Saturday, March 26, 2016

Legacies

                           

We read a great deal these days about President Obama’s legacy, about he is trying to create a list of accomplishments which historians will cite as the highlights of his eight years in office.
But, when we think about our former leaders what pops into our head are the quotes which we associate with each man. Reflecting on this idea I present a list of famous quotes which are attributed to some of our past Presidents. President Obama presents a stark contrast to the others, which provides commentary on his memorable accomplishments.


“My fellow Americans, ask not what your country can do for you, ask what you can do for your country.”  John F. Kennedy

“The only thing we have to fear is fear itself.” Franklin D. Roosevelt

“Four score and seven years ago our fathers brought forth, upon this continent, a new nation, conceived in Liberty, and dedicated to the proposition that all men are created equal.” Abraham Lincoln

“With Malice toward none, with charity for all, with firmness in the right, as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation's wounds.” Abraham Lincoln

“I feel your pain.” Bill Clinton

“Mr. Gorbachev, tear down this wall!” Ronald Reagan

“States like (Iraq, Iran, & North Korea), and their terrorist allies, constitute an axis of evil, arming to threaten the peace of the world.”  George W. Bush

“Until justice is blind to color, until education is unaware of race, until opportunity is unconcerned with the color of men's skins, emancipation will be a proclamation but not a fact.” Lyndon Johnson

“If you've got a business—you didn't build that. Somebody else made that happen.” Barack Obama

"If you like your health care plan, you can keep it.” Barack Obama

I did not include the famous “lead from behind” quote because I cannot find documentation that President Obama actually said this. I also must admit that thre is nothing scholarly about these quotes. Each is a quote that popped into my head when I considered what was memorable about these past presidents.

Just a little food for thought.

Monday, March 14, 2016

A Horse is a Horse of Course...

                                      

