Saturday, May 26, 2007

5/26

Nothing like driving in on a saturday to drain a perirectal abscess. Ah, the joys of private practice. Enthusiastically telling the referring doctor, "Ill be right in !" Hell, maybe next time it will be an obstructing colon cancer. But not today. Today it's an indurated, flaming red painful as hell, pus filled buttock abscess. This is going to hurt ma'am. The numbing medicine sometimes can't anesthetize all the tissues when there's so much active infection. Nurse, can I get 4 of morphine?
But that's what I dig about general surgery. You never know what's going to show up in the ER or on the floor. I couldn't stand to do the same thing day after day, like cardiac surgeons or bariatric specialists. And what is the deal with this whole "Center of Excellence" designation if you want to do bariatric surgery? I understand the need for oversight, but we are graduating hundreds of chief residents every year who have learned how to do the procedure under the guidance of expert laparoscopists. If you're comfortable doing it, then what's the problem? Unfortunately, bariatric surgery was like the wild west in the late nineties. It payed well and it was new and exciting. So every general surgeon and his brother decided to learn on the fly, practicing on humans, after watching a few videos at some weekend crash training course. Hence the high morbidity/mortality numbers that resulted initially. It's not like that anymore. I scrubbed in on nearly 70 lap roux en y cases during my residency, doing a majority of the case as a senior resident. It's unfortunate that the recklessness of surgeons ten years ago has hampered an obese person's ability to get bariatric surgery at his/her community hospital....

4 comments:

Charity Doc said...

For minor ER procedures such as I&D of huge abscesses, the best and most comfortable way for patients as well as for yourself, in my opinion, is to do it under procedural sedation. The term conscious sedation has really fallen by the wayside because there's really nothing "conscious" about it. For really quick procedures, etomidate 0.3 mg/kg rapid IVP works really well. Etomidate has a very safe cardiac profile without inducing hypotension, while preserving respiratory drive. Etomidate has a very rapid onset sedation and will give you about 10-20 minutes of deep enough sedation to pretty much allow you to do what ever you need with the patient. 20% of patients will have the side effect of myoclonus, which is benign and non-life threatening, but can get quite intense like a seizure in rare instances. The good thing is that the sedation doesn't last very long. I routinely use etomidate for closed reductions of orthopedic injuries. I occasionally use etomidate for huge nasty abscesses, but it really depend on the location of the abscess. For perineal/perianal/genital abscesses, the myoclonus can be problematic and interfere with exposure. For these abscesses, I prefer Diprivan, Brevital, or the Fentanyl-Versed combo. The biggest problems with these, however, are hypotension and hypoventilation. Always have a respiratory therapist present to be ready to bag these patient. Always have a nasal trumpet at hand. Always have IVF running wide open because hypotension is usually the rule.

For pediatric sedation, I prefer Ketamine. 4 mg/kg IM or my favorite, 2mg/kg IVP follow by a ketamine drip, prepared by mixing 2mg/kg of ketamine in 250 cc of NS so you can titrate for longer sedation if required.

buckeye surgeon said...

For large perianal abscesses, or any evidence of tissue necrosis, or just generalized patient intolerance, I will do these drainage procedures in the OR with either a spinal or endotracheal intubation. The problem with conscious sedation on the floor is it freaks out the nurses. You have to have someone "recover" the patient from diprivan or etomidate, and a lot of regular floor nurses are uncomfortable with that. I have used versed at the bedside to good effect.

Charity Doc said...

I was under the impression that is was an ER consult. All the absesses that I've ever consulted a general surgeon on are the humongous ones that had to be taken to the OR. The smaller ones I do in the ED and send to infusion center as well as wound care center for whirlpool.

Bongi said...

i would be somewhat sceptical of doing a perianal abses in casualties. they are often underestimated. you can get into difficulty. i would not advise it and i'd never ever ever do it myself. (except for the exceptions).

again i once got philosophical about perianal absesses and blogged it.