Leeches and Maggots and Skin Grafts... Oh My!

OK, this didn't actually happen in the ER, but it does fall under the category of 'make you want to barf'.  So, I have decided it is an appropriate addition to the Last Night in the ER series.  Apparently in 2004 the FDA officially approved leeches for use as a 'medical device' which led to one of my grossest NP experiences.

As usual on this particular wintery Tuesday morning, my brave clinical preceptor (we will call her 'The General', she had a very in-charge aura about her) and I were rounding on patients requiring wound care consults.  We checked on wound vacs, visited patients with decubiti the size of watermelon (well, almost), monitored cases of fournier's gangrene (look it up, just don't click on 'images') and prescribed healing vitamin regimens.  Then, after lunch, The General's pager went off.

Wound care consult needed on the 8th floor.  No problem, we had time.  So, we marched up the stairs to meet our next patient, a woman who had just had a TRAM flap procedure following a mastectomy for breast cancer.  A TRAM flap procedure essentially involves removing a section of skin, fat and muscle from the abdomen to create a new breast.  The flap in this particular patient just wasn't taking.  A sort of bluish color, it was evident her new breast was in danger of dying off.  We needed to do something to restore proper blood flow to the area.  Quick.

The General called her supervising physician (this was a little above our pay grade) for advice.  There weren't a lot of options, but he recommended we try...leeches!  Yuck.  Conveniently, the university hospital where we were working keeps a leech tank.  The leech tank was a cylindrical clear container filled with water and 'medical grade' (whatever that means) leeches

After a few quick calls we located the leech tank and marched along to retrieve it.  The General grabbed the little carrying handle and we delivered it to the patient's room.  The patient began to freak out.  Are you serious?!  Am I going to be able to feel them wiggle?!  Are you sure there is no other way?!  Eeewwww!  Then we explained once the little blood suckers finished their job they would simply detach and fall off in her bed.  Shrieks interrupted by periodic sounds of dry heaves and gagging ensued.

I retrieved the first leech from the tank with a little green net.  The General extracted the leech from the net with her gloved hand as it writhed and wiggled away.  She held it up to the poor patient's bluish skin until it latched on.  Then we repeated x 5.  With six leeches now attached to the bluish breast, all we had to do was wait as the little buggers drained the excess pooling blood from the surgical site restoring healthy perfusion to the area.  We did solve the problem of the engorged leeches falling off in the bed- we taped styrofoam cups upside down over the top of them resulting in some sort of modern art looking sculpture.

The General and I left the patient with styrofoam art on her chest to catch up on some charting.  We returned an hour later.  Un-taping each styrofoam cup individually, we removed the chunky, engorged leech from each.  Shoot.  We forgot to ask.  What do we do with them now?  We can't put them back in the tank- they spread blood bourne pathogens (apparently sharing leeches is the equivalent of sharing dirty needles).  I guess we have to kill them.  Is there some kind of protocol for this?  The General called upstairs to get some advice from the leech keeper.  "Uh-Huh, OK, we'll try that" she said into the phone.  "No strict protocol" she said to me, "we just have to kill 'em".  Ick. The leech keeper had suggested using alcohol.  We squirted some alcohol into each cup, swished it around and were left with six dead leeches.  Thankfully, we noticed the woman's breast had a bit more of a pinkish hue.

"I hear you can do kind of the same thing with maggots" The General said to me casually as we strode off to visit our next patient.  Just another day as an NP student...