SEBACEOUS CYST

While learning the role of the nurse practitioner, I am getting exposed to many different procedures and skills I have never done before as a registered nurse. One of them was incising and draining (I&D) a sebaceous cyst. I have watched physicians and other middle level providers do the procedure many times while in the ER and knew I could handle such a feat. I mean how hard could it be? I have been exposed to many disgusting medical situations in my medical career and have a fairly strong stomach. Well, that was until last week.

A 60-year-old man came into the family practice office to have a “cyst” removed. At least that was what was written on the appointment sheet. He was waiting in room 2. This was the last patient before I was to eat my lunch. My stomach was already growling and wanting food. It was a busy morning. I walked into the room and introduced myself as a nurse practitioner student. He was very pleasant and sitting on the exam table with the short white paper gowns they required the patients to wear. He even thought it looked “kind of young” looking because it exposed his belly button. The medical assistant had already put the necessary equipment in the room to I&D the cyst. Before doing anything else I needed to take a look at the cyst I would be working on. It was on his back. I asked him to stand so I could evaluate the cyst a little easier. I opened his short white paper gown. There it was. On the right side of his back just inferior from his scapula. It was a fairly large cyst. I got a measuring tape out of the drawer. It was a circular cyst measuring 5 cm across. It was moveable and firm. I asked how long he had had it. He responded since the 70’s. My next question was: Why take care of it now? He responded because he bumped it on the wall the other day and it started to bother him. Oh. Nothing like working on a 25-year-old cyst.

I prepared the 1% lidocaine with epinephrine to inject in his back so the procedure would not be painful. I asked him to lie on the exam table on his stomach. I pulled out the leg and foot rest. He actually was very pleasant and cracked jokes every once in a while. I put all of my equipment on a tray and placed it next to the exam table where I would be working. I am predominately right handed. I took out the betadine swabs and started to swab the cyst and the area around the cyst. When it was dry I then told him I was going to inject the lidocaine around the cyst to numb it. He was fine with that. I injected the lidocaine on three sides of the cyst. He only felt a couple of them but handled it well. When I was done I told him I was going to leave him alone for a few minutes to let the medication work. He was comfortable on the table. I gave him a magazine to read.

I came back several minutes later and got my equipment set up. I opened the I&D tray to the point I needed to put on sterile gloves. My patient was doing fine. The medical assistant was in the room to help. I knew I would need a lot of sterile 4x4 gauze. She was already thinking ahead and had a nice stack of it ready and waiting. Here we go. I took the #15 scalpel and told my patient I was going to begin. I started at the proximal end of the cyst and cut distally. After that was done I took some sterile gauze and started to squeeze the contents of the cyst. Within seconds of doing that a white thick cheesy substance started to come out in rather large amounts. Simultaneously with the thick white cheesy substance came the smell. It was awful. The noxious smell filled the room. My eyes started to water. The medical assistant looked at me with a look of “that is disgusting.” I continued to squeeze and more white thick cheesy stuff came out. My growling stomach was now growling for another reason. I was actually getting queasy. This had not happened in a very long time. The smell was overpowering. I knew it was going to imbed itself into the paint on the walls and never go away. As I continued to squeeze and use many sterile 4x4 gauzes I thought I would never look at cottage cheese the same again. In fact, any white cheese would be considered on my black list. I asked my patient if he was doing alright. He was. If only he could see my green face. I tried to breath through the thought of heaving. Afterall, that would not look professional now would it? This was the cyst from hell. My next thought was, “so this is what a 25-year-old cyst smells like.” That crap had been fermenting for 25 years.

The thick white cheesy stuff finally stopped coming. I filled quite a few 4x4’s. The room was engulfed with the noxious smell. My eyes were still watering. I was glad I did not have a lot of food in my stomach because otherwise it would have come up. Lunch did not sound so good anymore. I knew a pharmaceutical representative was waiting in the lounge. If they had anything that resembled this crap I would probably loose it. Please God…not Chinese food!! It was now time to pack the cyst. The medical assistant opened the ½” Iodoform gauze. I stared to slowly pack the cyst. It was deep and would need a good amount of the gauze. The cyst did not look infected.

After the cyst was packed it was time to put a 4x4 gauze and tape to cover it. The patient was instructed to make an appointment in two days to have the packing removed. He thanked me and he went down the hallway. I was so glad the door was open to get some fresh air into the room. As I walked down the hallway I started to smell the food the pharmaceutical rep brought in. It actually smelled good. The nauseating feeling I had was now gone. I had incised and drained my first sebaceous cyst. I hoped I would not have another one for quite some time. It would go on my “not so favorite” list. I could not wait to see what next week would bring. Maybe I should bring some wintergreen oil to put under my nose. That was always a must while working in the ER.