Vascular surgery.

I spent the day with a first-year surgery resident. The general surgery residency here is divided into four services: general A and B, vascular, and trauma. Originally I was supposed to be with one of the general surgery teams, but a number of people were out sick or on vacation, so I was put on vascular.

I spent most of the morning in the OR, watching two procedures. They were both Portacath implantations, which are not the most exciting to watch because the devices are implanted just under the skin and there isn't a whole lot to observe. The surgeons used x-ray to position the catheter in the appropriate vein, then cut a small pocket to fit the septum and closed the incision with one or two small stitches. The patients weren't even intubated; since the entire procedure took maybe 30 minutes and was minimally invasive (in terms of the size of the incisions and the risks of the procedure), the patients were only sedated. That certainly sped up the process; sometimes putting a patient to sleep can take a while if their airway is difficult to access, the tube isn't sitting properly in the airway, etc.

I elected not to watch the following two vascular procedures, one of which was another Portacath insertion. Instead, I followed the resident to the clinic and even though the rest of the day was incredibly boring, the first patient we saw was worth skipping the OR.

The patient was a 60-some year old woman who had been paralyzed two years ago when she contracted an infection following chemotherapy and radiation treatment for lesions on her lymph nodes. The poor woman contracted pretty much every horrible infection there is to contract - MRSA, VRE - you name it, she had it. She is allergic to penicillin but ultimately, penicillin is exactly what stopped the infections.

Following a 7-week stay in the ICU while she was battling the infections, the woman endured months of rehab because she could no longer walk. She developed sores on her coccyx and legs which blossomed into full-blown skin ulcers. She was given standard wound care treatment, but it didn't help.

The wound on her coccyx has since healed nicely without any treatment other than frequent dressing changes. The wound on her leg was manageable up until a few weeks ago, when it suddenly ballooned to about 4 inches long. The woman didn't have any fever, though, so the docs didn't think the wound was infected. That was all well and good, except that in the past week and a half, the ulcer has grown to over 7 inches long.

I was not exactly prepared when the resident removed this patient's wound dressings. If you can imagine what a human leg would look like if a dinosaur took a huge bite out of the calf, that's pretty much exactly what the ulcer looked like. It was ENORMOUS and wet and drippy and purulent and the tendons were poking out horribly, though no bone was (yet) showing. Lucky the woman was paralyzed and couldn't feel it - I can't imagine how painful a wound like that would be on someone with good sensation in the legs.

At any rate, the vascular surgeon looked at the ulcer for about five seconds and told the woman that she needed an amputation, pronto. They scheduled the surgery for next week.

Though I'm probably going to have the image of that festering, dripping ulcer in my head for quite some time, I guess experiencing these disgusting things now will only help later when I'll be the one who has to actually touch the patient. Yuck.