Wounds!

Despite the best attempts of the New York Times Wellness Blog to get me fired, I’m still here and doing fine. Somehow a post about how impressed I was with surgery, the professionals that practice it, and how many of my preconceptions about surgeons were incorrect, got all turned around into some “peak behind the curtain” into the secrets of the medical profession. This is terribly absurd and the article made a hash out of what I was trying to say. I was trying to relate some of the shock one experiences going from an academic setting into a clinical one for the first time, as a reminder to those who have done this before, and maybe preparation for those who have yet to make the jump. None of these things are secrets, and all could be culled from watching about 15 minutes of the Discovery channel or Scrubs.

But the confusion of some individuals over what I was trying to communicate is still my problem, even if I was quoted all out of context. Clearly the biggest issue is the change in audience, my sb audience includes a lot of scientists and doctors, and the way I write is somewhat geared to this group. Thus you’ll notice in my comments mostly positive responses – especially from medical professionals like Orac, PalMD and various others. When the NYT expands my audience to a group of people who don’t know my writing, my assumptions or my more egregious stylistic shortcuts, it is not surprising there was some confusion and hurt feelings, not to mention some people with absolutely no sense of humor.

This does not mean that there is no problem however, ultimately this is a sign that I need to remember that I am writing in a public arena and need to be more careful with the assumptions I make about my audience on any given day. Rather than clamming up for the next couple of decades until I’m tenured, instead I’m going to use this as an opportunity to broaden the appeal of the blog and help explain to a wider audience what evidence based medicine is, the process of learning it, and why I think medicine the best career in the world. Writing this way will help educate people about medicine and how its practiced, and at the same time improve my knowledge of medicine with the goal of making me a better doctor one day. So, back to basics.

First, an explanation of the role of a medical student in the arena of patient care. Medical students are being introduced into the profession of medicine. To accomplish this they take two years of some of the most arduous training imaginable, intensively learning about anatomy, physiology, pharmacology, biochemistry, genetics, pathology, microbiology, physical exam, history taking, and all the other knowledge that makes up the foundation of clinical knowledge. By the third year, which is what I am currently in, you have accumulated more knowledge in two years than you probably have in your entire life. You are tested, retested, observed, corrected, and tested again and after all this work you get the incredible privilege of participating in patient care in your second two years of med school. This does not mean your first week of patient care is any less of a shock to the system – it is very much different from the purely academic pursuit of medicine – it is more of an apprenticeship in which you learn by doing and is certainly the most important part of learning to be a clinician. At this point you are participating in patient care, usually at an academic setting, and you see patients, take histories and physicals, learn how medical decisions are made in the care of individual patients, and in the case of surgery, observe how operations are performed. While you are an important part of the patient care team, you are not responsible for clinical decisions at this point and are at the bottom of the proverbial totem pole. You work with interns, residents and attendings who are ultimately responsible for medical decisions. For the most part, you observe, participate, tell them what you would do, and then wait patiently as these more experienced clinicians explain why you are right or wrong and what is the correct course of action. It is training to develop clinical judgement and competence in patient care. Further, when I say that I “scrub in” to a surgery, it means that I am allowed into the sterile field (after scrubbing, gowning, gloving etc.) and am given the privilege of watching surgery up close. If you’re lucky you may get to participate, but in a very limited capacity, never beyond your abilities (usually just holding instruments, aiming a camera, applying traction, suction etc), always under the supervision of someone with between 5 and 40 years more experience than you, and in a very controlled environment. Always paramount is the patient’s well-being, and if it is ever in question you quickly find yourself shuffled back behind the doctors who are doing the very difficult and demanding work. Before you even step into the room one must remember the student has years of training to understand the pathology and anatomy of the case, the student has read up on the patients’ specific case, and has reviewed the surgical procedure, relevant pathology, anatomy etc. Before you work with patient on a medicine rotation you’ve done similar prep, and throughout the case are studying the patient’s case, lab results, textbooks of medicine, the scientific literature, etc., as part of your training. When you graduate from medical school and become an intern and then a resident you are still training for about 3-5 more years, you become directly responsible for patient care, and are under the supervision of an attending physician. This structure is ultimately very successful and academic medical centers provide the best medical treatment in the country, attract bright people, take all kinds of cases (the ones many other hospitals simply can’t handle), and constantly push the boundaries of medicine.

