Wednesday, November 11, 2015

Surgical Dilemma Part 1


“Come on, quickly, quickly, we think he’s dying,” a female voice called, the sense of urgency was unmistakable.
I tried to shake the sleep from my head as I pulled on some scrubs and followed this stranger.
Who is dying and who is this stranger? How did she get into my house, past all the dogs without making any noise at all?
“None of us know what’s wrong, but we can tell he’s really sick. No one else would lift a finger for him. They just want him to die,” she explained, looking back at me while she strided towards the black Mercedes which was parked in front. My five dogs didn’t budge as we went by, like we weren’t even there.
“Where are we going?” I asked, naively.
Why do I feel like I’m in some sort of bad movie?
We rode in silence in the back seat. There was a dark partition between us and the driver. The pitch black, cloudy night only allowed me to see the silhouette of my escort which revealed a large hat and overcoat.
“We should be there in a couple of minutes. I think this could be the end for him. He’s survived other serious catastrophes, so many other illnesses and surgery, but,” she paused, seemingly holding back tears, “but, this time…this time I’m sure he’s too far gone.”
“Could you tell me who he is?” I wondered out loud.
“The boss, the ruler of everything, at least everything in this world. If you can’t save him it will be the end…the end of everything we’ve fought for all these years. There’s the garage. I think we’ve made it in time.”
The Boss? Who’s the boss? The President? The Pope? Springsteen?
We pulled into the black garage. A faint light illuminated an elevator door which is where we stopped.
“Get out here,” she requested/commanded.
The elevator doors opened and I stepped in, alone.
The doors closed with a faint whoosh and the elevator started its ascent. There was only faint light which illuminated blank walls; there were no marks to tell me what floor I was passing. Finally, I came to a stop and the doors opened.
Must have been forty or fifty floors judging by the time it took to stop.
A stark corridor with red lights on each side led to a double door. I assumed that was my destination as I walked past more blank walls.
I guess my patient will be on the other side of those doors. This is all too James Bondish.
The doors flew open as I approached and I entered a bright, white, warm room. And, there was my patient covered up to his neck by a white sheet.
Even from across the room I was struck by his rapid, shallow breathing. As I walked closer I saw hollow flushed cheeks and the eyes were slightly yellow.
This does not look good for “the boss.”
A nurse came into the room through a different door as I approached the bed.
“Hello, Dr…”
I looked up at the nurse, “Excuse me, do you know ‘the boss’s name?”
“Satan,” she answered with a smile on her face. “I’m sure you can see that he is very ill.”
“That’s for sure, Ms…”
“Miss Vargus. I’m Satan’s personal nurse. I’ve been with him for many, many years. In the past I’ve always been able to pull him through his many accidents and illnesses, but this time he needs a surgeon. He needs you, Doctor.”
Wait, did I hear her right?
“You did say Satan, as in Lucipher, the Devil, Father of all Lies?”
“Yes, you heard correctly.”
“Why should the Devil need a surgeon? Isn’t he immortal, a fallen angel?”
“Yes, but his ‘physiology’ is not what you think. And, don’t believe everything you read. He has suffered so much. If you look from his perspective everything that he is accused of being and doing can be justified.”
Sounds like someone trying to convince themselves.
“If I refuse to be ‘Satan’s’ surgeon? What happens? Is it one of those if he dies, you die scenarios?”
“Please, just don’t think about that. Now, take this and these: his chart and the most recent labs and a CT Scan of his chest, abdomen and pelvis. Please hurry; he may not have much time.”
“You may be right about that. He doesn’t look too good. Do you have any monitors here?”
“Of course. I’ll hook him up while you look through his chart. These are his last vital signs.”
110/60, 110, 28, 37.9. Normal Saline hanging. OK, Satan, let’s see what you’ve been up to.
The chart was voluminous. There were entries written in Greek, others in Latin, and still others that I didn’t recognize. Miss Vargus must have seen the perplexed look on my face.
“I’m sorry,” she said, “start with this one. Everything from the beginning is translated into English.”
She pulled out a blue chart from the middle of the stack and handed it to me.
“The blue charts are the complete record in English. Also, if you want to save some time, the last chart is a summary. Dates, diagnoses, medications and procedures are tabulated. It might be quicker for you to start there. You’ll also find that each entry in the summary is cross referenced to the more detailed notes.”
‘Very efficient,” I mumbled as I opened this summary chart. I murmured under my breath, “You’d think, in these modern times, it would all be on a computer disc somewhere.”
“I’m working on that,” she called out, letting me know that even my whispered unintelligible comments did not go unnoticed.
Better be very careful.
I started at the beginning:
May 23, 2300 BC: URI, resolved spontaneously
April 11, 1302 BC: lacerated left arm from fall from chariot, healed over 4 weeks by secondary intention.
June 6, 998 BC: suffered food poisoning while in the house of Ahab, severe diarrhea for 4 days, recovered completely.
