Skin / Capillaries look dead to surgeon

Basically, what you're describing is this 1, the skin looks pale/dark/bluish different than normal.. He likely pressed with a thumb or finger and then released quickly by picking up thefinger/thumb. Under his breath he was counting seconds. To determine how fast the capillaries refill. He probably repeated the process in several areas.

Capillary refill should be 1 second or less. Capilary refill > 3 seconds says that flow is compromised for some reason.  Flow could be delayed for many reasons. Circulation of larger vessels may have been impaired--i.e surgical disruption of cutting blood vessels, smoking i.e causes a chemical constriction of vessels,  local inflammation (swelling)peventing/impairing flow i.e.like a log jam. The blood vessels that are being compressed, normal flow can't occur. Radiation burns may have destoryed blood vessels. Cold that has caused constriction(narrowing) of blood vessels. Skin pulled to tight can be compromised because vessels are distorted. Wound infection will change how fast caps will refill. So, identifying the source is important because that will lead to management.

What the PS didn't share with you was what he was thinking. So, you are in the dark. The fact that he gave you silvadene with instructuions could be one of two things 1.prevention of wound infection. 2 he thinks you have a wound infection. But with the absence of an antibiotic, it's still not clear cut, what his thinking his.

First lets deal with the cleaning, wash with a antibacterial soap preferably one he recommended.

Your action: Wash hands at the beginning of any procedure and end of procedure with antibacterial soap

1.Call office and ask which soap to use. I won't suggest because thats his job--consider it a medicine

2.Use a soap in a squirt container because bar soap can be contaminated

3.Use either disposible wash cloth --used only once and pitched. If that is not affordable, bleach some washclothes . Place on a freshly bleached handtowel on a table used only for this purpose, place bleached wash clothes on top of this. Cover with a freshly bleached hand towel. This is effectively a dressing station. Any dropping of cleaning materials need to go back through the entire cleaning process. The 5 second rule does NOT apply.

4. Use one wash cloth with squirt soap and wash site. Stay on the site. Don't move to other areas then back to site. The idea is you don't want to bring other contaminants toward your incision.

5. It doesn't say if he told you to do this in the shower. If he told you to do it in the shower Try to avoid flow of water from other body parts over incision area . If he said to rinse with another wet wash cloth then either use a tap water moistened w/c. or water from a jug. Doesn't matter if it is distilled or drinking . The point is cleanliness. Taps can harbor bacteria. If you are using tap water even shower tap take the time to clean with bleach at least once a day. Run for a few minutes to wash off bleach on tap . Dry incision with a separate bleached dry washcloth. Lay over incision and pat dry. Do not drag it back and forth over incision.

6. Apply slivadene  with a gloved hand or sterile q-tip. Once you have taken the silvadene out of the container ,don't re-enter container unless you change glove or q-tip. This will prevent contaminating your cointainer. Silvadene comes in a multiuse container and a tube.

7.Ask PS what his thinking is, he may be trying to avoid the word infection to keep you from worrying, but it makes it easier to try and maintain the highest standards of cleaning that you have available to you, if he shares what his thoughts are. In the absence of also using an antibiotic, He is in prevention mode by maintaining the highest local care of the incision

8. avoid smoking and alcohol.

Hope this helps.

sas - great post - so helpful!

sas; WOW!! You really know your stuff. I am an RN and I learned a lot from you regarding wound care.         You should combine your posts and publish a book!    Patient education is a huge part of nursing.  

I used to use a spray bottle (water and liquid soap) to wash my breast during radiation .  I sanitized it between uses. (very hot water)       I don't know if that is good advice for Sam's Mom.  The pressure of the shower was too forceful.           Also, would you suggest warm (not hot)  water to increase the circulation in the area?            A mistake I made in a different wound care situation was that I used too much silvadene.  surgeon told me to use it sparingly.  I wish someone would develop a spray form.   I used to smear some silvadene on a sterile gauze pad (using Q-tip) then lay the gauze pad on the breast.

