Wednesday, August 26, 2015

Rat

                        

It was 4:45 on a Wednesday afternoon, clinic had just finished and I’d be on my way home in fifteen minutes, unless…
“Beeep…Beeep…Beeep”
Rats, it’s the emergency room.
“Dr. Gelber, we’ve got an 85 year old lady from the county nursing home with a distended abdomen. Could you come and take a look at her?”
So much for going home on time. You think they could have waited fifteen minutes.
I made my way to the surgical side of the ER and found Madge. She was a wrinkled old lady, weighed in at 102 pounds, white hair, black glasses which magnified sharp blue eyes. Her most distinguishing feature at that moment was a belly that was the size of a medicine ball.
“Hello, Ms. W, I’m Dr. Gelber. How long has your abdomen been so blown up?”
“Glad to know you Dr. Gelber. Call me Madge. This old belly’s been growing for the last five days. I think it’s a boy.”
“Well, Madge, I think we’ll need to deliver it soon,” I answered. “Are you having any pain, nausea or vomiting?”
Her look turned a bit serious as she answered, “Mostly pressure, not really pain and a little nausea. And, I haven’t pooped in a week.”
“Passing anything out? Gas, diarrhea?”
“Nope, not a toot or tweet for five days.”
She had a collection of associated medical problems, typical for your average octogenarian. She had a little hypertension, a bit more congestive heart failure, atrial fibrillation, myocardial infarction a year ago, previous hysterectomy, nothing unusual, but enough to cause the Cardiologist to say she was at considerable risk for complications. She had mild abdominal tenderness, but her abdomen was tight as a ripe watermelon and about the same size. Her heart was beating at a rate of 124, blood pressure was 85/50.
Plain abdominal X-rays revealed massively dilated colon. In particular, the cecum (first part of the colon) measured eighteen centimeters in diameter, well beyond the 12 centimeter diameter when one begins to worry about it bursting.
I called my Chief resident, Dr. J, who deferred to the Chief on call, Dr. B., who came to see the patient and then disappeared. In the meantime I did all the paper work to get Madge admitted and prepared to go to the OR.
Her diagnosis was acute large bowel obstruction.
“At last I get to be around some young blood,” she commented as I finished my H&P. “All the men at AHP (the nursing home) are wet noodles, if you get my drift; you know soft and limp. Maybe, when I’m better, you can show me around the hospital, Dr. G?”
“Let’s get you better first. But, I don’t think my wife would appreciate me carrying on.”
“She’d never know. Besides I don’t see any wedding ring.”
I glanced at my naked finger.
“I don’t wear it. Too much taking it off and putting it on. I’d lose it in a week.”
Dr B. returned and he said a cecostomy was in order, under local anesthesia.
“I guess you talked to the Chief?” I asked.
Our Chairman, Dr. Di was a staunch proponent of cecostomy in this situation.
We took her up to surgery and performed the cecostomy, which means decompressing her cecum by placing a tube into it, under local anesthesia. The cecum was massively distended with the muscle fibers of the outer layer split apart by the distension, but there was no gangrene or perforation. It was the size of a volley ball. After it was decompressed it looked much healthier. The tube was left connected to a drainage bag and Madge went to the ICU.
Her journey was just beginning.
Over the next forty eight hours she stabilized. Her vital signs, renal function, lab abnormalities all normalized. She was ready to embark on the next stage of her odyssey.
The next step was to figure out the cause of her severe distention. Based on the tests that had been done, the assumption was that she had a mechanical obstruction on the left side of the colon. The most likely causes would be a tumor or narrowing secondary to diverticulitis. There was an outside possibility she had suffered from Ogilvie’s syndrome, otherwise called colonic pseudobstruction, although the initial X-Rays were more suggestive of a mechanical cause.
She was wheeled from the ICU to Radiology where she underwent a barium enema (BE), a test where a radiopaque dye is instilled into the colon and X-rays are taken at various points. This provides information as to the length, contour of the colon, demonstrating areas of narrowing (stricture) or dilation. Large tumors also can be seen with this test. Madge’s BE revealed an abrupt termination of the column of dye in the distal sigmoid colon.
“She’s going to need another operation,” I told Dr. B.
“Try to prep her using the cecostomy and we’ll try to do her surgery in three days.
It fell on me and my junior residents and interns to begin to flush her colon with saline every few hours, attempting to clean the abundance of stool trapped within the obstructed colon. The hope was that a clean colon would allow for a single stage resection and anastamosis, avoiding a colostomy and the necessity that she wear a bag.
It was a tedious job. Instill a few hundred cc’s of saline and let it drain, add some more and let it drain. At first it seemed hopeless as we kept getting some light brown saline, but little else.
Through it all Madge managed to keep her sassy edge.
“You know, Dr. G, when I’m all better and back at the home you should come and see. I’ve got my own room and it’s so cold and lonely at times. All the men there are just wrinkled old prunes.”
“Let’s just get you well first, Madge,” I answered.
“Oh, I’m not worried about that. You doctors here are so hard working and caring and conscientious. Some are pretty sexy, too. I know I’ll be back on the dance floor in no time.”
“Were you a dancer, Madge?”
“Third prize in the Queens borough ballroom dance off 1919. Leon and me knocked them over with our cha cha. Poor Leon, he was killed a few years later; run over by a horse. He was the love of my life, definitely not a dried up prune or a wet noodle, if you get my drift.”
I smiled at her as I finished my flushing of her colon.
“One of my interns will be back a couple of hours. Sorry about Leon.”
She didn’t answer. She was staring off at nothing, a smile on her face, lost in memories of Leon and happier days.
After four days and flushing and draining, flushing and draining we pronounced Madge clean. By we I meant my Chief resident, the Chairman of Surgery, myself, the second year resident, the intern, four ICU nurses, the custodian and two cockroaches who called the ICU home. Her surgery was scheduled for the next morning.
