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The Art of Medicine


Reed, Harrison MMSc, PA-C

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Journal of the American Academy of Physician Assistants: January 2016 - Volume 29 - Issue 1 - p 58
doi: 10.1097/
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Sometimes there is so much pressure inside that it feels empty.

I ran my fingers over the solid lump in the young man's leg, and the words scuttled through my memory. It was an infection; the red flesh and throbbing pain left little doubt of that. But conventional wisdom says if the matter inside doesn't give just a little, if you can't feel it fluctuate, then there is nothing to release.

And you keep your blade away.

“It's my fault, isn't it?” The man finally turned from his study of the blank wall to face me. The rest of his skin was a pocked minefield covered in the little scabs and scars of someone whose flesh often tried to crawl off the bone.

“These things can happen to anyone,” I said.

My finger settled on the center of the lump. It might as well have been painted with a bull's-eye. I convinced myself the solid mass moved just a little.

“But I mean, the heroin,” he said. “It makes it worse?”

I opened my kit and cleaned the skin. There was stuff we both needed to get out.

“It certainly puts you at risk for a lot of bad things,” I said.

“I use clean needles.”

That wasn't what I meant and he knew it.

“You're gonna feel a poke and a burn,” I said.

The corner of his mouth turned up a humorless smirk. But even those well acquainted with needles cringe a little when the lidocaine goes in.

“You know,” he said, “the last one busted open on its own. I wasn't even going to come in for this one.”

“You trying to put me out of work?” I said, and he laughed. “Don't worry about it. Sometimes it needs a little help to open up.”

I pressed the blade of my scalpel to the center of the abscess and let it slide through the skin. I pulled it out and waited for the rush of blood and pus.

Nothing happened.

“I really do want to quit,” he said.

I put aside my scalpel and picked up my forceps.

“That's a great idea,” I said. “I think you should.”

There was something in there; I knew it. But there was one last barrier to push through. I pressed the sharp tip of my forceps through the incision.

“I have a daughter, you know.” The man blurted it out like the words had been swelling deep inside his head.

My fingers finally felt a tiny pop as the forceps overcame the last resistance and slid deep into the man's leg. I pulled them out, and the source of his problem oozed out onto the gurney.

“Tell me about your daughter,” I said as I pressed my hands into the skin on either side of the wound.

There was no response and I glanced up from my work. Tears streamed down the man's face, and he rushed to brush them away with the sleeve of his T-shirt.

“I wasn't always like this,” he said. “I had good grades. I was going to go to college. But then I got my girl pregnant, and my parents kicked me out of the house.”

I picked up my hemostat and stuck the tip into the oozing hole in the man's leg. Sometimes you have to break open every little compartment to get it all out. This always hurts the most.

“I can feel it,” the man said and a little panic crept into his voice. “Am I supposed to feel it?”

“The infection changes the chemistry of your tissue,” I said. “Sometimes that means the lidocaine doesn't work.”

The deepest wounds can never really be numb enough.

“I don't get to see her much, since I went to jail,” he said, and the tears returned. “You think it's possible? For someone like me to get better?”

“It sounds like you already know what you have to do,” I said.

I finished my work and packed the wound so it would stay open, continue to drain.

“I know it's sore,” I said, “but now that it has drained it will start to feel much better.”

The man sat up on the gurney, his posture a little more relaxed than before. His eyes held a little less pressure.

“It already does.”

Copyright © 2016 American Academy of Physician Assistants