Now, onto the fun part. A clinical case. This is how we learn medicine, as being social animals, it’s almost always easier to remember medicine in the context of a person. You’ll always remember medical facts and treatments better if they are associated with an actual human being. And this is, of course, an artificial teaching case having nothing to do with an actual individual. I had a post all prepared describing a complicated procedure, but since we’re starting from basics, let’s begin with wounds.

The patient is a 52 year old construction worker who suffered from an open fracture (bones sticking out of the skin) of his left radius and ulna (bones of the forearm) from on-the-job accident. He was taken to the ER, his arm was evaluated with a plain X-ray film, and the break was cleaned, reduced, and set in the OR. He received prophylactic cephalosporin antibiotics before the surgery. 24 hours later he is on your floor, admitted to your service, and he complains of chills, and severe burning pain at the site of his incision. The patient is alert and oriented to time, place, and person, but is diaphoretic (sweating), pale and in some distress. He has a fever of 39.2, BP 140/90, and his heart rate 110 beats per minute. An examination of the arm reveals a brown, weeping wound at site of the repair, the arm is warm to the touch, and acutely painful. Physical exam and review of systems is otherwise unremarkable. Labs show an elevated white count. He has a history of type II diabetes and hypertension.

What do you do?
A) Treat empirically with a broad spectrum IV antibiotic like Cipro and culture the bacteria for a definitive diagnosis and sensitivity testing.
B) Clean and debride the wound.
C) Change the dressing and wait for the wound to heal naturally.
D) Send the patient back to surgery to debride (clean) the wound and start therapy with penicillin and clindamycin.

I think most of you will guess the right answer is D since I presented this as a surgical case. This is a classic infection with a bacterium named Clostridium perfringens (gas gangrene) and represents a surgical emergency. Typically when we’re learning in a classroom setting to get the students attention and interest one begins with a simple case presentation and some questions to get the students thinking about possible treatments. Then the presenter provides information on the differential diagnosis (aka other possible diagnoses) consistent with these symptoms, information from the current literature about the efficacy of various treatments, and a plan for the individual patient.

The two most common infections within a day or so of an injury or incision are group A streptococcal bacterial or clostridium perfringens which is associated with serious injuries and possibly contaminated wounds (like an open fracture or burn). One does not wait to diagnose these infections as they require immediate treatment. Group A strep would be treated with antibiotics without debridement.

Most post-operative infections occur between 5 and 7 days after the injury or surgery and for clean surgical wounds or slightly contaminated wounds the rate are about 1% and 3% respectively. The most common causes are Staph aureus, E. Coli and Enterococcus, but several other microbes may be responsible. The rate of post-operative infection has not changed significantly for decades, and is a common complication of surgery.

This case is an example of what I was referring to when I said surgeons don’t waste time with excessive diagnostics. This was not an insult, or a statement that they are not excellent diagnosticians. But the secret to being a good surgeon is being fast and decisive. Often with medicine you have the luxury of time to think, weigh options, do tests, try empirical therapies and deliberate extensively before acting (although regular docs are trained to recognize medical mysteries and act in a flash too). However with surgery the range of possible maladies is limited by the fact your recent procedure is likely to be the major source of morbidity in your patients. You don’t stop to consider a huge medical differential diagnosis. You are trained to know the complications of your procedures, how they present, the complications of surgery in general, and to act fast because time is often critical. This is the essence of good medical practice and not a statement about some aberrant behavior specific to surgeons. This is how they should behave.

Now remember, I am a student, and if you think I’m wrong feel free to correct or amplify my answers in the comments. I’m here to learn too. I think as part of my slow introduction to surgery next I might cover the very most common operations – hernia repair, appendectomy, and cholecystectomy – to introduce you guys to some less complicated surgeries, aseptic technique, how an OR functions, and some of the simple surgical instruments. Also, I’ll continue to emphasize that surgery is a big deal. It’s serious, it is necessarily hard on the body, should not be taken lightly, and surgeons will be the first to tell you this. The net benefit is often huge, but there are always risks to surgical procedures and surgeons weigh these risks against the benefit of the surgery every time, for each individual patient. This will be another focus in each procedure I present.