Category Archives: medical

The Nose That Knows Mohs

 

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Pressure dressing after Mohs procedure

Are you facing a Mohs skin cancer surgery on your face? If so, you probably have plenty of questions and concerns. If you’ve Googled it and looked at the pictures, you might even be having a slight meltdown right about now. Never fear, I’m going to share my experience along with a few pictures that aren’t exactly pretty, but they probably won’t send you into full panic mode. (If you’re very squeamish, the post-surgery photos will be at the bottom of this post, so don’t scroll down that far.)

I’ll start by sharing this photo of me taken almost one year after my Mohs procedure. I challenge you to guess where the scar is!

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1 Year Post-Moh’s On The Nose!

Can you tell? It’s right in the middle of my nose, just a little to my right of center, about a half-inch below where sunglasses would rest. I’m wearing only Jane Iredale  mineral powder foundation in this photo with no extra concealer. Without makeup, you would see a slightly reddened spot but no real scar to speak of, and a little bump.

My story begins with a visit to the dermatologist in November, 2015. I was concerned about a spot on my forehead, and a biopsy was taken. I pointed to the tiny, pearly bump on my nose that was barely visible and not really bothering me. “I’ve seen two other dermatologists in the past four years, and both told me this was nothing to worry about,” I said to Dr. Lambiase. He peered at it, squinting his eyes and raising his eyebrows. “Hmmmm, I’m not so sure about that,” he declared. “I tell you what, the buck stops here. We’re going to biopsy it.”

The Results

I was surprised when Dr. Lambiase’s office called to tell me that the biopsy on my forehead was fine, but my nose showed basal cell carcinoma. Dr. Lambiase wouldn’t be removing it because they were referring me to a dermatologist who specializes in Mohs skin cancer surgery, Dr. Sorace. His next available appointment was on December 23, the day before Christmas Eve. I wasn’t worried. My mom had a skin cancer removed under her eye without any problems. When I was working at UCLA Medical Center as an RN I had observed several Mohs procedures and occasionally did home visits for dressing changes. I was pleased to see that Dr. Sorace had done his residency and was even the chief resident at the UCLA Division of Dermatology, although it was years after I had worked there, so I knew he was good. I didn’t think for a minute that this “little” procedure would interfere with my plans for cooking dinner on Christmas Eve. From everything I had heard of Mohs, there was nothing to it!  As it turns out, there was a little more to it than I thought. Nothing terrible and nothing to worry about, but I think it’s always good to manage your expectations. That’s why I’m writing about it.  I hadn’t planned to, until a friend had a Mohs procedure on his forehead last month. I’m pretty sure I was one of those who told him there was “nothing to it.” When his wife called the evening after his surgery to cancel some plans because he was having too much pain, I winced a little in recognition. He was fine a few days later, but he did tell me it was the worst pain he had experienced, and he’s a pretty rugged manly type of guy. He also had surgery about six months prior to this on his upper and lower eyelids (by the same plastic surgeon who closed his Mohs) and said that was a piece of cake compared to the Mohs on his forehead. Mine hurt, too, for about two days. LOTS. I think it depends on where it is and other individual considerations. Your mileage may vary, and some people experience very little discomfort. Thinking I knew exactly what I was getting in to (perhaps an occupational hazard for a nurse, lol) I declined the offer of a pre-surgical consult with Dr. Sorace. The night before my scheduled procedure I decided to Google it. I HIGHLY recommend AGAINST doing that! Oh my goodness, what exactly was I getting myself into!?!

The Procedure

This part is the “piece of cake” that everyone talks about. There really is “nothing to it” from a patient perspective.  I arrived at Dr. Sorace’s office in Boerne, Texas with butterflies in my stomach and my husband in the waiting room for moral support.  If you’re not familiar with the concept of Mohs, here is a description from Dr. Sorace’s website:

What is Mohs Surgery?
Mohs micrographic surgery is the most effective treatment for skin cancer. It is a sophisticated surgical technique designed to maximize the chance for cure and minimize the amount of scarring.