I glanced through a couple of thousand years of minor ailments and injuries, but, starting in the 1890’s, something changed. The illness became more severe, the injuries worse and both were more frequent. Instead of the rare URI every fifty years or a sprained ankle once a decade, now there were bouts of pneumonia, GI bleeding, debilitating back pain and more.
I guess our modern world does not agree with Mr. Satan.
I opened up the full chart and perused the most recent notes.
“UGI bleeding secondary to esophageal varices.”
“Drinks a quart of whiskey a day.”
“Previous stent in LAD and right coronary.”
“Poorly controlled diabetes.”
The notes were all signed with an “X.”
There was another chart with the results of his most recent lab, each test was done within the last two days.
WBC 27.4
H/H 9.2/27.7
Na+ 135
K+ 4.4
Cl- 109
HCO3- 19
T. Bili 7.6
ALT 205
AST 320
Alk. Phos 887
BUN 38
Cr 2.4
CT Abdomen and Pelvis: Bilateral Pleural Effusions, Cardiomegaly, Dilated Bile Ducts, Three cm mass in the head of the pancreas or distal bile duct.
Let me look at these images
“Portal vein is patent and appears uninvolved by the mass, the rest of the pancreas looks normal, no obvious mass in the liver or enlarged nodes,” I said softly out loud.
“That’s why you’re here, Miss Vargus interjected. “Satan needs a Whipple. And, for whatever reason, your name kept coming up as the surgeon to do it.”
At first I felt a bit flattered. Out of all the surgeons in the world, all the academic All Stars and hot shots, Satan or his manager wanted me?
Then the indignation started to rise.
“You want me to save the life of the individual who has orchestrated all the evil and woe that has ever been in this world? Really? And, if I refuse?”
“We’ll pay you well. You won’t ever have another care in the world. All your debts wiped clean, your two kid’s college paid for and we promise to take care of you forever,” Miss Vargus explained.
“I don’t know, I just don’t know. Oh, by the way, who is this Dr. X. who has been signing these notes?”
“His personal physician. I’ve never met him, actually. He insisted on complete anonymity. He would visit him here or at one of the other locations. He never let me or anyone else learn his identity. Only the boss knows and, as you can see, he is not in any condition to tell you, at least not at the moment.”
“So, let me see if I I have the complete picture. Satan, the Satan, as in the serpent in the Garden of Eden, Job’s tormenter, the fallen angel, and the author of all that is evil in this world lies dying in the next room. He needs major surgery or he will surely perish. For some inexplicable reason you and your cohorts have chosen me to perform this operation. If all goes smoothly and he recovers he will be free to wreak havoc on humanity for the next ten or hundred or thousand years. But, if I refuse and you don’t kidnap some other poor surgeon, he will die and evil will die with him?”
“That is one perspective. But is he really evil? And, even if all that is evil has come from him and will continue to originate from him, can you in all good conscience, let a man die. Didn’t you take an oath? And, although I’m being selfish, there’s me. If he dies I go with him. I’ve been with him for so many years; he has kept me young, kept me alive. If he becomes dust and blows away with the wind, I go with him.”
“And his minions, his demons?” I wondered out loud.
“I only know what will happen to me.”
“I need some time to think this through. Give me a few minutes.”
“Very well,” she answered, “but I’m going to try to be positive and begin to get him ready for surgery.”
I sat on the lone chair and closed my eyes.
This presents quite the ethical problem. Let him die? Maybe, and I’m really not sure, maybe the world will be a far better place. Or, is it true that evil is so ingrained in this world that nothing will change. War, murder, hatred, greed and everything else will just go on.
On the other hand, suppose I do the surgery, cure him of his cancer. Could I go on? How could I live with myself knowing that I had the chance to eliminate the source of all evil. If I let him go, wouldn’t his demise bring humanity back to a semblance of Paradise?
What if I do the surgery and he dies anyway? Then what?Will his demons look for revenge? Or, would they celebrate? Suppose his demise creates a massive vacuum in the realm of evil? Would one of his demons rise up to fill it? And, maybe the world will suffer even more.
What to do? What to do? Maybe if I go in to look at him I’ll find some sort of clue; maybe God will guide me. What would my old chairman do? One thing I do know: Operating on Satan definitely does not fall into any “evidence based medicine” that I’ve ever heard of, nor do I  remember any chapter in “Schwartz” called “What to do if Satan needs surgery.
Life and death decisions are one thing, but life and death for all of mankind?”
I opened the door and went into the next room. I was greeted by the steady beeps of the monitors.
“Satan,” I began, “I’m Dr. __, a surgeon. They’ve asked me to come to see you, to perform an operation. The operation you need is called a pancreatoduodenectomy, also called a Whipple. It’s a big surgery, but it really is your only chance for survival. Do you want to have the surgery?”
He did not answer, but he opened his eyes and stared up at me with a  look of hope and fear. He grabbed my hand and gave a light squeeze and then his eyes rolled back in his head and his body convulsed in a spasm of pain. He calmed down after a minute and stared into my eyes again. This time I saw only fear.
