or subsequently determined to be
HIV-positive, it is not necessary to perform medication-
resistance testing to guide the PEP medication regimen.
The most important means of ensuring effective
PEP is rapid initiation of the medications.
• HBV
– Most US healthcare workers have been immunized
with the hepatitis B vaccine and, based on vaccine effi-
cacy data, almost all are protected [17].
3
• HCV
– Currently, there are no standard recommendations for
HCV PEP.
– The CDC recommends that exposed healthcare profes-
sionals receive appropriate counseling, testing, and
follow up.
– For seroconverters, pegylated interferon may be effec-
tive if started soon after HCV seroconversion or detec-
tion of an HCV viral load [18].
– Consultation with a hepatologist and infectious dis-
ease specialist is advised.
Where Can I Receive Additional
Counseling?
• Those exposed to blood-borne pathogens should commu-
nicate feelings of stress and anxiety to the appropriate
supervisors. The regulatory body that administers advice
regarding post-exposure management should also be able
to provide healthcare workers mental counseling.
• Additional resources (as of 2014) regarding post-exposure
management and counseling are listed below:
– Centers for Disease Control and Prevention (CDC):
1-800-893-0485
– National Clinicians’ Postexposure Prophylaxis Hotline
(PEPline): 1-888-448-4911 or www.ucsf.edu/hivcntr/
Hotlines/PEPline.html
– Needlestick!: www.needlestick.mednet.ucla.edu
– Hepatitis Hotline: 1-888-443-7232 or www.cdc.gov/
hepatitis
– National HIV Telephone Consultation Service:
1-800-933-3413
Immediate Steps If Exposed
• Dispose of instrument
• Wash site with soap and water // irrigate with saline
• Report incident
• Test source patient (with informed consent)
– Counseling with expert if source patient is unknown
• Baseline testing of exposed person
• First HIV PEP within 36 h (if applicable)
4 J.F. Sobanko
References
1. National Institute for Occupational Safety and Health. Preventing
Needlestick Injuries in Health Care Settings. (Publication no. 2000-
108). 1999. http://www.cdc.gov/niosh/docs/2000-108/.
2. Bakaeen F, Awad S, Albo D, Bellows CF, Huh J, Kistner C,
Izard D, Triebel J, Khan M, Berger DH. Epidemiology of expo-
sure to blood borne pathogens on a surgical service. Am J Surg.
2006;192:e18–21.
3. Makary MA, Al-Attar A, Holzmueller CG, et al. Needlestick inju-
ries among surgeons in training. N Engl J Med. 2007;356(26):
2693–9.
4. Panlilio AL, Orelien JG, Srivastava PU, Jagger J, Cohn RD, Cardo
DM, NaSH Surveillance Group; EPINet Data Sharing Network.
Estimate of the annual number of percutaneous injuries among
hospital-based healthcare workers in the United States, 1997-1998.
Infect Control Hosp Epidemiol. 2004;25(7):556–62.
5. Tolle MA, Schwarzwald HL. Postexposure prophylaxis against
human immunodeficiency virus. Am Fam Physician. 2010;82(2):
161–6.
6. Doebbeling BN. Percutaneous injury: risks and management. In:
Schlossberg D, editor. Current therapy of infectious disease. St.
Louis: Mosby-Year Book; 2000. p. 402–7.
7. Premier, Prevent Needlestick injuries. https://legacy.premierinc.
com/quality-safety/tools-services/safety/topics/needlestick/
non-acute-care.jsp. Accessed 20 Dec 2014.
8. Jagger J, Balon M. Suture needle and scalpel blade injuries. Adv
Expo Prev. 1995;1(3):6–9.
9. Donnelly AF, Chang YH, Nemeth-Ochoa SA. Sharps injuries
and reporting practices of U.S. dermatologists. Dermatol Surg.
2013;39(12):1813–21.
10. Goulart JM, Oliveria SA, Levitt J. Safety during dermatologic pro-
cedures and surgeries: a survey of resident injuries and prevention
strategies. J Am Acad Dermatol. 2011;65(3):648–50.
11. Cardo DM, Culver DH, Ciesielski CA. A case-control study
of HIV seroconversion in health care workers after percuta-
neous exposure. Centers for Disease Control and Prevention
Needlestick Surveillance Group. N Engl J Med. 1997;337(21):
1485–90.
12. CDC. Updated CDC recommendations for the management of hep-
atitis B virus-infected health-care providers and students. MMWR
Recomm Rep. 2012;61(RR-3):1–12.
13. Henderson DK. Management of needlestick injuries: a house office
who has a needlestick. JAMA. 2012;307(1):75–84.
14. CDC. Introduction to Travel Health & the Yellow Book. Website.
http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-2-the-pre-
travel-consultation/occupational-exposure-to-hiv.htm. Accessed 24
Nov 2012.
15. Henderson DK. HIV in the healthcare setting. In: Mandell GL,
Bennett JE, Dolin R, editors. Principles and practice of infectious
diseases. 7th ed. New York: Elsevier Churchill Livingstone; 2009.
p. 3753–70.
16. CDC. Updated U.S. Public Health Service guidelines for the
management of occupational exposures to HIV and recommen-
dations for postexposure prophylaxis. MMWR Recomm Rep.
2005;54(RR09):1–17.
17. Beekmann SE, Henderson DK. Health care workers and hepatitis:
risk for infection and management of exposures. Infect Dis Clin
Pract. 1992;1(6):424–8.
18. Jaeckel E, Cornberg M, Wedemeyer H, et al.; German Acute
Hepatitis C Therapy Group. Treatment of acute hepatitis C with
interferon alfa-2b. N Engl J Med. 2001;345(20):1452–7.
 The Surgical Tray
2
Joseph F. Sobanko