The basic idea of Mohs surgery is rather simple. The area where the skin cancer is located will be removed. The patient then returns to the waiting area while the tissue is being processed here in our laboratory. This will usually take about an hour. Dr. Sorace will then take a look at the specimen and examine all the edges and the deep tissue of the removed skin under the microscope. When the edges and depth are free of tumor, then the skin cancer has been completely removed. If the skin cancer is still detected at the edge or base of the piece it will be mapped. At this point the patient is brought back in to undergo further removal. Dr. Sorace will be able to go back precisely where the residual tumor lies and avoid damage to otherwise healthy surrounding skin.

Although the word “surgery” is involved, my experience was much more like a (very long) visit to the dermatologist’s office rather than an outpatient surgery center. The office was clean and comfortable, with a waiting area and several procedure rooms. This particular office even has a lovely patio overlooking a creek where you can wait when the weather is nice. My procedure was on my nose, so I remained fully clothed and was made comfortable in this chair.img_2939

After Dr. Sorace marked the surgical site, his MA numbed up my nose with injections of a local anesthetic. This was fairly painless, just a slight pinch with the first one. When I was fully numb, Dr. Sorace came in for the procedure. He remarked that with any luck, he would be able to get everything with this one pass. I felt absolutely nothing. Now at this point, some Mohs patients have posted that their doctor let them look in the mirror to see the “defect” and some even take pictures. He didn’t offer and I didn’t ask! If you are a Googler and simply MUST see it, go right ahead. The defect is always much larger than the original spot and it makes you wonder how in the world they’re going to manage to either sew it up or let it heal. My thought process was that I would receive information on a “need to know” basis, and that was a part I didn’t need to know! LOL  I went back to the waiting room, which was stocked with coffee, water and snacks. I waited for a little over an hour when I was called back again. Although I had convinced myself that Dr.Sorace would come back in and say that he hadn’t found any cancer cells to begin with, that wasn’t the case. There was a bit more than expected, so I would need another slice taken out. I can’t remember now if I required further numbing injections at this point, but I imagine I did. It was still completely painless. I remember asking what would happen if the cancer went down to the cartilage and was told that the location was up over bone, not cartilage.Now I’m a little more worried than I was an hour ago, and out I went to wait again. This was the waiting room hour where I mentally went over every worst-case scenario and rehashed every complicated head and neck surgery case I had seen in my years at UCLA, and wondered if I shouldn’t have arranged to have some kind of anti-anxiety prescription ahead of time. The worry was short-lived, I was called back and told I was good to go. The incision ran vertically from the top of my nose all the way down to an inch or two from the tip and was closed with stitches. Still no pain at all. The MA applied a pressure dressing and said I could remove it at home (I think it was 24-48 hours) then clean gently and I could apply a band aid. (See photo at the top of this post.)  She gave me a sheet of simple post-op instructions, which said that most patients experience minimal discomfort after the procedure, but if you had discomfort you could take Tylenol and call the office if that didn’t control it. I returned to my waiting husband feeling great and also hungry. It was lunchtime, so we decided on lunch at the nearby Cypress Grille, one of my favorites in Boerne. img_1903

This is immediately after the procedure, window shopping on the way to lunch in downtown Boerne. I was relieved to have the procedure over with, and didn’t feel self conscious at all that I was having lunch wearing a great big bandage on my nose. I was appreciative of the fact that the steri-strips on the pressure dressing were a close match to my skin tone, rather than the stark white dressings I had seen in the past!  We had a lovely lunch and were preparing to run a few last-minute Christmas errands when I noticed the beginnings of a headache. Within a few minutes, the headache turned into a throbbing pain as I felt the anesthetic begin to wear off.  I told my husband, who was about to take me TO THE GREEN BULL JEWELRY STORE, that I needed to return to the car, so you know it was bad! I don’t voluntarily turn down a trip to the Green Bull!!  I almost never get headaches and rarely take so much as an aspirin, but this was getting pretty intense and I wasn’t sure I was up to the 40 minute ride home before I could get a Tylenol, so we made a stop at a Walgreen’s to get some and headed home without completing the errands. I would suggest, if your doctor recommends Tylenol, that you have this ON HAND and take it shortly after your procedure.

