Urology Pearls: Was it actually just a cut?

Editor’s note: This is the second in a two-part series on this topic.

When Dr. A.’s condition got worse, it was time to take to the knife. His doctors moved quickly for there was no time to waste. It was not the kind of hurry seen at a hotdog eating competition where contestants swallow hotdogs whole; the doctor’s arm was not taken off at once, but the way a Hungarian man cuts into his salami – with consideration, and one piece at a time.

Yes, I am talking about Dr. A. whom I introduced in my last column. Here is a summary of what happened: Dr. A., a 51 year old surgeon was cleaning the fish he had caught using a fillet knife when he noticed that he accidentally cut the tip of his ring finger. Just a cut, he thought, as he stopped the bleeding by applying direct pressure to the open, fresh wound.

Twelve hours after his injury, he awoke with throbbing pain in his fingertip. A dose of antibiotics did not help. The pain increased, and his finger became red. Several hours later, his temperature spiked to 100.5 F, then to 101.3. He could no longer move his ring finger. It was tender to palpation and swollen.

At the hospital, Dr. A. became sluggish and apathetic. Without urgent intervention, his doctors realized, his condition could further deteriorate; he could lose not just his finger, but his life.

In the operating room, lights on, wrapped in scrubs, and ready for action, Dr. A.’s doctors noticed a long streak of redness extending from the tip of his finger all the way to his underarm. Ominous, dark clouds quickly descended upon them, and sweat broke out on their upper lips, under their surgical masks. Were the bacteria moving along Dr. A.s arm?

Were they spreading the way bacteria sometimes do in the upper extremity: first by gaining entry through a cut, then by moving along the ‘underground channels’ — the small gaps between muscles and the envelopes of connective tissue that surrounds them — escaping the molecules of antibiotics, invisible to the immune cells, the ‘soldiers’ of Dr. A.’s kingdom?

The doctors cut into the skin and deep into the sheath that surrounds the muscles and tendons in the infected finger. They saw cloudy fluid slowly oozing from the wound. They washed the wound with copious amounts of salted water. They left it open to allow the infection to drain, to air, to clean itself from the inside out. They prescribed antibiotics that would cover all imaginable bacteria: bacteria living in seawater, bacteria dwelling on fish, and resistant bacteria that colonize health care providers such as Dr. A.

On the next day during evening rounds, Dr. A.’s temperature continued to rise, he lost sensation in his ring finger. His ring finger became necrotic (medicalease for it was still attached, but it was literally dead).

Back in the O.R., the doctors removed the necrotic finger and opened the sheath that surrounds the muscles and tendons of the ring finger in the hand and along the forearm. They extended the antibiotics coverage.

In the following morning (fourth day after the injury), the pain continued. The doctors performed more surgery: more irrigations, and cutting deeper into the sheathes of the hand and the arm.

Agony. Fear. Horror.

When a wound heals, when a patient is cured, both the doctor and the patient laugh together. When a wound refuses to heal, when a cure is out of reach, when hope dissipates, when the realization of finality sinks in, the patient cries and his doctor cries too.

And that, I believe, is what happened to Dr. A. and his doctors. Later that day, the fever kept spiking, the pain worsened, and the doctors gathered. They looked at their patient, one of their own, a surgeon whose livelihood was dependent on his manual dexterity. They knew what needed to be done. They took him back to the operating room and amputated his forearm. Doctors call it guillotine amputation for it is as pleasant as the French Revolution.

Over the next several days, A.’s condition improved. The fever abated and there was no sign of infection. Six months later, The New England Journal of Medicine reported, “he was fitted with a prosthetic limb and returned to his clinical practice in a modified role.”

I told you that of all curses none is as evil as this one: may your doctors find your illness interesting enough to describe it in a case report. The case of Dr. A. proves my point. But there is a slightly optimistic, bittersweet conclusion to Dr. A’s story: A case report is a medical tale of the extraordinary. It is an exception that proves the rule, of miraculous immune response and of complete healing.

In almost all cases, a cut is just a cut.

Editor’s note: Dr. Shahar Madjar is a urologist working in several locations in the Upper Peninsula. Contact him at smadjar@yahoo.com or at DrMadjar.com