The Abcess

[ussfpa]

Hey Doc, I got this draining, blister looking thing that hurts like a mother. Can you take a look at it???



WEAR GLOVES
WHAT IT IS: A localized infection that has hollowed out a cavity in some part of your body. It is filled with purulent liquid or material the consistency of melted sharp cheddar.
HOW IT FEELS: Painfull. The pain is mostly from the pressure. Think of this as a big zit...a REALLY big zit.

PHYSICAL EXAM (PE)-simple abcess: Localized area of infection that is swollen, warm to the touch, fluctuant (fluid filled), or openly draining, and the surrounding skin will show some redness or destruction. Movement of nearby joints will not be inherantly painful to the joint, but may cause pain from an increase in the ressure to the infection site.

TREATMENT: Local anesthesia is of questionable benefit here since the blood supply to the skin is compromised...however, deeper use of lidocaine (2%) may show some benefit during the exploration of the cavity. Do not inject THRU the pus / cheese. Inject AROUND the area to generate a "field block" or an area of anesthesia. If a nerve block is available and your skill level is up to it, this can yield the best result.
CLEAN THE AREA: Betadine or other mild soap is fine
OPEN THE INFECTION: Use a scalpel and make a cut across the opening (or the raised "head") of the infection. This should be relatively painless and in fact generate some relief due to the release of pressure.
OPEN is GOOD. Express all the nastiness out of the cavity, if you have lab available, be certain to get some on a culturette and send for incubation.
Take a sterile cotton tipped applicator and ream the inside of the cavity breaking all adhesions and pockets. This may generate some "discomfort". The resultant cavity should then be packed with 1/8" or 1/4" iodiform gauze to prevent it from closing. If the wound closes, it re-opens the environment for more infectious growth. DO NOT SUTURE THE WOUND CLOSED!!! The cavity should have the packing removed periodically and the healing process should be visable from the bottom up. A white, net like matrix will form within the wound and should not be disturbed.
The cavity will heal in this manner, with less and less packing being used.

COMPLICATED ABCESS: All of the above applies with the addition of the following:
ANY abcess should be considered complicated if:
-It is on the face / in the mouth (proximity to the brain)
-There is red streaking going TOWARD the body (proximally)
-there is significant heat and associated swelling around the entire limb or involving a joint (cellulitis)
-There is swelling and or pain in the "lymph nodes" (the body's filters) between the abcess and the trunk traditionally in the armpits and / or the groin.
-there is an associated fever with ANY of the above signs.

Complicated abcesses get antibiotic treatment in addition to the incision and drainage.
Simple abcesses have the infection localized without infiltration to surrounding tissues. This means that antibiotics will not reach the infection once you remove it (by the I&D). The remaining skin / tissue is HEALTHY, thereby rendering the antibiotics useless.
In complicated infections, the offending bacteria HAS infiltrated the tissues, therefore, antibiotics have the ability to reach the infected area through the bloodstream and assist in the healing process.

The wound should be dressed with a dry sterile dressing. Antibiotic ointment (bacitracin) can help to minimize scar tissue if your environment allows it.
Close follow up is highly suggested

BOTTOM LINE:
1. Drain the infection, culture if possible
2. Allow it to close on it's own, DO NOT STITCH IT SHUT
3. Determine if the abcess is simple or complicated...if complicated, add antibiotics (Augmentin, Keflex, Dicloxicillin)
4. Keep the wound clean and dry

Primum non Nocere

[mbw]

During the PE do we ask the patient when the abcess originated as well as what it started as? Will that information change treatment? With the complicated is the antibiotic solely given as a cream or would a broad spectrum oral be a good follow up?

Taking notes,

Mike

[CPTAUSRET]

[QUOTE]Originally posted by ussfpa
Hey Doc, I got this draining, blister looking thing that hurts like a mother. Can you take a look at it???



WEAR GLOVES
WHAT IT IS: A localized infection that has hollowed out a cavity in some part of your body. It is filled with purulent liquid or material the consistency of melted sharp cheddar.


Primum non Nocere [/QUOTE

ussfpa:

Cool

Be nice to see something like this on a weekly basis:

Terry

[Axe]

Sir, this is the kind of forum I love to sink my teeth into!! (Pun intended)

What kind of cracker would one serve that "cheddar cheese" on? And could you recommend an appropriate wine?

Seriously, what factors determine the likelihood of developing sepsis from a close to surface abcess (besides delay in treatment, and also I assume virulence of the infectious agent?). Correct me as appropriate, but abcesses are after all, theoretically walled off, thus limiting spread, but I know that is not 100% true, since they can tunnel, right?

What is the maximum depth one should consider performing an I&D on a subdermal abcess in non-sterile conditions when proper facilities and aid personnel are not accessable? I am offering the hypothetical assumption that we are talking a week or two wait for care in a defervescing patient?

Also, I was instructed to debride white fibrin tissue from a pt.'s incised and drained dehisced surgical site with subsequent MRSA abcess and tunneling by the original surgeon, but you indicate that the white fibrin scar tissue should be allowed to develop. Is this just a difference in technique and treatment, or did the fact that I was treating a relatively large wound allowing for instrument manipulation in the field likely play a role here?

[frogstyle]

Doc,
That is exactly whats on my thigh!..

They should have opened and cleaned it.! Fuckers.
BTW Its only getting worse...

[sta marine]

Doc,
Oddly enough I just had this... The only thing is the bill says complicated abcess, but they treated it as a simple abcess. They cut it and packed it. Mine didn't have any of the indications of a complicated abcess and I didnt get meds. So why the hell am I being billed for it???? Bastards...