Sam'smom: I wish you all the best in your recovery. You are in good hands with the advice from sas.      You are brave to have gone with expander.    I am not going to have PS after mastectomy b/c of fear that radiated breast will not have adequate blood supply to nourish anything new.      But I am a "select"  case with the issue of radiated breast being very damaged. 

Eileen, on the 10th I will be 10 months post bilateral mast with DIEP reconstruction.  It was my third different BC and I had severe rads damage to both sides. (July 4th was my 14 year anniversary of the first time around).  I was pretty nervous about recon considering the rads damage, and I too am a 'select' case... if anything is going to go sideways it will happen to me.  I got through the 12+ hour sx, was in ICU for 5 days then home.  I did have a small bleed but it resolved, and some minor problems with seroma's and ab incision which also resolved.  I'll have Stage 2 revision sometime this coming winter.  I believe the length of time between rads and recon was the reson the DIEP didn't fail.  I encourage you to wait a couple more years and then make enquiries if you want recon.  Amazingly the vertical scars of my recon have almost disappeared - it seems that radiated skin doesn't scar too badly.  My flaps only have a thin line scar and after Stage 2 and tatt's they will be completely invisible.  Recon may be a possibility for you too in time, so please don't lose hope just quite yet.

My best to you, She

Wonderful news!  I am so happy for you!

WELL MY MY!. Obviously I'm tickled. That everything or part and parcel helped. I'll add another two that very much helped

1 Hotflashes---can occur from the sx loss of hormones; body affected by chemicals and increased fluids given in the O.R. and post op; Aromatase inhibotors and Tamoxifen; antidepressants/pain meds ---or combination of all the above. This can lead to skin issues. I described how to protect the chest with a tee from scratching. Now we go to the bottom. In the night, when we sleep we may scratch our bottoms and not even know it, then scratch other areas. The technical phrase is self innoculation, easier way of saying it is self contamination.

     A. Get MENS 100% cotton boxers, and sew up the fly. Avoids the wandering night scratching on direct skin. We tried two brands. Fruit of the Loom has the most room in the seat. If anyone finds a better product please post. The only negative is the waistband because of the elastic. Leg holes are also, roomy. The boxer short is only one thickness of cotton. Anyone thats flashing can understand what it means to have as little on as possible. They are enough like shorts that I don't hesitate going in the yard.

If you end up with any yeast infections or other types. Put them through the same bleaching process with hot water. It will eventually ruin their color, but you won't care because your protecting yourself.

      B. I did get a scalp infection during the height of my flashIng period. Worse bug than MRSA. Searched the web. Found a study published in April 09. It is from a Pediatrics Journal.The study group was on children with psoriasis and multiple secondary infections over their whole bodies because of scratching. What they did was use standard laundry bleach < 1 cup in a tub of tepid water and soaked for 10 minutes a day. The control group TUBBED in standard tap water. The study was stopped half way through because the the test groups infections below the waist healed so much they felt it was detrimental to the control group not to get them on the same protocol. The test group had the problem that they were now clear of the secondary scratch infections from the waist down. The testers problem solving----AND this may catch your breath ,it did mine-----They had the childern hold their nose close their eyes and go under water. It worked.  Obviously, they wern't under water for ten minutes. Before using this method please take time to find the article. Try search terms --Infection psoriasis and bleach,remember it was a pediatrics journal. There were multiple articles to follow by nonmedical people that didn't take time to read the original research. These kids were seriously afflicted with multiple bad bacteria. Check also with your doc, but have original article with you.--safety recommendations well ventilated areas, follow directions in Journal article. Don't exceed  once daily per article. Do not use on incisional ares

