TV medical shows can be pretty goofy, especially when you're a surgeon. Always amusing, to us anyway, is the great drama of the skin incision. This much you should know about real surgery: The skin incision is the easiest part. Human skin cuts about like a pork chop (or a Fruit Roll-Up, if you're a vegetarian); a scalpel is usually no sharper than a good kitchen knife. Knowing where and how deep to cut is also super-basic to the practice of surgery, about like starting the engine is to the practice of driving. The skin is (unless you're a plastic surgeon) ultimately just another thing standing in the way of what you really want to get at that joint, tendon or organ you're there to fix. And skin has many amazing properties: Gain 200 pounds and the number of square yards of your skin may nearly double. Your skin regulates body temperature, changes color to prevent radiation damage, oils itself, feels, grows hair and emits all kinds of sexy pheromones. But the wonders of dermatology are not why, after tens of thousands of them, I still pray a little before each skin incision. There's another thing about living skin when you cut it: It heals.
We depend utterly on healing unexplainable, amazing, taken-for-granted automatic mending of cut skin for any and every success we can possibly have with any surgery. We rely on it much as a farmer depends on his hard, dry seeds to turn into green plants, but our need is a little more intense: If the healing miracle fails, what I accomplish in surgery is only to hurt someone who came to me for help. And I'm likely to feel more than emotional pain plenty of juries can be convinced that an un-healing wound is sure evidence of malpractice. There's a whole lot on the line with a skin incision. And like most blessings, healing is not given much mind until it fails to occur. I learned this taking care of a patient named Manuel.
A routine case: Manuel was an office worker, 31 years old, a little overweight but in otherwise good shape. The two half-inch-long incisions I made on his knee doing arthroscopic surgery had not healed when he came to my office a week afterward to get his stitches out. So I had him come back a week later, then two more weeks later. The knee joint was ok but at the fourth week I was still staring at two gaping holes in unhealed skin. They were like cuts on a cadaver; it was creepy. There didn't seem to be a reason for this failure of his skin to close. His pre-op labs had been normal. I went through our old mnemonic FRIEND but there was no foreign body, radiation, infection, enteritis (like Crohn's disease), neoplasm (cancer) or diverticulitis producing these dry holes in my patient's knee. Maybe the miracle just wasn't going to happen this time. There didn't seem to be a reason for the cuts not to heal, but then there's no real reason for cuts to heal either. They just usually do.
One idea came to mind. Because openings into joints can let bacteria in, I had kept Manuel on oral antibiotics. But I recalled an experiment done with lab mice bred in a sterile environment. Without any bacteria around they couldn't heal cuts in their skin. Maybe my antibiotics were suppressing some bacteria that were needed to coax these knee wounds to heal. So I stopped the antibiotics and brought Manuel back a week later. No dice still no change.
By the sixth week Manuel, too, was nervous about his knee. He looked a little thinner, a little pale. Nerves? I asked about it. He said he had lost some weight but he had been trying to. He added in a mumble, "maybe it's just water weight."
Not something a man would say. This was a clue.
"Have you been going to the bathroom more than usual?" I asked.
"As a matter of fact, yes, doc. I seem to be drinking and urinating like mad."
Another clue. So, I sent him off to the lab. A quick blood test made the diagnosis.
Sometime since his pre-op blood tests, Manuel had developed diabetes. Wound healing problems (though usually less dramatic than Manuel's) are often part of this disease, when the diabetes is uncontrolled as it was in his case. The blood sugar test we did two weeks before the operation had been normal. It was quite high now. But Manuel started on insulin, stopped diuresing, got ruddy again and, to my great delight, closed up the cuts on his knee all in the following week. He wasn't very happy about having to inject himself for the rest of his life and, I think, suspicious that taking out the torn knee cartilage had somehow caused his diabetes, but Manuel was OK. His skin was healed. I could only think: "One treats, another heals."
Along with relief, I now had another "D," Diabetes, to add to my non-healing mnemonic. Am I older but wiser? Hardly. To say we understand the healing miracle, even having read the great scientists who've spent their lives learning about it, even having studied it firsthand, is to say we haven't really thought about it.
Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area.