Should I go back and say anything? Or will there even be a diffrence in the bill?

thanks,

p.s. See told ya I would come to you with my medical questions.

p.p.s. Holyshit this is getting like BAS. Hey doc don't tell me take motrin and suck it up, LOL

[ussfpa]

Originally posted by mbw
During the PE do we ask the patient when the abcess originated as well as what it started as? Will that information change treatment? With the complicated is the antibiotic solely given as a cream or would a broad spectrum oral be a good follow up?

Taking notes,

Mike
Origination shouldn't matter much...go by what the PE shows at the time of exam. Antibiotic Tx with the complicated should be ORAL, IV or any combination thereof depending on the severity.
Good questions!!!

Primum non Nocere

[ussfpa]

Originally posted by sta marine
Doc,
Oddly enough I just had this... The only thing is the bill says complicated abcess, but they treated it as a simple abcess. They cut it and packed it. Mine didn't have any of the indications of a complicated abcess and I didnt get meds. So why the hell am I being billed for it???? Bastards...

Should I go back and say anything? Or will there even be a diffrence in the bill?

thanks,

p.s. See told ya I would come to you with my medical questions.

p.p.s. Holyshit this is getting like BAS. Hey doc don't tell me take motrin and suck it up, LOL
Dude, no worries...if it takes more thn 12 minutes, they have authorization to bill you for a "complicated" visit..and yes, "complicated costs more.

Primum non Nocere

[ussfpa]

Originally posted by frogstyle
Doc,
That is exactly whats on my thigh!..

They should have opened and cleaned it.! Fuckers.
BTW Its only getting worse...
That I chose this topic this week...You were my muse ;)

Primum non Nocere

[ussfpa]

Originally posted by Axe
Sir, this is the kind of forum I love to sink my teeth into!! (Pun intended)

What kind of cracker would one serve that "cheddar cheese" on? And could you recommend an appropriate wine?

Seriously, what factors determine the likelihood of developing sepsis from a close to surface abcess (besides delay in treatment, and also I assume virulence of the infectious agent?). Correct me as appropriate, but abcesses are after all, theoretically walled off, thus limiting spread, but I know that is not 100% true, since they can tunnel, right?

What is the maximum depth one should consider performing an I&D on a subdermal abcess in non-sterile conditions when proper facilities and aid personnel are not accessable? I am offering the hypothetical assumption that we are talking a week or two wait for care in a defervescing patient?

Also, I was instructed to debride white fibrin tissue from a pt.'s incised and drained dehisced surgical site with subsequent MRSA abcess and tunneling by the original surgeon, but you indicate that the white fibrin scar tissue should be allowed to develop. Is this just a difference in technique and treatment, or did the fact that I was treating a relatively large wound allowing for instrument manipulation in the field likely play a role here?
OK...one at a time...
1. Abcesses ARE usually walled off, that is the whole antibiotic thing with a simple abcess...COMPLICATED ones DO tunnel...exactly correct.
2. TOO many factors to determine sepsis vs not...environment, LOCATION of abcess (joint vs muscular area), offending agent (flesh eating bacteria, pseudomonas, staph etc)
3. Depth is a consideration IF you go past the subcutaneous tissue. Short story to follow...follow up care is the key...DRAIN THE PUS!!!
4. When dealing with MRSA (Methcillin Resistant Staph Aureaus) ALL THE RULES CHANGE. Unitl you have 3 subsequent cultures which are negative over a 6 week period, MRSA can generate a re-infection or carrier state in the host. For this reason, you may have been instructed to remove any fibrin matrix present until the 3 "clean" cultures were obtained.
Curious as to how it was a known MRSA pt in the field, though it is not important...the answer remains.

I think I got them all.
Primum non Nocere

[Sneaky SF Dude]

Thanks Doc. This is going well so far. Good questions guys.

[ussfpa]

Man, I live for this stuff...great idea...:D

Primum non Nocere

[Sneaky SF Dude]

We should probably do one on GSWs, since some of the guys are going over still. Any volunteers?

[ussfpa]

No worries Sneaky...but I haven't seen a field GSW in many a moon. Lots of recent experience out there from guys with sand in their shorts...would love to hear from them on the field treatment and stabilization. I can pick up the clinical side from there. Once this "Abcess thing" festers out...;)

Primum non Nocere

[Sdiver]

Originally posted by Sneaky SF Dude
We should probably do one on GSWs, since some of the guys are going over still. Any volunteers?

Yeah Sneaky...fire away.

This is GREAT stuff. Thanks again for bringing it up and starting the thread.

[ussfpa]

While working in the University Trauma Center ED, Syracuse NY there was an obese diabetic woman who presented with "back pain" for 4 weeks.
Physical exam revelaed a 430 lb BLK female who was unable to raise her arms above her head. On removing her dress, a "mass" was evident between her shoulder blades. This mass was a fluctuant abcess. Being the fearless provider that I am, I began draininge with a 50cc syringe and large needle (14g indwelling). After 500cc of pus being drained, I called the surgeon.
The SGN came down, cussing about how he was "above doing simple I&D procedures for incompetent PA's, and WHAT THE HELL IS THAT SMELL!?!" I explained the situation to him as he bitched in the hallway and told him "that smell" was what I had pulled out of this patient so far.
After his intial history examination, this SGN took a scalple blade (#10 for those that know or care) and sunk it 3 inches into this woman's back (painlessly). He then cut a star in the flesh and peeled each of the "points" back suturing them into place to "promote drainage". the wound was THOROUGHLY drained and packed with ove 1 liter of pus being collected and a full 7 oz. of weighed "cheese" being removed. She was placed on oral antibiotics (dicloxicillin) and given a follow up appointment for 48 hours later. Where she was re-packed, her "points" were disconnected, and she presented the SGN with a lawsuit for her disfigurement. She was completely healed within 10 weeks. The suit was (eventually) dismissed.