How I used it for me. After 5 weeks of oral and topical medicine on my head and no progress. I thought about the requirement that cleaning towels in restraurants are required to be rinsed before use in a10% bleach solution. The Occupational and Safety  and Health Administration-OSHA does not require gloves to protect the worker in this situation.. So, I made a 2 parts bleach to 1.8 cups of tap water for a total of two cups(10% solution) and poured over my head --mon morning and evening, tues morn, wed morning. I was recultured wed. afternoon. REport came back clean. The bug was enterococcus faecalis one of the hardest to clear up. I tell you this because my research showed I(we) are more suseptible to this bug if multiple doses of keflex are taken over a short period of time. All my preop/postop preventive antibx's were keflex for 4 surgeries, AND  then add arimidex which can make you more suseptible to infections.  To a nurse reading this their going to go OH MY! BAD BUG. Seriously, almost would have preferred MRSA. My dermatologist MD and ARNP were  reserved about this even with the research articles given to them.  It didn't bleach my hair that was there maybe 1 inch . Rinse well. I did this over the sink in the garage. Talk with your doc before trying. This last paragraph is not supported by controlled studies.

Edit:july 5th2011: Several posts down is a post with hyperlinks to the pediatric research article on bleach baths, and other peer reviewed articles on the topic

Jbl--Suggest serial photos--a picture a day. Sometimes this can pick up progress or deterioration that we not be aware of because it's subtle--date photos compare day to day.

Outlining red area may also help in evaluating progress. Obtain a new pen or fine felt tip non indelible ink, reserve for this purpose only--choose item that is packaged v.s in a bin. This is not implying that it is sterile ,but you know someone else hasn't used it. Outline red area and date--once a day is enough or even once is enough. It will give you a reference point. If redness goes beyond outline that can indicate worsening. If the redness retracts i.e is less near outline inside circle, it can indicate improvement. When skin redness improves or worsens , it can occur rapidly or slowly. When it moves slow, it can be hard day to day to see the subtle changes. The ideal is a sterile marker that you may be able to pick up from doc's office or hospital. Regretfully, in too many healthcare facilities of any kind, docs and nurses pull the pen out of their pockets and mark as described. So, if someone tries this with anyone, I would suggest that you ask a sterile marker be used.  It's your body and you are already dealing with a problem, you don't need introduction of any other hitchiker bacteria

If you have a partner, have them evaluate each day with you in good light. Allows you to have someone to discuss progress with and helps in decision of seeking medical attention. Rapidly progressing redness needs  a "TODAY" evaluation by your doc. If you are sent to ER for evaluation, be cautioned that ER 's are colonized with many types of bacteria. If you have not been wearing a dressing because you have a closed nondraining red incision and the doc has instructed you to do this(very standard practice) , if you go to be evaluated , put a dressing on.

 Under all circumstances watch for handwashing and how personnel including docs, handle the gloves they put on before they touch your incision/wound area. They can completely contaminate gloves --so, being proactive is being self protective. Don't be afraid to ask for sterile gloves to be used.

If during  other testing that would require anything to come near your wound/incision area --ask for sterile disposable item if site is not dressed.  For example, one study from several years ago, identified that electrocardiogram wires are a hotbed of bacteria and recommended they be  disposable. There is movement throughout the USA for this to happen. The point goes back to what I said above be proactive, look at everything with new eyes -----"-what will protect me from any new bacterial contamination". If someone implies you are over reacting, simply you are not.

As with any nursing recommendation, my licensure requires that I advise you to ask your doc first before you do it. ASK your doctor.

Thanks for all of the information.  I have cellulitis right now and sas-schatzi has been a great help to me.  I have been taking Septra/Bactrim DS for about a week and a half now.  While my infection has not improved much, it has not gotten any worse, so I hope that's good.  I will be going in Tuesday to see my PS and if it hasn't gotten significantly better, I will be on IV antibiotics.  I had been having pain and swelling for weeks prior to the cellulitis dx.  I would like to stress that if you notice any abnormailities, redness, warmth, pain, chills (with or without fever) you need to see your doc and make him/her take you seriously.  I have a feeling if this had been addressed when I first brought it up to the doctor, it might not have become an infection, or at least not so advanced.  The sooner you take precautions, the better.  As far as the Silverdine goes, I will say it worked great.  I had necrosis and at my first post-op appt my PS gave it to me and the dead skin disappeared and now the wound has finally closed up well.  Now if I can just get rid of the cellulitis, I will be in great shape.  Good luck to you and I hope everything continues to go well for you. Take Care.  Allison

