History & Physicals:
Site Visit Summary:
For my first site evaluation, we reviewed two clinical cases and five pharmacology cards. For the first case, I presented an 80 y/o male with a chronic perianal abscess fistulizing to the rectum. The case was complicated by the area being irradiated secondary to prostate cancer along with having multiple comorbidities. The abscess had been previously drained one year prior with seton placement without resolution. The biggest feedback for this case was for me to focus more on the social history including the patients ADLs and IADLs. Since this is a case of an elderly person who lives alone, it is important to understand what support he has at home and what activities he can perform to prepare for discharge. For instances, without support he would benefit from subacute rehab. For the second case, I presented a 63 y/o female with multiple episodes of ileal prolapse from her ileostomy site that came in with abdominal distention x2 days per her nurses aid. This patient is non-verbal and has severe mental delays at baseline which means I cannot gather any history from her. Additionally, she is property of the state and history from the nursing home was very limited. I chose this case because it highlighted how to diagnose and manage a patient with limited to no history or ability to communicate in traditional ways. The main feedback for this was formatting. I included the general hospital course in the HPI which could have been omitted and the chief complaint should have been from the nurses aid rather than leaving blank.
During the second site evaluation, I presented one case, 5 pharm cards, and a journal article. For the third case, I presented a neurosurgical intervention case of a 36 y/o male who fell down a flight of stairs and was later diagnosed with a intercranial hemorrhage and subdural hematoma with mass effect creating a leftward midline shift. Once again, this is an example of how to work up and manage a patient where the history is limited because the patient was intoxicated in the emergency department and then became unresponsive for the rest of his hospital course. The main take away from this case was determining what further intervention is needed and how to monitor for signs of improvement or decline along with projected prognosis.
Journal Article Summary
Newton K, Dumville J, Briggs M, et al. Postoperative Packing of Perianal Abscess Cavities (PPAC2): randomized clinical trial. Br J Surg. 2022;109(10):951-957. doi:10.1093/bjs/znac225
Registration number: ISRCTN93273484 (https://www.isrctn.com/ISRCTN93273484).
Registration number: NCT03315169 (http://clinicaltrials.gov).
Question: Role of wound packing after drainage of perianal and perirectal abscess (September 2022)
Perianal abscesses are a common colorectal problem that has traditionally been treated with internal wound packing postoperatively with the assumption that this will facilitate further drainage by wicking and preventing premature skin close. However, this practice is not supported by substantial evidence and pain is often observed while removing the packing. This randomized controlled trial set out to assess if non-packing is less painful and if it is associated with adverse outcomes such as perianal fistula or abscess recurrence.
This a multicenter randomized controlled trial of 433 adult participants with a mean age of 42 years old admitted to an NHS hospital (50 different sites) for incision and drainage of a primary perianal abscess that ran between February 2018 to March 2020. Participants were randomized 1:1 to receive continued postoperative wound packing vs non-packing. Thus, 213 participants were in the packing group and 220 were in the non-packing group. Data was collected through symptom diaries, telephone, and clinic visits over a 6-month period, which was all blinded. The primary outcome was pain assessed by pain score on a 100-point visual analogue scale.
Participants in the wound packing group reported higher pain scores those in the non-packing group (38.2 versus 28.2 on the pain scale with a mean difference of 9.9; P < 0.0001). The occurrence of fistula-in-ano was low in both groups: 32/213 (15 per cent) in the packing group and 24/220 (11 per cent) in the non-packing group (OR 0.69, 95 per cent c.i. 0.39 to 1.22; P = 0.20). The proportion of patients with abscess recurrence was also low: 13/223 (6 per cent) in the non-packing group and 7/213 (3 per cent) in the packing group (OR 1.85, 95 per cent c.i. 0.72 to 4.73; P = 0.20).
Based on this data, fistula formation was 4% lower in the non-packing group and abscess recurrence was 3% lower. The study concluded that avoiding abscess cavity packing is the superior treatment as it is less painful without a negative morbidity risk. Based on this data, UpToDate now recommends avoiding wound packing after drainage of perianal and perirectal abscesses.
Typhon Case Logs:
During my surgical rotation I was exposed to a plethora of different surgeons and residents. I had three weeks of general surgery, one week of neurosurgery, and one week of urology. This diversity allowed for me to be taught by many different people and have a well rounded experience. The first thing I learned was how to do deep-dermal and subcuticular sutures. Prior to my surgery rotation, I was only familiar with how to throw simple interrupted sutures. On my second week, I began to learn how to tie a two handed surgeons knot and later on a one handed surgeons knot. I was suprised to learn there is even an art to cutting the knot properly. This rotation challenged and sharpened my understanding of anatomy. Five weeks later I feel much more comfortable with knowing muscle groups, vasculature, and landmarks than I ever have before. I remember during the first appendectomy and cholecystectomy I observed I had no idea what was going on or what I was looking at but by the final week I not only understood what I was looking at, I was able to know nearby structures and the general steps in completing the procedure. I referred the book “Surgical Recall” prior to each case to refresh myself on the most important anatomical structures and clinical pearls of the disease process/surgery being performed which I found very helpful. When the surgeon would ask me questions related to the case I felt confident answering them most of the time thanks to that book.
I also accepted an offer for my first job as a PA which is for a position in the emergency department. I think a lot of the practical suturing skills along with the workup for common surgical diseases will carry on with me in my new position. It gave me great insight to know what labs and imaging the surgery team is expecting prior to consulting them and also to know what is a surgical emergency versus what is elective or urgent.
Surgery has always been something I was curious about and could have seen myself doing, however, after this rotation, I realized that although i enjoyed my time I do not think that a career in surgery is best suited for me. I personally felt that I would not have as much autonomy as I would like to have if I chose a career in this area of medicine. However, I did not get experience in the outpatient setting so perhaps that setting allows for more autonomy than in the OR.
Overall, surgery was a great rotation for me to end with because it solidified both what I want and do not want in my career moving forward and was a great review of all organ systems from both an anatomical and medical standpoint.