Ok, I’ll do the surgery.
“Let’s go ahead and put him to sleep,” I ordered. “Did you happen to steal an Anesthesiologist?”
“Don’t worry, everything’s taken care of,” Miss Vargus replied. “The OR is in the next room. You relax for a few minutes while we put him to sleep.”
Relax? I don’t think so.
The truth was that I never “relaxed” before a big operation. Surgeries like Whipples or removing large tumors from the abdomen required planning, time to think about each possibility, the anatomy and potential pitfalls. Unfortunately, I wasn’t given the luxury of time to plan for Satan. I faced a very sick patient with a very complicated problem.
“We’re ready, doctor,” Miss Vargus reported interrupting all the worries which were brewing inside my head.
The operating room was certainly one for the ages. Bright light and all the latest equipment greeted me. Satan was prepped and draped, his head disappeared behind the drapes to an unseen Anesthesiologist. Vargus was circulating nurse, while two gowned and gloved assistants stood by to help.
I washed my hands, stepped into my gown, donned my size 8 white gloves and we were off.
I looked at Satan’s exposed abdomen and the OR lights followed my eyes.
Amazing lights.
“Scalpel,” I began.
The knife was slapped into my hand and I started with my usual chevron incision.
Lots of big veins. I hope Satan’s not cirrhotic.
Despite the big veins I entered the peritoneal cavity with little fuss. The liver was discolored by Satan’s jaundice, but not cirrhotic, there was no fluid, no signs that the tumor sitting in his pancreas or bile duct had spread.
You’re going to make this easy for me, Satan?
Indeed, so far it was shaping up as a very straightforward surgery. My initial exploration did not find anything that would preclude me from doing the necessary surgery. There was a definite mass in the pancreas and the common bile duct was enlarged, but nothing else appeared out of the ordinary or pathologic.
Satan, as a matter of fact, had very little fat. The structures stared out at me like pages in an anatomy book. I started my dissection, dividing the attachments to the second part of the duodenum. I was now able to pick up the entire duodenum and the head of the pancreas all the way back to the aorta.
But, as I dissected, a vision popped into my head. The serpent in the Garden of Eden, tempting Adam and Eve, their Fall and the exile from Eden. I saw Satan laughing. I hated what he did to them and I hated him. I stopped my work and shook my head, as if I was trying to rid my brain of cobwebs fouling its synapses.
“Is everything OK, doctor?” I heard Vargus ask.
“Yes,” I mumbled and the image faded away.
I still can do it. Maybe an “accidental” laceration to the portal vein, or a nick in the bowel. The world will be a better place.
I went back to concentrating on the surgery. It was time to begin the part of the operation which required the greatest care and judgment. I opened the peritoneum over the bile duct and began to dissect around the duct, freeing the hepatic artery in the process. I exposed the artery and followed it until I saw branches, which were the gastroduodenal artery and the right gastric artery which I dissected free.
As I worked, a new vision appeared. I saw Job in his suffering, sitting in a pit, his body covered with sores, a product of Satan’s “largesse.” Then I saw Jesus and Satan arguing in the wilderness, and then there was Jesus being nailed to the cross. I even turned my head to avoid the splatter as seven inch spikes pierced his hands and feet.
Horrible, horrible. Do it, do it now. Nothing will happen to you. You’ll probably become famous. Just a quick slip of the hand and he’ll be gone in five minutes.
But, I couldn’t. I guess it was too many years of “do no harm,” too many surgeries spent hoping against hope to snap another dying soul from death. But, now my patient was the author of death? It would be right to eliminate death.
Is it murder to kill a murderer?
 I kept on working, gently retracting and teasing the common bile duct, separating it from the portal vein.
“Hold the retractor this way, Mephistopheles,” I said to one of my silent assistants, moving his hand to the right.
“Or is it Beelzebub, Whoever you are, I need to see what’s behind the duct. Afterall, you don’t want me to make a hole in the portal vein, do you?”
I glanced across the table and, I swear, there was the faint red glow of anger filling my assistant’s eyes.
Now’s the time. No one would ever question you. Just say the vein was stuck to the bile duct and it tore. It happens all the time. Yes it happens…to others…but never to me.
 A bit more dissection and the bile duct was completely free. I encircled it with a vessel loop. The anterior surface of the portal vein was now exposed as I began to dissect between this vein and the neck of the pancreas. The pancreas easily lifted off the vein. Everything of importance had been dissected free. It was time to make a commitment. First, the gastroduodenal artery was ligated and divided. Next, the bile duct was transected. Pus and bile poured out from the obstructed duct.
I guess that’s why he was so sick. Ascending Cholangitis. He should be much better after the surgery, if he doesn’t die of sepsis.
