Sunday, June 28, 2015
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.
“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.
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.
“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
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.
Dissect a bit more, perhaps. Mobilize the tumor away from the aorta and the free it from the tissue behind.
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.
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.
Saturday, May 9, 2015
I’ve been practicing as a general surgeon for twenty five years, more or less. All these years have taught me one thing: how to worry. As a general surgeon I take care of very sick patients. I perform complicated operations on severely injured or septic people and care for them afterwards, watching for any little sign which may be the harbinger of something worse to come.
So, I worry. I worry about wounds healing, anastomoses leaking, infections brewing, blood clots forming and a variety of other events which can and do occur after surgery.
A case in point is Denny.
Denny was a young man who came to be my patient one night when I was on call for the emergency room. He had been stabbed eight years before I saw him and had sported a colostomy ever since that event. I guess he finally became tired of having a bag, because he had undergone a colonoscopy earlier that day in anticipation of having his colostomy reversed. Unfortunately, he developed severe pain after his colonoscopy. Despite his protests to the endoscopist that he was in pain, he was sent home. He returned to the ER, at a different facility from where his colonoscopy had been performed, where the work up revealed he had free intraperitoneal air, which meant his colon had been perforated during the colonoscopy.
Denny refused to go back to the hospital where the colonoscopy had been done and so I took him to surgery. I found that his colon had perforated at the splenic flexure, an area that was “defunctionalized,” which means that his colostomy was proximal to this injured segment of colon. The perforation was at the closed off “blind pouch.” There was essentially no fecal contamination and all that was required was to close the perforation. I did examine the rest of his colon and even contemplated reversing the colostomy at that time, but properly decided not to. I wasn’t privy to the findings from the colonoscopy and emergency surgery would not be considered optimal conditions to perform such a procedure. I did leave the blind end sutured to the segment of colon where the colostomy was so that subsequent reversal would be easier to perform. At least, that was my plan.
No real worries up to this point, but Denny’s troubles were just beginning.
He recovered uneventfully from this procedure and went home after about five days. During his post op visit he asked about reversing the colostomy.
“Sure,” I replied, “once you’ve healed enough from this surgery. I did leave the two ends of the colon together so that the reversal should be easier.”
He was happy with this answer and I sent him on his way with a follow up appointment for a month later and instructions to “take it easy” until I saw him again. Well, he missed his next appointment. I assumed he was recovering adequately as I had not heard from him. My office staff made their usual effort to contact him and found out his phone was disconnected. He had been well at the last visit so I wasn’t very concerned.
Two weeks later I was called from the ER where Denny had made a return visit, complaining of abdominal pain.
“Denny’s CT reveals some inflammation around his colon and Dr. M wants you to consult,” the ER physician reported.
“Sure,” I replied. “Is Denny stable?”
“Just left sided abdominal pain, otherwise he’s fine.”
I saw him later in the day and he already was feeling better. He quickly recovered and we made plans for him to have his colostomy reversed in about six weeks. He had preop evaluation with a barium enema. His recent colonoscopy had revealed only a bit of diverticulosis, which the BE confirmed.
He underwent a fairly uneventful reversal of his colostomy. There was a little bit of excitement as the distal colon which I had sutured adjacent to the colostomy was not where I had left it, but a bit of searching identified the wayward bowel and he sailed through his recovery and went home.
But, not for long.
Two months later I was called to the ER. Denny was there and complaining of lower abdominal pain.
“CT looks like sigmoid diverticulitis with a small abscess,” reported the ER doc. “he looks pretty stable. The hospitalist is admitting him and he’s consulted you.”
“OK, thanks,” I answered, “I’ll see him when I’m done in surgery.”
Denny didn’t look very ill and I fully expected his diverticulitis to resolve with only IV antibiotics. At first the plan worked. His pain improved, his low grade fever improved and his elevated WBC came down to nearly normal. But, after three days his condition changed. He developed fever and his WBC went back up. I repeated his CT scan and it revealed a new, larger abscess.
I made a call to Interventional Radiology and the abscess was drained and he settled down again…for a while. He continued to drain and then developed new onset of fever and abdominal pain. He had developed a second abscess. It was fast becoming apparent that he was headed to surgery again.
He was not so sick, however, that I needed to rush him to the Operating Room. Time was taken to drain the new abscess and properly prepare him for what I suspected was going to be a major undertaking. After a few more days of antibiotics, bowel preparation and soul searching his time arrived.
The operation was not what I expected. He had a few adhesions which were easily dispatched. The inflamed segment of colon was mid sigmoid, there was plenty of uninvolved proximal and distal colon.
Not nearly as bad as expected.
The time for worrying had not yet arrived.
I resected the inflamed segment of colon and prepared to do the anastamosis, that is to reconnect the two ends of the pipe, when I took a closer look at the bowel.
Is the blood supply to the proximal segment adequate?
Normally, I wouldn’t think twice about this. The surgery was for benign disease which means most of the blood supply is left intact. But, something about Denny made me pause and think twice. He had undergone several previous colon operations which almost certainly caused some sort of alteration to the normal blood supply.