Accidents Happen When

Common Safety Pitfalls When Setting
The wrong equipment is placed on the tray. The surgeon may
Up a Tray
be tempted to use instruments that are not appropriate for a
procedure.
Accidents Happen When
Unstable or inappropriate trays are used, such as those with
a broken leg or an improperly secured tray. Solution 1
Place the correct instruments on the tray. Assistants should know
which instruments go with each procedure. Photo examples may
Solution
be placed in locations where trays are assembled (Fig. 2.1).
Test the stability of the surgical tray prior to its use.

a b

Fig. 2.1 Photos of tray setups for common office-based procedures. (Stock bottle and punch trephine wrapper are shown for clarity but should not
actually be on the tray). (a) Shave removal. (b) Punch biopsy. (c) Excision

J.F. Sobanko, MD, FAAD

Department of Dermatology, Perelman School of Medicine at the
University of Pennsylvania, Philadelphia, PA, USA
e-mail: joseph.sobanko@gmail.com

J.O. Levitt, J.F. Sobanko (eds.), Safety in Office-Based Dermatologic Surgery, 5

DOI 10.1007/978-3-319-13347-8_2, © Springer International Publishing Switzerland 2015
6 J.F. Sobanko

Solution
c
Verify the sterility of all instruments being used (Fig. 2.2).

Fig. 2.1 (continued)

Fig. 2.2 Instruments should be sterilized before use. Blackening of the

box on the indicator strip signifies sterility
Solution 2
Anticipate special needs of the surgery that call for instru-
ments not routinely placed on the tray (e.g., chalazion clamp
for a lip procedure). Have these available on the tray before Accidents Happen When
starting the procedure. Instruments are removed carelessly from packaging. If a
sharp instrument (e.g., toothed forceps or skin hook) is
Solution 3 removed by tearing through the autoclaved pouch, the tips
Have pre-arranged packages that contain all of the instru- can puncture the skin (Fig. 2.3). Additionally, instruments
ments necessary to perform a particular procedure (i.e., can fall from the tray and puncture the foot.
‘punch biopsy bag’). An identifying label can be placed on
the outside of this package to assist with accuracy.

Solution 4
If a surgeon only performs a limited range of procedures,
having one generic tray will help with consistency and avoid
the confusion of setting up several specialized trays.

Solution 5
Instruments should be catalogued properly when being
stored. Individual sterile surgical instruments should be
placed in designated bins.

Accidents Happen When

The surgical tray is too far from the surgical field.

Solution Fig. 2.3 Puncture injury due to opening sharp instrument (here, a skin
Position the tray within arms’ reach between the surgeon and hook) through a pouch
assistant.

Accidents Happen When Solution

When non-sterile instruments are unknowingly placed on a Peel the plastic envelopes open like a banana so that the
surgical tray. instrument can be gently dropped onto the tray.
2 The Surgical Tray 7

Accidents Happen When Common Safety Pitfalls

Trays are not set up consistently, especially when instru-
ments are placed haphazardly on the tray.
Solution 1
Be consistent and organized in tray setup. All instruments
should to be clearly visualized, easily retrieved, and placed
safely back to their designated area. Consistency is important
so that the team comes to recognize where sharps are kept.
Solution 2
Orient all instruments in a horizontal line with the sharp por-
tion of the instrument facing away from the surgeon.
Solution 3
Place plastic organizing bins on the tray so that each instru-
ment can lie neatly in its own respective column.
of the Intraoperative Tray
Accidents Happen When
Reaching for an instrument in a messy tray. During a long or
bloody procedure, gauze pads, suture packets, and other
items obscure sharp instruments.
Solution 1
Maintain a neat tray. Dispose of all materials (i.e., sharps,
bloody gauze, and empty suture packets) that are not being
used in their appropriate receptacle in real-time.
Solution 2
Designate a section of the tray for soiled materials, keeping
the sharps in clear view.
Accidents Happen When
Suture needles are not stabilized on the tray. Loose suture
needles can unknowingly ‘hitchhike’ on another instrument.

Solution
Suture needles can be secured by inserting them with a nee-
dle driver on an object that is readily visible and that will not
be unintentionally grasped (i.e., Telfa®, Styrofoam sponge,
suture needle counter box, or magnet) (Fig. 2.4). The sponge

a b

c d

Fig. 2.4 Sharps are secured to a safe, visible object. (a) Telfa. (b) Styrofoam sponge. (c) Suture needle counter box. (d) Magnet
8 J.F. Sobanko

can be glued to the tray (Fig. 2.4b). The box provides easy
suture count and allows sutures to be organized by their cali-
ber (e.g., 4-0 suture is placed in the #4 slot, 5-0 suture is
placed in the #5 slot) (Fig. 2.4c).
Accidents Happen When
Live needles of a syringe or blades are placed unsecured or
unprotected on the tray.
Solution 1
Be aware of the device’s safety mechanism. If the mecha-
nism is reversible, activate it before setting it down on the
tray (Fig. 2.5). If it cannot be deactivated (e.g., accordion
device) then dispose of the needle and obtain a new one.