Next came the duodenum, just beyond the pylorus, I fired the GIA stapler. Finally the neck of the pancreas was divided. I didn’t even have to ask as sutures of 3-0 Prolene were popped into my hand to ligate the bleeding vessels which ran along the pancreas. I took care not to ligate the pancreatic duct.
That would be far too obvious. Now is the time, just a little slip while dividing all the branches coming into the portal and superior mesenteric vein. Don’t be a wimp. Just do it. Do it now…do it…
Just do it. A common saying. I don’t think Nike meant commit murder.
I can’t…can’t do it, not that.
There I was, staring at the portal and superior mesenteric veins. I’d reached the part of the operation where the pancreas has to be separated from these venous structures, requiring dissection and ligation of each little (and sometimes not so little) vein which drained from the head of the pancreas into these very substantial venous structures.
I started on the end closest to the liver and carefully and gently dissected each little branch, then clipped and divided each one. As I worked around one of the larger vessels the operative field suddenly was filled with dark blood. My surgical instincts told me to put my finger over the hole, but the flow continued.
“Suction,” I called out and one of the assistants thrust the suction device into the wound.
“Lap, another lap, sponge stick,” were my next commands. Each appeared in my hand and I packed the area and held pressure, buying time while I contemplated my next step.
What a fool you are, that could have been his end and you didn’t even plan it.
“No, no,” I spoke loudly.
“It’s Ok, Dr., you’ll get it under control,” Vargus reassured.
I knew that I would. I’d faced far worse situations without turning a hair more times than I cared to remember.
After a few minutes I removed the packs. The bleeding had slowed to a slow trickle and I was able to repair the portal vein with a single Prolene suture.
Should be smooth sailing from here.
I began the last parts of the resection: dividing the proximal jejunum and freeing it from the Ligament of Treitz so that it could be delivered into the lesser sac and then I started dividing the short mesenteric vessels which supplied the duodenum and pancreas using my trusty Ligasure device.
As I worked, new visions started to invade my mind: thousands upon thousands of innocent men, women and children dying of plague, slaves beaten and tortured by their masters, boys and girls, some still babies, horribly maimed and tortured by “adults,” Jews in concentration camps starved, beaten, gassed and then burned and other, more hideous sights I can’t even whisper. And, each ghastly vision had one common element, Satan, my patient, standing by, smiling, laughing, exhorting his human pawns to even more hideous acts.
What kind of monster am I saving? Can I be responsible? Look, there’s a big artery right here, bigger than usual. Just cut it, it’s too big for the Ligasure. You can just say that the Ligasure didn’t work properly. No one could ever know.
I looked up at the head of the table, saw the tube coming out of Satan’s mouth, his black hair peeking out from beneath the bouffant cap, heard the monotony of the monitors, the steady rhythm of the ventilator. And, then a new image appeared. It was the Warsaw ghetto. I saw a little girl, dressed in rags, running and then a loud noise and she was falling; falling in slow motion, blood and brain filling the air as the bullet pierced her skull; and then she just lay in the street, blood pouring from her head as uniformed soldiers walked by, laughing.
Satan, you don’t deserve to live.
I closed my eyes for a moment before I went back to work. I couldn’t do it. I finished the resection and threw the specimen in the bucket.
“OK, let’s put Mr. Satan back together,” I announced to my silent assistants.
I brought the small bowel and pancreas together and ducked the end of the pancreas into the side of the jejunum.  Then I connected the end of the common bile duct to the side of the small bowel and, finally, the duodenum was anastamosed to the small bowel, completing a Billroth II reconstruction. I checked each anastomosis, looked for bleeding, washed Satan out, put in some drains and closed him up.
I don’t deserve to live.
“You do fine work, doctor,” Ms. Vargus declared as I ripped off my gown. “You deserve to be rewarded.”
“I’m tired,” I declared. I looked at my watch and my blood stained scrubs. “Five thirty. I need to be at work in an hour. Just take me home.”
She gazed at me with a look I could not comprehend. Fear? Envy? Longing?  By rote I sat down to write orders.
“That task has been taken care of and there is no need for you to dictate an operative note. There will be no record of this procedure and no one will ever know of your great service. We will take you home now. I wish you well. And, thank you.”
“What about his postoperative care?” I protested. “I am not in the habit of performing major surgery and then leaving my patients to fend for themselves.”
“Don’t worry. He will recover completely. I promise.”
Somehow, she knew that he was cured. Sadly, so did I.
I felt a bit lightheaded and then I must have fainted. The next thing I remember is waking up in my bed with the buzz of the alarm clock at six am.
A horrible nightmare?
But, it was all too real. I was lying on the bed, still wearing my bloody scrubs. My mind was filled with the visions; disease, suffering, death. I couldn’t get the images out of my head. Satan’s cold, clammy hand grasping my wrist. I stared at my arm and could almost see his fingers. And, Vargus, that final look, what did it mean.