It was a big event. Dr. B was operating with the Chairman, with the intern and second year resident on hand to provide proper retraction. I was left out to hold down the fort in the rest of the hospital, but I managed to hover around the OR to see what was happening.
The surgery started uneventfully, but, as the colon was examined the surgical team was greeted by a left colon full of solid stool. The plan for a single stage resection and anastamosis faded away in a column of poop as they went to plan B.
Madge’s sigmoid colon was resected, the end was brought out to the skin as a colostomy and the distal colon was closed off and left in the pelvis, a so called Hartmann’s pouch.
Madge came through the surgery without a hitch and was wide awake and ready to flirt when I saw her on afternoon rounds.
“Did you guys give me a nice flat tummy? I want to look good in my string bikini this summer,” she quipped.
“You’re already nothing but skin and bones,” I answered, “but you do have a colostomy now, at least for a while.”
She gave us a pout and look of disappointment, followed by a shrug of her shoulders as we continued on rounds. She had completed stage two of her journey.
Her recovery was uneventful and she was back tormenting the male residents of the nursing home in a little more than a week. She came back to the clinic a week later where she was seen by one of the interns.
“An ole lady named Madge is asking about you, Dr. G,” Intern reported. “She says you missed ballroom night at the nursing home.”
I made my way into her room.
“I really can’t dance, Madge,” I confessed. “Dr. B, now he can dance.”
“Well, I guess we can skip the dancing and go straight to bed,” she propositioned.
“I think you’re more than I can handle, Madge.”
And, she went on her way.
She made a second appearance in the clinic a month later, looking quite well, eating, walking, she even gained three pounds.
“When can I get fid of this shit bag?” she asked.
She was now about six weeks post op and she still had the cecostomy tube, which was clamped.
“Let’s get your colon checked and then we can think about reversing the colostomy,” I explained.
“Good, the sooner the better. Even the old prunes at the home won’t give me the time of day with this bag.”
I set her up for a colonoscopy the following week, to be done by me, one of the last colonoscopies I ever performed.
As she was wheeling back to the endoscopy suite she remarked:
“You really know how to show a girl a good time.”
I smiled, “We’ll take good care of you Madge and we’ll get you all put back together as soon as we can.”
“I like a man who whispers sweet nothings …” and she was out.
The colonoscopy was uneventful, revealing diverticular disease in the descending and proximal sigmoid colon. She was scheduled for reversal of her colostomy ten days hence.
“We’ll leave her cecostomy for now. It may add a bit of protection for her after the colostomy reversal,” my Chief decided.
At 7:15 am ten days later Madge was rolled into OR room 12. Miss C, our cranky, dour, and very experienced circulator and Mrs. J, our equally skilled scrub tech made up our crew along with Dr. B, me and one of our interns. The Chairman, officially the Attending surgeon on the case, sat nearby in the OR lounge. Dr. B was in the last month of his residency and was functioning independently and was acting as teaching resident on this case. I was to be the surgeon of record.
And so it started. A midline incision was made and we entered the abdomen, greeted by a few adhesions to the abdominal wall which were quickly and easily dispatched. The small bowel was examined and packed out of the way. The colon leading to the colostomy was identified and freed from scar tissue. All that remained was to find the other end of the colon, dissect enough of it so that the two ends could be connected.
It was like running into a stone wall. Madge’s pelvis, where the elusive segment of colon resided, was socked in, a mass of adhesions with tissues more resembling concrete than colon.
Where’s the colon?
Where’s the bladder?
Where are the ureters?
Where, oh where will I dissect next?
“Let’s find the ureters first,” I announced to no one in particular.
“Good plan,” Dr. B responded.
Starting higher up in the abdomen away from the dense mass of pelvic scar I began my search. The proximal colon which led to her colostomy was freed from adhesions first. Behind was a mass of small bowel. I commenced the tedious dissection of this small bowel.
“Do you really need to free up all the small bowel?” Dr. B asked.
“You know the rules: either you leave it all alone or cut away all the adhesions,” I recited.
“Ok, Ok,” he answered.
Like the barber/surgeons of old I began to snip and trim, starting where it was easy and them moving along centimeter by centimeter until, an hour and a half later, all the small bowel was free.
This actually was very helpful. Some of the bowel, as expected, had occupied the pelvis and now it was liberated and safely tucked away in the upper abdomen.
(I have to comment on my terminology, specifically the term liberated. It’s a bit tongue in cheek. I remember reading an operative note for a colon resection. The surgeon dictated that “the splenic flexure was liberated…” I immediately had visions of colons running through the streets chanting, “I’m free, I’m free…” the term “liberated” in this context always brings a smile to my face.)
Progress was slowly being made. With small bowel out of the way, the ureter was easily identified. The foley was palpable within the bladder and careful dissection behind the bladder revealed a staple line; the staples within the closed off end of the colon.
“I think I just need to dissect enough to be sure that there is only colon, no vagina or bladder”, I concluded.
My Chief disagreed.
“You need to be sure it is free enough so there is not tension and adequate blood supply,” he answered.
I disagreed, believing that the more the distal colon was dissected, the greater the likelihood that blood supply would be compromised or a nearby structure would be injured. But, I complied with his wishes. He was, after all, more senior, more experienced and had the power to make my life miserable should he so choose.
With the ureters safely in view and the bladder now out of the way I worked on the colon and rectum.
First, straight down to the sacral prominence, a safe area where there were no vital structures. Then in front of the colon, separating it from the posterior vagina.
“Is this free enough,” I wondered out loud, clearly conveying my view that it was more than enough.
I received nod of acquiescence.
The colostomy was quickly freed from the skin, the actual stoma was resected (removed) to provide a clean end to anastamose to the distal colon. It was immediately apparent that the two ends would not reach each other. More dissection of the left colon followed, which meant liberating the splenic flexure (there’s that image again) which allowed the two ends to meet.
“Use the EEA?” I asked, requested, implored.
