First, to those of you who couldn't access the blog reliably over the last couple of days: Blogger has been having some unscheduled downtime for the last week as they migrate things and try to fix disks. There's going to be another outage this evening at 7 pm PST. The Blogger folks say that'll be the end-all, be-all fix.
Second, to those of you concerned that I might either leave nursing altogether or move to Seattle and disappear, don't worry. I think it was a combination of too little sleep and too much "Dancing With The Stars" that put me in such a foul mood.
I had planned to make chicken biryani this week, but a patient with an AVM pretty much blew those plans. Arterio-venous malformations aren't uncommon in people's brains, but they can appear anywhere on the body, sometimes with disturbing results. One of the most disturbing things is the color of the skin around them; it looks a lot like biryani before it's cooked.
This particular patient had an untreated facial AVM that was about the size of my hand, fully extended and with fingers together. I wear a size 7 glove, by the way, so that ain't a small AVM. The thing had displaced her right eye down onto her cheekbone and had puffed her eyelids out (and the rest of her periorbital tissue) to the point that the right side of her face looked like nothing human. When your eyeball and eyelid extend past the end of your nose, that's a problem.
Apparently the thing had come up suddenly and had grown so fast that there wasn't much she could do about it; AVMs can be like that. We'd embolized the thing a couple of times already, and she'll have surgery to remove it today. She'll lose her right eye--there's nothing we can do to replace an eye that's been displaced that far for more than a few hours--and will need some pretty extensive plastic surgery to minimize scarring, but at least she'll keep most of her skull.
Which is not the case, unfortunately, with another patient. This one had had basal cell cancer on his nose and had had it frozen off years before. Note to the interested: NEVER have a basal cell carcinoma removed by freezing. The process might not get all of it, and you may end up with a migrating basal cell cancer that invades your sinuses, your eye socket on one side, and your frontal bones.
Whereupon we would have to remove the whole damned upper quarter of your face and replace it with a flap graft from your scalp, or thigh, or chest. This is not a way to spend a week, never mind the disfiguring consequences of having thigh skin and muscle taking up what used to be your eye socket and frontal sinus.
Still, even that's better than having some piece of artillery go all crazy on your ass and blow off one side of your face. I'm not sure if it was a shoulder-mounted grenade launcher or what; all I know is that Walter Reed did all they could for the guy and then shipped him to us for definitive plastics and skull reconstruction. Thankfully his brain escaped harm, though I don't know how. We got him for a couple of days so that we could do the cranial reconstruction; he'll be shipped down a few floors sometime this week for the facial part of the deal.
All those, though, pale in comparison to what it must be like to be the parents of a twelve-year-old with a major aneurysm. Unruptured, so the question is this: should we go ahead with a carotid sacrifice and try to bypass and remove the aneurysm, knowing that our kid will likely be gorked out and severely disabled for the rest of his life, or should we skip the surgery and try to control his pain, living with the knowledge that the aneurysm could blow at any point and kill him?
You can see why "Dancing With George Hamilton's Tan" seemed like a good idea at the time.