I couldn’t stay in bed. I crawled out and into the shower. I had never felt so dirty, even after wading through septic abdomen’s elbow deep in pus and stool I’d never felt like this. I scrubbed and scrubbed, but the taint clung to me. I saw a flash of light, followed by the boom of thunder. Jumping from the shower I ran outside and stood naked in the rain.
God, please, make me clean.
I stretched out my arms, and stared up into the heavens as the rain poured down on me. Ten minutes later the rain stopped and I saw the red aura of the sunrise in the east. I went back inside, dressed and went to work. Before I left I threw the soiled scrubs into the fireplace and burned them.
The nightmare was far from over.

Look for Part 2 in a few weeks. Comments about what you would do in this situation are welcome.

Sunday, October 18, 2015

9 1/2 Weeks


I met Alice almost by accident. Sunday morning rounds were nearly completed when I passed Dr. T. in the hallway. We exchanged pleasantries and then walked on in opposite directions. But, seemingly as an afterthought, he called out.
“”Do you think you can go by and see a patient for me? Her name is Alice. She’s in room 402. She’s in the hospital with constipation and she’s pretty distended. I plan a colonoscopy tomorrow, but, maybe, just give her a quick look. She had a CT that just showed constipation.”
“Sure,” I replied, “I’m going in that direction anyway.”
Alice was petite, weighing in at 98 pounds and she certainly was distended, almost like she was about to deliver twins. She was 46, had always had “bowel trouble,” had previous back surgery and was on chronic pain medication, taking Percocet several times a day. She had not had previous abdominal surgery.
“Does your abdomen hurt?” I began.
“All over, but the Dilaudid helps,” she replied.
“When did the pain start?”
“About three weeks ago, but it got worse three days ago.”
“When’s the last time you had a bowel movement?”
“Nine weeks before I came into the hospital.”
I had to stop for a moment to completely absorb this statement.
I think this is a record.
“Did you say nine weeks?” I asked again.
“Yes, nine weeks.”
“…and you’ve been here three days, so it’s been nine and half weeks since you had a BM? Is that unusual for you?”
“Normally I go every three or four days. I did start to panic after a week, but I didn’t know what to do.”
“Are you able to pass gas?”
“I’m not sure.”
“Let me check your abdomen.”
She was extremely distended and had diffuse tenderness, and some signs of peritonitis, particularly tenderness to light percussion on the right side of her abdomen.
“I’m going to look at your CAT Scan and then I’ll be back.”
So much for getting rounds done at a reasonable time.
The CT Scan done the day before revealed just what one would expect in patient who had been constipated for nine and half weeks. The colon was dilated, filled with stool, but not much air. The cecum, the first part measured ten centimeters, approaching the diameter where blowout becomes a concern. The dilated colon stopped in the mid sigmoid colon, which is just above the rectum. There was no definite tumor or mass, but there was a definite transition point from dilated to collapsed colon.
I checked her labs next. Her white Blood Cell Count had been slightly elevated at 12,000 the day before, but today it had jumped up to 35,000. Her bicarbonate level was 14, which is low, normal being around 25. Low Bicarbonate suggests metabolic acidosis, a sign of severe metabolic derangement and sepsis.

Taking everything together there was no question. She needed surgery. She either had perforated her colon or she had dead or dying colon. Either way it was a life threatening surgical emergency.
Of course, Sunday is not the best day to get anything done quickly. There were a series of Orthopedic cases scheduled already.
“I need to do this lady soon,” I explained to the crew.
“It looks like you’re in luck. Dr. R. just cancelled his last two cases and we are finishing up with him now,” the OR nurse reported.
I explained my findings and concerns to Alice and her family, put her orders in the computer and waited for the OR crew.
Maybe just a colostomy will suffice. But, it would be better to eliminate the cause of the obstruction. Quick and simple will be best for her.
After about 25 minutes Alice was wheeled into OR room ten and was asleep a few minutes later.
A midline incision through the taut abdominal wall brought me into her abdomen which was filled with a few hundred cc’s of slightly cloudy yellowish fluid. I could see that the sigmoid colon was massively dilated, but it was not gangrenous. There was a faint, pungent odor.
Looks like I should be able to remove the offending portion of colon.
I could see where the colon transitioned to normal caliber just above the pelvis. I began to mobilize the colon by dividing the peritoneal attachments that tethered the sigmoid and left colon.
“Feels like there’s a hard mass in the colon causing the obstruction,” I observed out loud to no one in particular, my assistant nodding her head,
 I should be able to get this colon free and then…
Before I could finish this thought the dam busted and I was suddenly up to my elbows in thick, liquid stool.
“Shit…” Literally.
“Suction, lap, more laps, more suction.”
The suction became plugged with stool. I squeezed the colon closed with my hand and it fell apart. Like The Blob from the 1950’s or the river of slime from “Ghostbusters” liquid stool took over.
“I need an intestinal clamp, something atraumatic,” I said loudly.
The circulator scurried out of the room and came back with the GI instruments. In the meantime I had managed to isolate the source, rather the sources of the river of stool and began to get at least a semblance of control.
