I & D

One of the generally most recognized things in medicine is that an I and D procedure is one of the most rewarding experiences in it.  I and D stands for incision and drainage...of an abscess...I know...this sounds pretty disgusting...it is, but there is something so symbolic about removing the infection...draining it away.  It's like the puss and nastiness stand in one to one with the patient's pain and as you lance and remove the white curds and slime the patient's pain subsides and they are instantly better...like magic...few healing events in medicine come so quickly and with such little cost to all involved...all the patient must do is open up...literally.

The human immune system is quite an amazing thing.  It has an incredible built in memory, a cascading response system, and very few weaknesses...that being said it does have them and occasionally it runs into something which it can't fight off, kill, or digest.  When it does run into something such as this, it does a very logical thing, it creates a quarantine called an abscess.  The area around the infection or damage becomes so inflamed and swollen that the swelling (edema) closes off the blood vessels entering the area...effectively all routes in and out are cut off, leaving the invader to grow, multiply, and war with the white blood cells; but only in the area which the body has surrendered.  This counter measure of the body isn't a solution, it's a last ditch effort to keep the intruder from taking over the body and with it comes some untoward consequences.  The top three problems in forming one of these quarantine areas in the body is that, one, the bacteria isn't dead and there is still a high risk of "seeding" the rest of the body, two, if nothing comes out and the bacteria continues to grow a significant amount of pain can be caused by the ever expanding ball of puss inside your body, and three, the abscess protects the invader from blood born treatments such as antibiotics because if nothing can get out through the blood vessels, then nothing good can get in.  So in medicine and in life there comes a certain point where the pain is too great and the treatment hindered too much by the walls you put up around your embarrassments, your fears, and your failures and it's then that the site has to be opened and drained away or your risk loosing yourself, maybe your soul to it, of thinking only of that pain, and forgetting yourself and the love you have for those around you.

I hope that you never have to sit in front of loving parents and tell them that you don't know whats wrong with their son, that something is attacking his brain, and you don't know what it is.  All the tests I can offer, all the treatments that may become a possibility once we know what it is, none of that counts for anything against a child that looks like a walking skeleton, their child.  I walked out of the hospital this morning thinking I handled it very well....I did...but as the day went on I felt it eating on me, I felt the abscess growing and here I am typing this hoping this will afford me some comfort, maybe drain me of some of the poison in my veins...though I'm not sure I deserve it.

Newbie Doc

Catching A Break

So I was in the ED the other night and a little 6 year old boy came in who had been playing at the park on a bench about 4 feet up. Unlike most of the children who come in here with a cough and a fever or a splitting headache...maybe even a split head...this one had fallen just so on a cement curb and halfway up his right forearm had snapped it backwards at 45 degrees. Now I had heard that should something such as this occur we were, as interns, expected to do the brunt of the treatment which means managing the sedation, reducing the fracture, and casting the poor soul...this is all under the supervision of someone who is skilled in all of this (my attending). Now I've sedated probably 10 or 12 children and I've placed casts and splints on a whole lot more, but I have never manually reduced a fracture. The majority of fractures that you see are hairline and only need support or they are fractured in such a way that you don't dare mess with them (ie. Cranial fractures or growth plates)...but this kid had landed on his arm just right and thanks to his thoughtfulness...or thoughtlessness that night I got to see and feel exactly what resetting a broken arm feels like. With trepidation I fixed my mask tight on my face, no smiles, no frowns, no wide eyes of terror would peak out from behind the frozen visage that had become my face. I wrapped my hands around his forearm just below the break and placed my thumbs over the two bones in the forearm above the break. As I had been instructed I
thrust my thumbs foreward pushing the broke arm suddenly into perfect alignment. Possibly it was the addrenaline giving me extra reserve...but maybe it was that easy...the was a crunch and snap like twisting a piece of cellary to breaking or snapping a dry twig and suddenly the arm was back in alignment and the repeat radiograph looked like perfection. It was done and so was I, in the mere seconds that seemed to elapse while treating the boy it seemed that an actual hour and a half had passed...as I walked out of the hospital to my car in the dark I allowed myself a great big smile...it had been a great night.

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