Time sure is flying in the Virgin Islands! Week four has been truly incredible, filled with rewarding learning experiences. I cannot believe our time here is wrapping up.
Lexi and the lipoma
The week started off strong with four cases in the OR on Monday. The first two were the same, excision of lipomas on the back and shoulder. If you’ve never had, or heard of a lipoma, it is just a mass of adipose tissue, basically fat, that collects under the dermis. They are almost always benign but appear as a massive lump, so patients usually opt to have them removed. Alexis got to scrub in on one of the excisions and hold the huge lipoma that was over seven centimeters long. Although this was essentially the same procedure we have carried out many times in the office, these lipomas were so large, and in slightly more difficult locations (the back has thick skin and is highly vascularized) that the OR’s resources, staff, and anesthesia was necessary. The third case was a abdominal and umbilical hernia repair, and I had the opportunity to scrub in along with one of the PA students. This was really exciting, because unlike previously, I was needed to do many more things such as holding hemostats, suctioning, cutting stitches, and making sure Dr. Moorman’s incisional window was in the correct space. Our final case of the day was removing the margins of a previously-partially excised Dermatofibrosarcoma Protuberans from a 16-year-old-girl. The cancer had been on her superior scalp and it was strange to observe its removal because of her hair and the surprising thickness of the skin. The excision was closed with subcuticular stitches, surface stitches, and then a row of staples and sent to pathology. No dressing was applied. Her results have since come back as cancer-free with clear margins. Although we were done in the OR, our day was not over yet as Dr. Moorman had been called to see a consult in the med-surg with a staph infection on his leg wounds. Dr. Moorman and his entourage (us and the PA’s) marched over to check it out, where the wife of the patient referred to him as a legend. It truly has been wonderful to be working under a physician that is so widely respected.
Tuesday we were back in the office and it was slightly hectic. There had been some mistakes in the scheduling that had resulted in 17 patients within the first hour and the waiting room running out of seats. Although busy, it was a really fun day because three of the four PA’s had the day off, meaning Alexis and I got to go into all the rooms and do a lot more than we normally do. As per usual we did many skin checks, breast consults, and follow-ups, but we also saw quite a few interesting and unique cases. These included a man with hidradenitis (infected hair follicles), a two-year-old with a hernia, and transgender man consulting for a mastectomy as well as a gunshot wound, and a case of chronic venous stasis. I also got to remove the stitches from a lipoma excision Dr. Moorman had done last week.
Wednesday was quite a day. To be honest I don’t really know why, but we had an office christmas party. Christmas had been a part of the OR/office banter previously and spontaneously we decided to throw a Christmas party, with cookies, Cruzan, Christmas music, and all on Wednesday. This gives you a little bit of insight into the atmosphere of working with Dr. Moorman, as well as the relationship and good times we have with the PA’s. Stefán, our host brother, made red a green sugar cookies, Megan brought in a dairy-free carrot cake, and Elise and Kahley graced us with a box of birthday cake oreos with a label reading “Jesus” in front of birthday. Aside from the yuletide shenanigans, it was a fairly standard day with many irregular skin lesion removals and follow-ups. We did end the day, however, with the most complex case we’ve done in the office as of yet, a Blepharoplasty, also known as an eye lift. Dr. Moorman injected the upper eyelids of the completely awake patient with lidocaine, numbing and swelling them, thus making them at lower risk to cut all the way through. The strangest part was after he had sewn the eyelid back together, her eye didn’t close all the was due to swelling, making it seem as if she was watching the whole procedure and us observers. Everything went as planned and the patient left with newly energized eyelids and quite a few stitches. When we went home that night, Dr. Moorman pulled out some expired sutures, a foam block in a sock, and some needle drivers and went to work teaching us how to sew. He taught us two different stitching techniques, as well as many different types of knots, the most important being the surgeon’s knot, and we had it down by the end of the night.
Me suturing
Thursday felt like routine as we expertly navigated the halls of the hospital to the OR, ready for our fourth breast reduction. Two of the PA’s had the day off and I got to scrub in first and lay the marking stitches. Never in my life did I think I would sew stitches through human skin and it was a surreal experience I won’t ever forget. Skin, not surprisingly, is significantly thicker than cotton socks, and it was actually quite difficult to “poke” the needle through. Although I had practiced, my hands shook from nervousness and excitement but I did it successfully, laying two marking stitches and four subcuticular stitches from the areola to the breast line. I also assisted in holding the breast as Dr. Moorman tied a tourniquet, as well as incised part of the pedicle with a 10-blade scalpel. The rest of the procedure went smoothly aside from a brief power outage, which is apparently a normal occurrence on the island.
Thumb after Osteomyelitis removal
Friday was a great day, in and out of the OR. We only participated in one case, a quick, but fascinating thumb infection. The patient had come into the office earlier in the week with an irritated, inflamed, tender thumb, and had been diagnosed with osteomyelitis, a serious bone infection. In the OR, Dr. Moorman froze the thumb with a local anesthetic, removed the entire nail, and made a small, centimeter wide incision along the top. He then used a tweezer-like instrument to pick away at the infected, basically dead “spit out” bone, until nothing unhealthy remained. After stitching the incision up with two sutures he placed the nail back in the nail bed and wrapped it up, not exactly good as new, but significantly improved. Although there was another breast reduction after, Dr. Moorman let us go early and we had a day out on the town with Gabriella and the two kids. First we went souvenir shopping in Christiansted, one of the two main cities on the island, and then headed to the Cruzan Rum factory, a so-called must-see despite our minor status. I was glad to learn about the history and process of this essential export and local staple. Next we went to the Labyrinth, a local farm/botanical garden/artist colony with a chartres-style labyrinth, sugar mill ruins, and huge avocado trees. Lastly we visited the local’s favorite Chicken Shack where we gorged on rice, mac-n-cheese, and the island-famous Johnny Cakes.
Lexi and I with the kids at the Labryinth
On Saturday Gabriella gave us a tour of the East side of the island which we had yet to be exposed to. The striking differences in topography and vegetation as opposed to the thick jungles of the day before were clear as we drove through the cactus laden cliffsides. We stopped at Point Udall, the most Southeastern point and the first place to see the sunrise in the domain of the United States. We were then dropped off at the Grotto, part of the Buccaneer resort, to spend our afternoon on the beach playing frisbee and drinking virgin Piña Coladas. Today we had a relaxing morning playing checkers, cards, and Clue with the kids, and then spent almost four hours in the pool, splashing, laughing, and getting terribly, terribly sunburned. I am sad to have to use the word final as I look forward to our last week in the Caribbean.
Wow, sounds like you had a most excellent host family with special hands on care. I am curious if Dr. Moorman’s practice consists mainly of local citizens and/or do U.S. citizens fly to St. Lucia for surgery. As a Neurosurgical nurse for many years working in teaching hospitals on the East coast only medical students had the opportunity to “scrub in” under the direction of the scrub nurse, circulating nurse, resident and attending physician. Sounds like the Caribbean is the place to go for hands on learning as the U.S. has very strict procedures in place for surgical practice, i.e, post-op wound infections, wrong side surgery, etc. Sounds like an exciting time!