The Recovery

My biggest mistake was thinking I could go on my merry way with high-energy Christmas preparations and that I wouldn’t have any pain. The Tylenol took the edge off, but by that evening my nose felt like it had gone a few rounds with Muhammad Ali. Dr. Sorace gave me a follow-up call that evening (from an airport on his way to his own holiday celebrations on the east coast) and by this time I was convinced that my pain was abnormal and could only be caused by my stitches ripping through my skin. He assured me that this was not the case, and some pain could be expected. I used ice packs on and off and slept with my head elevated.

The next day, Christmas Eve, is kind of a blur. The pain was not intense and was somewhat controlled by Tylenol, but I wasn’t feeling at the top of my game. I did manage to get Christmas Eve dinner on the table, and we went to an evening church service.  img_1905

 

Later that night, I removed the pressure dressing and got my first look at the damage. It wasn’t pretty, but also not frightening.(Pictures at the end of this post) I cleaned the site gently and applied Polysporin and a non-stick gauze dressing. I awoke Christmas morning and realized it was going to have to be a little more low-key than I had planned. I didn’t feel AWFUL, but I did feel like taking it easy. I did want to do something, though, so we ended up driving through a lovely drive-through Christmas light display, and ended the evening with a stroll through the Christmas lights on the New Braunfels town square. My challenge on Christmas was to find a band aid that would actually fit on my nose! I had purchased several different sizes, but none of them worked. Someone really needs to invent a nose band aid! I ended up cutting a large flesh colored bandage so it would cover the length of my incision, and trimmed off the excess on the sides. Then I secured it with micropore tape. (Because it was Christmas, I cut it in the shape of a Christmas angel!)  Over the next few weeks, I got more creative and decorated my bandage with sharpies and stickers. I call this one, “Do You Want To Build a Nose, Man?” in honor of Frozen!

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Do You Want To Build a Nose, Man?

Within a few days, the pain had subsided and I was feeling good as new. The stitches were removed a week later (it didn’t hurt) and it all looked good. By two weeks I didn’t need to wear a band aid in public. The site itself did remain very tender for months, and I was very gentle when I cleaned around it. I didn’t use any makeup on the area for the first month, and then just a light dusting of Jane Iredale mineral powder for the next 6 months. I didn’t use a heavier foundation or concealer because it would require too much rubbing to remove, and I wanted to be very gentle. Because my skin is sensitive anyway, I didn’t use any harsh products or chemicals on the area in order to minimize the risk of a reaction.  For the first few months, I used a silicone patch called Scar-Away over the site for about 12 hours per day. I think it helped, as I don’t really have a scar. You are supposed to wear it 24/7 for best results, but I chose not to during the day. I also swear by a product  called   Anasept or  Puracyn Plus for wound cleaning and used it daily while healing. I have seen a few wounds become infected after a Mohs procedure, and it delays healing. As a nurse, I’ve seen this product work wonders on infected wounds, and I’ve never seen a wound become infected while using it.

I recently saw a new dermatologist for my one year follow-up (Dr. Lambiase moved to Kerrville and opened a new practice, I highly recommend him if you’re in that area) and everything is fine. She remarked on how great my Mohs site turned out!

In conclusion, don’t be too worried about your  Mohs procedure on your nose, but don’t be surprised if you’re not 100% for a few days and plan accordingly. Take advantage of a pre-surgical consultation so you can learn what to expect, and be prepared to take it easy for a few days afterwards!  Also, don’t be shocked when you first remove the bandage. It WILL get better!  CAUTION: Graphic post-procedure photos below.

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36 hours Post-Mohs procedure

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48 hours Post-Mohs procedure

4 Days After Mohs Procedure

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Why patients can’t stay out of hospitals. – By Zachary F. Meisel and Jesse M. Pines – Slate Magazine

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NursePoint: News – Nurse Consultations Prevent Nursing Home Transfers to Hospitals

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Study: Lax infection control at surgery centers – Yahoo! News

Study: Lax infection control at surgery centers – Yahoo! News.

