Skin / Capillaries look dead to surgeon

Shortlady I never used it either. Saw it the active topics when I signed on. This gentleman is giving solid advice. He is a treasure to this forum already. I might write him and tell him that. Social Security is like the IRS. WHatttttttttt? if you get my drift.

Did you get the info you needed from here? Is there something I can try and help with? I'll post this and look at the previous page. Pm me if there is something.  I generally sign on every day , but sometimes miss, AND i don't always check this thread.

My parents have the magazine so I will check with them and see if I can find out when it was. 

I posted earlier last year! I had extensive necrosis after BMX w/TE, on one side due to prior radiation. I used silvadine/two dressings per day for months - June through February, finally, slowly healed. Since then I have slowly been getting fills, 25cc at a time. About a week ago I noticed a tiny pinhole in the skin, which has since grown to about the size of a quarter of skin breaking down. We were at the end of the expansion. It has been 14 months since my original surgery. I am really shocked at this point since I was expecting to be doing my exchange surgery before the end of the year. My PS did not say much yesterday when he saw it except "put some neosporin on it" and come back in a week.I am guessing the skin just couldn't take the expansion and my expander is going to have to be removed. I guess I have to wait and see. I am really down over this, but not much I can do. Sas-schatzi, do you think I should be using silvadine rather than neosporin? I used the silvadine for months. I guess they both do about the same thing.

JB: I echo what sas-schatzi is telling you about your wound issues.  I also feel that you should get a second opinion.  Are you at Moffitt?  You can PM me and I will be happy to give you some names. 

Sas - I agree with She's post above.  You need to start a Wound Management thread.  This is a much needed thread for those of us in the trenches to link others to when they are facing wound issues with reconstruction.

Deborah

SAS & Deborah, thanks for your responses...I thought I posted another response but it did not show up so obviously I must have forgotten to hit the submit button. Anyways, first, I wanted to clarify that my PS did NOT do a fill when I saw him this week - in fact he said "we're done" because clearly the skin could not take anymore. I have not been unhappy with PS up until this point, but I did follow up and I had some silvadene left over and okay to use that instead of neosporin. Wound appears to be stable for about 3 days, but after all this will it heal again? I'm not so sure. I like the idea of getting a 2nd opinion. If the wound continues to be stable I will wait til my appt on thursday, if it gets worse, I'll get in sooner. Depending on what he says at next appt, I may seek the second opinion.

Sheila & Deborah, thank you both so much for all the support. It's all water under the bridge now as yesterday I had surgery to remove the TE. The skin was breaking down pretty extensively beyond the visable wound and it was just a matter of time. I don't know what triggered it. Having said that, the pinhole showed up after I had spent a few hours in the pool (chlorinated) and the skin on the breast which was very dry started peeling. I thought it was okay to be swimming since the wound had closed months ago. To be honest, I had probably the slowest expansion in history. We started in February, and only did 25 CC at a time, every 2 to 3 weeks because I was so concerned about the extensive scarring from the necrosis. I was recently worrying how the skin would ever survive the exchange. I do think we probably over-filled but I am not so sure it would have mattered in the long run. In defense of my PS (and my BS), they both told me up front before any surgeries that the TE on the rt side was questionable. Both docs initially suggested a lat flap would be a better option, or PS suggested I have the mastectomy but wait awhile on reconstruction due to possibility of necrosis. My fear of being w/out a breast pushed me to go the TE route despite their advice. They discussed with each other and agreed to try it. So - moral of the story - I probably should have gotten a second opinion, and I should not have let Fear be my guide...lessons learned. Regardless, today I woke up relieved that this is behind me for now. I am on the healing path, and will now explore my options. PS feels TE may still be do-able in the future but I will follow Deborah's good advice and get a second opinion. I see my oncologist in 2 weeks at Moffitt and will discuss with her as well, and hopefully get her support in seeing the PS at Moffitt. Thanks again for your support.

