Art of Debridement..
not just removing infected and unhealthy tissue..but..
1.how u differentiate the part that need to be remove and part that u want to keep
- the eyes cannot see what the mind doesn't now
- kena banyak assist buat debridement, tanya ur superior how to decide..
- study and banyakkan tengok wound..so nanti baru la dapat tahu yang mana slough, granulation tissue, necrotic tissue, etc
- yang penting anatomy la..kena tahu function each tendon tu..contoh..patient dah hilang jari little finger, so extensor tendon to 5th toe tu boleh la remove kalo dah infected..tak yah sibuk nak cover la..kikis skit2 la..
2. how to learn to debride..assist..assist and assist..
- jangan ingat masuk OT..alah..assist je..tak dapat nak buat..tak yah masuk...
itu satu assumption yang merugikan anda..
masuk je..jangan risau..setiap operation tu adalah ilmu baru untuk kita..
masuk dan tengok serta perhati betul2..
3. only assist? still not enuff..u have to observe..OBSERVE..not just see..OBSERVE
- beza bila masuk OT, assist semata2..
- jangan setakat masuk jadi retractionist or suctionist semata2..
- atau tersengguk..
- perhati dengan ilmu..observant..tanya..tanya..kenapa itu kena buang..camner nak cover soft tissue and bone..
4. how u HOLD AND HANDLE the instrument so that u can pick and remove that u dun want..without risking ur colleague to injury..
- instrument perlu bila nak buat debridement. eg mayo scissors, bone currete, scalpel etc
- pegang betul2..cara nak pegang tu pun kena perhati bila ur superior buat debridement.
- biar ergonomik..jangan sampai terpusing2 tangan tu pegang instrument..
- halakan scissors tu pada structures yang nak buang..bila handle pun tak betul..maka masa yang diambil untuk siapkan kes pun lama..dan makin bleeding la patient..
- yang penting..jangan riskan assistant anda dengan injury..
- tak heran ada yang sampai instrument terpelanting..
- jangan cederakan diri sendiri..
- macam mana nak tahu cara pegang yang betul?...tengok senior pegang camner..senior nak ajar..bukan setakat boleh ajar ikut phone..or verbally..kena pegang instrument tu..tunjuk dulu..junior tengok dan paham...
5. how to minimize bleeding..not just cauterize the bleeders..it's on how u cut the tissue..
- dah nampak 3cm infected and sloughy skin and soft tissue nak kena buang..janganlah potong sikit sikit..sekali potong..akan bleed..potong lagi..bleed lagi..
- kalo dapat kes necrotising fasciitis yang kena buat radical debridement..kalo potong skit2..bayangkan bila nak habih..dan bayangkan berapa banyak bleeding yang berlaku..
- so kena la plan.assess..yang mana nak buang..margin kat mana etc..zerrraaappp terus
6. how u extend the wound..
- plan camner nak extend the wound..kalo masih baru..discuss dengan superior..suggested skin incision..kena tengok dan assess..kemana infection tu tracking..
eg: wound kat kaki..tend to spread proximally, by tracking through achilles tendon..
wound kat leg, boleh tarcking proximally via the tensor fascia lata..
- salah extend..healthy skin and tissue boleh deprive of blood supply and later on boleh jadi necrosis..
7. how u prevent the healthy tissue from infected..
- ada yang buat debridement, cucuk mayo scissors then bukak..cucuk2..
IT'S WRONG..TOTALLY WRONG..
- make sure u nampak dan assess mana tissue yang healthy dan mana yang tak..jangan main jolok je..
- kalo main jolok je..dari depth yang healthy pun akan jadi infected sebab anda dah introducekan infection masa duk cucuk tadi..
- bukak betul2 dengan blade..TENGOK..
8. see what u cut..dun just chopped and chopped..
- tak boleh disangkal la..bila jadi assistant ni..ada yang mengantuk..lagi2 kalo kes pukul 3-4 pagi..
- so ada la saat tertido dan lupa nak suck the blood guna Yankeur tu.
- as a surgeon..clear the operation field dulu.. dap dulu blood clot ke, pus ke..identify dulu soft tissue, baru la u cut..
- ni bukan ayam yang boleh main potong potong dan potong..
9. knows the anatomy..
- anatomy..
- kena la tahu..
- basic nih..
10. knows how to protect the important structures such as tendon..neurovascular bundles and bones..
11. patience..
12. dun greedy..
13. post op wound..keep review and review..even the pt from different wards..ask the incharge what did the superior said about the post op wound..
14. if not satisfied..u should feels bad and try to improve..as u put the pt on risk of anaesthesia..again..
15. PLAN UR OPERATION..plan..plan..not during pt already in OT..but early during ur oncall days..go to ward..see the wound..and plan straight away..if not sure..ask the superior..
16. the art not ending here..still many u should learn..and i'm still learning..
