What did I do? (Day -272)

Vet Student Operating

Last night I spent laid awake wondering about the kitten that I operated on. I read recently a quote I in relation to Dr Harvey Cushing that resonated here with me:

“no one has any right to undertake the care of any patient unless he is willing to give that patient all of the time and thought that is necessary, and of which he is capable.”

Did I give the kitten enough time?

Enough thought?

And was I really capable to do what I had done?

Did I know what was going happen once the skull had been covered. Was there going be pressure trapped inside? Was the skin going be enough to protect the brain? Should I have done anything else?

Were my sutures too tight? Is the blood supply to my flap enough? Will it heal?

If I could I would have spent the entire night watching the kitten. The kitten would have been hospitalised. Instead circumstances prevented this; however the kitten was watched carefully by the foster carer that had been caring all week.

I spent hours and hours during the week reading every surgical book I could find with a chapter covering the brain, head or skull. I spent hours looking for case studies and relevant articles in the literature. There was so little. Either it is so common that no one thinks it is worth writing about, or it is so uncommon that no one has had the chance to write about it.

I reached out to some of my contacts asking for advice and got some great support.

There were instructions that the minute anything happened I was to be called. Any time. So in this case no news is good news. However I still laid wondering.

Tomorrow I will see the kitten again to check the wound. And so far today no news really has been good news.

I realise that I love surgery – however it is the outcomes that give me the biggest satisfaction. Knowing that my impact has helped the life of another being is such a reward. However it comes with great responsibility that I must accept.  Every single time that I step up to an operating table I am responsible. That responsibility is why I am laid awake.

I do not yet know whether what I have done is good or bad.

Covering the brain (Day -273)

Rotation flap to close kitten skin

This afternoon I performed the most delicate operation that I have performed to date. I was allowed to perform a skin flap to close up the skin over the kitten with the hole in its head that I wrote about a week or two ago.

Since then the kitten has had two surgeries – the first to clean up the wound and soft tissue as it was very dirty. Then following this a second surgery was performed to remove the fragments of the skull bone that were unfortunately not viable. Since then the kitten has been on antibiotics – and we were waiting for a clean wound so that we could close the skin over the hole in the skull to cover the brain.

This was a relatively simple operation to move some skin from one place to another. However in doing so I was using a scalpel blade just millimetres away from the kittens brain tissue – a single slip wouldn’t really be a good thing.

Now there are many different techniques that could be used for creating and using the skin flap, however I believe that simple is best, and so I created what is called a rotation flap. This is where I take the skin next to the wound and rotate it over the defect.
Rotation flap to close kitten skin

Here you can see where the defect was originally, and then I made my incision along the dotted line on the middle image before then moving this piece of skin over to cover the hole. Different people suture wounds like this in different ways, however in this case I like the half theory. I started my first suture in the top left corner of the wound, then placed my next suture halfway between this and the end. And then placed my further sutures halfway between these spaces as well. For me doing it this way makes a lot of sense as I can see where things are going go bad without losing too much time, or having to change too many sutures to fix them.

So after this the hope is that the skin heals and as the kitten is still growing that the defect in the skull will close up with time.

Is it a brain, skull, or something else??? (Day -283)

Vet student in surgery

I remember many years ago watching ER with Carter dealing with a burn victim and on failing being told it doesn’t get any worse than this. No matter how much time you spend in clinic there are always going be surprises. Especially when you think it cannot get any worse, something will come in and take that place. I’ve seen some horrific things, sometimes enough that I wonder if I sleep if I will get nightmares.

The scary thing is however that a lot of horrific things are also extremely cool. Today was one of those horrific things that was also amazingly cool.

Cool because the kitten was alive. Cool because the kitten was ok neurologically. And cool because it was not something that you will see every day. Actually not sure when you would see it at all.

Now these are where the skills that cannot be taught in the classroom really are tested. I like a challenge, and this is definitely that. When the discussion you are having is whether what you are looking at is skull or dura (the covering of the brain).

Yes. There is a kitten running around. Playing. Drinking. With a great massive hole in its head.

So now to do something? I’ve spent hours and hours in textbooks and cannot find a single mention of what to do. We’ve not got CT or MRI. I so wish we did so that we knew what it was, and what was underneath.

Is there a brain abscess? Dunno… Maybe.

So kitten is scheduled in for cleaning of the wound. And then maybe we will know more.