“Hand sew. You know what they’ll say in conference,” Dr. B replied, alluding to the required presentation of the case at one, or several, of our weekly meetings where the cases done that week were presented and discussed.
“And, I’ll take the heat,” he continued, “not you.”
“Ok, I’ll sew it. But it won’t be easy. We’re pretty far down in the pelvis.”
I did my best to put the two ends back together. First the back wall of interrupted silk sutures, then the inner layer of continuous Vicryl, an absorbable suture material, and, finally, the outer front layer of silk.
Each suture placement was a chore as I endeavored to be precise; to be sure I caught the full thickness of the bowel wall, while not compromising the lumen diameter. When I finally finished, something just didn’t feel right.
“You know,” I commented, “something isn’t right. I just can’t be sure that the two ends have come together properly. Do you think the cecostomy will provide some protection for the anastamosis?”
“You know it won’t,” Dr. B replied.
“Well, I just don’t trust my anastamosis. Maybe we should do a proximal colostomy?” I wondered out loud, a bit facetiously.
Dr. B didn’t say a word at first. I suspected he was wondering if he should call the Dr. Di, the Chairman of the Department and the official Attending on the case.
“I’ll be back in minute,” he said and he broke scrub.
“Dr. Di agrees. We should do a transverse colostomy,” he announced when he returned.
While he scrubbed his hands again, I mobilized the right transverse colon and we created a transverse loop colostomy, fashioned so that it functioned to completely divert the fecal stream away from my pelvic anastamosis. We closed Madge up and she woke up without a problem, after five hours of surgery.
She sailed through the post operative recovery. Stage Three was over. She still wasn’t finished, however. Now she sported a tranverse colostomy and the cecostomy was not completely closed either. She was going to need at least one more surgery.
A month later I was walking past one of the exam rooms in the surgery clinic when I heard a familiar voice.
“There goes my young stud,” she cackled.
I made an abrupt U turn and went into the room where Madge was being checked by one of the interns.
“You know I’d be with you in a minute, Madge,” I answered, “but I’m spoken for.”
“Another broken heart,” she replied, “and I’m stuck with dried up prunes. And, I still have to wear this bag.”
“Let’s see,” I mused as I perused her chart, “it’s about six weeks from the last surgery. I think we may be able to do something about that in the next few weeks.”
I was Chief Resident now, so I went to talk with Dr. Di., who agreed Madge could have her next procedure in two or three weeks.
I examined her again that day. Her midline wound was healing well, the colostomy looked pink and healthy, but the cecostomy site still had not closed completely. There was a five millimeter open wound with some mucus draining.
“It’s getting smaller,” Madge commented, “doesn’t hurt a bit.”
She was scheduled for the seventh, which was in three weeks. Orders were written and she went on her way, with plans to be admitted to the hospital on the sixth, the day before surgery, when she would have all the necessary preoperative preparation.
The big day came and Madge said she would be happy to be rid of the bag. Of course she took the opportunity to offer herself to me one more time.
“After this surgery you must stop by and see me in my rook over at the home, Room 202. Every night it’s the same routine: dinner, television, the sounds of arteries hardening and saliva dribbling. Come by and see me. We can go dancing.”
And she winked at me as she was rolled into Room twelve.
This surgery was a straightforward closure of a loop colostomy. The actual surgery was done by my fourth year resident with me acting as teaching assistant.
The incision was made around the stoma and the dissection carried down into the subcutaneous tissue.
“Did you take your slow pill today?” I wondered out loud. My junior resident, Dr. T., was moving like a glacier, one cell layer at a time.
“Open your eyes and see,” I suggested. “There is a plane of dissection between the colon and the subcutaneous fat. The mesentery and the subq fat look different and, look, god has left a white line which says ‘cut here’.”
With a bit of guidance the fascia, the layer below the fat was finally reached.
“Now, dissect along the fascia so that the colon can be liberated (there’s that word again),” I instructed.
My words were greeted by a lost stare out into space.
“Right angle clamp, please,” I requested.
I hated to do it, that is take over the dissection, but, poor Madge was not getting any younger.
I dissected the colon free from the fascia using the clamp, allowing my junior resident to cut in between the jaws of the clamp, which provided some semblance of “doing the case.”
The colon finally free, it was delivered up into the wound and continuity restored via a two layered, sutured, side to side anastamosis.
“What next?” I asked as the fourth finished tying the final silk suture.
“Put it back inside, close her up and then make rounds?” he answered.
“Well, some people would consider that a right answer. If I were actually doing the surgery, I would tack some omentum over the sutures lines. It adds an extra layer of protection, although the way Madge handles surgery, I think you could have used paste to put her back together and it would have healed just fine.
The surgery finally done, after four tedious hours, Madge was tucked away in the Post Anesthesia Care Unit and proceeded through another smooth and uneventful recovery.
She did manage to proposition me on a daily basis until she was discharged once again.
I thought she was done with surgery. Four stages for the treatment of a colon obstruction was a bit unusual. One of the frequent discussions/controversies in general surgery was how to handle acute large bowel obstruction. Should it be a one stage procedure with resection of the offending segment of colon coupled with some sort of on the OR table bowel cleansing, a two stage procedure with resection of the diseased segment and creation of a temporary diverting colostomy, followed by a second operation to restore colonic continuity, or a three stage procedure with an initial diverting colostomy, a second operation to remove the cause of the obstruction and then a third procedure to reverse the colostomy.
Dear Madge had undergone four stages.
I saw Madge in the clinic a week later, healing quite well, eating normally, having normal bowel movements and overall quite satisfied. Her only complaint was persistent drainage from the cecostomy site.
“It should close, just give it some time,” I reassured her.
“I’m sure it will, Dr. G,” she replied and then she smiled at me. “of course, It might be best if you came to check on it over at the home a couple of times a month.”
I smiled back. Good old, dependable Madge.
“I think your coming to the clinic will be adequate,” I answered.
“Stuck with all the old prunes,” she murmured.
