Busy Friday at the BMC

Today was a bit of a crazy day.  Friday is usually an outpatient clinic day, but I spent the majority of the day in the theatre (which is ok with me).  I started off the day by doing incision and drainages (I&D) of abscesses on three babies.  The first was just one month old and had been given an immunization and developed a large thigh abscess.  The abscess is rather big and actually connects down to the baby’s knee joint.  I am hoping that it will not disable this child at such a young age.  The two others had abscesses on their necks.  I don’t enjoy doing procedures like this on babies because they don’t give them any sedation . . . they just hold them down so they don’t wiggle away and you cut open the abscesses.  The pain must be horrible.  Doing three in a row like that was tough on my ear drums and heart.   

In the main OR I repaired two inguinal hernias in an old man, 78 years old, and a child just 3 years old.  I also took a young 4-year-old to surgery for a typhoid perforation.  If they drink dirty water, they run the risk of getting typhoid.  In the end stages of the disease the patients develop perforations of the small bowel.  This child is very sick and I am actually very worried for her.  I followed that up by doing an I&D on a young man that has a dental abscess.  That is fourth patient I have seen with a dental abscess in a week.  There is no one to go to take care of dental cavities and they will turn into abscesses.  I have drained all kinds of abscesses, but for whatever reason I think that dental abscesses are one of the worst.  They are hard to drain and they just stink! 

The last case I did for the day was a sequestrectomy.  This was a 11-year-old boy who had a wound on his leg for 3 years.  He states that it started like a small blister and slowly grew.  He denies any trauma or broken bones.  When skin infects go untreated they can move and infect the bone beneath, called osteomyelitis.  The bone tries to heal itself and grow good healthy bone, but it never quite gets rid of the infection underneath.  The bone will grow around the infected dead bone.  Sometimes the patients will heal for a bit but eventually puss will form and find its way to the skin, they get these chronic draining wounds.  In this boy, the dead bone had actually found its way to the skin and was sticking out in various places.  You can notice in the picture below.  If you moved one side of the bone you could see a little piece sticking out of the skin by his ankle also wiggle.  His father said he had not been to school in a year because the other kids make fun of him and then he gets in trouble for fighting them.  He had been to several other hospitals and they all said to return when his wounds healed, however with bone sticking out of the skin his wounds would never heal.  He needed a sequestrectomy, which is the surgery to go in a removed the infected dead bone pieces and that is what I did for him today.  He had an open wound on his leg now that will heal in over time, but all of the infected and dead tissue is gone so he finally has a chance to heal.  We will bring him back to the theatre tomorrow to do his first dressing change.  I had forgotten to take a picture of his leg at the end of the case so I will have to do that tomorrow.

The boys foot is to the right.  You can see at the left most wound there are pieces of bone sticking through the skin.  Also, all the way the right in the lower wound there is another piece of bone sticking out of the skin.  If you pulled on one side it would wiggle the other showing that it was a connected piece of bone underneath. 

This is the piece of bone that I removed from under the skin.  Inside of it was all kinds of dead infected tissue. 

This is the boys wound at the end of the case.  There is good healthy bone at the bottom of the wound.  It is maybe 3 cm deep and this will need daily dressing changes until it closes by filling is with good healthy tissue.

In between the cases, I rounded on all of my patients in the wards and reviewed other cases that they asked a surgeon to see.  I had two other patients that I was worried might need surgery but both were improved which was great news!  After finishing in the OR, I did head to clinic where stack of charts were waiting for me (as hard as I try I can never avoid clinic!).  Some I booked for a later date for surgery.  Others did not need surgery at this time.  There were some post-operative patients that others had done back for review.  I admitted a young girl with a central abdominal mass.  It causes her pain.  She had had dramatic weight loss and does not eat.  I will most likely take her to surgery Monday to see what is going on.  All we have here is an ultrasound . . . my ultrasound skills are rusty and today I could not really tell what the mass was associated with so on Monday I will just have to use my eyes and find out.