Jeremy was a cowboy in the rodeo. He also was responsible for keeping me up for most of three nights in a row. He was the fortunate survivor of a run in with a very angry horse.
Animals are supposed to be our friends, at least dogs and cats, horses, pigs and cows. Some birds, the occasional snake and even tarantulas have been companions to humanity. Our encounters with these domesticated beasts are supposed to bring pleasure, happiness and feelings of wellbeing. Except, when they don’t.
Melvin was set upon unmercifully by two feral dogs, losing large chunks of skin and muscle from each leg and one arm before the beasts could be restrained. Sandy was a young lady tattooed from head to toe. She had a pet python who mistook her for his dinner one day and tried to swallow her whole. I see half a dozen patients every year with fever and painful swollen lymph nodes secondary to cat scratch disease. Bird bites, tarantula bites, dog bites and so many other bites have made it into the hospital over the years.
But Jeremy; he stands out. Maybe it’s because he showed up in the ER very early in my career in private practice; maybe it was the running battle between his divorced parents, maybe it was the conversation with Dr. Red Duke, or the lack of sleep I accumulated over the four days it took to stabilize him. Probably all of the above combined to make him one of my more memorable disasters.
I had been out in private practice for about four months and I still had the feeling of invincibility common to surgeons as they leave the safety of residency and head out to save the real world.  It was eleven pm when the phone rang.
“Dr. G this is Dr. F in the ER. I’ve got an eighteen year old man here who got kicked in the right side by a horse. His heart rate is 130 and BP is 90. There’s a big area of swelling on his right side. He’s on his way to CT as we speak.”
“OK, thanks, I’ll be in to see him,” I answered. I turned to my wife.
“I need to go to work,” I said.
“Surgery?” she asked.
“Don’t know. I hope it’s nothing major.”
I pulled on some clean scrubs and left.
Jeremy was just finishing his CT as I arrived. As he was wheeled back to the ER I scrolled through his scan.
Broken rib, looks like a pretty big subcapsular hematoma of the liver, not much else.
This was my reading of the scan, but usually I was pretty accurate, as I had spent the last two years of my residency reading abdominal CT’s with the senior Radiology residents.
The Radiologist’s official reading was in agreement.
Jeremy was awake and alert, complaining of pain in his right side. He had been competing in a local rodeo and one of the horses decided nobody was going to ride him and decided to vent his anger on Jeremy,  delivering a solid kick squarely to Jeremy’s right side. There was a big bruise on his right side and I was sure I could make out the imprint of a horseshoe. Certainly not lucky for Jeremy.
Jeremy’s Dad was at his bedside showing nothing but the proper concern. Mom and fireworks would come later.
Jeremy stabilized after a couple of liters of IV fluids and I decided surgery was not needed at this time. I tucked him away in the ICU and was back in bed by 2:00 am.
Later in the morning Jeremy was looking fairly stable. Heart rate was around 110, blood pressure was 110/70, urine output and oxygen saturation were good. His hgb had dropped for 14 to 10.5.
“Looks like he’s pretty stable,” I reassured his dad.
“His mother will be happy,” he replied.
“I haven’t met his mother yet,” I answered.
“She’s been away, on a business trip. She’s flying in this afternoon and will be here later.”
“Oh, well I guess I’ll meet her later. I’ll check on him this evening,” I added and I left to attend to other sick people.
A few hours later a message came to call the ICU regarding lab results.
“Jeremy’s hemoglobin has dropped to seven,” the nurse reported, “and his heart rate is 125. Blood pressure is 100/60.”
“Give him two units of Packed RBC’s,” I ordered.
Looks like he’s going to need surgery. I hate operating on the liver.
That was the truth. I loved operating on the biliary system, pancreas and everything else around the liver, but the liver itself was one of my least favorite organs to work on.
Maybe it’s because you can’t really take it out. Every other intra-abdominal organ could be removed if necessary, its functions then assumed by other organs or replaced with medication. The esophagus can be replaced by a segment of colon or even small bowel, stomach can be reconstructed, much of the bowel can be resected with impunity, dialysis can replace kidneys if necessary, there is insulin and enzymes for the pancreas, but the liver is different.
No other organ does its job. It metabolizes and excretes bilirubin, detoxifies noxious chemicals releases glucose along with so many other functions. Liver transplant is the only real viable alternative if a liver fails or has to be removed. I was not really anticipating having to remove all of Jeremy’s liver, but the point is that the bleeding needed to be stopped and sometimes this can be problematic when dealing with the liver.
I considered repeating his CT scan, but decided that this wouldn’t change the inevitable.
So the blood transfusion was started and he was scheduled for surgery. It was six thirty when I went to explain the situation to his parents, both Mom and Dad now present.
“You let him ride in the rodeo. I told you to stop it,” I heard Mom hissing loudly.
“He’s an adult. I can’t live his life,” Dad replied in more of a whisper.
“You could if you were more of a man,” Mom answered, the hissing growing louder.
I took that moment to interrupt and introduce myself to Mom.
I’m Dr. G, I’m pleased to meet you,” I began, addressing Mom. “I think you know that Jeremy needs surgery. I’d hoped he would stabilize, but that hasn’t happened.”
“I’d like to send him to the Med Center,” she stated.
“That would be fine with me,” I answered, “but he’s not stable at the moment. He really needs to go to surgery. I think we’re just about ready to start. Afterwards, when he is stable, we can try to arrange for a transfer.”
She looked at me with an expression which said, “You better take care of my Jeremy or else…”
I left the worried family and met the OR crew as they began to wheel Jeremy down the hall from ICU to the OR.
“Don’t worry,” I reassured him, “we’re going to take good care of you.” This has been my standard line to worried patients over the years, short and to the point, but very effective.