a b

Fig. 2.5 Sheath safety mechanisms protect the sharps on the tray. (a) Syringe needle. (b) Scalpel

Solution 2 ments on the surgical tray. When possible, position the

These instruments can be secured in the plastic containers surgical tray between assistant and surgeon.
noted above.
Solution 2
Accidents Happen When Create a neutral zone whereby an instrument is placed
Instruments are passed between surgeon and assistant. down on a secure mat before another member of the team
picks it up.
Solution 1
Do Not Pass Instruments! The surgical team should be posi-
tioned so that both surgeon and assistant can reach for instru-
2 The Surgical Tray 9

Common Safety Pitfalls When Cleaning Accidents Happen When

Up a Tray A standard protocol for the person who disposes of sharps is
not formalized.

Accidents Happen When Solution

A tray is not kept orderly during a surgical procedure and Responsibility of sharps removal from the tray should fall on
sharps become hidden under gauze pads or other objects, a pre-specified person (i.e., surgeon or assistant). Safety is
leading to sticks (Fig. 2.6). enhanced when the tray is neatly organized prior to cleanup
and all parties are aware of their responsibilities.

Accidents Happen When

The scalpel blade is removed from the blade holder with bare
hands (Fig. 2.8).

Fig. 2.6 Inappropriately using fingers for tray cleanup

Solution 1
The neater the tray during the procedure, the more unevent-
ful the cleanup.
Fig. 2.8 Unsafely removing blade with hands from scalpel handle
results in a laceration
Solution 2
Use a forceps or hemostat to sift through the tray to identify
all sharps (Fig. 2.7). Grab needles with forceps or a hemostat
(not a needle driver, to preserve jaw fidelity) and dispose of
them without touching the sharp with your fingers.

Fig. 2.7 Proper tray cleanup safely sifting with forceps

10 J.F. Sobanko

Solution 1
Use a blade remover (Fig. 2.9).

a b

c d

Fig. 2.9 Blade remover device. (a) Position blade between jaws of device. (b) Close jaws. (c) Gently twist. (d) Remove blade from handle, dem-
onstrated by the arrow. Resistance may be encountered at this stage

Solution 2
Use a hemostat to remove the blade (Fig. 2.10).

a b

Fig. 2.10 Removing a blade with hemostat. (a) Grip base of blade on scalpel holder with small displacement of the wrist, without moving
the belly side (inset shows position). (b) Pull base of blade 90° away elbows, keeping fingers connected (highlighted by wooden stick and
from scalpel holder (inset demonstrates the position). (c) Slide blade off double-headed arrows in b vs. c)
2 The Surgical Tray 11

c Solution 2
Multiple sharps containers hanging from the wall of a proce-
dure room (i.e., one near the door, one near the bed) limit the
distance to travel for sharps disposal.

Accidents Happen When

Disposing of sharps in overfilled disposal boxes. Avoid the
temptation to force a sharp into the overflowing container.

Solution 1
Sharps containers must be emptied by the appropriate parties
well before they reach capacity.