I saw her again a month later. She was still draining from the cecostomy site. As a matter of fact, the open area looked larger, with a bit of intestinal mucosa poking out.
“It looks like you’ll need another surgery to close up the cecostomy,” I informed her.
She shrugged her shoulders and nodded her approval. Then, as if sensing some disappointment on my part, she added, “Can I have a private room this visit? One never knows when a handsome young red headed doctor will come calling and try to take advantage of a girl.”
I smiled and said, “See you next week.”
The surgery came and went off without a hitch. My second year resident performed the surgery while I acted as teaching assistant.
We dissected around the cecum, following it down to the fascia, cutting away all the scar tissue and, finally, delivering the cecum into the wound. There was a 1.5 cm hole which was closed in two layers, then reinforced with a bit of fat before it was dunked back into its rightful home within the peritoneal cavity. We closed her up and she went to the PACU, for the final time, I hoped.
Sure enough, except for shifting her affections from me to the younger and handsomer junior resident, her post operative recovery was smooth sailing.
“I’m a little disappointed, Madge,” I explained to her on the day she was discharged, “you seem to have shifted your amorous affections from me to Dr. K.”
“Well, Dr G., I’m not getting any younger. You had your chance and you blew it. Besides, Dr. K is really hot,” she answered.
“Good luck, Madge,” I responded. “And, I say this with all affection, but, I hope I don’t ever see you on my OR table again.”
She smiled and nodded her understanding, but then added, “Do you have Dr. K’s phone number?”
“You’ll have to ask him yourself. I’m sure he’ll be around to see you before you leave.”
She sighed and then added, “I guess it’s back to the prunes.”
I did see her back in the clinic about a week later, one last time. She healed without a problem and thanked me for helping to save her life.
Her case had been different than most. There was no discussion about one stage, two stage or three stage procedures.
Madge had undergone a five stage procedure.
A few weeks later I had a meeting with our Chairman, Dr. Di, and I brought up her case.
“Remember Madge, the old lady who had the large bowel obstruction and had the five stage colon resection?” I asked the Chairman.
“She was a rat,” he answered, his response taking me by surprise.
“I thought she was very nice,” I answered.
“I don’t mean a rat, as in James Cagney, ‘you dirty rat’, sense,” he said in his grandfatherly tone. “No, I meant she’s a rat because she could be operated on over and over and never turn a hair.”
He explained further.
“Years ago there was an experiment done. A number of rats had surgery, all the same sham operation. After the first operation, some of the rats died. The survivors were operated on a second time and a few more died. The third time a few more. But, after a number of operations some of those rats just went on like nothing happened. You could operate on those rats every week and they wouldn’t turn a hair. They just woke up and went on their way.
“Madge was a one of those rats.”


Sunday, June 28, 2015

Fourth of July

        

I was  a newly minted second year resident and it was my second night taking call at the county hospital.
I am ready for anything, I thought.
“Call ER, Dr. Gelber”
It was 9:15 am.
“We’ve got a fifty year old male with a stab wound to the abdomen,” the ER attending reported.
And so it started.
I made my way down there and found Jose. He was stable and there was a two cm wound just above his umbilicus.
In those days we usually locally explored the wound and if it penetrated the peritoneum the patient was explored.
I called for some local anesthetic, an instrument tray and some retractors. Just as I had learned as an intern, I extended the stab wound and followed it down, down, down, deeper into the abdominal wall. Through fat, then fascia, then muscle, then more fascia I explored. After five minutes I found peritoneum and the stab wound kept going.
Looks like he’s going to the OR.
We, that is myself and my interns, got him typed and crossed, started antibiotics and called my Chief, a fourth year resident.
“I’ve got Jose here with a stab wound to the abdomen, penetrates the peritoneum. I think he needs to go to surgery. He’s stable and he should be ready whenever you are.”
Twenty minutes later, off he went.
Maybe I can finish some of the work I need to do. Write some progress notes, check some X-Rays.
“Beep…beep…beep”
ER again?
“Twenty nine year old male with a gunshot to the chest and abdomen just rolled through the door.”
“I’m on my way,” I answered. I then started my fast walk back down to the ER. Sometime during medical school I decided that there are very few emergencies that require me to run. If the patient is so sick that I have to be there ten seconds sooner, then he probably wasn’t going to survive, no matter what I did. But, I can walk pretty fast.
Miguel was rolling into room 4 as I arrived. He was awake with a BP of 90/50, heart rate of 110.
“Do you have any medical problems?” I asked, “Any allergies to medicine? Do you take any medicine regularly? Any surgery for anything in the past?” Can you tell me what happened?”
“I was sittin’ on my porch reading the good Book when these two dudes came up and shot me,” he explained. “Bam. I wasn’t doin’ nuthin.”
“What about any other medical history?” I asked again.
“No, I never go to the doctor, ain’t never been sick, don’t take no meds or drugs. Don’t drink o’ smoke,” he answered.
“Ok,” I sighed. “let’s get another IV going, and get him a gram of Mefoxin.”
I gave him the once over. He had one wound in his right chest which exited his right lower back and a second wound in his lower abdomen which went straight through. Tattoo’s extolling the virtue of his mother and his love for Angie adorned his chest and back. A large scar ran from his left shoulder to his mid forearm.
“What’s this scar from?” I wondered out loud.
“Cut myself shavin’,” he answered and then he smiled.
“Type and Cross for four units PRBC’s. Let’s get a single shot IVP to make sure he’s got kidneys and I’ll need a chest tube tray and he’ll need a Chest X-Ray,” I barked out, hoping either the nurse or my intern was paying attention.
I called up my Chief again.
“Gunshot wound to the chest and abdomen for you,” I reported. “I’m about to put in a chest tube and then we’ll take the picture for the IVP. He’ll be headed your way in about thirty minutes or so.”
And so it went.
Andrew came in with a stab wound to the right chest, the result of him losing an argument over a girl.