Jeremy was fairly stable as I made my long midline incision. His heart rate was 120, BP 110/60.
Upon entering the abdomen I was greeted by blood, blood and more blood, dark blood wafting up from between loops of slightly pale bowel. There was more blood around the liver, redder, fresher along with large congealed clots.
We, that is myself and my assistant, scooped out all the blood and began by packing “laps” all around the abdomen, starting with right upper quadrant around the liver, then around the spleen and in the lower abdomen.
The money is on the liver. At least I don’t see a lot of active bleeding.
I pulled the packs from the lower abdomen. This area was pristine, no active bleeding, no hematoma. Next I “ran the bowel” which means I checked the small bowel from its beginning at the Ligament of Treitz until it terminated in the cecum. No injury. The packs were pulled from around the spleen. The left upper quadrant was also spotless; without bleeding or injury.
Time to work.
I gingerly removed the packs from around the liver. There was adherent clot over most of the right lobe with a laceration into the parenchyma and a small amount of oozing of red blood. The capsule of the liver had been disrupted over most of the right lobe.
Maybe just leave a drain? No, he’s been bleeding. I definitely need to do something.
I left the clotted blood which coated the denuded liver surface in place and approached the laceration. This was a crevice which ran from the superior right lobe laterally and inferiorly. Bright red blood was slowly welling up and then running down the liver’s surface. Carefully, carefully I put my hand behind the liver and gingerly lifted the right lobe, this brought the laceration closer to me so that I could actually see what I was doing. I packed laps behind the liver which helped hold it in place. I divided the right triangular ligament, which is a peritoneal attachment holding the right lobe. This allowed me to bring the laceration even closer. Now I could see into the depths of the liver, clean out the clot under direct vision, find what was bleeding and stop it,
I hope.
I began by washing away the clot, irrigating it with saline, doing my best to cause as little disturbance as possible so as not to stir up new bleeding.
What’s happening?
My thoughts preceded my words.
“Is there a problem?” I asked the anesthesiologist. “All of a sudden everything is bleeding.”
Indeed, the surface of the liver was now a continuous ooze of blood which was filling up the belly. The laceration was briskly filling up with bright red blood. The trickle had become a flood.
“Nothing’s changed…wait, how did that happen?” the anesthesiologist replied.
“How did what happen?” I inquired, a sense of urgency in my voice.
“His temp is 93.5. I’ve only given him 2 units of blood, but something has caused his temp to drop. I don’t know how long it will take to warm him.”
How did he get so cold? Maybe a transfusion reaction? Just pack him for now, get him warmed up and then come back and fix the problem.
The commotion at the head of the table faded away as I tuned out everything and concentrated on the problem at hand.
“Laps, a bunch of them,” I ordered, the level of my voice rising only slightly.
I packed laps into and around the lacerated liver, holding pressure and then packing more until they stayed dry.
I closed his belly quickly and we rolled him back to the ICU. His blood pressure was 100/60, heart rate 110, temp 93.7.
I rushed through the immediate post op tasks of dictation and orders and then went to face his worried family.
I found Mom and Dad in heated discussion.
“Would you believe it?” Mom stated as she turned to me. “Wonder man here has an insurance plan that doesn’t cover ‘animal related injuries.’ What kind of insurance is that?”
“One of the questions was about animal related activities,” he replied, a bit sheepishly. “I couldn’t lie.”
“That is not a concern at present,” I said. “Worry about that later. Right now I have some news for you. I guess you can tell that I’m out of surgery. We had a bit of a problem…”
“Jeremy’s OK isn’t he? He better be OK,” Mom almost threatened.
“He’s OK, at the moment, but as we were working he started bleeding more, bleeding from places that should not have bled. His blood wasn’t clotting. I did what I could do to control everything, but he’s still not out of the woods and I’m not a hundred per cent sure what the problem is.”
“How is he now?” Dad asked, his voice filled with nothing but anxiety and worry.
“He’s stable, blood pressure is normal, all his organs seem to be functioning. It looks like his body temperature dropped and blood doesn’t clot well if you’re cold. We’re doing what we can to warm him and make sure there are no other clotting problems. I packed a bunch of surgical pads around the sites which were bleeding and that has controlled everything, at least for the moment. He will need to go back to surgery in about 48 hours to remove them. In the meantime we need to correct his temperature and any other abnormalities. And, hope he doesn’t bleed anymore.”
But, he did continue to bleed. Besides his low body temp, his coagulation studies were abnormal. Most likely everything was intertwined. Blood clotting is a complicated series of events which starts with platelets plugging a hole in a blood vessel, followed by a cascade of enzymatic reactions which lead to a mature clot. Biochemistry teaches us that such reactions work best at normal body temperature. Significant lowering of body temperature causes derangement of normal clotting. And, once a body starts oozing it tends to beget more oozing, sometimes leading to the flood I witnessed within Jeremy’s belly. Thus, my decision to pack around the site of bleeding and stem the tide for the moment. This action, I hoped, would buy time to correct the underlying problem.
It worked, at first. I checked his coagulation status. His PT was elevated at 22 and his PTT was 48. His platelets were OK at 110,000. The nurses were working on warming his with a heating blanket and warmed fluids. He was transfused two jumbo units of FFP, plasma which would replace the clotting factors which had been consumed.
Maybe he’s out of the woods.
But, eight hours later, at four in the morning, his heart rate started to rise, his blood pressure dipped and his hemoglobin dropped from 10 to 8. There were a few bright spots. His body temperature was normal and his PT was down to 17 and PTT was normal.
