The Missing Gauze
It seems like as the years pass, I am seeing more and more abscesses in the ER. Hardly a night goes by that I don't incise and drain at least a couple of boils, and occasionally I'll see a couple more "wound checks" of abscesses previously drained by another doc. More often than not, these abscesses will have been packed with iodoform gauze. Just pull the string, pat the patient on the back, and move along.
Not this time. The gentleman in room 5 has already removed his dressing to reveal a one cm incision without any gauze sticking out of it.
"Looks pretty good," I said, thinking this patient would be even quicker than the typical wound check. Not so.
"I can't find the packing," he said. "I think it's inside there somewhere. I checked the bandage, the floor, everywhere." At home, of course, where he had removed the dressing.
I looked closer at the wound, gave it a little squeeze. No pus, just some blood tinged oozy stuff. Definitely no sign of any gauze. I wondered aloud how much gauze the other doc had packed it with.
"It seemed like a lot," said my new patient.
Hmmmmm, thought I...no way in heck is there any gauze in that wound. With a teeniny little incision like that, the gauze is much more likely to have come out than worked it's way inside...but I can't just not check.
"I'll have to numb you up a bit so I can look around in there." So I give him a local, I gently spread apart the edges....nothing. I scooped across with forceps....nope. Irrigated a bit, then dissected gently, then probed some more, finally extended the incision, looked harder, probed deeper....nothing. It just wasn't there. But maybe it was, how could I be sure?
So I told him to come back to see the guy who packed it originally, since only he knows for sure how much gauze he packed the wound with.
posted by scalpel at 8:50 AM
8 Comments:
Personally, I think packing is overdone, especially the iodoform tape variety. My reasons are: I'd often see people in ER followup (in our community, the ER docs generally referred their victims to the surgeon on call for that day, which means they never saw their own results. A bad idea) with big abscesses opened too minimally and packed so tightly that there was no effective drainage. The goal is adequate drainage, in which case packing is unnecessary, except as done for wound debridement. On the other hand, I came, over the years, to drain some things less widely than I was trained, when there were cosmetic considerations. Nevertheless, packing with iodoform can't make up for inadequate drainage. My opinion, for what it's worth.
Thanks for commenting. You packed many important points into that tidy post. :)
I try to follow up most of my own laceration repairs in the ER (unless they need further evaluation by a specialist) even if I have to adjust my preferred suture removal date by a couple of days either way. It's a bit harder with abscesses, given that the packing can't stay in too long and considering the sporadic nature of ER shiftwork.
If I lived in a small town I'd follow up everything myself, but I can't see driving 45 minutes each way just to pull out a string.
We have an absolute epidemic of community acquired MRSA abcesses in our community. Initially we saw them in the meth users but now we are seeing a great deal of children. We were treating with Septra and Clinda and now are seeing some cases of Septra resistance,scary!
I don't pack much either. What I do is incise generously and take a plug of skin, either a diamond shaped or half diamond shaped piece depending on the area and cosmetic considerations, of course. Most people bluntly disect with a Kelly forcep. I find this to be way too inadequate. I always stick my finger in to muck around and break up the loculations. Sticking a finger in there is a must to size up the cavity. Yes, drainage is everything. I've never had a bounce back/failed I&D with this practice, even with MRSA. None of my I&D ever ended up later in the OR and the hands or a grumpy surgeon.
Anonymous 10:07
In my area, MRSA is very succeptible to Rifampin. Clinda is ineffective. Septra and Doxycycline/Tet resistance is already rearing its ugly head.
Wide incision and drainage is still key.
In this area, doxycycline or Bactrim are the first line drugs most of us use, although I see a lot more bounce-backs with Bactrim than doxy. Clindamycin is the one we use for backup or initially more severe cases. Zyvox use is still not widespread, but if clinda resistance developed down here, I'd be all over it.
I personally try not to cut any more than is necessary, and I would only excise necrotic tissue. It seems to me that the "ripeness" of the abscess determines how wide an incision is required for adequate drainage. I rarely find it necessary to incise more than half the width of the boil, and I would add that irrigation of the cavity after breaking up the loculations can be helpful.
I generally pack all but the simplest of abscesses.
Who are you Scalpel or Sword?
Does anyone know how often repacking should be done? I had a 4 inch incision on the back of my thigh (Mon.) with directions to return Wed. I will drive 45 min. to a bigger clinic - I live in a small town. I'm also concerned about working. I'm a teacher who runs around school all day. Any ballpark figures about when I will go back to work??? Thanks for any info.
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