          The evil culprit rears its ugly head.
“There’s a big rock of poop causing the obstruction,” I noted.
Indeed, this “fecaloma” had completely blocked the sigmoid colon and eroded into the wall of the bowel, setting a trap for me as I mobilized the colon. As soon as the colon was free it exploded, releasing its noxious contents. The resultant inundation left poop everywhere, on every loop of bowel and filled the pelvis.
With the proper intestinal clamp in hand I stemmed the flow and went on with the resection. I had to make two passes with the GIA to divided the dilated bowel while there was no difficulty dividing the distal colon, stapling it closed with the RL60 stapler.
Home free.
I finished resecting the sigmoid colon and examined it on a separate table.
This colon is as strong as soggy Kleenex.
“Uh, Dr. Gelber, I think there’s a problem here.”
Liquid stool was filling up the abdomen again.
I hurried back to the cesspool which was Alice’s open belly and valiantly struggled to stem the flow again. The staples had not held the friable colon together. Once again, we went to work, sponging and suctioning until I could see enough to mobilize the colon away from its usual position on the left side of the abdomen, find the hole and carefully put a clamp across it.
This time it held, at least enough to allow me to get my bearings and assess the situation in a calmer, more orderly manner. I made a closer inspection of the remaining bowel.
The right side of the colon didn’t look very good either. Muscle fibers in the cecum were split under the tension caused by massive dilation, the ascending colon had patches of frank gangrene as did the splenic flexure.
It all needs to come out.
Back to work. I began by dividing the attachments to the cecum and was then able to liberate the hepatic flexure with minimal fuss and the remainder of the colon followed until everything was free. I zipped through the mesentery with the Ligasure and before long the colon was resting in a large basin on the back table. At this point we all changed gowns and gloves and tried to put banish the pungent odor from our nostrils. Even with benzoin (a fragrant compound often used in surgery) on our masks and repeated washing of hands I knew that the fine aroma of stool and dead bowel would linger with me for the rest of the day.
This nasty beast has been far too much trouble. Time to finish this case.
We spent the next twenty minutes washing, washing and more washing. Liter upon liter of warm saline was poured, sprayed, percolated and pumped into every nook and cranny of her abdomen. We squirted irrigation fluid into the pelvis, above the liver, around the spleen and between every loop of bowel until the fluid came out as clean as it went in.
Finally, I brought the end of the small bowel out as an ileostomy, took one more look around her belly and closed her up. Ensconced safely in the ICU, I washed my hands one more time, wrote orders, dictated the op note and, last of all, told her family the sordid tale of her surgery.
I called Alice’s Attending physician and consulted one of the Pulmonary docs, checked on Alice one more time and finally left the hospital for the day.
Alice was kept on the ventilator, she was very slow to wake up from anesthesia and her blood pressure hovered in the 80’s; occasionally dipping into the 70’s. A massive volume of IV fluid and support with Levophed and Vasopressin were necessary to maintain an acceptable blood pressure. (These two medications help maintain vascular tone, which helps maintain blood pressure in patients with septic shock). Her kidneys started to shut down, but timely adjustment of her fluids and medications by a Renal consultant turned this around.
The following day she looked a little better, more awake, good urine output, but still requiring pressor support with Levophed and Vasopressin. She continued to smolder along over the next 48 hours, neither improving nor deteriorating. I became a little concerned about her abdomen at this time as it became more distended and the ileostomy stoma looked dark purple instead of pink. Her lactic acid level rose to a very high 14, a sign of worsening acidosis, which indicated seriously poor perfusion of something and worsening sepsis. Although she maintained adequate blood pressure and kidney function, it became clear that something was amiss or amuck or afoul.
Alice was taken back to surgery.
The previous wound was opened and a couple of liters of clear fluid was drained.
That explains the abdominal distention.
In the lower abdomen there was some cloudy, foul smelling fluid. As I gently freed up the small bowel and delivered it out of the abdomen I discovered the new source of Alice’s woes. The distal small bowel was dead, not completely, but patches had frank gangrene. I resected about 25 centimeters of terminal ileum and redid her ileostomy.
She also had a portion of abdominal wall which was dying and this also was excised. I put her back together as well as I could and delivered her to the ICU and hoped for the best.
The next twenty four hours brought hope as she required less support with the pressors. However, she didn’t wake up.
The following day came with new events which proved to be too much. She began to have cardiac arrhythmias, frequent Premature Ventricular Contractions (PVC’s) and runs of, Atrial flutter and Ventricular Tachycardia. The Cardiology consultant added his words of wisdom to the already exhaustive list of consultants.
“Acute MI,” he said with a solemn expression on his face. “Ejection fraction is only 30%,” he said shaking his head.
She’s not going to make it.
Alice continued along for a couple of more days, but she didn’t wake up, her kidney function gradually declined and her family wisely withdrew support, allowing her to pass away.