“Transfuse two units PRBC’s and give another jumbo unit of FFP,” I ordered. “I’ll be in to see him.”
What to do? What to do? There must be some blood vessel which continues to bleed. Should I operate again? I’ve already been there. Maybe, maybe there’s a better alternative? Yes,  there is another alternative which might work. I hope Dr. L. is on call.
My plan was simple. Rather than dig through the injured liver looking for the source of bleeding, the problem would be approached from a different angle.
“I know you don’t like to get up early, but I really need your help,” I explained to Dr. L. I told him the whole story.
“Do you think you can do an arteriogram and embolize whatever hepatic artery is bleeding?” I finally requested.
“It might work,” he concluded, “although I’ve never embolized for this type of injury before.”
It was true. Angiography and embolization of arteries for trauma is commonplace these days, 25 years ago such a practice was sporadic.
I called Jeremy’s Mom and Dad and explained his condition and the plan.
An hour later he was wheeled down to the angiography suite.
I stretched out on the couch in the doctor’s lounge.
Maybe I should go home and sleep for a couple of hours. With my luck I’ll get called back as soon as I walk in the door.
I closed my eyes for a few minutes, until I was interrupted by a call from Dr. L.
“There was a tiny blush from a branch of the right hepatic artery. I did a subselective embolization of the right hepatic. I think he’ll be better,” Dr. L. reported.
“Thank you,” was all I said.
Six thirty. I guess I’ll make rounds and then check on Jeremy.
Jeremy did stabilize. His heart rate came down to 95, BP stayed around 110/60, he was awake and alert, talking, wanting to eat.
“Clear liquids for now and we need to take you back to surgery tomorrow to remove all those packs,” I reminded him and his parents.
I scheduled the next procedure for the next day to be done around 4 pm. Unfortunately, I was on call and had to deal with a perforated ulcer before tackling Jeremy. It was around 7 pm when the OR crew came to pick him up.
“I’ll be out to talk to you as soon as I’m done I reassured Mom and Dad and a multitude of other relatives and friends.
“Could you talk to another doctor on the phone” Mom asked.
Really, do I have to?
“Another relative?” I asked, a bit facetiously.
“It’s Dr. Red Duke,” she added.
“Oh, OK.”
Dr. Red Duke was a local celebrity. He was a general surgeon at the Texas Medical Center, was regularly featured on local news shows where he would explain a variety of medical and surgical maladies and what to do about them. Outside of that I really didn’t know him.
“Hello, this is Dr. G.”
“This is Dr. Red Duke,” he answered in his thick Texas drawl. “Tell me what you’re dealin’ with thar, young fella.”
I presented the case as succinctly as I could and he listened without interruption.
“Sounds like you’ve done a fine job, doctor. My only advice is that when you remove those lap pads, soak them in peroxide first. If you do that, they won’t stick and you won’t stir up any new bleeding. Good Luck.”
“Thank you, now I think they’re waiting for me.”
I hung up and headed to the OR where they really were waiting on me.
“Sorry to keep you waiting,” I explained, “but I had to get some advice from Dr. Duke.”
“You mean Red Duke.”
“Sho ‘nuff,” I answered in my best Texas accent, “the family called him. Now let’s get this done with.”
This return to OR was most uneventful. There was only a couple hundred cc’s of old dark blood, the packs easily came out after soaking them with saline and there was no bleeding. The abdomen was washed out, I left a drain by the liver and closed him up.
Maybe I can get a full night’s sleep.
No such luck. I was in bed by ten, but at 1:00 the phone rang.
“Jeremy is very short of breath. He’s breathing at about 36 (normal 12-16), his oxygen saturation is 90% on 100% nonrebreather, heart rate is 120, BP is high at 150/95.”
“I’ll be in to see him.”
I’m getting tired of this.
For the third night in a row I climbed out of bed and made the twenty minute drive to the hospital.
Jeremy was sitting upright in bed, his oxygen mask in place, breathing at a rate of about twenty eight.
“What’s going on, Jeremy?” I began. “Any pain?”
“Just feel winded, like I can’t get enough air into my lungs.”
His oxygen saturation was at 91%, heart rate was 120. BP, urine output were OK. His chest X-ray looked a bit congested and there were bilateral pleural effusions, which means fluid around his lungs.
“Do you think we need to intubate him, Dr. G?” the ICU nurse asked.
“Give him some Lasix, 40 mg, now. I’m going to talk to Pulmonary.”
I called Dr. P. and told him the story, while Jeremy got the Lasix.
“Dr. P. will be in,” I told the nurse, but I could already see improvement with the Lasix.
Jeremy put out about 4 liters of urine. His breathing calmed and he began a steady improvement. His bilirubin rose to about 6, possibly related to the embolization of his liver, but then came down to normal.
There was no more bleeding, no respiratory difficulty, he was soon up walking and eating and he went home about twelve days after the original injury.
The control of bleeding utilizing angiography and embolization was a technique I had used prior to Jeremy, primarily for bleeding secondary to pelvic fractures and bleeding from tumors which could not be accessed surgically. The technique now is more common, often being used for trauma to the spleen, as well as liver and the aforementioned pelvic fractures. It is a true life saver in those cases where the patient has an isolated injury to an organ which will tolerate the embolization.
The liver has a dual blood supply, receiving blood from the hepatic artery and the portal vein. In this case, embolization of the artery did the trick.
I saw Jeremy about four years later. He came to see me because he thought he had a hernia. He had given up riding in the rodeo and was working locally as an electrician. He did not have a hernia.
His Dad paid me ten dollars a month for a couple of years, determined to make up for the lack of insurance. I told my office staff to write off the balance and forgive the rest of his debt after about two years.
I stay away from horses, except for the occasional trips to the race track.












