Minor surgery and its complications

What put my time into a crunch,

Was a biopsy, not a shave, but a punch.

Then the red flow,

Just wouldn’t slow.

He lost some blood, yes, a bunch.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  I’m just back from a working vacation in Petersburg, Alaska and an educational trip to the AAFP Scientific Assembly in San Diego.

The skin lesion cries out for a punch biopsy.  The size of a business card, it sprawls across the top of the foot.  I spotted it on a routine diabetic foot check.  It hits all the ABCDE alarm criteria: Assymetric, Border (irregular), Color (inhomogeneous), Diameter (more than 6 mm by far), and Evolution (patient had it for years but it started changing in the last couple of months.

I warn the patient about the possibility of infection, bleeding, pain, and the certainty of scar; along with the possibility of catching a cancer early.

When I had the infrastructure set up, with materiel handy, I could do the procedure in 4 minutes.  Now the nurse and I put together the biopsy punch, suture, needle driver, anesthetic, and scissors.

Alcohol, local anesthetic, betadine skin prep.  The biopsy punch is a circular knife the size of a ball point pen end, the surgical equivalent of a cookie cutter.  I take a plug of skin near the edge, including part of a distressingly black bump.

I would never believe that much blood could come out of a 4mm hole.  It doesn’t spurt like an artery, it just flows.  In all the time I have warned patients of bleeding, such a complication has never occurred.

(Once the patient had an infection after the punch removed the entire, 1mm malignant melanoma.)

The blood streams while I work to try to find the source.  In short order I recruit a second nurse, call in two hemostats and an absorbable suture, don my headlamp and remove my glasses.  Five minutes of local pressure doesn’t slow the flow, but pressure 8 mm closer to the toes gives me a dry field.  I clamp an apparent bleeder and throw a noose of absorbable suture around it, and for a moment the bleeding stops.

It starts again.

Forty minutes later I put a deep vertical mattress stitch in, pull it tight, and the red flow disappears, leaving me 4 patients behind, sweating and exhausted.

I confine my operative ventures to the skin, nothing deeper, because I can handle those complications.


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