Fig. 2.10 (continued) Solution 2

If a sharps container is at capacity, sharps must be disposed
of in a sufficiently empty container, even if it requires leav-
Accidents Happen When ing the room to do so (a non-ideal situation).
Sharps disposal boxes are not placed close to the surgical
area. Recapping of instruments and needle sticks are more
likely if sharps disposal boxes are not placed in conveniently Reference
located areas of a procedure room [1].
1. Makofsky D, Cone JE. Installing needle disposal boxes closer to the
bedside reduces needle-recapping rates in hospital units. Infect
Solution 1
Control Hosp Epidemiol. 1993;14(3):140–4.
Place sharps containers adjacent to the surgical field. The
surgeon or assistant should not need to walk across the room
for sharps disposal.
 Working with a Surgical Assistant
Justin J. Leitenberger
Accidents Happen When
The surgeon and assistants do not have a predetermined strat-
egy to address intraoperative movements and communication.
Solution
Prior to beginning any procedure, the surgeon should address
what is expected of the assistant. This is particularly impor-
tant for transient assistants (e.g., medical student on a 1-week
rotation). It should be specified whether verbal or nonverbal
intraoperative communication is preferred. If unsure, assis-
tants should seek clarification of what tasks will be expected
of them. Surgeons should actively direct their assistants.
Accidents Happen When
Novice assistants are thrust into a procedure without orienta-
tion (especially salient for academic centers with high turn-
over of rotators and trainees).
Solution 1
Clearly define the role of the assistant and assess his/her
comfort level with assisting prior to entering the room.
Solution 2
Provide written instructions on surgical-assisting prefer-
ences (i.e., how to cut sutures, appropriate amount of small
talk with patients, and sterile technique).
Solution 3
Encourage cross-training of surgical staff to perform multi-
ple tasks within the surgical unit. If a staff-member is unable
to come to work, another employee will have been trained to
step-in and assist.
J.J. Leitenberger, MD
Department of Dermatology, Oregon Health and Science
University, Portland, OR, USA
e-mail: leitenbe@ohsu.edu
J.O. Levitt, J.F. Sobanko (eds.), Safety in Office-Based Dermatologic Surgery,
DOI 10.1007/978-3-319-13347-8_3, © Springer International Publishing Switzerland 2015
3
Accidents Happen When
Frustrations and tensions mount between the surgeon and the
assistant due to poor communication, inability to anticipate
the surgeon’s needs, or the level of difficulty of the proce-
dure. This dynamic shifts the focus away from the procedure
and introduces the risk of sharps injury.
Solution 1
The surgeon should take a mental ‘time-out’ to reassess and
evaluate how to communicate his needs to the assistant
calmly.
Solution 2
Give feedback after a procedure where an assistant per-
formed inadequately. Always try to highlight positive feed-
back around a negative criticism. The surgeon should seek
feedback from the assistant as well.
Solution 3
Be discrete. Whenever possible, do not give feedback in
front of a patient to avoid shaking the patient’s confidence in
the healthcare team.
Accidents Happen When
The surgeon’s and assistant’s hands are in the field simulta-
neously without prior explicit direction by the surgeon. With
both persons’ hands in the field, any instrument being held
can injure the other’s hands by its unexpected presence. For
example, a surgeon ties a knot while the assistant prema-
turely attempts to cut the knot. The assistant may stab the
surgeon with scissors, and the surgeon may stab the assistant
with a live needle, forceps, or skin hook.
Solution
The assistant must: (a) wait for direction, or (b) ask permis-
sion from the surgeon prior to entering the field. This direc-
tion may be verbal or nonverbal.
13
14
Accidents Happen When
The surgical assistant performs tasks without adequate visu-
alization of the surgical field (e.g., blotting or retracting
blindly).
Solution
Surgical assistants should reposition themselves, the patient,
or the surgical tray so they can visualize the surgical field.
This can be accomplished by standing on a foot stool across
from the surgeon or often by standing next to the surgeon.
Accidents Happen When
More than one person is handling a sharp instrument or needle.
Solution 1
Establish a hands-free instrument and sharps transfer rule.
The surgical tray should be used as a neutral zone.
Solution 2
While not advised, if a hand to hand instrument transfer
becomes unavoidable, ensure that it is done safely. The per-
son initiating the sharp item transfer should engage any
safety mechanism (if available), pause, then hold the item
out in clear view over a neutral space away from the patient.
Once eye contact is made with the receiving person, the item
may then be presented with ample room to grasp it safely.
J.J. Leitenberger
Accidents Happen When
Multiple assistants are gloved and participating in a surgical
field. A crowded field can result in miscommunication and
possible needle sticks.
Solution
Minimize the number of participants to only those necessary.
If multiple rotators are competing for surgical experience
then consider alternating cases.
Accidents Happen When
An assistant or patient talks too much. Distractions can
quickly lead to avoidable sharps injury.
Solution 1
Keep small talk to a minimum. Politely ask for silence.
Solution 2
A helpful assistant can minimize small talk by answering
questions and not asking open-ended questions of the patient
in return.
Solution 3
Ask about patients’ music preferences and play their favorite
radio station at a non-distracting volume. While video may
benefit the patient, it can possibly distract the surgical team.
Another random document with
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 Habits which concern Others.