He earned a right chest tube and entered the queue to go to surgery.
Next came Miriam, complaining of severe abdominal pain. She said it started after she had rough sex with her boyfriend.
“How rough,” I asked as politely as I could.
“Well, I was laying on the bed like this…” And she spread her arms and legs.
“…and Billie, that’s my boyfriend’s name, was at the foot of the bed and he jumped on top of me. I got the wind knocked out and then my belly started hurting really bad.”
“Did Billie come with you?”
“I’m right over here, doc,” a voice called from the doorway.
There was Billie, about six foot three, at least three hundred pounds.
“Is that what happened?” I asked.
“Just like she said,” he replied.
I palpated her abdomen. She was diffusely tender, more in the left upper abdomen. I looked at the monitor: heart rate 130, BP 100/60.
I turned to the nurse.
“Give her a liter of LR and send blood for type and cross and I need a peritoneal lavage tray.”
The nurse pointed to the cabinet, intimating that I should help myself to the tray.
I walked my intern through the procedure. As she slipped in the lavage catheter bright red blood shot out.
“I’d call that positive,” I observed and we pulled the catheter out.
I called my Chief again and Miriam was whisked away to the OR.
I had just made it up to the ICU to check on some of our other post op patients when my beeper went off. The number for the ER popped up.
Will it never end?
 John arrived, hypotensive, complaining of severe abdominal pain. He’d stayed drunk for most of the last three weeks and now he had all the findings of severe pancreatitis. He was admitted to the ICU, required intubation and ventilator support and was dead six days later.  Over the course of his illness he exhibited ten of Ranson’s eleven criteria for predicting mortality from severe pancreatitis. Six or more and mortality is predicted to be 100%.
It was four in the afternoon now and I sensed a lull in the stream of sick and injured. The day wasn’t half over and I’d already done a week’s work.
My Chief called and asked me to come up to the OR where they were about to wheel Miriam in to Room four for her surgery.
“Dr. M is taking a break. Come and do this case with me, that is if the ER has settled down.”
“Seems quiet at the moment. I’ll be there in a minute.”
Performing surgery is always the best part of being a surgeon. I hustled over to the OR and we spent the next hour and half taking out Miriam’s spleen. At surgery it looked like the spleen had exploded, leaving bits and pieces held together by clotted blood.
I hope Billie let’s her be on top from now on.
No sooner had I tucked Miriam away in the Recovery room when my now despised beeper went off and the familiar number to the ER appeared.
Five MVA’s? Give me a break,” I cried, but then headed down to the ER where I spent the next twelve hours.
They were waiting for me, five patients strapped to back boards, faces splattered with blood and bits of glass. Their car had driven off a bridge and plunged about fifteen feet into a ravine.
“Chest X-Ray, Femur X-ray, Pelvis X-ray, CT of head, C-Spine X-ray, start another IV, Type and crossmatch. Let’s go, let’s go. And so we went, nurses and my two interns sat with the patients as they made their way from the ER to X-Ray to the CT Scanner and then back to the ER.
Fractured femurs, fractured tib fib, fractured pelvis, right pneumothorax, left pneumothorax, tension pneumothorax, multiple rib fractures all made an appearance in one of those patients. Call Ortho, call Neuro, call Urology. And with all the injuries, none of those five needed a general surgery procedure outside of a chest tube.
No sooner had I finished shipping the last of the MVA’s off to ICU when Eli came in by ambulance, Gunshot wound to the head. He was breathing, but very shallow, heart rate was 100 and BP was 100/60. There was dried blood on the right posterior scalp and the defect in the skull was palpable. He did not move the left side of his body.
He was intubated with the help of a friendly Nurse Anesthetist and was taken away for CT of his head, one of my interns babysitting. With everything else relatively quiet I kept my eyes on Eli and my intern.
The CT revealed extensive injury to the right posterior brain with bits of bone and bullet mixed in.
I called the Neurosurgeon on call and then prepared Eli to go to OR where he was to have the wounds debrided and ventriculostomy inserted. It was now 8:06 pm and the admission count stood at eleven. The night was still young.
Eight thirty came and went without another call, but eight thirty three brought two more stab wounds, one with multiple abdominal wounds and the other with one to the chest and each arm.
Back to the routine: “Tell me what happened? Do you have any medical problems? Any surgery in the past, any allergies, do you smoke? Drink? Use drugs? Take any medications?”
The abdominal wound was easy to assess as a big wad of omentum was hanging out one the abdominal wall. Antibiotics, type and cross and off to the OR.
The second one had a hemopneumothorax and superficial wounds to the arms. A right chest tube delivered 800 cc blood and then nothing more. The patient was stable, the post chest tube X-Ray looked good and, with any luck, would not need any further intervention. He was trundled off to the intermediate care unit. ICU beds were becoming precious. Two more bad patients and I would need to go begging for beds in the Medical or Cardiac ICU’s.
As if on cue the ER called again. This time it was Barbara, fifty years old with right lower quadrant abdominal pain, nausea, vomiting, elevated white blood count. Everything to suggest acute appendicitis. I called Sara, one of the new interns, to go and evaluate her with the promise that she could do the surgery if Barbara truly seemed to have appendicitis.
Just as Sara ran off, the ER called again, gunshot wound to the leg was coming in. George, the other intern, and I arrived in the ER just as Maurice was being wheeled into one of the trauma rooms. He was awake and screaming. There was a big gauze bandage soaked in blood wrapped around his leg. I started my usual banter and he just screamed, the scent of alcohol permeated the room.
“Let me look at your leg,” I requested with a bit of force in my voice.
“Get the fuck away from me,” he answered.
“How about your foot?” I asked.
“Fuck off.”
I took that as a yes and looked at his foot which was cold, blue and almost lifeless.
“Maurice, I am sorry to tell you that you need to have surgery. It looks like the bullet has injured you femoral artery. If you don’t have surgery you will almost surely lose your leg,” I informed my belligerent patient.