                  











Sunday, February 21, 2016

Why Did This Happen?

                   

It was a Whipple. Not Mr. Whipple of Charmin fame, but the operation which carried the name of Whipple. The proper name is Pancreatoduodenectomy and it is a procedure which most surgeons decline to undertake.
Named for Allen Whipple, the operation consists of removal of the gallbladder, a portion of the common bile duct, the head of the pancreas and the duodenum with the most proximal jejunum. In its original form it was performed in 2 stages, first the resection and then, the following day, the reconstruction. It is an operation for tumors in the head of the pancreas, distal common bile duct and duodenum. Occasionally it is utilized for benign strictures of the distal bile duct, often due to chronic pancreatitis.
To me the operation presents a study in anatomy and an exercise of careful dissection. The portal triad, consisting of bile duct, hepatic artery and portal vein must be teased apart, vessels to the liver preserved and the pancreas gently lifted off the superior mesenteric and portal vein.
Mark needed such an operation.
Mark was 52 and came to the hospital because he had turned yellow. He had noticed the color change for about two weeks. He also felt weak, had vague abdominal discomfort and had lost about fifteen pounds. In the Emergency Room he was found to have gallstones, dilated bile ducts and “focal” pancreatitis on CT Scan of the abdomen.
His bilirubin level was 12, which is why he looked yellow. Normal bilirubin level is under 1.0.
Fortune put me on call for the ER that day and I was consulted by Mark’s admitting physician. His presentation was not typical of gallstone pancreatitis. His pain was mild. The bilirubin was too high, weight loss did not go along with acute pancreatitis.
And, when I reviewed his CT Scan, the finding of “focal” pancreatitis looked like a tumor to me and to another Radiologist colleague with whom I was reviewing the images.
Further work up with MRCP revealed the stricture in the bile duct and a definite mass in the pancreas.
Mark needed a Whipple.
He was otherwise healthy. The surgery was scheduled for two days later.
At 9:08 am on a Tuesday I made my chevron incision in Mark’s upper abdomen, dealt with the usual bleeders in the abdominal wall and entered his peritoneal cavity. There was no fluid, usually a good sign, the liver was discolored from his jaundice, but free of any masses. Palpation of the head of the pancreas revealed the expected hard mass, a sign of either inflammation or tumor.
Next came the first decision. Should I biopsy the pancreas? Would such a biopsy change anything? Suppose the biopsy revealed cancer. The treatment would be to resect the tumor, that is, to continue with the Whipple procedure. But, suppose the biopsy only revealed inflammation, or fibrosis, without any tumor? The answer is that it wouldn’t make a difference. Mark still needed the Whipple. Pancreatic cancer is a funny beast. It causes an intense fibrotic reaction. The tumor often is obscured by this fibrosis and diagnosis, particularly on intraoperative frozen section is often very difficult. Mark’s presentation was textbook cancer of the pancreas. Even if his jaundice turned out to be benign disease, which was unlikely, the proper treatment was still the Whipple.
The first decision was, therefore, simple; no biopsy.
Next I removed the gallbladder. It contained a bunch of stones, but otherwise wasn’t inflamed. It was in the bucket in about ten minutes.
Time to get going.
I Kocherized the duodenum, which meant I divided the peritoneal attachments of the duodenum which allowed me to lift the pancreas and duodenum off any underlying retroperitoneal structures. The main structure of concern was the Inferior Vena Cava. I was now able to hold the entire head of the pancreas in my hand. The mass felt hard, while the neck felt soft and spongy, the way normal pancreas was supposed to feel. I mobilized as much as I could, until I could feel the pulse of aorta adjacent to the pancreas.
Time to tackle the porta hepatis.
This part of the operation is the time to be careful and methodical. The common hepatic artery arises from the celiac axis, a major branch from the aorta. This common hepatic artery branches into the proper hepatic artery which is one of the major structures of the porta hepatis and supplies arterial blood to the liver, and the gastroduodenal which supplies the duodenum and the pancreas, but also gives rise to the right gastric artery which is important to preserve in the so called pylorus preserving Whipple which is what I planned for Mark.
Carefully I exposed the arteries. It turned out to be one of the easier dissections of these structures I’d ever performed. There was considerable space between the common bile duct and the arteries, making separation of these structures very straightforward. All the branches were dissected and encircled with silk ties, but none of these arteries were divided yet.
Next the bile duct was identified, dissected free and also encircled. It was dilated to about 1.6 cm, about twice normal size. Behind the bile duct was the portal vein, usually the make or break structure in Whipples. This large vein is formed where the superior mesenteric vein and splenic vein meet. It abuts the head of the pancreas and tumors often grow into and around it, which renders these tumors unresectable, at least for cure. The anterior surface of the vein is dissected free so that the neck of the pancreas can be lifted off the vein.
Mark’s portal vein easily separated from the pancreas.
Once all this dissection being done it was time for the real operation to start.
The gastroduodenal artery was ligated and divided, while the proper hepatic and right gastric arteries were preserved. The bile duct was also transected, an act which always fills me with an oxymoronic combination of fear and delight. This unusual feeling is due to the repeated drilling during residency to “know where the bile duct is, do not injure the bile duct,” every time a gallbladder was removed.
Next the neck of the pancreas is lifted off the portal vein and divided, vessels running with this organ are sutured as there is always some bleeding. Great care is taken to not suture the pancreatic duct.
The portal vein is now separated from the pancreas. There are always a number of small branches running from this vein into the head of the pancreas. Each is dissected free, clipped and divided.
The jejunum, just beyond the ligament of Treitz is divided and the vessels going to the distal duodenum are divided, mostly using my trusty “Ligasure” device.
Finally, the uncinate process of the pancreas is freed from the its connections posterior to the portal vein. Mark had an unusually large collateral vessel in this area which required special attention to control. The vessel was feeding into the pancreatic mass and could not be preserved. I always worry when I find, and sacrifice, an unexpected and unusually large artery; worry that it might be important. In Mark’s case I my worries were well founded.
These final maneuvers completed the resection and the specimen: head of the pancreas, duodenum and portion of bile duct was handed off to the circulator who passed it on to Pathology for immediate examination.
