“I wasn’t sure what to do”. If I had a dime for every time I’d heard a patient use those same words, I could retire to my homestead and hang up my stethoscope once and for all. In this case the speaker was a 20 year-old male who looked like he was a couple of dozen pounds underweight. The chart said he was here for redness and swelling of his ankle. This was almost right.
Upon interviewing the patient, he claimed he was in his usual state of health until 4 days prior to his visit when he began having pain and swelling just above the right ankle on the outside of his leg. He denied fever or vomiting but stated the pain was now making him nauseous. He further denied trauma to the area or of ever suffering from something like this before.
Exam of the area showed a 6x8cm area of swelling (hard to the touch) which was red and very tender. The area of redness extended well past the hardened area and was less tender but still hurt to touch. The area felt warm and tense, like a giant pimple ready to burst – which is essentially what an abscess is.
Every day, in every emergency room in America, someone presents with an abscess – it is that common an ailment and would likely be even more common during a disaster or other wide scale disruption in society. Any break in the protective barrier that is your skin can allow bacteria to enter deeper into your tissues, where it can then hide to some degree from your body’s natural defenses and begin to do what all life seeks to do – reproduce.
The causes for the abscess initially could be as simple as an insect bite or a shaving cut. The most common types of bacteria found in these infections is staph and strep – which (not coincidentally) are the most common types of bacteria found on the human skin.
Once the infection is noticed by the body, it is your defensive (immune) system that causes all the outward signs of the abscess. The redness is due to chemicals released by your immune cells to alert other immune cells that they need help and to begin fighting the infection. The swelling is caused by an accumulation of pus; which is a collection of white blood cells, bacteria, and all the collateral damage being done as they fight each other.
Left untreated, the abscess can end in one of two results. The body wins by segregating and trapping all the bacterial invaders and causing the swollen area to burst, releasing the pus and fighting off the last of the bacteria while you ooze. Or the bacteria can relocate within the body and continue its assault until it overcomes the body’s defenses (“blood poisoning” or sepsis) and the victim dies. Before we had antibiotics and an understanding of this process it was a common way for our ancestors to go out.
With modern medical systems in place, the treatment is powerful antibiotics and often a procedure known as incision and drainage – which is exactly what it sounds like. A cut is made (hopefully with anesthesia) into the abscess and the contents cleaned from the wound. The wound is then left to heal after draining for several more days – basically an induced version of the “pop-and-ooze” the body works towards. The patient is then placed on an antibiotic and re-examined at intervals to ensure good healing.
So what happens if you don’t have access to those powerful antibiotics? You can still resort to addressing the problem the same way doctors did for a thousand years before we had these drugs – incise and drain.
Before you stab your buddy’s abscess with your K-Bar, however, you might want to ensure you have the right diagnosis. Cutting someone’s skin in austere conditions is opening them up for infection, if they didn’t already have one. Also, you might want to consult an anatomy text to make sure you aren’t going to sever any major blood vessels or nerves in your attempt to right the bacterial wrong. Remember the old medical adage “do no harm” applies to those who attempt to play doctor as well.
There are instances when you might not want to incise and drain (I&D): Extremely large abscesses, deep abscesses in very sensitive areas , abscesses in the palm of the hand or sole of the foot, or abscesses on the face. These are instances where we in the ER refer to a specialist and you should consider the risk of doing something verses the risk of waiting and watching.
If there is anyone in your group or community that is a nurse, PA, physician, or even a paramedic see if you can get a second opinion and assistance with the procedure. You can also take classes now that will give you some minimal exposure to, and experience with, performing this skill. There are also videos on YouTube that show the procedure and explain it better than just reading about it here.
There are many herbal treatments for abscesses that are beyond the scope of this article. These may apply to general wound care as well and I’ll address those in a future article as well.
As for the young man in the ER – when his procedure was complete and he had his prescription for the antibiotic, he turned to me and said, “that wasn’t so bad”.
“So you know what to do next time?” I asked.
“Yeah, come to the ER” he said.
Hopefully for him (and for you) there will be an ER to come to. If not YOYO (you’re on your own).