“Fuck you.”
“Does that mean ‘fuck you, I want surgery’ or ‘fuck you, I’d rather lose my leg,” I asked him.
He calmed down for a bit and agreed to surgery and allowed me to finish my survey of him and his injuries. A few minutes later he was up in surgery.
My pager went off again, only this time it was the OR calling. Sara was ready in the OR with Barbara and her appendicitis. I was to assist her, as the Chief was tied up with our stream of trauma patients. I was happy for a respite from the ER, which had reached a brief  lull. I made sure no one was waiting that might need surgery and that there were no injured parties on the way and then I made my way to OR 5.
It was 10:15.
Barbara’s surgery took about an hour as I walked Sara through the appendectomy. She did a fair job. Of course my reprieve from the ER couldn’t last. I had just lain down for a break when the call of the ER came again.
Another stab wound to the abdomen.
Back to the ER where I found Drew, nineteen years old, BP 70/40, heart rate 140, conscious, but barely.
“Need to intubate him and start another IV,” I commanded, going into captain of the ship mode.
The nurse anesthetist easily slid the endotracheal tube in, we ran in a couple of liters of Ringer’s Lactate IV fluid and he perked up a little. Blood pressure came up to 90/60 and heart rate fell to 120.
Poor Drew had a two inch wound in the mid abdomen just above the umbilicus with a small amount of blood pooling. He was pale and thin and palpation in the wound went all the way in the peritoneal cavity.
Blood was hung and I put the call into the Chief.
“This patient needs to go right away. He arrived hypotensive and we’ve got blood hanging now,” I reported.
“Just finished one, three still are waiting, but they’re stable. We’ll come get him now. Keep up the good work,” he answered.
A nice little pat on the head. It’s two am, the bars are just closing.
Why do people feel the need to assert their manhood when drunk? Closing time until about three am is prime time for trauma. Drunk and disorderly takes on new meaning as the nightly revelers leave the safe confines of the pub and saloon and wander into the street. Knives, fists, clubs and guns raise their menacing heads.
“Hey, it’s the Fourth of July…no, it’s now the Fifth of July…people have been partying all day and night. I don’t think there will be many more,” I lied to myself out loud.
Like clockwork the ER called again.
“Two drunk guys with stab wounds, one in the neck, the other in the abdomen, Both look pretty stable.”
I made my way back to there just in time to see the ambulance wheel I a young boy, five years old complaining of severe abdominal pain after being assaulted by his mother’s boyfriend, thrown against the bathroom sink.
Devon looked up at me with bright blue eyes and winced if I even lightly tapped his abdomen. He was otherwise stable, although a little tachycardic with heart rate 120.
I also quickly evaluated my two stabbing victims, who, it turned out, had stabbed each other over the matter of twenty dollars and a pool match. The neck was mid neck, had penetrated through the platysmal layer and would best be treated with exploration. The abdominal stabbing also penetrated fairly deeply and would also need to go the OR.
I talked with the Chief again, who came to evaluate the child. As I was talking with him my intern put up the boy’s Chest X-ray which revealed free intraperitoneal air.
“One more for the OR,” I stated. My Chief just sighed.
“How many is that?” I wondered out loud. We’d both lost count.
Over the next few hours three more MVA’s arrived, all with a variety of fractures: ribs, femurs, humerus, tibias, fibulas, but nothing that would need general surgery.  I tucked them away to await their Orthopedic procedures and then went to make morning rounds.
It was six am.
With my two interns in tow we started in the ICU, visiting the myriad pre and post op patients whom we had met in the twenty four hours we’d been on call.
As we finished my Chief called.
“Dr. M is tired and he’s leaving. We’ve got three more patients to explore. The stab wound to the neck, and two stab wounds to the abdomen. Come on over to the OR so we can knock these out.
So after spending almost an entire day in the ER I finished up in the OR, Exploring a  neck which had only a lacerated anterior jugular vein and a tiny tear in the thyroid cartilage, then doing exploratory laparotomies on two patients where I repaired six holes in the small bowel, resected a short segment of colon and did a colostomy.
We checked on a few of the sicker patients before we left.
It was 3:25 in the afternoon.
By my count I had admitted twenty five patients, mostly seriously ill and injured.
Jose had suffered injury to his liver, colon and mesenteric artery.
Miguel had been shot in the colon, stomach and pancreas.
Miriam had shattered her spleen after her three hundred pound boyfriend had jumped on her spread eagled naked body.
Maurice had suffered injury to his right femoral artery and vein. His leg was saved, but that didn’t improved his personality at all.
Eli survived his surgery, but succumbed forty eight hours later.
Drew survived injury to his diaphragm, stomach, spleen and left kidney, walking out of the hospital after a two week stay.
Devon suffered a perforation of the third part of his duodenum and a laceration of his pancreas. Timely surgery allowed the injuries to be repaired and he recovered uneventfully. His mother’s boyfriend went to prison for five years.
All in day’s work.





Sunday, June 14, 2015

Amazing Case

                               

Over the many years I’ve been trying to perfect the art of surgery I’ve been involved with some truly interesting and amazing surgeries. By far, those cases which pique my interest the most are the retroperitoneal tumors. I don’t know if it’s the challenge of having navigate my way around an array of anatomic structures bearing names that are learned in first grade, such as aorta, kidney and pancreas, or the satisfaction that comes from knowing that successfully performing these operations gives the patient hope, or if it’s the joy of performing a truly anatomic dissection, but these are some of my favorite cases.
I know that I may face rebuke from my half a dozen fans for making such a statement, one which directly contradicts the Surgeon’s Prayer:”Lord, protect me from the interesting cases…,” but there is still a bit of the adventurous surgeon inside of me.