The point...OPEN IS GOOD, PUS IS BAD.
When in doubt, drain it...with prejudice, no reservations, no second guesses.
Good follow up care is invaluable

Primum non Nocere

[Allison]

Frogstyle- Please go see a doctor darlin, don't let it get worse. An hour with the doc could save you a lot of pain and time in the future.
Hence the story above. I won't eat cheese for a long time now.

[Purple36]

Dude, that was just DISGUSTING. Good thing I already had dinner......

[frogstyle]

dont fret ladies... USSFPA IS my Doc as of now. I believe we are linking up tomorrow..

Back to my wound....

I woke up to take a leak at 0400.

Felt lots of pain from the wound.

Woke up and saw a blood trail that looked as if somebody had been gunned down on my shitter. I was bleeding rather heavily.

And was still oozing.

It took 30 minutes of direct pressure to stiffle the flow.

My theory is that in my sleep the wound grew scab. My knee bent at an odd angle. when I walked to the bathroom this tore the wound open and made me a fresh bleeder...


I am on Augmentin and Vicodin. Between the two I smile and shit all day long....

[Axe]

USSFPA-I retract the declaration in my PM that you had answered all of my questions.

I still need advice on the proper cracker to serve that cheese with. I am hoping Newport Bar Guy can recommend the wine!:p

[Sneaky SF Dude]

Originally posted by Allison
Frogstyle- Please go see a doctor darlin, don't let it get worse. An hour with the doc could save you a lot of pain and time in the future.
Hence the story above. I won't eat cheese for a long time now.

You girls quit baby-ing the SQUEAL. How the hell is he ever going to learn? Froggy, just ignore it (medical term-benign neglect - one of my favorites) it'll be all right, I promise:)

[SOTB]

Originally posted by ussfpa
....1 liter of pus being collected and a full 7 oz. of weighed "cheese" being removed....

So I suppose Clearasil was not an option.........

I re-read this again and only then saw this truly the second time. Its so f**king disgusting I'm without words. <shiver>

[Sneaky SF Dude]

You have to smell it to get the full appreciation. Not cool to puke on the patient, eh Doc?

[RIT_MEDIC]

USSFPA:


Causes of... sir??

Great thread and topics.


James D.

EDITED for kudos

[SOTB]

Originally posted by 2ndgener2b
USSFPA:


Causes of... sir??


James D.

Can I take a pop at it?

Would it have been being a fat tub-of-shit and not using subject's body for anything other than a platform upon which rests the remote control and a bowl of microwaved popcorn?

Oh sorry. Of course she had a hormone condition which caused great increases in weight. Uncontrollable, neither through exercise or dieting..........

(edited to include: and continuously supine on the bed for 4 months)

[ussfpa]

Originally posted by Southoftheborder
Can I take a pop at it?

Would it have been being a fat tub-of-shit and not using subject's body for anything other than a platform upon which rests the remote control and a bowl of microwaved popcorn?

Oh sorry. Of course she had a hormone condition which caused great increases in weight. Uncontrollable, neither through exercise or dieting..........
Well Put! Hmmm.."Pop at it" uh huh...
From her history, MOST of her time was indeed spent "reclining" in front of her TV on her couch which was covered in that heavy clear plastic (for cleanliness). Often only in her bra and shorts since clothes were generally uncomfortable. Soooo, what probably started as a pimple or ingrown back hair (ewww!) was made considerably worse due to the tightness of her body pressing on plastic all day, and her diabetes.
Diabetics have a tendency to "not heal well" due to a number of factors, including decreased capillary blood supply. Add to this the amount of FAT that must be fed by said same blood supply, and you have less and less ability to fight small local infections. Small infections become big infections.
We determined this to be the probable cause from the other numerous blackheads, cysts, and pimples in various stages that were on her back and the backs of her legs.
Ain't medicine pretty :D

Primum non Nocere

And I have puked due to a patient only twice...when I tried to pull a bloated floater by the arm and the critter infested gas filled limb "popped" and fell apart in my hands...and when a guy I was giving CPR to puked in my mouth, but I was young, ahhh the memories :p

[RsovRanger]

Hence the invention of the rescue mask with built in one way valve.

[ussfpa]

Originally posted by RsovRanger
Hence the invention of the rescue mask with built in one way valve.
No shit on that one...smartass LOL :D

Primum non Nocere

[SOTB]

Originally posted by ussfpa
....We determined this to be the probable cause from the other numerous blackheads, cysts, and pimples in various stages that were on her back and the backs of her legs. Ain't medicine pretty :D....

I have been telling everyone I talk to who thinks about going enlisted into the service to consider doing the Ranger Medic to SF Medic then Army PA or Army Doctor route. Reading this doesn't help me with visualizing for them the "rewards" they will find during their career.

Bottom line. Disf**kgusting!

[RIT_MEDIC]

Originally posted by ussfpa
...when I tried to pull a bloated floater by the arm and the critter infested gas filled limb "popped" and fell apart in my hands...