“Looks like adenocarcinoma of the Pancreas,” the friendly neighborhood Pathologist reported, “margins are free.”
“Thank you,” I replied and I set about the task of reconstructing the damage I had created.
At this point in the operation what I have is the divided pancreas, bile duct and duodenum. These organs are designed to meet at the Ampulla of Vater where bile and pancreatic juice are dumped into the duodenum to join and digest ingested food. The task at hand is to reconnect each structure to the intestine to restore the normal digestive function. Connecting the Pancreas to the bowel is considered the Achilles heel of the Whipple procedure.
Back to work. The divided pancreas was dissected free a bit more which allowed me to put the about three centimeters of the divided pancreas inside the small bowel. Sutures of 3-0 Prolene were used to suture the thin, weak capsule of the pancreas to the bowel. Sometimes the pancreas is more fibrotic and will hold suture fairly well. Mark’s pancreas was more normal and the sutures held, but I knew I was going to worry for a few days.
The bile duct was next, an anastomosis using 4-0 Vicryl in a single layer, straightforward and uncomplicated.
Finally, the duodenum, just beyond the stomach, was anastamosed in 2 layers to the small bowel, using 3-0 Vicryl and 3-0 silk. Drains were placed, the belly closed and he was brought to the recovery room.
Mark was very stable for the first 24 hours. There was slight tachycardia, heart rate around 105, but nothing else unusual. The two drains put out serosanguinous fluid as expected and the volume of fluid put out was low.
Labs on the first day revealed a bilirubin of seven, down from thirteen preop. His white blood cell count was high at 21k, but this is not uncommon with the stress of such a major operation. His hemoglobin level actually was higher than preop.
Hemoconcentration, very common after Whipples.
I increased his fluids and went on my way. That evening I made my usual call to the ICU to check on Mark and my other ICU patient.
“He’s more tachycardic now, heart rate 130,” his nurse reported. “Urine output is OK and oxygen saturation is 100%. He looks comfortable.
“Give him a fluid bolus, a liter of lactated ringer’s,” I ordered and I went to bed.
I didn’t hear anything more that night. I saw Mark first thing the following morning. His heart rate still was hovering around 130. His WBC was 20k, he had a mild metabolic acidosis and his renal function was a little worse.
I ordered a stat CT of the abdomen and gave him more fluid and antibiotics.
What’s wrong with Mark?
His drains weren’t putting out very much and the fluid was the expected serosanguinous. The NG tube was bile, his abdominal exam was unremarkable.
Everything looks OK, except for him. Maybe the CT will help.
The CT was finished later in the day: Post op changes, no fluid collections, nothing that would explain Mark’s persistent tachycardia and elevated WBC.
Maybe he’s just one of those patients who becomes tachycardic under the stress of surgery.
Over the years I’ve had a handful of patients whose heart rates go up for a few days after surgery, even after a relatively minor procedures. For example, one young woman had excision of a retroperitoneal node to diagnose lymphoma. She maintained a heart rate in the 120’s for five days afterwards. The resident staff, including me, scratched our collective heads and searched for an etiology. None was ever found and her heart rate eventually became normal and she went home.
Unfortunately, this was not the case for Mark.
The next day I noticed that one of his abdominal drains now was putting out bile. Even worse, Mark was tachypneic, respiratory of 36.
He’s septic. I need to take him back to surgery.
I expected that he had a leak from the pancreatic anastomosis. What I found was very unexpected.
There was bilious fluid in the abdomen, as I anticipated, but the some of the bowel was dead. Specifically, the loop of small bowel which I had used to reconstruct the GI tract was necrotic, about forty centimeters. The small bowel beyond the duodeno-jejunostomy was pink and viable. In addition the right colon didn’t look right.
I began by taking down each anastomosis. The pancreas, bile duct, stomach and duodenum all looked OK, well perfused and essentially healthy. I resected the gangrenous bowel and redid each anastomosis. The pancreas was even more difficult to handle, due to the surrounding inflammation and edema.
Maybe I should ligate the pancreatic duct and not do a pancreatic anstamosis? Or, maybe remove the rest of the pancreas?
There were plus and minuses on each side. Ligating the pancreatic duct likely would preserve the pancreatic endocrine function and prevent Mark from becoming a very brittle diabetic, but would also likely lead to pancreatitis which could be severe. I wasn’t sure Mark would survive a bout of rip roaring pancreatitis.
Removing the pancreas eliminated the risk of pancreatitis, but would leave Mark with pancreatic endocrine insufficiency, which meant diabetes which could be difficult to manage as well as the need to take supplemental pancreatic enzymes for the rest of his life.
In the end I redid the pancreatic anastomosis, wrapped it with omentum and put drains all around it. The bile duct and duodenal anastomosis were straightforward.
I looked at the right colon again.
It looks dead.
Fifteen minutes later this part of the colon was sitting in a bucket and I was creating an ileostomy.
Finally finished, Mark was deposited in the ICU where his overall condition improved immediately. His heart rate came down, his bilirubin came down, he maintained his blood pressure, renal function remained stable and the drains were only putting out serous fluid.
Still, a question nagged at me.
Why did Mark develop this devastating complication?
I wish I knew. I’ve postulated that the unusually large vessel which was supplying the pancreas may have also been the major arterial supply to the proximal small bowel. The colon gangrene I chalked up to low flow and vasoconstriction, although it is possible that sacrificing that vessel also affected the colon.
Perhaps the middle colic artery, which is the major blood supply to the right colon took an anomalous course adjacent to the pancreas. Maybe the mesentery twisted causing the gangrene, although it didn’t look this way at the second operation.
I never found out for sure.
I had planned to return Mark to surgery 48 hours later, to examine the bowel for further ischemia and necrosis, but his overall condition so dramatically improved that I cancelled this procedure.
I also wish I could say that Mark made a 100% complete and uncomplicated recovery, but this was not the case. He improved for about ten days. But, on the eleventh day he started putting out more fluid from one of the drains adjacent to the pancreatic anastomosis.
He required prolonged support on a ventilator, dialysis for a time and TPN. He had this fistula for about three months before it finally healed and he was able to get on with his life.
His pathology revealed adenocarcinoma of the pancreas, no spread to any lymph nodes.
I hope he is cured.