I am so sorry mricha02.  I totally feel your pain.  I am having a hard time with clothes too.  I had a bilateral mastectomy though, so my problem is that with this cellulitis I cannot wear any sort of breast form.  I can imagine it would be pretty hard to be lopsided.  I had my surgery may 21st and still haven't gotten one fill.  I am hoping this infection goes away.  It is so stressful worrying about whether I will have to get the TE removed.  Good luck at your PS appointment.  It sounds like they got everything cleared up, so that's good.  Take Care.  Allison

EVERYONE THANKS FOR YOUR POSTINGS- I too am learning.

SHE- the emailing photos is masterful. I bet that doc takes it to a meeting of other docs.See below re Equipment

NATIVE MARINER--greatttt advice on homehealth.

To add asome thoughts about homehealth. They are required to provide dressing materials and all items needed for whatever their orders are to do. SHE described in her post that she told the nurse exactly what items to bring and the nurse brought the wrong stuff, my guess is this nurse didn't bring them into the house. The nurse likely came in read the orders and said --sorry I brought the wrong items ==hrumphhh

This is the scoop. The easiest way to maintain cost of expendable material is not to provide them. There is no excuse for not providing the right material , unless that nurse received a same day assignment of a patient and they don't have it in their car. Even then it could be reasonable to expect them to return to their office to get the right materials. There are some homehealth nurses that drive in excess of 100-250miles a day-- that may be a reasonable excuse. BUT being well supplied with a cross section of needed items is part of what they should have in the car. Being prepared for that same day assignment is expected. Even of high end items like silver alginate--you keep a few in the car. I just measured my old boxes --3 boxes 33 by16 by 12 deep inches and 2 boxes 16by13 by 12 deep. A Cooper car doesn't work in HH.   Homehealth abbreviate HH nurse has to get her stock from the company office that may have policies about dispensing /giving items to the nurse. The office can make it very hard to be well stocked. Then mgt critizises/ disciplines the nurse when they get the complaint phonecall because the nurse didn't have the equipment. The nurse is damned in either direction.

Here's how you as a patient should handle HH

1 ASK for a HH referral to be arranged prior to surgery(as NM described). It requires insurance approval. So, if sx planned at a future date ask that it be started for approval at the visit scheduling surgery. ASK for "Physical therapy to evaluate and treat" that allows all of what NM described. ASK for" Occupational therapy to evaluate and treat" There function is to show you how to use your arms and function in the house to keep it simple.

 2.Day of sx put on your list to make sure "referral to HHA for incision care with dressing changes with product/ frequency" and other referrals are actually written on the discharge order.

3. Nurse cannot usually see same day unless special need of antibiotic, dressing change,injections etc. They will call to schedule time and ask if they need to bring anything that is not on the orders already faxed to the agency. Ask for a box of gloves(should be automatic-oh well) The nurse cannot provide POUR SALINE IF THAT IS PART OF YOUR ORDERS YOU NEED A SCRIPT FROM YOUR DOC AND GET IT FROM PHARMACY.

4. If equipment that they are required to provide isn't provided, call the HH main office and complain.You will be provided with the state number to call for complaints and also for medicare patients a federal 800# at your initial visit by the nurse --it's the law. This is a huge deal to the agency to get a State /Federal complaint--use as necessary.

will edit later  thanks everyone sas

Momo, I am so sorry that you are going through this. It's 10 pm my time , i checked your homepage and I see you are from Ireland.  Sorry I am cluless what time is it there . I know it's about a seven hour difference, but that would make it about 4am???. I've seen your post and am going to pop out to figuire a timeline related to your events related to front and back to keep facts straight. But for the time being your first thought of being seen in am by breast care nurse is right at the very minimum. Please, do the following in the mean time. Outline the red area on the breast as described above several posts ago. Have your husband do it. Then in the best light available the two of you look at it. Light is/can be a problem as it reflects over curved surfaces. Yellow and blue light will change what you see. The best is clear daylight. I'm closing this now in hopes you see this because if you start right now it will take at least 1/2 to get it done. I'm continuing to work on your post and will be back asap.

thanks, sas--I'm  a nurse not a doc, but if any words help I would be happy

Sas.... I have had quite the busy day. Even though I did not post a reply I did get a chance to read your fabulous suggestions prior to calling my doc's clinic.

