Vera is a 35-year-old woman with diabetes, obesity, and Fournier's gangrene.

Yep, this is Fournier's gangrene, chapter 2.

She presents with several days' history of swelling and pain over her vulva. On examination, there's a 3 x 15cm red, hard, hot swelling over her vulva. The resident suspects Fournier's gangrene, AKA necrotising fasciitis of the perineal/perianal/genitalia area. She is taken to the operating theatre.

Vera is a big lady. The anaesthetist has to work to get an arterial line and a central venous catheter in and then to anaesthetise her. I'm asked to catheterise her (put in a pee tube). It took some time to clean her nether regions because she is so swollen down there. It takes even longer to actually find the urethra (pee hole). It's not easy in a woman as it is because the vagina and the urethra are quite close together and often the folds in one's genital area makes the urethra hard to find at a quick glance. Vera is both swollen and obese and her genitals are distorted from her severe Fournier's gangrene. I fail to catheterise. The resident succeeds... eventually. Once she is under, the resident takes the knife to the skin. The skin opens, releasing gas bubbles. Yep, infected, all right.

The more the resident debrides (and I hold the flesh apart and pass him instruments when asked), the more necrotic (dead) tissue is seen. Fournier's gangrene is treated by debridement (removal of the dead tissue). We have to remove all the dead tissue. The problem is, there doesn't seem to be an end to this. Normally, incision and drainage (removal of infected tissue) takes about half an hour. An hour and a half later, we're still scraping. The resident digs deeper and deeper into the vulva to the point where he pauses and asks the other resident in the OT if he should stop -- he is getting close to the pelvic floor and he is concerned about damaging the muscles. He's also very close to the vagina and is at risk of perforating the wall between the flesh inside the vulva and the vaginal wall.

The debridement is mainly done by a diathermy, which is like a thin poker that can turn red hot to cut or cauterise wounds. The result is burnt tissue that stops bleeding and a heavy scent of cooked bacon. My stomach rumbles. The mixed smell of vulva pus and cooked bacon makes me hungry and nauseated at the same time.

We stop several times during the debridement. Twice because Vera started waking from the anaesthesia so the anaesthetist has to jump in to top her up. Once because Vera's oxygen levels starts dropping and the anaesthetist has to use an oxygen bag to bring the levels back up before it was safe to continue.

About 3/4 of the way through, the resident hits a small artery and it spurts blood all over his face. Luckily he wears glasses, a hat, and a face mask. He shoves a piece of gauze to stem the bleeding and tells me to hold it there whilst he washes his face and rescrubs.

I spend about 15 mins just standing there, my hand pressed firmly over this wad of gauze soaking up this spurting artery in a woman's badly infected vulva.

The resident returns, clean. On looking at the 5x15cm opening the resident had made over the vulva, there are obviously still some remaining dead tissue. They're brown and squishy instead of pink and bouncy. But there is only so much the resident can scrape off. He tidies up his handiwork and packs the wound. It'll have to be closed on another day, once the infection has cleared up sufficiently.

I go to have dinner.