Saturday, June 06, 2009

What the Rose Is

I am not easily disgusted. Perhaps that is one reason why I've been able to maintain participation in my profession, although I must admit that in my particular area of nursing practice I do not see a lot of trauma. Enough, certainly.

I medicated Jackie with a small boatload of Ativan and morphine before changing her arm dressings. A few weeks ago she had bumped her arm on a table while helping her son move into a new house. Because she regularly took Coumadin due to heart valve surgery years ago, she thought nothing of the bruise she developed on her forearm. Not at first, anyways.

Necrotizing fasciitis. It really doesn't occur all that often, thank the stars. Maybe a thousand cases each year in the U.S. Sometimes it takes a while for people to see that they have a big problem because early symptoms are typically just increased pain at the injured site and flu-like symptoms.

The pain is usually out of proportion to the injury, but pain is subjective. The disease is rare and even many emergency department personnel may not have seen examples of it. Unfortunately it gets missed; that is, until the swelling and bulbous blisters develop. Then all fucking hell breaks loose. Pandemonium.

The most common organism causing necrotizing fasciitis is Group A Streptococcus, which is basically everywhere and comes in a hundred or so variants. It can give you a sore throat or it can kill you.

Back to the patient: Jackie was watching one of those home-and-garden television channels. When I went back to her room after giving the drugs a few minutes to take effect, she began to tell me her plans for redecorating her hospital surroundings.

"I'd like to repaint the walls sea-green and maybe put in a water feature," she said in all seriousness. Then she pondered out loud about patterned material for new window drapes.

When I took morning report the nurse had warned me that Jackie freaked out a little when she initially saw her affected arm the day before when the dressings were changed for the first time after surgery. That's why I was somewhat generous with the drugs.

Oh fuck that. I'm always appropriately forthcoming with pain and anxiety medications. I work in a fucking hospital, for pete's sake. It's stressful for people. (Note to seekers: We can tell you're lying.)

The necrotizing fasciitis had affected her arm from elbow to hand. The outer aspect of her forearm had to be thoroughly debrided. The doctor, a local plastic surgery genius, took muscle and skin grafts from her thigh and reconstructed the arm.

If you are unfamiliar with these sorts of wounds it might appear as if someone took a blowtorch and a sledge hammer to Jackie's arm to make human meatloaf. I feared that perhaps she thought so. But upon my inspection, it actually looked good. Considering the circumstances.

I pointed out the neat lines of staples that secured the edges of the skin graft. The flexor digitorum profundus was intact and working for her and she could move her fingers. But the muscle over it had largely been excised. I explained that her arm would look as if a palm-sized half-inch of the outer aspect of her arm had been scooped away, and it could be lighter in color than surrounding intact skin.

"This muscle graft swelling will go down eventually," I told her, "That's why I'll wrap this up when we're done, and you'll keep it elevated on pillows."

"Oh, that's a nice print!" Jackie said, referring to the television show. "Can we use that for the pillows? Purple silk is so cool and comfy," she added.

I worked very slowly, explaining every step. Her fingers were good, uneaten by the disease. I carefully pulled away the petroleum dressings which had remained nice and moist. Using sterile technique I gently rinsed the wound, not that it really needed it.

We discussed new furnishings. "Maybe a solid lobster-red for the chair instead of that drab print," said Jackie.

"It's like you're reading my mind," I proclaimed. "I love that color!"

Soon the wound was covered with yellow sticky-moist petroleum gauze, covered and protected with sterile cotton gauze, re-splinted to prevent contraction, and wrapped just-right in ACE stretchy bandages.

Then on to the donor site, which was probably about the size of your computer monitor screen. "It looks good," I told Jackie, "And we can secure the dressing with this mesh stuff that you can pull up like a stocking over it. That way it won't fall down when you're walking." I think I used six, maybe seven, five-inch-by-nine-inch Xeroform dressings to cover the whole site then protected it with gauze and ABD's.

Usually plastic surgeons prefer to do these changes themselves; maybe have a physician's assistant or nurse practitioner do it. He must trust us. You have to be fucking careful as all get-out when you're working on donor sites. Very clean, very slow. If you accidentally pull up the donor site you can give the patient a wound that might never heal, and if you introduce another infection then you can just kiss everything off right there.

Same goes for the newly repaired and grafted site too, of course.

In the old days, maybe just twenty-five years ago, they would have just cut her arm off.

Later that day we sent her off the get a PICC line for home antibiotic therapy. She would basically be hooked up to a continuous twenty-four-hours-per-day Penicillin infusion for a month, which sucks a bit less than being one-armed.

She had a line of staples along her inner thigh from her groin to her knee, where they took donor muscle. "This doesn't even need to be covered, Jackie," I said. "But let me know if you want something thin over it so the staples don't rub on anything."

There. Done. Half an hour later she was sleeping.

My boss gave me one of those gift-card things we sometimes use for patients, and Maria the nursing assistant had a few minutes to run to the gift shop to get a little vase with a rose in it. She put that on Jackie's hospital table so she could see it the moment she awoke.


Eli Blake said...

I remember taking a biology class in college (circa 1983) and the instructor, when he wanted to get our attention would start talking about things like flesh eating bacteria.

On another occasion he took out a foot long ascaris and calculated (based on an estimate of 150 people in the lecture hall) how many of us had one in us right at that moment.

GingerJar said...

That was sweet...getting her a rose.