Not only for our own sakes, but on account of all with whom we
associate, it is our duty to take great care of our habits. The general
principle which should lead us to do this is, that we cannot live for
ourselves alone. We must think of others; we must speak and act
with them in our minds. And we are bound to form such habits as
shall tend to their good—to make us useful in the world. We must, in
a word, deny ourselves. If, while we are children, we take pleasure in
giving a part of what we enjoy, be it only a bunch of flowers, or an
apple, to one of our school-mates, we shall thus prepare ourselves
to make others good and happy, when we come to manhood. But a
selfish habit will be very hard to change hereafter.
We should form the habit of associating with good persons. A lad
may have many pleasant things about him; he may be witty, or bold,
or smart; but, if he is coarse in his manners—if he is vulgar, profane,
or addicted to falsehood, we should shun his company. We are apt
to become like those with whom we freely associate; and although
we do not mean to imitate their faults, and do not think there is any
danger of it, yet we may soon fall into the same bad habits. To be
safe, therefore, we should never trust ourselves unnecessarily with
any but good people.
You may think it will be easy to break away from the company and
acquaintance of a boy, when you find him to be very bad; but it will
not be so. Many have been ruined for life by the friendships they
have formed with vicious children, while at school with them. They
continued to associate with them, and caught their vices in youth,
and even up to manhood. If we wish to do good in the world, we
must be good; and we cannot be good, if we are very intimate with
bad persons.
 It is our duty habitually to speak well of others. We are
accustomed to do the opposite of this—to say all the bad things of
others which we think the truth will allow. This is wrong. A little boy
once said to his mother—“When will these ladies be gone, so that
we can talk about them?” And what was to be said about those
ladies? Probably the family were in the habit of speaking of the faults
of their visiters. If there was anything that could be ridiculed in their
dress or their remarks, then was the time to discuss it.
Now, we all know the power of habit; and if we could only learn to
think what good things we could say of others, and keep all that was
bad to ourselves, what an immense improvement there would be
among school-children, and in the whole world! It is our duty to love
all men; let us, therefore, try to speak well of every one, and we shall
soon love them. If we talk much against them, we cannot love them.
We should practise punctuality, for the sake of others, as well as
ourselves. He who is punctual, will accomplish far more in a day,
than he who is not so. Washington was remarkable for this virtue. He
once rode into Boston without any escort, because the soldiers were
not punctual to meet him on the line, at the time they promised. His
mother taught him, when a boy, to have certain hours for every
employment, and to do everything at the appointed time. This habit
helped, in his after life, to make him a good man. He was able to do
what, without it, he never could have done.
We injure others by a neglect of punctuality. A girl says to herself
—“It is a little too cold, or a little too warm, to go to school to-day;” or
—“I feel a slight headache;” and so she remains at home. Now, she
thus not only loses all she might that day have learned, but gives her
teacher trouble. He must note her absence; and when the time
comes for a recitation the next day, she is behind her class, and
gives him and them farther trouble. We ought never to say—“It is
only once—I will not do so again;” and think thus to excuse
ourselves; for, from the force of habit, the oftener we are tardy, or
otherwise fail in our duty, the more frequently shall we be likely to do
so, and the more injury shall we do others, of course, by this fault.
So that, on every account, we should be punctual.
 Among the habits essential to a good character, is moral
independence. We hear much said about being independent in
regard to property. Some persons think that condition all-important.
But it is only so, if it can be proved indispensable to a higher and
nobler independence—that of character. Let us inherit a patrimony,
or earn a fortune by industry and economy, or by the power of
superior talents; we shall still be miserably dependent on others, if
we do not form our own opinions, as respects our duty, and practise
what we feel to be right, and not merely what others tell us is right.
We should first understand in what true independence consists. It
is not eccentricity, or oddity, or affectation; nor is it an unreasonable
pride and confidence in ourselves. We sometimes see boys, at
school, who put on airs, and pretend to be very independent in all
they say and do. There is no virtue in this. Ann is called very smart,
because she is not afraid to speak her mind, as she terms it, about
everybody and everything. She does it, when she knows it will give
others pain. This is not true independence.
Sarah is always saying queer, strange, and, what some call,
independent things. But she does this merely for display. She is very
dependent, for she lives on the opinion of others. She is always
imagining what people will say of her. Another girl is trying to be
eccentric. If she can find out what her companions expect her to
think, or do, or say, she will strive to think, act, or speak, in exactly
the opposite way.
True independence is a habit of forming our own opinions on all
subjects, without regard to those of our neighbors. It leads us, under
all circumstances, to think, speak, and act according to what we
believe to be our duty. We should never wait for others to act,
through fear of doing differently from them. It is our duty to be
considerate of the feelings of others, and to be prudent and
accommodating where their happiness is concerned. But if we feel
any course to be right, we should always pursue it, let us suffer as
we may from the unjust censure of others.—English Magazine.
 The Black Skimmer of the Seas.

This bird, which is sometimes called sheerwater, is a lover of the

ocean, and spends nearly his whole life in skimming along its
surface, or in sitting upon its shores.
A person, on looking at the creature’s bill, might think it a very
clumsy contrivance; for the lower mandible, or jaw, is a great deal
longer than the upper one. People used to think that there was some
mistake of nature, in giving this bird what seemed to them so
inconvenient a tool for getting a living with. But this was only one of
those instances in which ignorance led to presumption, and
presumption to folly. A better knowledge of the sheerwater’s ways of
life has served to show, that in this case, as in all others, the Author
of nature has shown wonderful skill in adapting means to ends; in
supplying His creatures with the best possible contrivances for the
trade or profession they are to follow.
Now, the black skimmer is made for a fisherman; he is made to
feast upon shrimps, and small fishes of various kinds, that live near
the surface of the water. Accordingly, he is provided with a bill, the
lower part of which is the longest, and which he can dip in the water
while he is skimming close over its face. In order to prevent this from
impeding his progress, it is shaped like the blade of a knife, and thus
it cuts the water with ease. As he speeds along, his bill scoops up
the little fishes, and by the impetus of his flight, they are carried
along in his bill, and swallowed as he goes.
No better proof of the success of the ingenious contrivance
furnished by nature to the sheerwater can be needed, than that he is
a lucky fisherman, and seems to enjoy an almost perpetual banquet.
His wings are made of vast length, on purpose to assist him in
sustaining his continued flight; and thus he seems to sail as if the
wind were made on purpose for him; and he feasts as if the wide
ocean were his larder.
This singular and interesting bird comes to us along the northern
shores of the Atlantic, in May, and retires to the south in autumn,
where he spends the winter. His favorite haunts are low sand-bars,
raised above the reach of the tides. He builds his nest on dry flats,
near the ocean. His body is nineteen inches long, and his wings,
when expanded, are forty-four inches from tip to tip. Thus the
sheerwater, instead of being shabbily treated, is a striking instance of
the adaptation of nature’s work, to the purposes of its great Author.
 The Squirrel.