I wish I could report that timely surgery had rescued Alice. I don’t know how many similar patients I’ve taken care of, how many times I’ve told families “We’ve eliminated the source of infection; the perforation, the blockage, the gangrene, the abscess; now it’s time to heal.”
Very often it’s this healing phase which proves to be too much. Organ systems which have suffered the supreme shock of serious systemic infection are unable to recover and gradually shut down. The initial sepsis leads to what is called multi organ system dysfunction which progresses to multi organ failure which often leads to death.
After I finish operations such as Alice’s I’ve learned not to say: “Alice (or Andy or Mabel or anyone) will be better now.”
I’ve learned that the human body often does not suffer lightly intrusions by combinations of bile, blood, GI contents or urine mixed with microorganisms which thrive in such an environment. The body does its best to fight such invasions and may be successful. But, sometimes as the battle is fought and the war looks like it will be won, the body dies.
And, nine and a half week’s worth of poop is more than most of us could handle.

Tuesday, October 13, 2015



I have, on occasion, described the perfect surgical practice as one where one operates every day, performing a wide variety of cases, while never having any patients in the hospital. Perhaps this fantasy is a bit facetious. Boiled down it means that the surgeon gets to perform the most interesting part of surgery, that is the actual operation (unless it’s a vein stripping) while never having to deal with the more mundane and frustrating aspects of the surgical practice, such as dealing with a draining wound or impatiently waiting for the post op ileus to resolve.
There is one aspect of the surgical practice, even a perfect one, which is absolutely necessary: the office.
In the office new patients are seen for the first time, evaluated, examined, treatment options explained and discussed and decisions made. Patients recovering from surgery come to have their wounds checked and concerns addressed:
“When can I go back to work?”
“When can I drive?”
“What can I or can I not eat?”
“When can I start having sex?”
“Will this lump go away?”
“Is it supposed to be numb?”
“Do I have cancer?”
Each question is patiently answered, worries and fears are laid to rest, as the patients make their way down the path towards recovery.
Most clinic days are a predictable mix of patients who suffer from hernias, gallbladder disease, lumps, bumps and pockets of pus, with an intermittent spattering of thyroid conditions, gastrointestinal masses, hyperparathyroidism and other less common ailments.
There was a day however when my office patient was filled with a stream of colorful patients. I should have known something was up when I saw the name of the first patient:
Hazy Racy Autumn.
Unusual name…swollen groin…here I come, Hazy.
I knocked on the exam room door and went in.
“Ms. Autumn? I’m Dr. Gelber. What brings you in here today?” I began.
I’m not sure how to describe Hazy Racy Autumn. She was tall, taller than me and her height was accentuated by a tall furry hat perched upon long blonde hair. She looked to be the forty years she had reported on her history form. She had a long silken blue and pink housecoat on and fuzzy Winnie the Pooh house slippers on her feet.
“Racy, please,” she replied as I shook her hand.
“Ok, but what brings you in here?”
“Dr. N. said it was my nose; my limp nose.”
Her nose looks OK to me. Besides, I’m not much of an ENT doctor. Limp nose, swollen groin…lymph nodes.
“You mean your lymph nodes, I think,” I explained.
“That’s right. Lymph nodes. Under my arm and in my groin. There swollen according to Dr. N.”
“Is that why you went to see him?”
“Three months ago. He gave me antibiotics and then more antibiotics, but the swelling is still there.”
We went through the rest of her unremarkable medical history and then it came time for me to examine her. I’d already noticed that her submaxillary glands looked enlarged, giving he a little bit of a chipmunk look.
“Put this on so I can examine you,” I requested, handing her one of our cheap paper gowns.
“Oh, I don’t need that,” she decided as she jumped up on the exam table and opened her housecoat, which revealed Hazy Racy Autumn and nothing else.
She had neatly trimmed her pubic hair into a blonde replication of Adolph Hitler’s mustache, the remainder was clean and smooth.
I saw Miss Autumn in the early 1990’s, a time when the current custom of clean shaven pubic areas was not in vogue. The only women who regularly shaved “down there” were strippers and hookers. Perhaps I was presumptuous to assume that Ms. Autumn was in one of these lines of work. My inquiries as to what she did for a living were answered by a vague, “I work from home” response.
I proceeded with my exam, noting multiple enlarged nodes in each groin as well as each axilla, all 2-3 centimeters in size.
“I think we should take out one of these lymph nodes. That’s what Dr. N. wants me to do and I agree with him,” I explained.
“Is it something bad, Doctor?”
“Well, I worry that it could be lymphoma, a cancer of the lymph nodes, but there are other less serious possibilities. The simplest thing would be to biopsy one of the groin nodes. Do you want to have that done?” I asked.
“Yes, yes, of course,” she replied with a shrug.
I finished my exam and explained the procedure and Hazy Racy Autumn was scheduled for a lymph node excision two days hence.
A fine start to the afternoon. What’s next? J.F. Romanov, lump on foot and buttock.