A few seconds ago sas-schatzi wrote:

Friends I'm reposting this here----------it has implications for you and your childern. Many of you don't post where you might see this.

2 minutes ago, edited a few seconds ago by sas-schatzi wrote:  I'm re-postig this from another thread. tested hyperlink. There are implications , not just for us, but all women and childern males as well as females. Children being exposed to high levels of estrogen. Could explain why early onset puberty has been such a problem. AND newborns being born that have signs of going through puberty.

Hillck-----I'm even more bummed that article was published in DEC 2006. It should have been a Public Health Warning issued from some agency. You noticed that at the end of the article they said they were going to lay low. It was fascinating that the Mongolians to empirically figure this out and have been doing it for 2 thousand years. That's HUGE.

TO ALL---read the below hyperlink.-----How it affects us is--Now we may have to make choices about milk.

Another thought the government has NOT dealt with the public impact of what this article identifies. Guess it's not politically correct.

I'm going to add the hyperlink here and re-post it on a couple of threads.

http://news.harvard.edu/gazette/2006/12.07/11-dairy.html

Bump

JYG- any thing you find interesting? That helped---------It's been suggested for posting--------can't do

Bump

Anyone interested I wrote a new topic thread on constipation------ah the things we share-sheila

http://community.breastcancer.org/forum/6/topic/781867?page=1#post_2830873

bump for NancyL&H sheila

Bump------for those with wounds that need tending

BUMP

member name deleted      Based on what I see here from your description and all the members responses . The pyhsical description appears to be improving ? Is that true. Redness reduced, heat reduced, fever reduced. YOu Have been seen by a doc daily.   It appears to be improving versus getting worse? You are taking pictures daily.Lay them out sequentially, in good light with no shadows. That will show color progression, which is important in evaluating getting worse or better. You already established that the skin was hot and now it's not, You state no systemic temperature. I think stated amount injected was 2cc , but you described a baseball size lump. that falls more into description of possible tissue reaction to the drug, abcess from the injection itself, Hematoma from hitting a blood vessel that ultimately sealed it self off.  What the body does is seal off an area in the occurence of anyone of the three.

Your symptoms and signs sound as if they are improving.

Well at least the monograph says it's not a vesicant or irritant and treat extravasation/infiltration symptomatically. That's a positive. which You are doing.

Couldn't find anything that described any specifics for treament other than what the monograph below stated, whereas, some had lengthy descriptions of treament if infiltration/extravasation occur. Some were amazingly lengthy. All were for treatment immediately following infiltration/extravasation.  Your occurence is a week old Right?

The blistering was described that it could occur. Problem with blisters is the origin. Is it in response to the drug or is it a bacteria. Only culturing the fluid from a blister would tell.

The key is monitoring. Continue daily visits or if they have stopped daily visits and you are emailing daily pics, that will have them pick up condition change. You have seen at it's worst. That actually helps in moitoring, All the early s/s's indicated trouble. But they are gone now. My initial response was based on the fact that s/s's were still present. That's why all the questions above. Need to know if this is true?

The reason I keep using infiltration/ extravasation is --those are the terms used to describe a drug that is to be given IV , but moves into the tissues b/c the vessel ruptured for whatever reason. Halaven is indicated to be given IV only. So, for simplification that's why using these two terms is correct.

When a drug is to be      given IM or subcutaneous(subcu)--the espected is that infiltration/extravasation into the tissues  to be absorbed, is the goal of administration

The terms have a meaning that is a negative in one sense and intentional in the other,

C&P from monograph  between lines---------------------------------------------------------------------------------------------------

Good peripheral venous access or a patent central line should be ensured before administration.

There is no evidence that eribulin mesylate is a vesicant or an irritant. In the event of

extravasation, treatment should be symptomatic.

This document plus the full product monograph, prepared for

health professionals can be found by contacting the sponsor,

Eisai Limited, at: 1-877-873-4724.

This leaflet was prepared by Eisai Limited, Mississauga, ON

L4W 5A4.