The more we examine the works of nature, the more we shall be

made to feel that there is infinite variety in them—that almost every
part of the universe is filled with inhabitants appropriate to it; and that
each individual thing is fitted to the place it occupies. Among plants,
for instance, there are nearly a hundred thousand kinds already
recorded in the books of the botanists; among animated beings,
there are, perhaps, even a greater number of species. And what a
countless number of each individual kind, whether in the vegetable
or animal world! Every part of the earth is occupied. The earth, the
air, the sea—each and all are inhabited by myriads of living things.
And how wonderfully are they all adapted to their several designs!
How well is the fish fitted to his element; how admirably is the bird
adapted to the life he is to lead!
Among quadrupeds, the lively little fellow, whose name we have
placed at the head of this article, is a pleasing illustration of the
success with which nature accomplishes her designs. The squirrel is
made to enliven the forest, to live among woods, to gather his food
and make his nest, and spend a great part of his life amid the
branches of the trees. And how perfectly is he at home in his
domain! He springs from limb to limb—from tree to tree; he ascends
or descends the trunks at pleasure, and seems to be as safe, in his
airy evolutions, as the ox, or the horse, upon the solid ground—or
the bird in the air, or the fishes in the river.
How perfect an instance of adaptation is this! How nice must be a
piece of machinery, that could be made to operate with such celerity,
in such a variety of ways, and with such certain success! And how
pleasing, as an object of mere beauty, is the squirrel! How graceful
his form—how cheerful his aspect—how seemingly happy his
existence!
 Gothic Architecture.

The modes of building in different countries, and in different ages

of the world, have resulted in several distinct styles of architecture.
Among the ancient Egyptians, it would seem, from the low and
massy forms of their edifices, that they were fashioned in imitation of
caves—the first habitations of savage man. The temples, of which
many ruins remain along the borders of the Nile, seem almost like
structures hewn out of the rock; so heavy are the columns, and so
low the arches.
Among the Greeks, the style of architecture seemed to be
suggested by the wooden cabin, supported upon the trunks of trees.
Thus the lighter and loftier columns supporting their edifices, seem to
be a leading feature of their buildings.
In China, the houses appear to be fashioned after the tent, as if
the idea had been borrowed from the pastoral age, when the
inhabitants subsisted upon flocks, and dwelt in tents.
The Gothic architecture appears to be an imitation of the grove;
the roof being supported by pillars, branching upward. The engraving
will give some idea of this style of building. It flourished from the year
1000 to 1500, A. D., and was particularly used in the construction of
churches, monasteries, and other religious buildings, during that
period. In France and Germany there are still to be seen many
churches in this style; and though they have an ancient and gloomy
appearance, they are very beautiful, and the sombre light within,
seems well fitted to a place of worship. In England, also, there are
many Gothic edifices of the olden time, among which Westminster
Abbey, in London, is a fine specimen. In Boston, Trinity Church is
somewhat in the Gothic taste; and at Hartford there is a fine
specimen, in the Episcopal Church. There are also several other
edifices in this country, of recent structure, which are imitations, in
part, of ancient Gothic buildings; but a pure example of this style is
hardly to be found, except in Europe, and among the edifices of past
centuries.
 Merry’s Life and Adventures.

CHAPTER XIV.
Recovery from sickness.—​Change of character.—​Story of a quack.

