You can have a long day without having a long day, and today was one of those days. Coming home from the clinic we were all totally drained, I soon collapsed after dinner like a lung in pneumothorax, and napped a bit before bed. It wasn't that busy at the clinic today, but I certainly did saw some interesting things and got to do a few practical things.
A lady with suspected stroke in the morning. My GP was rather concerned cause he was chasing up the CT results in between every patient, so I asked about the onset thinking he's probably pressing time to push that tPA (thrombolytic that can only be used in ischaemic stroke within 3 hours of onset). Much to my surprise, he's not waiting to administer tPA. In the country, due to logistic reasons, they do no give tPA simply because a CT within 3 hours of onset of a stroke is not likely to happen. A shocking difference between country medical practice and stroke-unit equipped hospitals.
Tuesday afternoon is RoSL (Removal of skin lesions) time for my GP, I had asked him eagerly for permission to do some yesterday, and my stoic GP dismissed me with his usual impatient nod, any yes is a yes and I will take it. I am always very excited when I get to cut people (if you are reading this following a google search hoping to find some cutting fetish then I am sorry, this is not one of those. For cult membership, please email me to arrange for a meeting back alley). I have so far manage to cut out 2 skin lesions (2 BCCs, one on my own) and was eager to claim more scars under my scalpel.
My GP (R is the name) does things quite differently to what I am used to. For one, if the lesion can be cut out with a puncture biopsy knife, then he's more than happy to take it out in one go. It's fast, but without the tails of the conventional wedge, it's a bit harder to stitch, and I am not sure if the scars will be more prominent. Secondly, not only does he sandwich the lesion with local on either side, he goes under and through the lesion! His reasoning is that you can lift up the lesion with the needle a little and inject local under it. I am not sure if that is a good idea as it may puncture the lesion, it is faster, but I am not sure if it is a shortcut I'm comfortable taking. Lastly, he cuts the lesion with very small if any margins. He usually just circle the lesion and cut along the circle. No 'eye of a tumor', I love the eyes of a tumor.
I helped cut out a melanoma on the nose, a huge one on the scalp (~2.5cm in diameter, 1.5-2cm raised, it's a ball on top of the head). I then got to cut a BCC on the shoulder and a haemangioma over the scapula. R watched me suture the shoulder incision, then a bleeding incision on the face. He must have gained some confidence in me by this point (or that he wanted to go home early, which tends to happen quite a bit) cause he left me to stitch up the last patient on my own (with the practice nurse).
The patient had melanoma that was not completely cut out last week (without any safety margin, I am not surprised!!), and R ended up removing a skin tissue that is 4cm long and 2.5cm wide over his suprasternal notch. R had his last patient of the day waiting, so soon as he's done cutting, he left me with the gaping hole to be stitched up. It was the biggest wound that I have sutured to date. I placed a mattress suture in the middle to hold it together, then closed the rest with simple sutures. On hind sight, I should've placed more than one mattress. Nevertheless, the practice nurse thought I "did a great job", R thought it "beautiful", S (another GP who poped his head in to check if the treatment room was available just as I was finishing up) was impressed, and most of all I am happy with my work :)
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