Last revised: December 14, 2011

HALAVEN^TM is a trademark owned by Eisai R&D

Management Co., Ltd.

------------------------------------------------------------------------------------------------------------------------

If all the questions are showing that s/s's are improving, do as they say i.e continue to treat it symptomatically, as directed. Blisters that erupt like a volcano and little blisters occur around  the ruputed blisters in a circle. AND the little blisters grow until they rupture like a volano with little blisters around them, that's descriptive of a specific bacteria. Report this asap. Expected response would be a culture and sensitivity of fluid from a moist blister, a specific antibiotic started immediately until sensitivity report back(sensitivity reports are generated at 72 hours after culture).  An adjustment in the antibiotic treatment based on sensitivity report as necessary, is done at that time.

Report any condition change that shows worsening.

That I think covers all my thoughts. I will bump a thread I worked on a long time ago re: wound evaluation, care, and setting up an in home dressing station and bring the link here if I can. Good luck!

community.breastcancer.org/for...

sassy

2nd post to same member

member name deleted. To get to a wound care specialist almost universally you need a referral from a doc--your PCP may be faster to get to an appoitment with than the MO. Suggest that if you are in an immuncomprimised state to where a mask when going to a medical facility. Some would call this overeactive, I call it safe. Have you been able to read above post? I edited this am to add more detail and link. sassy--4 posts back

Edit: the halaven patietcare specialist response re: wound care specialist referral is the expected safe response from the company because it demonstrates on the recording of the call, that they recommended the highest standard of care available. Your PCP or MO may say no at this time to a referral based on wound presentation. I say this just in case they do say no, you will understand why, The PCP/MO are basing their response on direct visualization of the wound.

The PCP/MO may refer you ,even though their judgement of the wound doesn't warrant a refferal at this time. It falls in line with CYA. The PCP/MO can document they made a referral to the definitive highest level of care. Whatever their reasoning if you are referred, it will give you a sense of convidence that the wound has been evaluated by the most highly trained physician. Not just any doc can put up a shingle and call themselves a wound care specialist. They have to go through a special training program. Nurses in a wound care specialty center are also required to go through special training. The best nurses have the certifications from an accredited program. Emory University being the most well known on the eastern side of the country. Not sure what's available in the west. The Docs go to Cincinatti if a Bariatric chamber is part of the wound care centers treatment abilities. Too much detail . OCD lol sheila/sassy

RESPONSE TO MEMEBER POSTING REPONSE TO MEMBER QUESTION

MEMBER NAME RESPONDING TO MEMBER QUESTION DELETED-THIS IS MY RESPONSE TO HER:

 Can't attest to halaven because i haven't seen the label. But drugs carry that info on drug label. Clearly identified in mongraph I read this am. Clear. This nurse either was completely unfamilar with the drug---basic rule from nursing school NEVER GIVE A DRUG THAT YOU DON'T KNOW NAME/ACTION/ROUTE/.S.E/CONTRAINDICATIONS(NEVER USE)/DRUG INTERACTIONS/ALLERGIES.  OR SHE BREACHED A RULE OF ADMINISTRATION .I.E. SYRINGE NOT LABELED OR SHE HAD TWO SYRINGES AND MIXED THEM UP. ----bOLD BUTTON WON'T GO OFF. SORRY. AS EVERYONE HERE HAS SAID SHE SCREWED UP ROYALLY.

3RD RESPONSE TO MEMBER

MEMBER NAME DELETED- sorry, don't know how I didn't remember the references to bleeding. There were many--DUH.