Saturday, February 6, 2016

Med School Memories

The first year of Medical School was a jumble of lectures and labs punctuated with brief encounters with actual live patients.
 There was the half day at one of the local Emergency Rooms where I was joined by a fourth year student. I'd been in med school for about three weeks. I had become well versed in the anatomy of the back muscles and the histology of the liver and spleen, but I knew nothing of authentic diseases or their treatment.
We met one of the ER Attendings, an Internist, and I was treated to a few hour of medical heiroglyphics. We were quizzed on the therapy for urinary tract infections, a pretty simple question. As I began to answer, the fourth year spouted off a litany of different antibiotic choices, drowning out my suggestion of Penicillin. At that time in my medical career I thought penicillin was the antibiotic and was effective treatment for any and all infections. This may have been true in 1945. But, it was now 1980 and the list of antibiotics was growing longer everyday. I stayed quiet for the final few hours, listening and learning rather than demonstrating my ignorance.

My next encounter with real patients was a four week elective in Urology, myself along with two of my classmates. Our instructor was Dr. Leake. We also had two sessions with Dr. Cockett. Leake and Cockett. Can you think of two more appropriate names for Urologists? One of the highlights of these four weeks was visiting Mr. Godfrey.
Poor Mr. Godfrey had cancer of the prostate and was receiving combined Radiation and hormonal therapy. We saw him twice a week and each time Dr. Leake wanted us to do a rectal exam on the unfortunate  Mr. Godfrey. Without even a sigh Mr.Godfrey turned on his side and suffered through this biweekly ritual. The last session of this elective finally came which meant the last four rectal exams Mr. Godfrey would have to endure. We all arrived sporting those big "We're Number One" gloves frequently seen at sporting events.
“OK, Mr. Godfrey, time for your rectal exams.” We chimed in unison.
 Dr. Leake was not amused, but our patient had a nice chuckle.
There were no other memorable clinical encounters until the third year. The entire class eagerly began “General Clerkship.” Four weeks were allotted to teach us how to talk to, listen to and touch the, up until now, sacred creature called, “The Patient.”
We were told to let the patient talk, to listen actively and guide the patient down the history road so that they would impart as much information as possible. We were taught how to guide a rambling patient back to the clinical road which lead to the formulation of the all important “Differential Diagnosis.” Thus, it was emphasized over and over, the history would guide the next steps of a patient’s evaluation.
We discussed the philosophical and practical concerns along with the grave responsibility that accompanied the “Laying on of Hands.” The actual physical exam meant bursting through societal taboo’s against penetrating another individual’s personal space, sometimes invading their most personal and intimate parts, always towards the goal of healing.
“Just the act of physical touching may be beneficial to your patient’s wellbeing,” one psychiatrist lectured.
We were treated to Dr. L demonstrating a complete physical exam (except rectal and pelvic) on one of our classmates. He spent about forty five minutes observing, palpating and auscultating, in the end declaring:
As you can see, this complete physical need not be an all day affair.”
In our more modern times, when a primary care physician may see 50-60 patients a day, performiong a forty five minute exam on each patient would make for a very long day indeed.
We all waited with fear and trepidation for the “Pelvic Day.” This was the day when each student would receive indoctrination into the intricacies of the female pelvic exam. Professional models were hired, each set up in a private cubicle where the student was given about ten minutes of monitored probing.
“My uterus is retroflexed,” my model reported, “so you would need to do a rectal exam to properly feel it. You should be able to feel each ovary however.”
“Until you’ve done about two hundred pelvic exams you may as well be waving your fingers in the wind,” Dr. A, one of our instructors, commented.
Finally, the last pieces of the physical exam came up: the aforementioned rectal exam and the male genital exam. These we did on each other.
“Never go to a Proctologist who can palm a basketball,” one instructor joked.
“You should be concerned if you feel both your examiners hands on your shoulders during a rectal exam,” another quipped.
