Has anyone ever lured the on-call surgeon out of the mess?

Apologies for the delay. A mixture of on-calls, time off and working on other medical education projects got in the way. Also, I couldn’t find the ? ST Elevation patient’s notes until this week as he had left, and I had to track his hospital number and discharge summary to see what happened.

Drum roll.

Coronary Angiogram (normal angiogram from a different patient)

The angiogram showed a near complete occlusion of the anterior descending coronary artery. I assumed this meant it really was a STEMI, but it turns out this angio result does not prove much beyond the fact he has ischaemic heart disease. I learnt from the interventional cardiologist that the level of occlusion does not in itself actually prove as much as you would think, unless it is a total occlusion or you have a past angiogram to compare it to. Just like in peripheral vascular disease, collaterals develop in chronic ischaemic heart disease.

The clinical outcome of the two revascularisation methods depends on:

1. The total number of diseased vessels revascularized (more vessels–> CABG > PCI)

2. The presence or absence of diabetes. Not only is atherosclerosis more common in diabetes, but it is also more aggressive. This is probably why completely replacing the furred up artery rather than propping it for a little while longer before it re-occludes makes sense.  Some schools of thought feel that CABG should be preferred in all patient deemed to have rapidly progressing coronary artery disease.

3. Left main disease (if present –> CABG > PCI)

4. Left ventricular dysfunction (if present –> CABG > PCI)

In light of the clinical history, the type and level of occlusion (single vessel, not left main stem), the lack of diabetes, decent left ventricular function and the patient’s fitness for intervention, PCI was preferred over CABG and performed there and then. Boom.

A few days later, my consultant gave me the task of referring this patient with extensive venous ulcers to the vascular surgeons.

Beautiful venous ulcer. Did not interest the surgeons.

Normally, this would be pretty straightforward. However, at my hospital there is an excommunicated on-call surgical registrar who has to decide whether or not to refer the patient to the real surgeons 30 minutes drive away. Making a referral to him is greeted with all the enthusiasm you would expect Tim Cook to have for the Galaxy S3 launch party.

The fact that the patient had these ulcers for 8 weeks did not convince the surgeon to come.

The fact it was deeply troubling the patient, who could not leave the house as he could not wear socks, did not convince the surgeon to come.

“Have you taken a swab?”

“No – there are no clinical signs of infection.”

SIGN guidance on signs of infection: cellulitis, pyrexia, increased pain, rapid extension of area of ulceration, malodour, increased exudate. Swabbing wounds without signs of infection is pointless, as all wounds will be colonised. Colonisation does not impair healing.

“Is there any slough?”

My surgery pathology abandoned me. I could not remember the definition of slough.

“I’ll check”

A google search later, and armed with my textbook definition of white-yellow fibrin that is adherent to the surface of a wound that does not wash off with simple irrigation, I confirmed that there was no slough.

“Fine. What are the obs?”

“Stable, apyrexial.”

“So why do you need me now?”

“It looks really bad.”

His unimpressed silence wouldn’t end.

Much as I hate to admit it, looking back, he was probably right. According to NICE, “necrotic material or slough within a wound margin which acts as a medium for bacterial proliferation and therefore should be removed by debridement”. The size of the ulcer in itself is not an indication for anything urgent.

The patient could be managed as an outpatient, despite the extensiveness of the ulcer. Provided there was no concern regarding a different diagnosis (e.g. neuropathic ulcer, arterial ulcer, rheumatoid ulcer or Marjolin’s ulcer) and no features of an acute need for debridement (signs of infection including odour, necrosis or slough), then there is no need for any urgent action. The patient could have an ABPI done, and provided that was >0.8 a non adherent compression multicomponent bandaging could be used. The SIGN guidelines also suggested that:

“Use of pentoxifylline (400 mg three times daily for up to six months) to improve healing should be considered in patients with venous leg ulcers.”

The surgeon was right this time. Next time, I’ll arm myself with the guidelines.

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