It is definately easier to take the bag to the body rather than the body to the bag sometimes. Mine are usually in the water though. Blew chunks once in my second stage while doing body recovery after drowning victim had been in water 3 weeks with turtles and other fresh water aquatic life feeding on him.



James D.

[RangerX]

I saw this and had to chime in.

Abcessess are indeed nasty, and cheese is no doubt good terminology to use when you witness one.

No Shit there I was at Martin Army Hospital doing my EMT clinicals with one of the funniest guys I ever met as a partner (Dominic Pilla God bless your soul brother) When a Nurse approched us (since we were standing around and feeling pretty useless at the time) says come with me. She goes on to say that we as EMT's may never witness anything like this, but we thought it would be a good experience for you to witness this proceedure. We were both unprepared for what we were about to witness. She led us into the examination room and there was this poor old dude on all fours, ass in the air.....He had the biggest nastiest nutsack. Im talking horse nuts. Yep....Abcess of the scrotum sack. It gets worse... While trying to keep our composure and remain proffessional meantime the room smelled like ass and we were looking at huge horse nuts, the Doc shoots him in the sack with lidocaine. After a few minutes Doc comes back and proceeds to cut a dime size hole around the infected area. He then grabs a handfull and proceeds to sqeeze. You want to talk about Cheddar....Holy shit it came out with catsup on the side. He just kept sqeezing and the prepetual projectile puss just came shooting out. In GOBS!! When nothing more would come out. He then proceeded with hosing the infected area with peroxide that made the paper on the table a huge mass of bubbling puss and blood. It looked like a poorly baked pie. After all was done he jammed the infected area with gauze and wrapped up his nuts. The dude walked out of the ER like John fuckin Wayne. That is all.

RLTW
RR

[SOTB]

....meantime the room smelled like ass and we were looking at huge horse nuts, the Doc shoots him in the sack with lidocaine. After a few minutes Doc comes back and proceeds to cut a dime size hole around the infected area. He then grabs a handfull and proceeds to sqeeze. You want to talk about Cheddar....Holy shit it came out with catsup on the side. He just kept sqeezing and the prepetual projectile puss just came shooting out. In GOBS!! When nothing more would come out. He then proceeded with hosing the infected area with peroxide that made the paper on the table a huge mass of bubbling puss and blood. It looked like a poorly baked pie....

I just wanted to say thanks fellas.

Thanks for not only giving me the required motiviation to skip chow for the rest of the week but for also implanting dynamic images into my brain-housing group for the next time I'm popping some pimple on my ass.

Oh, and after what Frogstyle posted, you can believe that I'm popping it as soon as I know its there.

I thought this weekly thread was going to be about cool stuff, like setting broken bones, giving women breast exams, pick-up lines for nurses, etc.......

[Purple36]

"We determined this to be the probable cause from the other numerous blackheads, cysts, and pimples in various stages that were on her back and the backs of her legs."

Please, oh please, make the bad man go away.......

[Smoothie104]

Originally posted by RangerRecruiter

It looked like a poorly baked pie.





Now that is rich!!

[Smoothie104]

edited and PM'd

[Sneaky SF Dude]

This ain't the "Grooming Tips" thread.

[Chris_L]

http://www.strangecosmos.com/images/picturejokes/10463.jpg

[Smoothie104]

OH GOD!

I almost Yacked on the keyboard.

A couple of years ago I ground off almost half of my little toe, it looked kinda like that

[Teutates]

Just a few comments…

Incising an abscess hurts…. I am not sure why people are posting you won’t feel the cut…you feel it…or rather the patient does….. unless the overlying skin is necrotic (dead) which is very rare.

Lidocaine doesn’t work well because of the purulence…it makes the pH of the tissues acidotic which inactivates the anesthetic… so use it liberally and hope it will help a little…we typically supplement with IV stuff like morphine and versed (pain and amnestic meds)

As for depth of the I&D…typically the abscess does all the work….. you shouldn’t have to make any deep cuts… just a superficial incision and then an aggressive finger does the rest of the work breaking up the loculations. You have to break up ALL the loculations to appropriately drain the purulent pocket… so all fibrinous bands need to be dealt with….they should not be left in place.

Most abscesses are from skin bacteria….. I have seen the “so-called” flesh eating bacteria three times in my career…all patients died…and none presented as abscesses…always just a cellulitis that progresses despite aggressive antibiotic treatment and ultimately excision despite the fact that its never been shown to help…you just don’t know what else to do as you can almost watch it spread hour to hour.

And as already mentioned…treatment is drainage of the pus… and antibiotics treat any associated cellulitis (redness)….. antibiotics alone will never treat an abscess….

Hope this helps….

[Sweetbriar]

Yes, abscesses are painful for the patient. Please do your patients the favour of having your game plan together along with everything you think you'll need to handle the situation BEFORE you start cutting. It helps if the damn procedure doesn't take FOREVER.

signed-
a former patient who has had good treatment
and really, really, crappy treatment.

[ussfpa]

Originally posted by Teutates
Just a few comments…

Incising an abscess hurts…. I am not sure why people are posting you won’t feel the cut…you feel it…or rather the patient does….. unless the overlying skin is necrotic (dead) which is very rare.

Lidocaine doesn’t work well because of the purulence…it makes the pH of the tissues acidotic which inactivates the anesthetic… so use it liberally and hope it will help a little…we typically supplement with IV stuff like morphine and versed (pain and amnestic meds)

As for depth of the I&D…typically the abscess does all the work….. you shouldn’t have to make any deep cuts… just a superficial incision and then an aggressive finger does the rest of the work breaking up the loculations. You have to break up ALL the loculations to appropriately drain the purulent pocket… so all fibrinous bands need to be dealt with….they should not be left in place.