The bowel did appear healthy and adequately perfused. I could see arteries in the mesentery which were intact and I even thought I could feel a pulse.
Perhaps check it with a Doppler? Better safe than sorry.
Unfortunately, this was not very helpful. The Doppler is a sort of ultrasound which detects flow in blood vessels. In Denny’s case there was definitely arterial blood flow in the mesentery, but I did not hear it very well in the bowel.
Perhaps it would be best to resect more colon? To remove more bowel would leave him with very little colon as I would be forced to remove the previous anastamosis and then there would be difficulty reconnecting the two ends.
What to do? Go with my gut? (I hate that expression)
Reason and experience told me that doing the anastamosis without removing any additional bowel would be OK and so I proceeded.
And the worry started, also.
Perhaps it is a part of growing older and wiser, but I worry much more now than when I first started out as a surgeon. We were always taught to not take chances, to be sure of what was being done or else pursue and alternative course, one that would eliminate uncertainty.
“If it’s not safe to do an anastamosis, do a colostomy. Better a live patient with a colostomy, than a dead patient,” my mentors said.
“If you’re not sure if it’s the cystic duct or common bile duct, don’t assume, don’t cut it, don’t do anything until you are sure,” another instructor bellowed.
“See the nerve, see the nerve,” a third teacher commanded.
But, what about those times when the operative course is not cut and dry?
Do it this way and the patient should be fine, unless this happens. But if I do it the other way, then this could happen.
Denny presented several options, each with positives and negatives:
1. Do the planned procedure, the resection and anastamosis and presume it will heal.
2. Extend the resection which will leave him with a very short colon, but less worry about healing.
3. Do the planned procedure, but add a proximal colostomy or ileostomy. The proximal diversion of the fecal stream would allow the colon anastomosis to heal and then could the ostomy could be closed in a few months.
There were plusses and minuses for each alternative. Number one was best for Denny, assuming he healed properly. No further surgery needed, fewer long term complications such as frequent diarrhea associated with a short colon.
There would be little worrying with Number two as the blood supply would not be in question and healing should proceed with little risk of anastamotic breakdown, but he would likely be troubled by very frequent bowel movements.
Number three might be best as it preserved his colon, but would require another operation down the road to reverse the colostomy or ileostomy.
What to do? What to do?
In the end I decided on Number one, my original plan. The colon looked OK, had been properly prepped and, if everything healed properly, this would be best for Denny.
But, it didn’t stop me from worrying.
What does this worrying entail?
That night I called to check him. Normally I check on my ICU patients, but Denny did not need to be in the unit.
His heart rate was a tad high at 110, but everything else was fine: good urine output, no fever, no unusual pain. I didn’t really expect any issues immediately post surgery. His issues, should they develop, would become manifest in 4 days or 10 days or 2 weeks.
So, I waited and checked and waited. I carefully palpated his abdomen on daily rounds, looking for any tenderness which was greater than expected. I looked at his heart rate, coming down from 110 to 104 to 95 and my confidence rose as it dropped.
Tachycardia is the first sign that something is amiss.
The first wisp of flatus almost brought cheers as his bowel function returned to normal. By the fourth day after surgery everything was normal: White blood cell count, heart rate, kidney function. He was tolerating a liquid diet and his bowel function was normal.
In addition, my heart rate, blood pressure and everything else was normal.
Denny went on to an uneventful recovery and is back to normal.
Was my worry warranted, productive, or unnecessary? Shouldn’t I be as vigilant and worry about every patient?
The vast majority of the surgery I do is cut and dry. Right upper quadrant abdominal pain with gallstones? Take out the gallbladder.
Malignant tumor in the cecum? Take out that part of the colon.
Single hyperfunctioning parathyroid gland causing severely elevated calcium level? Take out the offending gland.
Straightforward cases such as these, performed properly, usually have uncomplicated postoperative courses and rarely cause me to lose any sleep, except when they do. I always maintain a watchful eye, but complications in well planned and well executed surgeries rarely rear their ugly head.
But cases like Denny, where the proper course is not as clearly defined, are different. Suppose he had leaked from his anastamosis. Or suppose I had taken a different course, removed more colon and he developed intractable diarrhea. Or suppose I had taken the intermediate course and he developed a pulmonary embolus and died during the surgery to reverse his ostomy.
Worrying about complicated cases goes with the turf of being a physician. In the end all one can do is look back and say: “I looked at all the possibilities and chose the best option. If the same situation arises again I’ll do the same thing. Worrying doesn’t help.”
But, the little nagging pest named worry still whispers in my ear.
Sunday, February 8, 2015
Almost every morning I get to put on a show for a captive audience. I stand before my audience, employing a variety of tools inherent to the task at hand, performing my duties as an aura of solemnity pervades the air. This daily undertaking can be considered life saving, perhaps even life giving. I do know that as I near the end of my mission the sense of excitement grows until the triumphant climax. And, when I’ve finished there is a period of rest and relaxation.
Is this performance some sort of complex surgery? Or, a life saving medical procedure? No, but it may be just as important. What I do is make the daily meal for five (sometimes six) dogs.