What is the Retroperitoneum? As the name implies it is the part of the abdomen which is retro, or behind, the peritoneum. The peritoneum is the thin membrane which covers much of our intraabdominal viscera or organs. The stomach, most of our intestines, the liver and spleen all lie within the peritoneal cavity. Behind this cavity, in the back of the abdomen lie the organs and blood vessels of the retroperitoneum. The pancreas, kidneys, ureters, adrenal glands, aorta and inferior vena cava are the retroperitoneum’s major structures; organs and blood vessels surgeons have learned should be accorded the utmost respect and avoided if at all possible.
“Stay away from the pancreas,” barked Dr. F.
 “Find the Ureter,” commanded Dr. D.
“Be careful of the Vena Cava,” warned Dr. B.
I must have a masochistic bent to welcome potential calamity into my OR suite.
 Eulie came to the office one day. She was sixty eight, in reasonably good health, only mild hypertension and had vague complaints of abdominal pain. She bore with her reports of her recent CT Scan of her abdomen and pelvis.
“Occlusion of the Inferior Vena Cava by thrombus or tumor 7.4 cm in length, starting above the renal veins and extending to below the confluence of the hepatic veins. Comparison with CT Scan performed on May 23, 2014 reveals the intraluminal mass has increased from 3.8 cm to its present size. Minimal flow is noted within the vena cava. Renal veins appear patent.”
Eulie had never had any symptoms suggestive of acute occlusion of the IVC and my first impression was that this was a tumor. Her physical exam was unremarkable.
“I think you are going to need surgery to remove what looks like a tumor in the Inferior Vena Cava,” I recommended. “I need to go over to the hospital to look at the actual images.”
The scope and intricate nature of the proposed surgery were explained and she left, surgery tentatively planned for two weeks hence.
“It looks like a tumor growing in the vena cava,” I commented as I scanned the recent CT Scan.
Dr. L, an exceptional radiologist, agreed.
“It looks like you should have a good cuff of Vena Cava below the hepatic veins to work with,” he observed.
“Yes, but I hope I’ll just have to ligate it. It looks like it’s been pretty much occluded for a year,” I replied, alluding to the scan from last year.
“Let me know what you find,” Dr. L. requested as I walked away.
I put Eulie out of my mind for the time being as I had plenty of other sick people to occupy my time.
Ten days later Eulie popped up again as her name appeared on my schedule for the following day planned to follow two cholecystectomies on two other patients.
The next morning I removed the two gallbladders in workmanlike fashion, warm ups for Eulie’s far more complicated surgery.
I made my usual preop visit to her and said hello to the large contingent of family and friends who would be waiting on her, then I went off to make rounds on a few patients while the staff prepared the operating room.
At nine twenty eight am Eulie was wheeled back to the OR, moved from stretcher to OR table and in less than ten minutes was asleep. The operation still had to wait while anesthesia personnel placed a central line, arterial line and the nurse placed a urinary catheter and cleansed her abdomen with the antiseptic solution: Chloraprep.
Finally they were ready for me. But, first the time out:

“Eulie ___, 68, DOB ___, she’s scheduled for resection of Vena Cava tumor, no allergies …”
I mumbled my agreement and we commenced.
I started with a long midline incision from xiphoid, which is the lower end of the breastbone, to just above the pubis.
A real operation for a change. No scopes, no monitors.
I really don’t have anything against minimally invasive surgery. Laparoscopic, thoracoscopic and endovascular approaches are much better for the patient. But, there is something about getting your hands into the patient, actually feeling the organs , normal and pathologic that adds a dimension to the surgery that is almost completely lost with laparoscopic approaches and absolutely absent from robotic surgery.
The firmness of the liver contrasting with the soft suppleness of normal bowel, the pulses of major arteries and the hardness of malignant tumors cannot be fully appreciated by the limited sense of touch transmitted through long laparoscopic instruments. William Halsted, the founder of the department of Surgery at Johns Hopkins Hospital eschewed the use of gloves because he did not want to lose the tactile sense he had with his bare hand. Bare handed surgery seems barbaric now, but back in those days the first rubber gloves were made for Dr. Halsted’s nurse, because her hands were sensitive to the mercuric chloride and carbolic acid used as antiseptics during surgery at that time. I wonder what Dr. Halsted would say now as we have almost given up the sense of touch during surgery. Progress?
Back to Eulie’s operation.
At first nothing unusual was seen in Eulie’s abdomen. No free fluid, no immediate signs of malignancy, just normal liver, stomach and bowel. I ran my hand over the presumed area of the Inferior Vena Cava and everything was soft, at first. But then as I palpated the area of the porta hepatis there was something hard behind the bile duct, portal vein and duodenum.
Time to start the surgery.
First there is mobilization and exposure. There were several layers of organs between me and the Inferior Vena Cava. First is the colon and omentum. Cut on the dotted line and bring the colon and omentum from right to left and five minutes later it’s out of my way, leaving the duodenum, porta hepatis and part of the pancreas to contend with.
Mobilizing these structures starts with a Kocher maneuver, named for surgeon of old Emil Theodor Kocher. The attachments of the duodenum to the retroperitoneum are divided which allows me to lift the duodenum and the head of the pancreas off the Inferior vena cava, leaving Big Blue (as the IVC is affectionately called by me) exposed.
At this point it is apparent that the mass in the IVC is not a clot; it is most definitely a tumor. The renal veins and aorta are also exposed. The tumor extends well into the retrohapatic cava. Proximal control will require a different approach.
I turn my attention to the IVC which is adjacent to the caudate lobe of the liver. This part of the IVC is one I usually wave at while doing hiatal hernia surgery as it is adjacent to the esophageal hiatus, which is where the esophagus passes through the diaphragm. Normally, I do my utmost to avoid any contact with it.
More mobilization, this time division of the lesser omentum and retraction of the left lobe of the liver and caudate lobe and the IVC is exposed again, this time almost behind the liver, but just above the tumor. Dissection of the vena cave even more proximally proved to be dicey as Big Blue took a dive towards the back. There was adequate vena cava to clamp above the tumor but reconstruction, if necessary would be a bit more problematic.
