Wednesday, January 16, 2008

What are the odds?

It was a quiet late summer Saturday afternoon. The pager went off. The message--Call TT at 555-5555.

I always do a mental check list of possible problems when I recognize the patient's name. This one had had a tummy tuck done 6 weeks previously. She had healed with no problems or issues. She hadn't asked for a refill on pain medication. All of her follow up visits had been routine. I couldn't begin to image why she was having me paged.

"TT, this is Dr. Bates. How can I help you?"

"Dr. Bates, my incision has popped open!"

"Slow down and take a deep breath. Try to stop crying and repeat what you just said. I'm not sure I understood you."

"I fell when I stepped out of the boat. I landed on some gravel and my incision on my right side has opened up."

"Okay, where are you and how long do you think it would take to get to my office? The building is locked because it's Saturday, but I can get us in. I'll look at you there and if I can I'll fix it for you there, I will." No need to further stress her with the possibility of surgery at the hospital. She was already thinking of the added cost of this, having maxed out her savings and credit to have the initial surgery. "Just come on"

"It'll take us about two hours. I'm all dirty. I need to change clothes."

"Don't worry about your clothes, just come."

Boy, was I surprised! As my husband likes to say, "you can't make this stuff up". This is not a "complication" that you warn patients about after surgery. This is different from wound dehiscence. This literally was a healed wound that had incurred the pressure of the fall onto one rock with the point of maximum force right over the healed scar at her right hip. Scars at 6 weeks are only at approximately 55% of the final strength that will be reached at approximately 10-12 weeks post-injury. Even then scars only have 80% of the tensile strength of uninjured skin. But what are the odds.........

When they arrived at my office, I found an open wound about 18 cm long, gaping nearly 5 cm at the widest point. It was centered over the right anterior hip bone. There was dirt, grass, and small gravel in the wound. There was no active bleeding . I got her to lay down on the exam table and did a local block using 0.5% Lidocaine with Epi and 0.5% Marcaine without Epi. Then I thoroughly cleaned the wound out with normal saline and Betadine solution, picking out the grass and gravel. Cleaned some more. Then I closed the wound with vicryl and PDS. I reassured her that most likely in two years, we wouldn't be able to tell which part of the scar had been reopened. I sent her home on antibiotics, but she declined pain medicine (had some left over from the surgery). Both TT and I were relieved that it wasn't any more serious than it was.

Now when patients ask for 100% guarantees of their postop courses, I use this example of how even best laid plans can be changed by "life", the "universe", whatever. Some things are not in our control. I tell them I will do everything I can to ensure a good outcome. I ask them to help me by following instructions and using common sense. But what are the odds.....


Bongi said...

as we always say, "you cut, you cry"
but wow!! what are the odds?

T. said...

I sincerely hope I am always as lucky as TT was to have a physician like you.

rlbates said...

Bongi, very odd--huh?

Thank you t.

Femail doc said...

I'm coming to Arkansas if and when I ever get the nerve to get a nip or tuck on my aging self. You are one cool surgical asset: take a deep breath, drive two hours, and I'll pick your dehisced wound free of gravel and stitch you up in the office.

rlbates said...

I'll take that as a compliment. Bet you don't need anything "nip/tucked".