Most abscesses are from skin bacteria….. I have seen the “so-called” flesh eating bacteria three times in my career…all patients died…and none presented as abscesses…always just a cellulitis that progresses despite aggressive antibiotic treatment and ultimately excision despite the fact that its never been shown to help…you just don’t know what else to do as you can almost watch it spread hour to hour.

And as already mentioned…treatment is drainage of the pus… and antibiotics treat any associated cellulitis (redness)….. antibiotics alone will never treat an abscess….

Hope this helps….

ROTTED Flesh has many flavors...and smells, all dependent on the offending bacteria that is eating it. More often than not, most abcess are not "rotting of the flesh" so much as they are "proliferation of the bacteria"

Not to be misleading, I think my original and follow-up posts all stated that Abcesses are painful, that their incision would indeed cause some discomfort, (IMHO morphine would be extremely generous, but certainly can be considered on a case by case I guess...never used it for one myself nor have I seen it used). I would be hard pressed to recall the name of any physician I have ever worked with who I think would consider co-signing a versed scip for an I&D. BUT, that is MY experience and is obviously not yours.
In 99% of the cases draining the abcess relegated SIGNIFICANT relief due to relief of the pressure. I have even lanced peri-anal abcesses that shot clear across the room, one little slice...and all was well with their most personal of worlds.
There are a hundred ways to accomplish the same result in medicine, as long as the prinicples remain as gospel.
And unless an abcess is early in its lovely little life, it has been my exerience that the skin has indeed been necrotic, had a lack of significant pain receptors, and the incision itself has been a minor issue UNLESS you get into healthy tissue.
Not wanting a debate here, understand what I posted just a few lines above...maintain the prinicples, techniques are as varied as individuals.
Not that your experience is wrong, it just hasn't been mine. And with that, I would not concurr with, or recommend some of, your techniques for treatment.

Primum non Nocere

[Doc T]

there are techniques and there are opinions... you stated you wouldn't agree with some of my techniques...not sure i really talked much about the technical aspect of incision and drainage except to say you should open it widely...

drug use would be an opinion.....and perhaps my patients make it to the ER sooner than your patients so that overlying necrosis is rare and therefore healthy tissue above the abscess is what I am incising. I am sorry for all those people in the military that you will be I&D'ing if you give no supplemental meds... pain is pain whether you are stoic and "suck it up" or not...its still felt. Most abscesses with overlying necrosis basically drain themselves... as did frogstyle's abscess when he got up from bed that night.... I agree that incising through necrosis should not be painful but breaking up the loculations would still be....

but again, opinions are just that, opinions....just not sure I'd have any returning patients if I didnt' give pain meds in addition to the lidocaine...they'd look for a more empathetic physician... in the military, things may be different...

just my two cents....

[Chris_L]

My hats off to all of you on here who practice their medical expertise. You have my utmost admiration and I commend you, for dealing with and treating the most ghastly ailments, disorders, and injuries such as the picture of that most terrible brown recluse spider bite that I posted.

My skin crawls every time I look at that picture, it is utterly disturbing, and this from a guy who previously had no fears or worries about spiders whatsoever; that is until I saw that pic and learned the potential damage that a brown recluse spider bite can inflict on human flesh.

[ussfpa]

Originally posted by Doc T
there are techniques and there are opinions... you stated you wouldn't agree with some of my techniques...not sure i really talked much about the technical aspect of incision and drainage except to say you should open it widely...

drug use would be an opinion.....and perhaps my patients make it to the ER sooner than your patients so that overlying necrosis is rare and therefore healthy tissue above the abscess is what I am incising. I am sorry for all those people in the military that you will be I&D'ing if you give no supplemental meds... pain is pain whether you are stoic and "suck it up" or not...its still felt. Most abscesses with overlying necrosis basically drain themselves... as did frogstyle's abscess when he got up from bed that night.... I agree that incising through necrosis should not be painful but breaking up the loculations would still be....

but again, opinions are just that, opinions....just not sure I'd have any returning patients if I didnt' give pain meds in addition to the lidocaine...they'd look for a more empathetic physician... in the military, things may be different...