In about two months after my accident, I rose from the sick bed,
and was permitted to walk abroad. Although it was autumn, and the
sere and yellow leaves were now nearly stript from the trees, the
face of nature bore an aspect of loveliness to me. I had so long been
shut up, and excluded alike from fresh air and the out-door scenes of
life, that I was like a man long deprived of food, with a ravenous
appetite and a full meal before him. I enjoyed everything; the air, the
landscape, the walk—each and all delighted me. My fever was
entirely gone, and, having nothing but weakness to contend with, I
recovered my former state of health and strength in the course of a
few weeks.
But I was not restored to my full flow of spirits—nor, indeed, from
that day, have I ever felt again the joyous gush of boyhood emotions.
My accident, attended by the wholesome shame it produced, had in
no small degree abated my self-appreciation. I was humbled, if not
before the world, at least in my own esteem. My sick-bed reflections,
too, had served to sober my mind, and give me a sense of
responsibility I had never felt before. I had, in short, passed from the
gay thoughtlessness of a boy to somewhat of the sobriety of
manhood.
I did not, myself, remark the change in my manners or my
character; but others did. My uncle, particularly, noticed it, and
became uneasy, or, rather, vexed about it. He was a jolly old man,
and wished everybody else to be jolly too. Nor could he readily
comprehend why such a change should have come over me: he did
not easily appreciate sickness, or its effects; nor did he estimate the
sobering influences of reflection. He insisted upon it that I was “in the
dumps” about something; and, half in jest and half in earnest, he
scolded me from morn to night.
In spite of all this, I continued to be a much more serious
personage than before, and my uncle at last became alarmed.
Though a man of pretty good sense, in general, he entertained a
contempt for physicians, especially those engaged in regular
practice. If he had faith in any, it was in those who are usually called
quacks. He believed that the power of healing lay rather in some
natural gift, than in the skill acquired by study and practice. As
usually happens in such cases, any impudent pretender could
deceive him, and the more gross the cheat, the more readily was he
taken in, himself. Having made up his mind that I was, as he
expressed himself, “in a bad way,” he was casting about as to what
was to be done, when, one evening, a person, notorious in those
days, and an inhabitant of a neighboring town, chanced to stop at
the tavern. This person was called Dr. Farnum, and, if I may use the
expression, he was a regular quack.
I happened to be in the bar-room when the doctor came. He was
a large, stout man, with grizzled hair, a long cue adown his back, and
a small, fiery, gray eye. This latter feature was deep-set beneath a
shaggy eyebrow, and seemed as restless as a red squirrel upon a
tree, of a frosty morning. It was perpetually turning from object to
object, seeming to take a keen and prying survey of everything
around, as we sometimes see a cat, when entering a strange room.
The doctor’s dress was even more remarkable than his person: he
wore small-clothes—the fashion of the time—and top-boots, the
upper portion being not a little soiled and fretted by time and use. His
hat had a rounded crown, in the manner of an ancient helmet; and
the brim, of enormous width, was supported on each side by strings
running to the crown. His over-coat was long and ample, and of that
reddish brown, called butternut color. I noticed that the hat and boots
were of the same hue, and afterwards learned that this was a point
of importance, for the person in question assumed and maintained
the designation of the “but’nut doctor.”
Having greeted my uncle heartily, and said “good day” to the
loungers around the fire, he took a seat, spread his feet apart, and,
sliding his hands up and down his legs, from the thigh to the shin-
bone, called for a glass of flip. This was soon provided, and taking a
large quid of tobacco out of his mouth—which he held in his hand, to
be restored to its place after the liquor was discussed—he applied
himself to the steaming potation. Having tasted this, and smacked
his lips, a lickerish smile came over his face, and turning round to the
company, he said, in an insinuating tone—“Does any on ye know of
any body that’s sick in these parts?”
There was a momentary pause—and then Mat Olmstead, the
standing wag of the village, replied: “Nobody, I guess, unless it’s
Deacon Kellig’s cow.”
“Well,” said the doctor, not at all abashed at the titter which
followed—“well, I can cure a cow; it’s not as if I was one of your
college-larnt doctors; I should then be too proud to administer to a
brute. But, the scriptur’ says, a marciful man is marciful to a beast—
and I prefer follerin’ scriptur’ to follerin’ the fashion. If Providence has
given me a gift, I shall not refuse to bestow it on any of God’s critters
that stand in need on ’t.”
“Well,” said Matthew, “do you cure a cow with the same physic
that you cure a man?”
“Why not?” said Farnum; “it’s better to be cured by chance, than
killed by rule. The pint is, to get cured, in case of sickness, whether
it’s a beast, or a man. Nater’s the great physician, and I foller that.”
“What is nater?” said Olmstead.
“Nater? Ah, that’s the question! Nater’s——nater!”—
“Indeed?—but can’t you tell us what it is?”
“I guess I could, if I tried: it’s the most mysteriousest thing in the
univarsal world. I’ve looked into ’t, and I know. Now, when a cow has
lost the cud, so that it won’t work up or down, I go to a place where
there’s some elder; then I cut some strips of the bark up; and I cut
some on ’t down; and I cut some on ’t round and round. I then make
a wad on ’t, and put it down the cow’s throat. That part of the bark
that’s cut up, brings the cud up; that part that’s cut down, carries it
down; and that part that’s cut round and round, makes it work round
and round: and so, you see, there’s a kind of huzzlety muzzlety, and
it sets everything agoin’, and all comes right, and the critter’s cured
as clean as mud. That’s what I call nater!”
This speech was uttered with a very knowing air, and it seemed to
derive additional authority from the long cue and broad brim of the
speaker. He looked around, and perceived a sort of awful respect in
the countenances of the hearers. Even the shrewd and satirical
Matthew was cowed by the wisdom and authority of the doctor. My
uncle, who had hitherto stood behind the bar, now came forward,
and, sitting down by his side, inquired how it was that he had gained
such a wonderful sight of knowledge.
“Why,” says Farnum, “there ’tis agin, squire; it’s nater—it’s clear
nater. I never went to college, but I had a providential insight into
things from my childhood. Now, here’s my but’nut physic—it’s true,
an Indian give me the fust notion on’t; but I brought it to perfection,
from my own study into nater. Now, all them doctors’ stuffs that you
git at the pottekary’s, is nothin’ but pizen; thur’s no nater in’t. My
physic is all yarbs—every mite on’t. I can cure a man, woman, or
child, jest as sure as a cat’ll lick butter! There’s no mistake.”
“Well, how did you find it out, doctor?” said my uncle, seeming
anxious to give him an opportunity to unfold his wisdom.
“Can you tell why a duck takes to water?” said Farnum, with a
look of conscious importance. “It’s because it’s in him. ’Twas jest so
with me. I had a nateral instinct that telled me that there was
something very mysterious in the number seven. I expect I got some
on’t from the scriptur’, for there’s a great deal there about it. Well,
one dark, rainy night, as I was goin’ along thro’ some woods, thinkin’
about somethin’ or other, I came to a bridge over a river. The wind
was blowin’ desput hard, and it seemed to go through me like a
hetchel through a hand of flax. I stood there a minit, and then I
looked down into the dark water, wolloping along; and, thinks I, it’s all
exactly like human nater. Well, now, if you’ll believe me, jest as that
are thought crossed my mind, I heerd a hoot-owl in the woods. He
hooted jest seven times, and then he stopped. Then he hooted
seven times more, and so kept goin’ on, till he’d hooted jest forty-
nine times. Now, thinks I to myself, this must mean somethin’, but I
couldn’t tell what. I went home, but I didn’t sleep any. The next day I
couldn’t eat anything, and, in fact, I grew as thin as a June shad. All
the time I was thinkin’ of the bridge, and the wind whistlin’, and the
river, and the dark rollin’ water, and the hoot-owl that spoke to me
seven times seven times.
“Well, now, there was an Indian in the place, who was famous for
curin’ all sorts of diseases with yarbs. I went to see him one day, and
tell’d him I was sick. He ax’d me what was the matter, and I related
the story of the owl. ‘You are the man I have been seeking for,’ said
he. ‘The spirit of the night has told me that I shall soon die; and he
has commanded me to give my secret to one that shall be sent. In
seven weeks from the time that you were at the bridge, meet me
there at midnight.’
“True to the appointment, I went to the bridge. It was a rainy night
agin, and agin the wind howled over the bridge—agin the owl was
there, and agin he lifted up his voice forty-nine times. At that moment
I saw the dark Indian come upon the bridge. He then told me his
secret. ‘Man,’ said he, ‘is subject to seven times seven diseases; and
there are seven times seven plants made for their cure. Go, seek,
and you shall find!’ Saying this, the dark figure leaped over the
bridge, and disappeared in the waters. I stood and heerd a gurgling
and choking sound, and saw somethin’ strugglin’ in the stream; but
the Indian disappeared, and I have never seen him sence. I went
from the place, and I soon found the forty-nine yarbs, and of these I
make my pills. Each pill has seven times seven ingredients in it;
though but’nut’s the chief, and that’s why it’s called but’nut physic.
You may give it in any disease, and the cure for ’tis there. I’ve tried it
in nine hundred and thirty-seven cases, and it haint failed but six
times, and that, I reckon, was for want of faith. Here’s some of the
pills; there’s forty-nine in a box, and the price is a dollar.”
 Such was the doctor’s marvellous tale, and every word of it was
no doubt a fiction.
It may seem strange that such an impostor as this should
succeed; but, for some reason or other, mankind love to be cheated
by quacks. This is the only reason I can assign for the fact, that Dr.
Farnum sold six boxes of his pills before he left the tavern, and one
of them to my uncle. The next day he insisted upon my taking seven
of them, and, at his urgent request, I complied. The result was, that I
was taken violently ill, and was again confined to my room for a
fortnight. At length I recovered, and my uncle insisted that if I had not
taken the pills, I should have had a much worse turn; and, therefore,
it was regarded as a remarkable proof of the efficacy of Farnum’s
pills. Some two or three years after, I saw my own name in the
doctor’s advertisement, among a list of persons who had been cured
in a wonderful manner, by the physic of the butter-nut doctor.
I have thought it worth while to note these incidents, because they
amused me much at the time, and proved a lesson to me through life
—which I commend to all my readers—and that is, never to place
the slightest confidence in a quack.
 The Apple; a German Fable.

