21 September 2021
This morning I had a long chat with Dr. Tong after she had finished the third surgical debridement of the wound during this admission. "It went well," she said.
The big news is that there has been no reappearance of the yellow slough in the wound so the healthy tissue is able to grow unimpeded. But Dr. Tong did a few other things today.
The first was to confirm that Joyce's lymphatic channel (the third channel in the leg along with the arteries and veins) had good circulation down to the middle of her calf. "That's good," she said.
The second was to sew up that deep gap between the muscle and the tissue to protect the nerve from the Wound VAC that is now closing the wound. She put a couple of stitches in to close the gap.
She also used a muscle stimulator to see if radiation had much damaged the leg muscle. "It's weak," she said. But, as I told her, Joyce had been walking as much as 8,000 steps a day just before surgery. And she is getting physical therapy at the hospital, although with the surgery, that's painful so "sometimes she does it and sometimes she doesn't," Dr. Tong said.
'It went well,' she said.
They did put an epidural back in for pain management. And her pain level will determine when she can come home, which could be as early as Friday.
The trick will be whether or not she can tolerate the Wound VAC dressing changes with nothing more than oral medication. Then in-home nursing can do the changes, which we can supplement if there's a problem with the Wound VAC with wet-to-dray dressings.
They will have to do a few dressing changes to see how she tolerates the pain so most likely she won't be released until next week.
She is still on antibiotics as a precaution.
But at this point, Dr. Tong said, surgical debridements are no longer necessary. As long as the yellow slough doesn't form in the wound, she should start healing.
Which brought up the next issue. The road map.
Joyce told her she doesn't need to have the tissue completely fill the wound before a skin graft from her thigh would close it. She just wants this over.
So Dr. Tong will watch for tissue growth and when the muscle is closed over, she'll consider closing the wound. "And she'll never have to see me again," Dr. Tong joked.
But if the tissue doesn't grow, they'll have to consider two other options.
One is the hyperbaric program at St. Francis Hospital, which we discussed a year ago. Kaiser hasn't tapped into that option very much, Dr. Tong said. And Joyce told her she didn't want to do a daily sessions like that.
The other option would be a layer of Integra, a processed tissue that would cover the muscle and allow the skin graph to adhere. "It's very expensive," Dr. Tong said, "but I would do it for her."
The best option, though, is that Joyce can tolerate the Wound VAC and go home to let the tissue grow enough that a skin graft can be placed to close the wound.
Dr. Tong thought, one way or the other, this will all be concluded by the end of the year. "Hopefully," she said.