just my two cents....
I PM'd your XO, (he will know what that means, and probably slap me for it)...
I think what we are seeing here is a small difference in military and field medicine vs civilian side ED medicine.
I understand your experience level and your scope of practice. AND IT IS GREATLY RESPECTED.
I think a point of consideration with these threads though is the field aspect. What are these medics going to carry in their rucksacks? Is the service member going to be functional soon after completion of the procedure in order to complete his mission (training or otherwise).
I have worked in military medicine for 20 yrs (this year) and I worked my first civilian ED in 1985. The two practices of medicine are like dusk and dawn...similiar in appearance, but quite different.
In the original post I believe I suggested doing a deep field block around the area, and that it would be helpful when cleaning out the wound (loculations can be a bit of a dictionary challenge for most of the infantry types). Pain control is a significant aspect of ANY medical procedure...BUT, liberal use of lidocaine in a field environment does something else if there is limited benefit...it uses up all your lidocaine. And guys are FOREVER needing to be sewn up "on the fly". This has to be a consideration to the FIELD medic. The same with administration of most narcs (re: morphine)
The levels to which we ALL go for patient comfort in the CIVILAIN ED can be staggering...why...$$$ and rtn visits.
As you so properly pointed out, people not happy...people don't come back. But I did also mention that it was MY EXPERIENCE that I had personally never had seen the consideration of an agent like versed for this procedure. Even at my most recent civilian employ- the University Trauma Center in Syracuse (where I had considerable experience both fast track and ED proper). I had just never or heard of this being used for something that routinely gets shuffled away from the docs for 3-5 minutes of attention by someone with less important things to do.
I have a great deal of empathy for my patients. I care greatly their level of pain and discomfort. Sometimes however, they DO have to just "suck it up". Patient and setting dependent of course, like the rest of the points in this thread.
Post procedural pain meds are typically low grade oral Narcs sure...but again, operational considerations for the military have to be taken into consideration. We can't have someone gorked out and feeling good if he cant walk a straight line in the woods or safely handle his personal weapon. There has to be a balance struck in the field. Often times in civilian medicine, this balance is not necessarily a consideration.
Doc, honestly, your "2 cents" are disguised in a 24k gold leaf and worth much MUCH more. The experience that you can bring to these boards is overwhelming and greatly appreciated. What I can offer is the result of my experience and schooling only and to try and put it into an operational scenario or setting. The LAST thing I want is to be sharpshooting each other over stuff or for there to be anything less than a learning environment here.
If it turns into that, then we will be doing a disservice to the medics on this board. But they are medics, highly trained, highly skilled, will splint your body with 3 blades of grass, some 550 cord and a bad buys bandoleer spitting beetlenut juice and willow bark on your gums to make you feel better...resources come scarce and they do incredible things with them. That is what this thread is all about.
I hope this clears things up...now can you please sign my chart so I can get back to work???

Primum non Nocere

[Smoothie104]

A couple of years ago I crashed my race bike trying to make a pass on the last corner of the last lap at around 125mph. Broke bones in both feet, 1 collar bone and ground off part of my little toe. I was banged up pretty good. I did the usual post-wad self diagnosis, movements of hands and feet, breathing ok,

While waiting for the meat wagon I asked the corner workers to take my boots off so they wouldnt cut them off later. Freed my busted wing too,for the same reason. They had me somewhat immobilized and I couldn't see my feet. I start getting this wicked burning/stinging sensation in both feet and Im thinking shit, some sort of nerve damage, every time I ask the EMT's whats wrong with my feet they tell me to relax and the Doctors will tell me.

I get to the hospital, they stick me in a room for almost 50 min and no one comes back, so I start yelling "Hey you Fuckers!" as loud as I can. A PA comes in and asks if its me that yelling, I tell him that I've been there for almost an hour with no pain medicine. I ask him whats wrong with my feet, he doesn't answer me. He puts me on the drip though, Demoral and Versed.

My Father is a retired Surgeon, my Brother is in his 2nd Year of residency. Both of them said it was odd that I was given Versed, and that it is an amnesiac as well.

Any thougths or info?


Now I'm flying high, and I mean high. A nurse comes in to talk to me, I can hear her but I can't look at her. I do drool in front of her though. I mumble something about my feet and she says "The doctor will be here soon"


A Doctor comes by and asks If I came from Roebling Road Raceway, I blink once for "yes" and I'm thinking finally some help, but no, he just wants to know who to call to get a track day for his Miata. WTF???? I ask him whats wrong with my feet, because I still can't see them. He looks down at them, scrunches his face up, raises an eyebrow and says "hold on"

When I finally see the Doc, she is a spitting image of the "Weakest Link" host. She says "what the hell happened to your feet?" Jesus.....

That burning sensation trackside? I came to a stop directly on a Fire Ant hill.

All that for a slightly bigger plastic trophy. Not a good Sunday.

[domer4]

Was watching Trauma life in the ER last night. Slow TV night. They brought in some guy who was a tree trimmer. He slipped and fell, on the way down hit a branch that went straight up his asshole. Tore up a bunch of stuff and stopped just short of hitting his lung.

[mbw]

I LOVE that show! Saw that incident.

Mike

[Doc]

Welcome Aboard Doc T!

Glad to have you in here.

Doc

[Sneaky SF Dude]

Welcome aboard Doc T. Share the knowledge.

[Doc T]

thanx for the welcome.....:D

[flashbang]

Originally posted by Axe
USSFPA-I retract the declaration in my PM that you had answered all of my questions.

I still need advice on the proper cracker to serve that cheese with. I am hoping Newport Bar Guy can recommend the wine!:p


Ritz would be the proper cracker with a few glasses of a nice cab. to wash it all down.

Remember: "Every thing sits on a RITZ"



:D Bill

[Purple36]

Originally posted by Teutates
Most abscesses are from skin bacteria….. I have seen the “so-called” flesh eating bacteria three times in my career…all patients died…and none presented as abscesses…always just a cellulitis that progresses despite aggressive antibiotic treatment and ultimately excision despite the fact that its never been shown to help…you just don’t know what else to do as you can almost watch it spread hour to hour.



Question on Flesh Eating bacteria.

A friend of mine recently spent over a week in the hospital and thus far the docs aren't sure what is wrong with him.
Started with a fever that shot up to 104.5. He got to the Emergency room and was admitted. Symptoms other than the fever: Red rash on leg that goes up to groin area and swollen lypmh glands.
Aggressive Antiobiotic treament innefective, now on a cocktail of antifungal/antiobiotics.
Infectious disease specialists still aren't sure what's going on.
Anyone heard of any thing like this?

[Axe]

The symptoms you have listed aren't sufficient to narrow it down much without having a history on the patient, lab results, etc. Hopefully something will grow out of a culture that will tell the docs just what they are looking at. Best wishes for your friend.

