Monday, November 17, 2008
in surgery you work with what you are presented with. sometimes you simply don't have a choice but to try amazing or ridiculous things. i have mentioned my weird sh!tometer (here and here) but this is another one that scored highly.
he was mentally retarded, or so his siblings said. i actually thought he was just a bit slow of thought but had been rendered useless to society by years of being told that he was mentally retarded. he presented to us with a skin cancer (squamous) on the forehead. but it was no small thing.
it had apparently been growing for a few years. his caretakers elected not to take him to a hospital for medical treatment because they felt that evil doctors would use him as a guinea pig because he couldn't "think for himself". so they left it to grow. finally when the smell of this fungating rotting bleeding mass on his head disturbed their breakfast in the morning they brought him in to have it checked out. i considered telling them to eat breakfast in the lounge but i thought better of it.
the mass was about 10cm in diameter. it had infiltrated the left eye socket, causing the eye to look up, as if it was trying to get a glimpse of its tormentor. the ct scan revealed that not only was the eye socket and the eye a victim of invasion, but the mass had infiltrated his frontal lobe. i even wondered if the family had actually brought him in because of personality changes. then i realised that i would also struggle to enjoy breakfast with that mass across the table from me and, let's face it, the family weren't overly concerned by the actual well being of the patient.
the never-say-die prof of head and neck surgery immediately mustered the troops. the troops were the neurosurgeons and the plastic surgeons. to me the fact that the neurosurgeons were needed implied there would be no surgery. they tended to bail if there was any way out. i just assumed the radiotherapists would be asked to the party at the last minute. to my amazement all roll players (the neurosurgeons) agreed to give it a try and surgery was scheduled.
once all the subspecialities had played their roles and once all the knives had been laid to rest what was delivered to me in icu was, well to me at least, shocking. they had removed the mass, but along with it, the left eye and eye socket, the left parotid gland, a fair portion of the skull and more than just a sliver of the frontal lobe of the brain. the massive defect which was left was closed by the plastic surgeons using a free pectoral flap (they used his chest muscle with its overlying skin which they essentially transplanted onto the defect). the oddly misplaced muscle and skin lay on a liquid bed of cerebrospinal fluid and seemed to move in a way similar to a water bed when i touched it.
things went not so well and the family, now no doubt enjoying a daily hearty breakfast, threatened to sue for disfigurement. the irony was that the surgeons involved, whether judiciously or not, had attempted to fix what was presented to them. they did not cause the problem, but they simply tried to address it. they were like the pioneer surgeons of old who tackled massive fungating breast cancers with surgery as the only modality, because there was nothing else. these days no breast cancer and no squamous skin cancer should ever get that large and be that challenging, not only because of the obvious disturbance to an otherwise most enjoyable breakfast, but because they should present for surgical attention long before then. it is such a pity then when those very people who prevented this vent their misplaced wrath on the very people who did their best with the presented material and tried to help.