You are right...I do live in Ireland and my surgeon's office is about a 2 hour drive away. So it has been quite a long day. I am so glad I read your post before I went there because I was so much more prepared.

They started me on an antibiotic for a cellulitis. I have had 2 doses already and honestly... the pink looks like it's fading already. I go back on Wednesday for another eval of the front and back!!!

I am exhausted. the travel alone is daunting. Not to mention that I feel run down as a baseline these days.

I am so delighted to have met you and all the other wonderful ladies in cyber space. The power of the information found on this bulletin board is fabulous.

thank you very, very much

Momo, Hi this should reach you.

Some ???'s for your doc

1. Did they culture your wound. 2.What were the results. 3. Was the antibiotic used based on the culture results.---should be automatic, but get an answer.

In your PM, you discussed dry drainage on dressing. Well dry was once wet. Wet and dry can shed. So, dirty dressings should minimum have top layers changed or reinforced(means to cover with another sterile dressing over old) to protect you and family. Sometimes and internal dressing is not disturbed for a reason. REmeber a dressing is a barrier. To keep things in as well as out. You also mentioned that the wound  is very wet, but actually I'm confused now. You said several post ago, that they closed the wound with internal and external stitches. If this is true, than it must be oozing somewhere. The problem with a oozing wound is the hole that it is oozing through, can plug up .Then you are a set up for an abcess--collection of infected or noninfected fluid(term -sterile abcess) below the skin, that may  eventually need draining or a seroma/ hematoma(collection of fluid and blood). Which leads to a big question did they put a drain in when they debrided you. The picture I have from what you have said from above post and your PM is----closed incision -that is draining/oozing, and the internal dressing is wet enough that you have drainage through to the external dressing. This won't do. He needs to address this because a wet closed incision is at risk of getting emacerated. Emacerated tissue does not hold sutures well, and they can eventually pull away and the incision open up. And it is a set up for bacteria to thrive because basically they have a food supply or as  I said in an above post a MEDIUM to grow in . There are wounds /incisions that have special reasons for not changing the dressing until a given time. BUT it doesn't sound like yours is that type.Have doc explain?

Some seromas/hematomas are left to absorb over time, can take months. 

So, 1 why is it draining so much.

2. Is there a super asorbent dressing material  that can wick away the drainage. There are multiple types of thes products, but they are used on open wounds i.e calcium alginate, silver alginate, sorbsan and new products are produced everyday. Products that you have in Ireland , we may not have here

3 Whats the plan now.?  While it's draining so much , it likely should be changed more frequently to keep it dry. Discussion of freqency and whose to do it.?

4 If it opens, is the site an appropriate wound site for a wound vacuum. Do you have wound vac treatment system  in your area?

Hate to bring up idea that it might open, but this is within the realm of possibility.

Remember the outlinging and taking daily pictures if possible. SHE's suggestion of sending them by email could save a lot of two hour trips each way.

Your PM question re: when and what other tests should be done now. The response of "We'll worry about that later , get through this". You have a right to have an verbal outline at least, of what is to come. The days of doing just what the doc tells you, without question(s)has long since past.

Momo, Thanks again. I'll try to check later tonite to see if you posted. What time is it there if it's 5:45 pm here

 ANYONE viewing that wants to pop in with ideas/cautions/ pearls of wisdom . Please, do so.

SHE wow thanks your amazing.  I'm worried MOMO hasn't posted , but we will just have to be patient, sas