[frogstyle]

USSfPA,

See me in the TR. Youre welcome to get a copy of my chart from my Physician and check it out. And post it for the masses to learn from. Sorry I dont have any pics.

And FWIW... The pain was immense. I am no stranger to pain and will say that the packing of my wounds with Iodororm with ZERO narcs onboard was HELL. I had one wound with 7 feet of guaze packed into it. It sucked bad.

[Sharky]

I think I had one of them one time. On the back of my thigh. Swollen, red and hurt like a bitch. Looked like a huge pimple without a head on it. Just a swollen bigass red hump. Murph says go down to the aid station. So, I go down and show Doc (Chief)Hurley. He tells me to drop my pants and get on the table face down. I was nervous about it but did it anyway. Doc was in a mood so I didnt joke around. He walks back with a scalpel. I ask him what hes gonna do. He says cut it open. I say what about some painkiller doc. He says oh yeah, comes back with a rag, says open wide, shoves it in my mouth and says bite. So, dumb ranger bites. Doc cut it open. Nasty green shit went everywhere. He was pissed. Hurt like hell, but like you said, damn it felt good to get that pressure out of there. Relief. He shoved some orange looking skinny gauze in and told me to get the hell out. Made it back in time for PT. Doc always did like me.

[Purple36]

Originally posted by Axe
The symptoms you have listed aren't sufficient to narrow it down much without having a history on the patient, lab results, etc. Hopefully something will grow out of a culture that will tell the docs just what they are looking at. Best wishes for your friend.

Thanks, that appears to be the frustrating aspect of this whole ordeal.....the culture doesn't clear up the mystery, which according to my friend is why they added the Anti Fungal meds to the mix. He's out of the hospital, but apparently not healed. I saw his shin area and it looked like a deep purple burn over the majority of his lower leg. Bizarre. It's never a good sign, when the infectious disease specialists start calling you the "Enigma."

[Axe]

If it were me, I would be getting myself to a tertiary care facility, like Mayo, Cleveland Clinic, Johns Hopkins, Duke, or all of them until someone figures it out. Chances are great that he isn't the first one to have had it, whatever it is, but perhaps the docs at the facility he is at just hasn't seen "it" before.

[Doc T]

Originally posted by Purple36
Thanks, that appears to be the frustrating aspect of this whole ordeal.....the culture doesn't clear up the mystery, which according to my friend is why they added the Anti Fungal meds to the mix. He's out of the hospital, but apparently not healed. I saw his shin area and it looked like a deep purple burn over the majority of his lower leg. Bizarre. It's never a good sign, when the infectious disease specialists start calling you the "Enigma."

how did they attempt to make the diagnosis? just blood cultures? If it was the invasive strep that people tend to call "flesh eating" you'd know by now as he wouldn't be home and he'd probably have more than just his leg involved at this point. If they still don't have a diagnosis did they try taking any tissue biopsies? Has he had any studies to prove deeper tissues aren't involved (ie. CT scan of his leg)? Is it better than it was or just staying exactly the same?

and you are right...its never a good thing when any doctor calls you the "enigma" or a really interesting case...

doc t.

[Purple36]

Doc T, I don't know how they did the biopsies, I'll give him a call.
Hopefully, it will all work out ok.

[Doc T]

And FWIW... The pain was immense. I am no stranger to pain and will say that the packing of my wounds with Iodororm with ZERO narcs onboard was HELL. I had one wound with 7 feet of guaze packed into it. It sucked bad. [/B]

i feel vindicated...see even big strong military men feel pain when you I&D abscesses....;)

glad you got taken care of...


doc t.

[wolfhoundcowboy]

I realize I'm late getting in on this post. I was gone on a clinical rotation last month when I ran into a problem in this area. I had an absess come in to the hospital and the doc looks at it and tells me to do an I&D on it. No problem I had already done 2 that day. I made my incision and nothing came out. After I squeezed and dug around still nothing comes out. I called the doc in and he shrugs and says must have been a cyst. He didnt seem to think his misdiagnosis was that big of a deal. He had me leave it open and told her to go see her normal doc on monday.

My Question is was his misdiagnosis a big deal? Or did it not really matter. Also how do I make a better diagnosis before i go cutting into the wrong thing.

Thanks

[frogstyle]

What a turd... That Doc needs to meet my attorney.

[flashbang]

Originally posted by wolfhoundcowboy
I had an absess come in to the hospital




Ain't never seen a walking absess..............Oh, I get it..You had a patient with an absess.....Completely different.

Quite often an absess will become cystic. It can be hard to tell but in my experience an absess is usually inflamed and hot to the touch, plus a little less firm to the touch.

As a practical matter all the pt.s regular doc is going to do is fish arround a little more find the cyst and pop it out.

Other times you'll see what truly is a combination absess/cyst. A cyst at the center surrounded by a nasty infection. Same tx. I&D it, culture the exudate if you can, pop out the cyst if it's in your skill set to do so and go from there.

[ussfpa]

Originally posted by wolfhoundcowboy

My Question is was his misdiagnosis a big deal? Or did it not really matter. Also how do I make a better diagnosis before i go cutting into the wrong thing.

