An Unappreciated Organ

Greetings from Milot.  It’s quite comfortable today and we’ve already begun working on the inventory system and running clinics. Internet access is limited and Rachel will be posting my blogs as I e-mail them.

What is the body’s largest organ?       

Before you start snickering, it’s not inherently obvious. Although the liver can weigh several pounds, and the skeleton has high density by volume, they are not, by cell count or size as large as the skin.

I’m currently on the charter flight from Miami to Cap Haitien, with several other volunteers from around the country, including a dermatologist from St Louis. Earlier last week, I toured the Center of Wound Healing at Georgetown University, where a multidisciplinary team works with patients, who have developed wounds from trauma or disease that won’t heal. Many are diabetic, where the combination of disease of the small vessels, dysfunction of the white blood cells from hyperglycemia, and neuropathy lead to foot ulcers that will not heal, or become infected, leading to sepsis and death. At some point, the disease can progress to where amputation is necessary, creating a new wound, and causing significant disability. The cost to both the patient, and society is dramatic.

In Haiti, we have additional challenges. Given the large number of open flames used for heat, cooking, or other local traditions, burns are common. The use of water that is unclean to cool the injury  can inoculate the area with bacteria. There are great distances that may need to be traveled on foot, to reach medical care, and additional trauma occurs. I have seen burns that area days old, and have begun to fester. Even if they heal, the open burn scar can progress to a Marjolin’s ulcer, a type of skin cancer. I had read about this during my training, and perhaps had seen one in 25 years. They are far more common here. Untreated burns heal by contraction, which, if they occur across a joint can inhibit movement. Sadly this is not uncommon in children.

Highly pigmented skin is protective against most skin cancers; so it’s not surprising that when tumors develop in the local population, they may present at advanced stages. When I went to the OR today, our ENT/Plastics team was excising a large skin cancer in a 20 year old albino woman. It was on her face and had grown into her maxillary bone and the edge of her eye. They were able to get around it and place a skin graft.

We also have the sequelae of tropical diseases, including parasites that block the lymphatic system leading to massive limb swelling, skin breakdown, and disability. One patient had swelling of only one leg, which was unusual. When conventional therapies did not work, a biopsy was obtained and read back in the states – Kaposi’s sarcoma due to undiagnosed, advanced HIV.

Surgeons have been known to say, “Don’t let the skin stand between you and a diagnosis,” acknowledging that we have to violate a protective barrier to repair what has gone awry. We at the same time are dependent on the skin to overcome our insult, and many post-operative complications are related to wound healing and infection.  The process is amazing when you think of it.

Finally, the skin, like all organs, is subject to changes with aging and sun exposure. The amount of resources spent on cosmetics, various spa treatments, and surgery is an economy unto itself.

I’ll be putting on my sunblock and mosquito repellant, but every time I come to Milot, I’m proud to have “skin in the game.”