There lived a rich man at the court of King Herod. He was lord
chamberlain, and clothed himself in purple and costly linen, and lived
every day in magnificence and joy. Then there came to him, from a
distant country, a friend of his youth, whom he had not seen for
many years.
And to honor him, the chamberlain made a great feast, and
invited all his friends. There stood on the table a great variety of
excellent viands, in gold and silver dishes, and costly vessels with
ointment, together with wine of every kind.
And the rich man sat at the head of the table, and was hospitable
to all; and his friend who had come from a distant country, was at his
right hand. And they ate and drank, and were satisfied.
Then the stranger addressed the chamberlain of the king: Such
splendor and magnificence as your house contains, is not to be
found in my country, far and wide! And he spoke highly of his
magnificence, and pronounced him the happiest of men.
But the rich man, the king’s chamberlain, selected an apple from a
golden dish. The apple was large and beautiful, and its colour was
red, approaching purple. And he took the apple and said, This apple
has rested on gold, and its form is very beautiful! And he reached it
to the stranger and friend of his youth.
And the friend cut the apple, and behold! in its middle was a
worm! Then the stranger cast his eyes on the chamberlain. But the
lord chamberlain looked upon the ground and sighed.
 The Pretender and his Sister.

“The Pretender! What a curious title!—and pray who can he be,

Mr. Merry? And who is the girl at his side, that you call his sister?”
I will answer these questions, my gentle reader,—and let me tell
you now, that there is nothing I like better than to answer the
inquiries of my young friends, when I am able.
Well, as to this Pretender—he was a personage that figured in the
history of England, some hundred years ago. His name was Charles
Edward. He was a grandson of Charles II., a king of England, who
was driven from the throne about the year 1690; and, thinking that
his father, James III., ought to be king of England, he determined to
make an effort to set him upon the throne. He was born 1720, and
when he was twenty-two years old, he entered upon this great
project.
Being at Rome, he induced the Pope to espouse his cause; he
then went to Paris, and king Louis XV., having promised to assist
him, fitted out a fleet, with 15,000 men; but they were defeated by
the English, as they were on the point of sailing. After this, the
French king would do no more for Prince Charles Edward, and the
daring young man set out, in 1745, in a little vessel of eighteen guns,
and arms for 1500 men.
He landed on the northwest coast of Scotland, and the people
there seemed delighted to see him. He was a descendant of the
former kings of Scotland, of the Stuart line, and it was natural
enough for them to have a feeling of favor for one who thus claimed
kindred with them. Accordingly, the Scottish nobles flocked to the
standard of Edward, bringing with them hundreds of their brave
soldiers.