Thanks
Yes and no...was it a life threatening mistake...no. But, does it DEMONSTRATE that this guy is half assed about the little things...which then would point me in the direction of half assed about the IMPORTANT things...damn skippy it's a big deal.
Your description is still a bit odd. Even cycts have "stuff" in 'em.
Look up EIC Epidermal Inclusion Cyst. This is the most common type which is mistaken for an abcess. This cyst is different from an abcess in that there is no infection present. It is a large pocket of material which we try to take out as an entity. Sac that contains it and all. Otherwise, you just leave a bag there to fill up again.
Look up the differences in the PE of both, you will be able to distinguish them. I will post some of them later today. I'm late for a dive :D

Primum non Nocere

Like Froggy said...guy is a malpractice suit waiting for a good lawyer and a bad day. Indifference in medicine gets people permanently disfigured.:mad:

[Doc T]

Originally posted by wolfhoundcowboy
I realize I'm late getting in on this post. I was gone on a clinical rotation last month when I ran into a problem in this area. I had an absess come in to the hospital and the doc looks at it and tells me to do an I&D on it. No problem I had already done 2 that day. I made my incision and nothing came out. After I squeezed and dug around still nothing comes out. I called the doc in and he shrugs and says must have been a cyst. He didnt seem to think his misdiagnosis was that big of a deal. He had me leave it open and told her to go see her normal doc on monday.

My Question is was his misdiagnosis a big deal? Or did it not really matter. Also how do I make a better diagnosis before i go cutting into the wrong thing.

Thanks

Is there a chance that it wasn't a misdiagnosis but that you failed to enter the purulent cavity with your incision and drainage? A cyst also has fluid so if you did an adequate incision and nothing came out it then the doc calling it a cyst is just one misdiagnosis on top of another... why did you both think it was an abscess in the first place? where is it and what did it look like on physical exam?

Occasionally, if i question whether something is truely an abscess or not I will either stick a needle in it and see if pus comes out or get a CT scan of the area... we have often had patients who had had perirectal/perianal abscesses I&D'd in the ER come back complaining of continued pain and fevers only to find on CT that they were inadequately drained on the first occasion....

doc t.

[flashbang]

I was going to launch into the pilonodial cyst area, not going to do that. I failed ask some important questions prior to my inital reply.

Bill

[ussfpa]

Was when this GORGEOUS young woman came into the Civilian clinic in Watertown NY...walking funny, refused to sit down, etc...
How can I help you today? With tears streaming down her face and a great deal of embarrassment..."My butthole hurts me SOOOO bad" PLEASE! Can you make me feel better?
The exam ensues with my trusty nurse present. The knockout, on knees and elbows on the table, spreading her buttcheaks as wide as she dared due to the golfball sized pearl on the edge of her anus...
This will make you feel MUCH better...one quick slice and pus shoots across the exam room to slap the wall 4 feet away. The nurse goes to vomit and the beauty queen lets out an exstacy sounding moan of relief worthy of a good porno.
The rectal exam that came next pushed the rest of the badness out from the incision, and brought even louder moans and "oh thank you...that feels SO MUCH BETTER's"...10 minutes and it was all over.
When I walked out of the room I got the worst laserbeam eyeballs from the nurses who were listening intently outside :eek:
What took the cake though was when "knockout" came out calling me her hero and offering to take me to dinner :D
Declined the diner, but did get a plate of cookies and a thank you note from her 2 nights later.
Such is a day in the life :p

Primum non Nocere

[RsovRanger]

What would cause that to happen?

I'm a dirty nasty bastard especially in the field but I have never gotten one of these. barely get zits.

[ussfpa]

Originally posted by RsovRanger
What would cause that to happen?

Assuming you are talking about the abcess and not the knockout on her elbows and knees...:D
All kidding aside, putting on the professional hat here...
There can be any number of reasons, ingrown hairs (she did shave / not wax), anal fissures (small tears in the rectum from dropping a major deuce-yes, even the hottest of hotties drop these too...not just Reaper375) trauma from chafing, sexual practices, unclean "marital aids", transferred foreign bacteria from partners genitals / mouth / hands etc...
Self contamination of these wounds can initiate the infection, people's embarrassment is usually what makes them so bad when they FINALLY come in after 1-3 months.

Primum non Nocere

[SOTB]

Originally posted by ussfpa
Was when this GORGEOUS young woman came into the Civilian clinic in Watertown NY...walking funny, refused to sit down, etc...
How can I help you today? With tears streaming down her face and a great deal of embarrassment..."My butthole hurts me SOOOO bad" PLEASE! Can you make me feel better?
The exam ensues with my trusty nurse present. The knockout, on knees and elbows on the table, spreading her buttcheaks as wide as she dared due to the golfball sized pearl on the edge of her anus...
This will make you feel MUCH better...one quick slice and pus shoots across the exam room to slap the wall 4 feet away. The nurse goes to vomit and the beauty queen lets out an exstacy sounding moan of relief worthy of a good porno.
The rectal exam that came next pushed the rest of the badness out from the incision, and brought even louder moans and "oh thank you...that feels SO MUCH BETTER's"...10 minutes and it was all over.
When I walked out of the room I got the worst laserbeam eyeballs from the nurses who were listening intently outside :eek:
What took the cake though was when "knockout" came out calling me her hero and offering to take me to dinner :D
Declined the diner, but did get a plate of cookies and a thank you note from her 2 nights later.
Such is a day in the life :p

Primum non Nocere

ussfpa,,

LMAO. If Terry won't adopt me, will you? And if not, would you consider letting me hang around your work area? Taking out the trash, adjusting lighting when you are cutting, holding your clipboard, etc. Don't mind my vomit (if I do), it won't bother me at all.....

[sta marine]

I think all us guys have the Hot girl fantasy. We're the doctor a HOT young girl has to strip for us to examine her. But Honestly doc, how often is that??? How many times do you have to see dirty, nasty women?