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Nurses call for one-day walkout Thursday – Medical News – sacbee.com

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Doctor Leaves Medical Practice to Fulfill Dream of Becoming a Nurse

Doctor Leaves Medical Practice to Fulfill Dream of Becoming a Nurse

While many people aspire to be doctors, Yoshiya Yamada, a former doctor in Japan, always had inspirations to become a nurse.  On Friday, May 28, that dream became a reality as he joined 94 of his fellow nursing classmates at the Samuel Merritt University (SMU) Commencement ceremony at the Paramount Theater in Oakland, California.

Yamada had been practicing medicine for nearly 20 years in Tokyo.  For fifteen years he examined and treated patients by performing gastrointestinal endoscopy procedures.  “My work was to find the small cancer by colonoscopy and remove those regions by endoscopic procedures,” said Yamada.

Ever since he was a child, Yamada knew he wanted to help people.  When it was time for him to decide on a university, Yamada was disappointed that he could not find an organized nursing school or program for males.  “I wanted to become a nurse in Japan, but this profession was mostly encouraged for females to enter, not men, so I became a doctor instead.”

Fusae Abbott, DNSc, RN, Professor and Director of the SMU Case Management program and a Japanese native, is not surprised to hear that Yamada had a difficult time pursuing his dream to become a nurse.  “In Japan, there are few programs that have opened their doors to those who want to change careers to become a nurse.  Especially in this case, where a doctor wants to become a nurse, it might be almost impossible to find a school which would accept Yamada.” 

That is why Yamada decided to move to the United States in pursuit of his dream of becoming a nurse.  He applied to Samuel Merritt University in September 2007 as a ‘special status student,’ working on his prerequisites to enter the nursing Bachelor of Science in Nursing (BSN) program.  By May 26, 2009, Yamada was eligible to enter the University’s Accelerated Bachelor of Science in Nursing (ABSN) program.  The 12-month accelerated program is designed for someone who already has a baccalaureate in a non-nursing field.

“This was an intense course,” laughed Yamada.  “I studied more here than at medical school.”

But the intense school work, coupled with ESL studies, did not deter Yamada from fulfilling a desire he’s had since he started working in the healthcare profession.  “As a doctor my workload was to diagnose, remove, and treat the cancer and move on to the next patient.  I see the nursing field as being interactive, social and more involved in the medical field than doctor,” said Yamada.

“He worked incredibly hard in his classes and in the hospital,” said Joan Bard, DEd, RN, and Associate Professor in the School of Nursing (SoN).  “He has overcome barriers that we can only imagine to complete his education at SMU.”

His preceptor, Regina Foronda, RN, described Yamada as a fast learner who quickly developed the critical thinking skills he needed to be a nurse.  “I am excited to welcome Yoshi as a nurse as he has the passion and compassion that so many of us forget about,” said Fornonda.  “He is going to be a great asset to the nursing community.”          

In Japan, Yamada worked with cancer and HIV patients.  Dr. Abbott agrees his new role as a nurse is a perfect fit for him.  “He has such a strong desire to participate in caring for patients.  I know he will enjoy nursing and the whole circle of healthcare services.”

Nearly 7 percent of the more than 2.1 million RNs working in the U.S. are men, according to the 2008 National Nursing Sample Survey.  A small increase from 5.8 percent in 2004.  Nationally, female nurses outnumber men by more than 15 to one.  Since the 1970’s, Samuel Merritt University has graduated more than 330 male students.  In the past five months, the University has graduated more than 230 nursing students (male and female) from the School of Nursing.

By Elizabeth Valente, SMU Media Relations Director

Samuel Merritt University, located in Oakland, California, has been educating health science practitioners who are committed to making a positive difference in diverse communities since 1909.  Nearly 1,400 students are enrolled at SMU, with campuses in Oakland, Sacramento, San Francisco and San Mateo.  The University offers undergraduate and master’s degrees in nursing.  For more information visit www.samuelmerritt.edu.

(Photo taken by Corinne Chastain, ABSN graduate.) 

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To Curb Rising Costs, Hospitals Try to Reduce Repeat Admissions – washingtonpost.com

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