Consulting with wet pants… but it could have been much worse.

You know you’re in trouble when, during a routine skin excision, you start wishing you’d ordered cross-matched blood. Okay, so maybe that’s a slight exaggeration, but as the pulsing deep temporal artery spurted like a Yellowstone geyser, I started wishing that the infiltrative BCC had chosen to infiltrate somewhere else.

Bleeding in surgeryI summoned my colleague for help, calmly mentioning that I was “having a slight problem with haemostasis” in an attempt not to alarm the patient — the statement being reminiscent of Monty Python’s Black Knight saying “It’s just a flesh wound” after his arms were amputated. Several artery clips and ligatures later, we managed to tie off all three of the arterial branches that had been transected as they traversed the tumour excision margins.

The specimen was removed, the defect repaired uneventfully and the patient left the surgery happy enough. Those of us left behind (including the nurse facing the mess, the backlogged patients and my now-running-late colleague) were not as chipper, but the only real casualty was my outfit.

My new blouse and favourite trousers had been sprayed, liberally and repeatedly, with scarlet. I felt like a living piece of modern art. After rinsing out these offending items, I was suddenly faced with a teenaged-girl-like “I have nothing to wear” crisis, but fortunately was able to scrape over the respectability line by putting my dark-coloured trousers back on and borrowing a cardigan to go over my undershirt.

Having wet pants is not pleasant but, according to the Medical Board, it’s preferable to consulting with no pants at all. I wished I’d worn a gown, but it’s not standard procedure and I didn’t expect to be Jackson Pollocked.

I try to live life by the six Ps (Prior Planning Prevents Piss Poor Performance), but the truth of the matter is that surgical challenges, like everything else in medicine, can catch you unaware. Our medical training teaches us to respond coolly and logically under pressure, but the fight or flight response can result in unwise decision-making, particularly in the inexperienced.

I recall a story I was once told of a GP registrar who got into trouble excising a skin cancer, when, unable to close the defect, he panicked and decided to reattach the lesion. Yes, you read correctly. He took the specimen out of the jar and started to sew it back onto the patient’s leg.

I’m not sure how he planned to explain his actions to the patient, or whether he even realised that the hole he was digging for himself was far bigger than the one he was filling with formalin-soaked tissue.

Personally, I’d much rather get timely help to save my skin than struggle on alone in an attempt to save face. Anyway, the story goes, the practice nurse had the nous to alert another of the practice’s GPs, who swept in and saved the day.

Thanks to my colleague’s skilled assistance, my surgical “uh-oh” experience also had a happy ending. The histopathology came back with clear margins, the patient’s post-op course was smooth, his wound healed beautifully and the blood washed out of my clothes without staining.

I’ve been left with a much better appreciation of the anatomy of the deep temporal artery and some good hands-on practice at clipping and tying off its branches, although I’m going to try to steer well clear of that particular artery in future.

It could have been a lot worse: I could have been wearing white.

(The involved patient has consented to having this published)

First published in Australian Doctor on 7th September, 2012:  On getting help

http://www.australiandoctor.com.au/opinions/the-last-word/the-last-word-on-getting-help

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What it means to be an Australian – with skin cancer

Each year on the 26th of January, Australia Day, Australians of all shapes, sizes and political persuasions are encouraged to reflect on what it means to be living in this big, brown, sunny land of ours.  It is a time to acknowledge past wrongs, honour outstanding Australians, welcome new citizens, and perhaps toss a lamb chop on the barbie (barbecue), enjoying the great Australian summer.  It is also a time to count our blessings.

We whinge a lot about our health system.  While I am certainly not suggesting the model we have is anywhere near perfect, it could be a whole lot worse.

Dr Justin Coleman recently shared this NY times article via Twitter @drjustincoleman

It talks about the astronomical and ever-rising health care costs in the US and suggests that this, at least sometimes, involves a lack of informed consent (re: costs and alternative treatment options).  The US is certainly not the “land of the free” when it comes to health care.

There are many factors involved, not least being the trend in the US to provide specialised care for conditions that are competently and cost-effectively dealt with in primary care (by GPs) in Australia.

The article gives examples such as a five minute consult conducted by a dermatologist, during which liquid nitrogen was applied to a wart, costing the patient $500.  In Australia, (if bulk billed by a GP) it would have cost the patient nothing and the taxpayer $16.60 (slightly higher if the patient was a pensioner).

It describes a benign mole shaved off by a nurse practitioner (with a scalpel, no stitches) costing the patient $914.56.  In Australia, it could be done for under $50.

The most staggering example of all was the description of the treatment of a small facial Basal Cell Carcinoma (BCC) which cost over $25000 (no, that is not a typo – twenty five THOUSAND dollars). In Australia, it would probably have cost the taxpayer less than $200 for its removal (depending on exact size, location and method of closure).  The patient interviewed for the article was sent for Mohs surgery (and claims she was not given a choice in the matter).

Mohs  (pronounced “Moe’s” as in Moe’s Tavern from The Simpsons) is a highly effective technique for treating skin cancer and minimises the loss of non-cancerous tissue (in traditional skin cancer surgery you deliberately remove some of the surrounding normal skin to ensure you’ve excised all of the cancerous cells) . Wikipedia entry on Mohs  This can be of great benefit in a small minority of cancers.  However, this super-specialised technique is very expensive and time/ labour intensive. Perhaps unsurprisingly, it has become extremely popular in the US.  ”Moh’s for everything” seems to be the new catch cry when it comes to skin cancer treatment in the US.

In the past two years, working very part time in skin cancer medicine in Australia, I have diagnosed literally hundreds of BCCs (Basal Cell Carcinomas).  The vast majority of these I successfully treated (ie cured) in our practice without needing any specialist help. A handful were referred to general or plastic surgeons and one, only one, was referred for Mohs surgery. The nearest Mohs surgeon being 200 kilometres away from our clinic may have something to do with the low referral rate, but the fact remains, most BCCs (facial or otherwise), can be cured and have a good cosmetic outcome, without the need for Mohs surgery.

To my mind, using Mohs on garden variety BCCs is like employing a team of chefs to come into your kitchen each morning to place bread in your toaster and then butter it for you. Overkill.

Those soaking up some fine Aussie sunshine on the beach or at a backyard barbie with friends this Australia Day, gifting their skin with perfect skin-cancer-growing conditions, may wish to give thanks that when their BCCs bloom, affordable (relative to costs in the US, at least) treatment is right under their cancerous noses.

Being the skin cancer capital of the world is perhaps not a title of which Australians should be proud, but the way we can treat them effectively, without breaking the bank, should be.

Happy Australia Day!