In the post above I described the following, Ill try C&P (mouse cranky)

"you described a baseball size lump. that falls more into description of possible tissue reaction to the drug, abcess from the injection itself, Hematoma from hitting a blood vessel that ultimately sealed it self off.  What the body does is seal off an area in the occurence of anyone of the three." The other term used is wall it off. When there is drainage as you describe, it should have been cultured at first viewing by MO, because drainage may appear to be bloody when it actually is abcess fluid mixed with blood. It would look a dark reddish brown. The only way to know what the fluid was is the culture. Also when the body creates the wall around a hematoma or abcess it is hard as you described. In feeling/palpating the area. it would be referred to as abcess margin or wound margin. The wall protects the body from the fluid inside the the wall from entering the body. It will often spring a leak to the outside, that reduces the pressure on the wall. If it didn't spring this leak, the expanding fluid would rupture the wall internally.  The abcess fluid then can spread through other tissues and affect a wider area and or be absorbed into the systemic circulation. So, the leak to the outside is in a way a good thing. I kow your thinking right now. )(*^%$^&^&.  But better out than in. Treatment that you should expect is an INCISION and DRAINAGE--I&D that will allow for the release of the fluid inside the abcess. That is accomplished by knife puncture. Followed by two cultures--one for aerobic bacteria , the second for anaerobic bacteria. a drain placed to keep incision site open. Reclosure of the incision site would allow for a return to the original situation.

Your post describes bleeding/drainage has stopped. 

What you can expect

1.could be permanent -no further problem -fluid inside ultimately resolves over time,

<address></address><address>2. pressure of fluid inside springs a leak to the outside--s/s's increase in pain and pressure if fluid is building up again, reopening to outside should not have the same pain as #3 because the drainage tract is not healed. It's like a patch on a tire, not as strong as the tire-------seek physician intervention</address>

3. wound ruptures internally and fluid spreads through tissue.---s/s's(sign/syptoms). increasing pain  and  pressure  at the site. sudden stark icrease at rupture and reduction of pain and pressure.----seek physician intervention.

Options

1.Definitive person to do I&D is a surgeon b/c they will decide if abcess needs 1.surgical removal and debridment(cleaning out). 2.simple I&D. Your Breast surgeon is competent to do this.

2.PCP can , but likely would send you to ER or surgeon.

3.ER-- the examining physician is competent to perform an I&D, but would likely call the surgeon on call, they would consult regarding ER doc's findings. Between them they would decide if ER doc performs I&D or surgeon comes in.

4.If ER doc does I&D or PCP they likely will refer you to surgeon or the wound care center for further evaluation. Put on a broad spectrum antibiotic as I described above send you home with instructions. Those instructions would include "If condition changes or worsen, call doc on call or return to ER.

5.The other determination is that you would be admitted for IV antibiotics. If this is the determination they would put you in wound percautions isolation. This is appropriate. But you are also immunocomprimised. SO, you would have to ask for Revese Isolation too. The steps for each are just wee bit different

     a.Wound percautions protect teh staff and environment(door to roo) from contamination from wound.

      b.Reverse Isolation protects you, from staff and outside environment (door to room).

So, if you are admitted you need to be in wound and reverse isolation.(They may not agree to reverse isolation if your numbers are good).

So, the post of yesterday where I described in much shorter terms, compared  to what I have done now, described in minute detail ad nauseum, that I asked to bedelete. I now with complete info return to that recommendation. Of couse, it's now after 5pm on Friday.

If you go to ER, call ahead and use these word'" Immunocomprimised oncology patient coming in for evaluation of wound and needs reverse isolation.", They will put you into revese isolation , draw labs--CBC, check neutrophil and wbc count. Likely do blood cultures while drawing CBC. A second set of lab cultures would be drawn from a different site in 15 minutes. Your port would be one site(likely) and arm the other.

The completeness of this is not meant to scare you, but prepare you. With knowledge we can better understand the course of events. I'll watch for a post back. sheila/sassy

 4th Response to memeber asking question

There are some typos and punctuation errors. but mouse misbehaving. Rather than really screwing up post, I will leave them alone.

I am going to cut and paste these responses to the link I suggested above. I have used that link many times in similiar situatioms. It will delete your name. Everything that I have written to you is applicable to others in the same or similar situation. 

Good luck. sheila/sassy