“All in good fun to lighten the tension,” they said.
Maybe they should have volunteered to be subjects… all in the name of education, of course.
Finally, we were finished with general clerkship and were ready to be set loose upon the unsuspecting patients of Rochester, New York.
“Go do an H&P on the new admission in 612, a Gertie Black, CHF,” my third year resident ordered.
Ready or not here I come, Ms. Black
I perused the chart of patient Black before venturing into see her. I glanced across the nurse’s station into her room and caught a glimpse of my new patient. She was about five feet tall and five feet wide. At the precise moment I looked over at her she bent over. Her hospital gown did little to cover her ample assets and I was treated to a “full moon over Rochester.” So went my introduction to clinical medicine at Strong Memorial Hospital in Rochester, New York.
It wasn’t long before I was churning out 10-15 page H&P’s on a daily basis. The history part, the H, was not a problem. Ask the right question and listen. My patients had no qualms about opening up to me, revealing the darkest secrets of their lives.
“I… like… to smoke… a few… joints… every day… well… several… times… a day,” Mr. M. confided. He had been doing this for most of his seventy years. His very measured, deliberate speech no longer was a surprise.
“I prefer women’s underwear,” another man confided. “It’s more comfortable.”
“I put my cat in the drying machine when I was seven,” an elderly woman reported. I really didn’t think it was relevant to her having hemorrhoids, but one never knows.
“I drink a little every day, maybe three beers a day, and a couple of glasses of wine, and I have two martinis after dinner and a brandy at bedtime,” a councilman confessed.
And so it went.
The intricacies of the physical exam, the P, were more of a challenge.
As a class we shared our interesting heart murmurs, palpable lumps and bumps, hernias, rales, rhonchi and wheezes. Gradually, I thought I was developing some physical exam proficiency.
Then came my day. I was chosen to present to Dr. M on rounds. My patient was Cora, sixty years old, with COPD and Congestive Heart Failure, admitted with shortness of breath.
I questioned her every way I could, going back to her childhood days, looking for any every possible contributing factor to her severe COPD. I tried to anticipate any and all questions.
I examined her from top to bottom and then bottom to top. She had a barrel chest, an S3, mild JVD, expiratory wheezing and, I decided, a right ventricular heave.
I wasn’t really sure about the right ventricular heave. A definition follows:

“When there is pulmonary hypertension, the Right ventricle has to overwork, it has to pump against the increased pressure in the lungs. So if the heel of the hand is placed immediately lateral to the LEFT sternal border, one can feel the right ventricle being pushed anteriorly. The heel of the hand is lifted off the chest wall with each systole, and this is the heave.”

 I’m still not sure if I felt anything. But, I read it was associated with severe COPD and poor Cora certainly qualified. I convinced myself it was present. And, this was my chance to impress the Attending staff.
My moment came.
“Cora is a sixty year old female who was admitted to the hospital complaining of shortness of breath…two packs of cigarettes a day for forty years…distant breath sounds bilaterally…right ventricular heave…being evaluated for lung transplant.”
Silence.
I’ve done it. There speechless. I’m sure they’ve never been so dazzled by a med student.
“Dr. Gelber,” Dr. M began, “could you demonstrate how one examines a patient and determines the presence of a right ventricular heave?”
Wait, I know this.
“Good morning, again, Cora,” I greeted her as  I moved to her bedside. “I need to check your chest.”
“Whatever you need to do, Dr. G,” she turned to Dr. M. “Dr. G’s a good doctor. He spent an hour with me yesterday, just listening and checking me. It’s OK, go ahead and do what needs to be done.”
I put my hand alongside her sternum. Unfortunately, I put it on the right side and felt nothing.
“I’m not sure it’s there,” I murmured softly.
“It would probably help if you put your hand in the proper spot,” Dr. M. observed.
“Oh, yeah,” I stammered, even more softly.
I moved my hand to the proper spot and still felt nothing.
Dr. M. moved in. he put his hand along the left sternal border, watched her breathing and then turned to our group.
“Definitely no right ventricular heave,” he announced. “Maybe, Dr. Gelber, you should be a surgeon.”
A seed was sown.