Medicine From The Trenches

Experiences from undergradute, graduate school, medical school, residency and beyond.

Memorial Day at the Veterans Hospital

Typical Wound Rounds

It was one of those typical wound rounds days at our VA Hospital.  We made our (the complete vascular surgical team) over to the long-term care wing of the hospital to do our weekly check of patients who didn’t have formal vascular clinic appointments or who were bedridden with chronic wounds. The mid-level practitioners would put names of patients on a list at the nurses station for us to check.  The patients who were ambulatory or wheel-chair bound would return to their rooms so that we could  check them as we made our way down a T-shaped hallway with two long wings. The entire process generally took from 2-4 hours depending on how many patients to see and how extensive the wounds were and what care was needed.

The hallways

Most of the rooms down these hallways were semi-private (2 vets to a room) with a ward (4 vets to a room) at the proximal ends. At the end of the hallway were the private rooms for those vets who were in isolation for infections or for those who were too loud or ventilated  and would not be amenable to sharing a room with another vet. The rooms at the far end of the hallway, though private, had views from the window that rivaled any 4-star hotel. They overlooked the front grounds of the hospital and the baseball diamond. Flying in the breeze was the state flag, the POW-MIA flag and the flag of the United States. The entire VA complex sat upon a hill that overlooked the surrounding town and mountains in the distance. No matter what time of year, the views were spectacular and I always paused to admire nature’s show for these men who had given so much.

Chronic Wounds

We made our way from room to room. Many of these patients were post toe amputations and needed wound checks. Others were diabetic with foot ulcers from poorly fitting shoes or injuries that they could not feel and thus the wounds had become infected.  Many of the vets were long-time smokers and diabetics with peripheral vascular disease  from smoking and neurovascular disease from their diabetes.   Some were despirately trying to “keep their feet” while others had both lower extremities amputated starting with the toes, then the feet and finally the leg above the knee. With each room change, there came a new challenge or a new evaluation. We removed dressings, evaluated vascular supply and made recommendations for each patient. With each week, I grew to know these patients and to learn to predict whether the wounds would heal, or an intervention was needed, or progression to limb amputation. Sometimes it wasn’t wonderful to tell a patient that he would lose his foot but a good amputation with a well-healed stump could mean a return to ambulation and increased freedom. It was the progression of things each week.

Moving toward the end of the hall

This week, we decided to divide the duties with the interns doing post op checks and the more senior residents examining those patients who needed evaluation for possible surgical interventions. I elected to see the last two patients who were bedridden and in isolation for MRSA (meth resistant stap aureus). I knew that these guys had extensive wounds that would take some time inspect, debride and re-dress. I loaded my pockets with enough bandages for the dressing change and left my coat on the cart outside of the door as I donned the yellow isolation gown, a mask , gloves and shoe covers. I greeted my first patient and set to work removing the old dressings.  We had ordered that dressings be changed every six hours on this patient but it was clear that his dressings were being changed daily instead of three times daily.  How was this wound going to heal? It’s the wet to dry dressings that debride the wound and help to clear the necrotic tissue that would promote healing.  I chatted with “George” as I completed the inspection and dressing change. I left my initials, the date and time on the outside of the dressing. If this was still here in the AM (I had planned to stop in early and check), I would be writing an incident report. If George was to keep his leg, this dressing needed to be changed. For George, a very pleasant gentleman who was post stroke, this was limb salvage.

The last room

I moved into Fred’s room after I cleaned up and washed my hands from George’s wounds. It was now well past dinner time and the sun was low in the sky. Fred’s bed was facing the beautiful setting sun. Fred had congestive heart failure, diabetes and emphysema. He was a small thing gentleman with bright blue eyes that still held a twinkle when you greeted him with “Semper Fi”. Fred had been a marine and by his looks, a real scrappy guy. I always chatted about baseball with him and he loved the company. Sometimes he sang “Take Me Out to the Ballgame” off key as I worked on his infected decubitus ulcers. Twice we had taken Fred to the OR for surgical debridement where we cleared away foul-smelling dead tissue down to the bone. Fred had little tissue left on any of his pressure points and had been failing rapidly.

Today, Fred appeared to be dozing quietly in the setting sun. I touched his hand which was wrinkled and warm. I noticed that Fred wasn’t breathing and had likely died a few minutes earlier. He looked peaceful and happy as the sun’s last rays of the day were settling on him. On the ball field, one of the local town teams was finishing up a game. Most likely, the last thing that Fred saw was his beloved baseball and a beautiful May sunset. To the man who had given so much so that I could come and dress his wounds, God had given one last baseball game in sunset.

There are thousands of veterans in hospitals around the country presently. They love company and they don’t care if you are not related to them. They are very appreciative of everything that we do for them. Many times, the interns and medical students would complain about wound checks but for me, they are the highlight of my week. I might make a difference that will allow a vet to keep his feet or I might be reminded of how special these guys are and why I love what I do and have the opportunity to do it because of them.


25 May, 2009 Posted by | surgery | 1 Comment