The dogs, in no particular order, are:
Coconut, 12 year old Westie, the elder statesman of the group
Daisy, about 8 years old, a one eyed Bassett Hound
Zoe (Baby Girl), 7 year old Norwich Terrier
Leo, 3 year old very, very stupid Shih Tzu, who thinks he’s the alpha dog
Freckles, about 2 year old Spaniel of some sort
Winston (sometimes home, but now away at school in Waco where he’s premed) 6 months old Miniature Schnauzer mix.
Every morning starts with the same routine. Wake up, attend to some personal needs, head downstairs with Zoe in tow (being Baby Girl entails some privilege), get the newspaper, make the daily food for Isaac, my fifteen year old Eclectus parrot and, finally, the show begins.
First, all the important props are gathered: food bowls, a knife and spoon, cans of dog food, cheese and any other fare I see fit to feed this pack. At first only Zoe will linger around the kitchen island where each dog’s meal is to be prepared.
Zoe came from Hungary and the first thing she did when she exited the plane was eat. She has lived for eating ever since. She hovers around the preparation site in case any stray bits of kibble or shreds of chicken should fall to the floor. Zoe has been on a special diet which helps keep her love of food in check and has helped bring her weight from a far too heavy 19 pounds to a much more acceptable 14.
The show starts with The Preparation of the Leftovers. This may be chicken, steak, roast pork or anything that is appropriate for a dog’s stomach. This part of the meal is chopped into measured bits, cubes or strips which can be easily consumed by the canine crowd. It is microwaved for about thirty seconds and then distributed. Coconut, being the most senior and the most discerning gets a large portion. Leo, under the delusion that he’s the boss and should have everything Coconut has, gets a little less. Daisy and Freckles each get the same, while Zoe gets enough for her to think she’s getting what the others have, which is usually only 3 tiny bits and always lean.
Next comes the dry food. About a cup for Daisy, a bit more for Freckles and a bit less for Leo. Coconut hates dry food and never touches it under any circumstances. Zoe gets her special weight loss formula. By now, other dogs have started to gather around me in anticipation of the great climax. Leo, Daisy and Freckles will all be sitting staring up at me, while Zoe is still on the prowl for any tiny bits that may escape to the floor. Coconut, as always, maintains his cool and stays on his bed, confident that his breakfast will come to him.
The next ingredient is the canned food. I’ve been through many brands and styles, searching for the perfect one which appeals to them all. Alpo, Purina, Cesar, Science and many others have been tried and found wanting. One may be too chunky, another doesn’t taste right, still another may appeal to Daisy, but not Leo, or Freckles but not Coconut. Finally, I stumbled upon Blue Wilderness, a ground up variety which mixes well, comes in a variety of flavors and, so far, is acceptable to the entire pack.
Each gets their fair share, enough to fill up their tummies and add a bit of flavor to what I’m sure is very bland dry food. Poor Zoe is limited to her weight loss formula, fighting a never ending battle which is familiar to many.
Finally the food is mixed. Of course, by now my pack of dogs is all around me, barely able to contain their enthusiasm as they anticipate the coming gourmet repast. Daisy, being a very verbal Bassett starts to half howl, half cry. She knows that she gets her food first. Leo and Freckles still sit quietly, staring at their food bowls and Zoe, never one to miss an opportunity, still mills about hoping to find a wayward morsel.
And, at last, the piece de resistance, cheese garnishes each bowl. Muenster, Cheddar, Colby Jack, anything but Pepper Jack, is broken up and put on top of each food dish. Three microscopic bits for Zoe and generous helpings for the rest. Voila, the daily meal is ready.
First, Daisy, who by now is in a frenzy of anticipation. She races into the “music room”, pushing any unsuspecting bystanders out of her way and she jumps onto her bed and sits as I put her bowl down. She sniffs it carefully, declares it good and digs in.
Next, Freckles smoothly glides out of the music room, where she followed Daisy, and takes her place just outside the door and stands to get her breakfast.
Zoe then runs to her spot, which is under a desk built into the breakfast area. She does a 360, sometimes a 720 while her bowl is placed into her nook and then digs in.
Coconut has coolly remained on his bed in the utility room. His meal, good enough for even the most discerning palate is laid in front of him. I bow to the king and then close the door, allowing our elder statesman to eat quietly in solitude.
Then there’s Leo, the dumbest dog ever born. He runs to his spot, which is on the Ottoman next to a big overstuffed chair. He jumps up and usually slides off the opposite side, crashing onto the floor, as I put his food in its place.
The show is now nearly over. Everyone is hunkered down, enjoying a gourmet meal. One by one they finish. But, they’re not finished. Because, they expect dessert. I gather up each bowl while Freckles sits by the large basket which holds a variety of dog treats. Zoe also appears, then Leo. Daisy and Coconut are still in their respective rooms, waiting. I don’t want to disappoint them, so they each get one treat, a Greenie or jerky treat. Each goes his or her own way; going off to savor the treat, while I’m left, like a good maid, to clean up; wash each bowl and put them away and to fill their four water bowls.
Each dog settles down for a nap. The show is over.
I leave for “work.”