The final part of the dissection was to lift the porta hepatis off the vena cava and tumor. The porta consists of the extrahepatic bile ducts, hepatic artery and portal vein, all vital structures. Once again, the surgery gods shined their faces upon me as the porta hepatis was easily dissected free and retracted away from the cava.
And, there we were, me and the vena cava and the tumor, staring at each other. A moment of truth had been reached. The real operation was about to commence.
Clamp…clamp…cut? No.
Dissect a bit more, perhaps. Mobilize the tumor away from the aorta and the free it from the tissue behind.
Easy…No problem.
Now, do a bit of work around the kidneys, where there might be a bit of a problem. The left renal vein comes in right above the lower end of the tumor. The right Renal vein right below it, but leaving almost no way I can resect the tumor without doing something with the renal veins.
Left renal vein is no problem. Ligate it and all should be well. This vein can drain throught the gonadal and adrenal veins which branch off the left renal. These branches provide adequate collateral flow for the left renal vein.
But the Right Renal vein is an issue.
I’ll have to reimplant it somehow. I’ll deal with it later. Time to get the tumor out.
I started with the Ligasure, a marvelous device which seals and cuts blood vessels. This Ligasure eliminates the old clamp, clamp cut and tie, reducing a three minute maneuver to ten or fifteen seconds.
As I buzzed away, very efficiently I must say, I was forced to pause as blood started squirting at me, bright red, arterial blood. Suction was applied followed by my finger, right over the aorta. It seems my wonderful Ligasure was not very competent at sealing this particular vessel. Oh well, a bit of  old fashioned halstedian surgery is good for the soul. I called for 4-0 Prolene and the small artery arising from the aorta was sutured with minimal fuss.
Was it just a minor annoyance? Or, a bit of ominous foreshadowing?
I continued on with my dissection until the vena cava and the tumor were completely free, both renal veins were dissected and I had adequate vena cava above and below the tumor to, at least, ligate.
The moment of truth had arrived.
The left renal vein was clamped and divided, then the right renal vein, followed by the retrohepatic cava.  This vessel was clamped without any change in Emil’s vital signs and then the vena cava below the tumor was clamped, once again with no change in vital signs. Finally the vena cava itself was divided above and below the tumor which was removed and sent off to the waiting arms of the Pathologist for her gentle perusal.
Home free? But, where’s that blood coming from?
There was dark blood welling up adjacent to the liver from the area of the proximal clamp.
Suck…suck…
Just great, there’s a tear in the vena cava above the clamp.
“I need another vascular clamp,” I announced, hoping the tech was paying attention, “a straight clamp.”
Carefully, carefully I slip the clamp on the cava above the area which is bleeding and the pool of blood disappears into the suction, banished, forever I hope.
Doesn’t look like enough to sew. Maybe I can slide the clamp a few millimeters higher?
With as much care as I can muster I loosen the clamp enough to move it closer to the heart. This leaves me with about 5 millimeters of vena cava to work with. Plenty to ligate, but not enough to sew a graft.
OK, ligation should be good enough. The cava’s been completely occluded for at least a year anyway.
“4-0 Prolene, please,” I request and then I stick out my hand.
The suture appears, not rudely slapped into my palm, like TV or the movies, more gracefully, gently.
“I’ve never done a case like this,” the tech announces. “Is this like an aortic aneurysm.”
“Yes, only more so,” I answer.
Worse, much worse. If that clamp comes off before I finish sewing then poor Emil will be dead.
Think of having a big hole in the bottom of the heart.
But, it doesn’t come off, the cava is ligated successfully and I can finally breathe.
What next? The right Renal vein.
It won’t reach the cava. I guess I’ll need to make  Big Blue a bit bigger. There is also a large lumbar vein which I’ve preserved, much larger than normal which suggests it may have been acting as an important collateral vessel.
“I need a graft, looks like a 20 mm Hemashield Platinum will work,” I announce, hoping the circulator is listening.
She is right on top of things, the graft is already in the room.
With minimal fuss I suture the graft to the clamped Vena Cava, reimplant the renal vein and the lumbar vein. The moment of truth arrives, the clamp is released and voila everything looks good.
Specifically, Emil has normal vital signs and there’s no bleeding anywhere. The Pathologist reports back and says the tumor looks like a sarcoma, the caval margins are free of tumor, but the cancer does extend to the radial margin, which means it has grown through the wall of the vena cava.
Nothing else to do. The duodenum was up against the tumor and I think the risk of resecting this far outweigh potential benefits.
“Number one PDS to close please.”
And so it went.
Emil’s recovery was marred by a brief episode of hypotension which responded to IV fluids and a couple of units of blood. She had a transient rise in BUN and Creatinine, but these rapidly returned to baseline and she was home in 5 days.
Emil was a case of knowing what is and is not possible. The left renal vein has collateral vessels which allow it to be ligated with minimal fuss. The right renal vein is not as forgiving. The Inferior Vena Cava lies deep within the retroperitoneum. Proper knowledge of how to expose and work around Big Blue should be a part of every general surgeon’s training. It is a vessel which can be most unforgiving if injured; sometimes trying to sew it is akin to putting stitches in wet tissue paper. Happily, this was not the case with Emil.
Complex surgery, like Emil’s, require some planning and forethought. What I mean by this is that after all the preoperative evaluation; the history, physical, blood tests and imaging is done, the plan for the actual operation needs development.
What incision is best?
How best to expose and control the vena cava?
Will anything need to be done with kidneys or their major vessels?
Will the vena cava need reconstruction or simple ligation?
These and other questions were mulled over again and again as I tried to anticipate each and every possibility. In Emil’s case all my planning led to a successful operation and outcome.
A few days after the surgery the Oncologist on the case stopped me.
“I read your operative note. I’ll bet your heart was racing during much of Emil’s surgery,” he commented.
“No, just all in a day’s work,” I lied.
We both smiled.