Surgery in the ER

This picture was taken at Kindred Hospital.  You can see how they marked where the infection was, and you can see it oozing infected puss from the ankle.  

On April 24th, while Richard was in Kindred Hospital, he was being bathed, which was not an easy procedure, and in the process they hit his external fixator on his leg and when they did so, it was excruciatingly painful for him. He mentioned it and they took a look at it and thought that the ankle was infected, so they called the hospital and they said to bring him in to the ER and they would probably perform surgery on him that night. I made it to the hospital with him and waited in the ER for quite a while, but they never could take him in because the operating rooms were full. We were told that the surgery would take place the following morning. Upon hearing this, I left, thinking it was just not going to be done that night. When I went to the hospital the next morning, Richard was VERY animated in telling me what went on that night after I had left.  

When he got to the hospital, they asked him what his pain level was and he said 8 so they gave him 8 mg of morphine. Since they didn't have an operating room, a resident surgeon came into the ER room that he was in, at this point, it was just after midnight. He was not the surgeon Richard had been told was going to handle the situation. He told Richard that since they couldn't operate in the operating room, they were going to start draining the infection there in the ER. Then, when Richard asked the resident what he was going to get for pain, he told Richard that he wouldn't feel anything. Richard insisted that he receive morphine if he was going to be cutting on his ankle.  The doctor finally relented and said that he would give him 4 mg of morphine.  He got eight for just laying there earlier, but now when they were cutting on him, he was to just get 4.  That is what was written in his chart for how much he would get for a dressing change on his wound vac, so that is what the doctor went by.  

He injected the ankle in 3-5 different spots with a local anesthetic, which was extremely painful.  Then he started cutting and squeezing and swabbing the ankle. Richard was screaming that it hurt, but the doctor didn't seem to notice.  Richard said that he was "screaming like a little girl with her arms being ripped out."  This went on for about 15 minutes.  When he finished, he had it packed and bandaged so that they could work on it again on the operating room the next day as orginally planned.   The external fixator was still in.  The assistant surgeon came and talked to him before the surgery and Richard said that if they were thinking about removing the external fixator, this would be a good time, because he was not going to let them remove it while he was awake.  So, the next day at around 6:30 in the evening,  they went in and cleaned out that ankle and removed the external fixator.  Of course, the entire time, he is denied food because he was going to be taken in for surgery, so it was well over 24 hours with no food at all. One would think that a medical professional, who thought that a procedure would be painless, saw the patient thrashing about with pain, that they would stop and increase pain meds.  Why he didn't is really beyond my understanding.  

Here are x-rays from before the fixator was removed, but seem to have been taken just previous to the surgery: 

When I saw it at the packing change, this is what I said, "They changed the dressing on the ankle.  It was horrible.  It makes me wish for the days when he was heavily sedated.  He was in extreme pain and basically made them stop until he had more meds. He is resting now.  The wound is large and gaping.  I thought those days were over.  I see a would vac on this in the future.  I wonder if he will ever be off a wound vac."  

It was at this point the doctor emphasised how important it would be that he take his antibiotic.  He explained that the infection had not gotten on the hardware, but that it was close.  In order to keep the infection off of the hardware, the anitbiotics would need to be taken religiously. (This was just prior to his being admitted to St. John's, where his antibotics were withheld from him, and the infection did get on the hardware, which eventually had to come out because of it.)

I have to say that this two days was probably among the most difficult times of the entire ordeal.  Richard develped a pretty high pain tolerance through all of this.  I plan on writing another post about pain tolerance and medication, so if you are interested, you can keep an eye out for that. The fact that Richard was in such pain at this time speaks volumes to me, because by this time, he was pretty used to constant pain.  

I should also let you know that "The Center For Infectious Disease" was involved at this point as well, because this was a MRSA infection, and they keep a pretty close eye on those types of things.  

Lessons to be learned: If a doctor is doing a procedure on you without proper pain medication, tell them that you deny the surgery.  They have to have your permission to do surgery, and without it, there is nothing that they can do.  We realize now that he should have just told them that they didn't have permission to "drain the infection."  If you are in the medical profession, listen to your patient, and notice if they are in obvious pain, rather than just ignoring the fact.  

After the fixator was removed, and some healing had taken place, the ankle looked like this:  

PS - All of these pictures are of the outside of the ankle.  The injury (and it was quite a significant injury, it was listed as severed at the scene of the accident) was on the inside of the ankle.