you did what to who?!

So we have a patient who has been in the hospital for a long time. Every time I think I get a chance to go look at his full record and figure out what he has, I'm pulled in another direction. Tomorrow is a Friday, so after I'm free to go I'm going to take some time and figure out how on earth he got into the predicament he is in now.

See, Mr. H has an open wound. We're talking HUGE open. It's a midline incision of basically his entire abdomen. I think he'd had surgery for colon cancer, and then the wound dehisced---it dried out and fell apart instead of healed. So he's been laying down with this packed open wound for like a month. All his intestines are just sitting out and about. They've irrigated and drained it multiple times. Now the body has a reactive process in which it covers things like this up with fibrous tissue---the same stuff that makes a scar. So when I saw Mr. H's open wound finally in the O.R. today, it's not like guts hanging out---it was more like a pink bag sticking out of his abdomen. Granulation tissue has covered up the guts part. And here it is.

So wounds close if you have the sides of the wound pulled together---but Mr. H's body/skin is waaaaay far apart on both sides of pink guts bag. So what they did today is take pieces of tissue called Alloderm and sew it together and then covered up the wound with it. Alloderm---it is the dermis, or innermost part of the skin,...from a cadaver! Just strips of this stuff. You like stick it in water for a half an hour til it's soft. Then you sew it up piecemeal making it fit like a puzzle. And I helped sew it on.

So my senior resident, whom I adore by the way, I must reveal his name cuz it's so characteristic: Dino. Yep, Dino. He's originally from NYC. Dino says to me mid-stitching, "Now Katie, if you mess this up, YOU are presenting the case at M & M." M & M is a mnemonic that I cannot remember (something and Mortality maybe? Morbidity and?) for a weekly conference that all medical teams have. You talk about patient management that went wrong, where and how it went wrong, and what to do to not screw it up the next time and what-not. A lot of ethics. You also present deaths at the conference. So thanks a lot Dino, while I'm throwing stitches for like the 5th time EVER on this cadaver skin to cover up this guy's abdomen, tell me once again that if it doesn't work it's my fault! He was kidding of course...

The Alloderm is Mr. H's last shot at getting his wound closed. My attending kept saying he was both a charlatan and a shaman for attempting this deal. It's also super-expensive stuff, so much so that the head O.R. nurse came storming in and told off my attending, saying "They're not going to give you that much money! You just spent my entire Surgery budget!" It was quite dramatic.

At the end of the day today, we were consulted for a man with primary breast cancer. Yep. This is another thing for me to look up tonight. It turns out that his primary care physician had found his breast lump like over a year ago---and now the guy comes in with shortness of breath. He has metastases all over his body, including his lungs, which has caused fluid to leak into his lung sacs (pleural effusions), squishing his lungs so he can't breathe well. Basically he was untreated, or rather treated only with Vitamin E (to which my attending yelled some expletives), and now he will die much sooner because of it. It's a terrible mess, and we're going to see how best to fix it starting tomorrow.

Just another day at the good 'ol VA.