Wednesday, June 13, 2007

My Cavs are about sunk. It would be nice if professional basketball players could knock down wide open jump shots. It's been their achilles heel all season. Nobody on the squad has a reliable J. Lebron gets triple teamed, passes to the open man and, time and again, Marshall or Jones or Sasha or Gibson clangs a brick. Must be frustrating as hell for the King. And we have no cap room to sign anyone of significance this summer. Marshall, Hughes, and Damon Jones (all signed in the summer of 2005 when we had a gazillion dollars in cap room) have all turned out to be complete busts. Danny Ferry (who killed our team when he was a player, i.e. the Ron Harper trade) seems to be looking to do the same thing as a GM. He needs to start taking some heat.

About a week ago I operated on a 85 yo lady for fulminant c difficile colitis. She had peritonitis, metabolic acidosis, the whole she-bang. Thankfully, she weighed maybe 95 pounds, so the proctocolectomy took about an hour and fifteen minutes. She had been doing reasonably well post op until yesterday morning when her skin looked very erythematous at about the midpoint of the wound. I was obviously concerned about a wound infection, so I removed a couple of staples only to encounter serosanguinous fluid and a loop of bowel poking out. She had a persistent ileus, and her albumin was 1.2, so dehiscence was not unexpected. (maybe I should have put retaining sutures in, but sometimes that's difficult with an ileostomy.) I took her to the OR because I was worried about her eviscerating in the ICU. The suture knot was intact, but her fascial edges were completely non-viable. The PDS had simply tore through the gummy fascia with the increased abdominal pressure from the ileus. So how do you close the abdomen? I actually used the biologic alternative Alloderm (an acellular dermal substitute) and sutured it circumferentially to the rectus sheath with running prolene. Voila, tension-free bridging of the gap. The only problem with Alloderm is that you have to wait at least 20 minutes for the damn stuff to sit in saline. It comes out of the package hard and chalky like drywall and you just have to wait for it to become fully saturated. That's a major problem, as far as I'm concerned. Sometimes you don't know what size you need until you're ready to use it, so you can't always start the soak business as you're prepping the patient. It's a pain in the ass, frankly. The other material out there is called Permacol. I used it as a resident. It's actually small intestinal submucosa from a pig. It comes out of the bag ready to use (albeit with a reeking odor) and it seems to work just as well. These new biologic alternatives to abdominal wall closure are a great resource, especially in contaminated cases.


Dr. A said...

Bummer about the Cavs. Hope they can win one or else sports talk radio will call this debacle "The Sweep."

Lizzie said...

Hi Doc, glad you have joined the blogging community. I enjoy your writing and getting your perspective.

Jeffrey Parks MD FACS said...

thanks lizzie... how long the hiatus?