I picked up the chart, knocked and went into the next exam room.
“Ms Romanov?” I asked, “I’m Dr. Gelber, what can I do for you today?”
“Hello, Doctor,” she answered with a bit of an accent, holding out her hand. “I am glad to meet you.”
She was stocky, didn’t wear any makeup, and had dark brown hair with wisps of gray which was tied back in a ponytail.
“I have a lump on my, what do you call it, butt and one on my foot. They do not pain.”
                   “How long have they been there?”
“About two months.”
The rest of her history was unremarkable.
“Ok, put this gown on and I’ll be back in a minute to examine you.”
I left her alone and sat at my desk and wrote out her history while she changed. When I’d finished I knocked on the exam room door and went in, with my Medical assistant, as always, in tow.
Ms. Romanov sat on the exam table, completely naked. My assistant handed her one of our paper gowns, which my patient loosely placed across her waist.
“Where are the lumps which you feel?”
“You Americans are always so ‘funny’ about nakedness,” she observed. “Let me show you what I can do.”  
She shifted her legs up and down  before deftly bringing each leg up and placed it behind her head as the paper gown floated to the floor; a remarkable demonstration of her flexibility.
“You must have been in the ballet to be so flexible,” I commented, doing my best to act nonchalantly.
“Ukrainian circus,” she answered. “But, you see the lump good, no?”
As she said those words I looked at her right buttock and, sure enough, her exhibition did demonstrate the outline of a mass in the right buttock, about 6 cm in diameter, mobile, discreet, almost certainly a lipoma.
“And, you see my foot, the left one?” she added.
I palpated the left foot and felt another mass on the lateral aspect, about 3 cm in diameter, likely a fibroma.
“Anything else?” I wondered out loud, referring to the physical findings. Ms. Romanov, however, interpreted these words differently.
She pulled her legs from behind her head and jumped on the floor and executed a handstand and began moving her legs back and forth in a scissors-like manner.
“I’m sorry, Ms. Romanov, I meant, do you have any other lumps that you are concerned about?”
She went back to sitting on the exam table and answered in the negative.
She related that she wanted to have the lumps removed and we set a date for her surgery. I left her to get dressed and went on to the next room.
Next was Karen Smythe, 58, breast cancer. She came with a mammogram showing a suspicious mass in her right breast and biopsy which revealed infiltrating duct cell carcinoma, the most common type of breast cancer. The mass appeared to be about 2.5 centimeters on the mammogram and there was an enlarged lymph node, also apparent on the mammogram.
Not good..
“Good morning, Ms. Smythe, I’m Dr. Gelber. What brings you in here today?”
“Mrs. Smythe, my husband is Malcolm Smythe. He’s on City Council. Dr. Z sent me. She said there’s a lump in my breast,” she answered, her voice quiet, but steady.
“She’s right, there is a lump and I see they did a biopsy. Did Dr. Z tell you the results?”
“No, she just told me to come here.”
Great, I get to tell this poor lady, whom I’ve just met for the first time, that she has breast cancer. Here goes.
“Well, Mrs. Smythe, I’ve looked through all the reports and the biopsy show that the lump in your breast is cancer.”
“It is?”
“I’m afraid yes, it is.”
Her calm quiet demeanor started to change as tears welled up in her eyes. She did her best to compose herself as I handed her a Kleenex.
“Am I going to die, can it be treated?”
“It certainly can be treated,” I replied, “there are far more women living and walking around with breast cancer than die from it. Let me ask you a few questions.”
I took some more history and then left the room while she changed into an exam gown.
My heart sank a little when I looked at her breast. There was some retraction of the skin and dimpling over the area of the tumor. The mass was about three centimeters and there was a hard, but mobile mass in the right axilla.
Stage III at least. She’ll need chemo before any surgery.
“Mrs. Smythe, I think it might be best to have you see one of the cancer doctors, an Oncologist, before we think about doing surgery. Let me call one that’s on your insurance. I’ll be back in a few minutes.”
I called Dr. S and arranged for her to be seen that afternoon. We sent Mrs. Smythe away with some literature on breast cancer, instructions to call with any questions or concerns, and a box of tissues.
Something isn’t right when a patient has to first hear that he or she has cancer, particularly breast cancer, from a complete stranger, even if that stranger is a doctor.
I zipped through the next five patients who were all post op from hernia or gallbladder surgery.
“Eating Ok?”
“Any fever?”
“Bowels working?”
I reached my last patient, Billie Jean Muller, 59, abdominal pain.
“Good morning, Ms. Muller, I’m Dr. Gelber. What brings you in here today?”
I’m not very creative with my introductions.
“Dr. M sent me. I’ve been having pain in my abdomen for a while.”
“How long is a ‘while’?”
“Ever since my hysterectomy.”
“And, when was that?”
“I wrote it down on the paper.”
‘I know, but I like to hear what you have to say. I find it helpful when trying to figure out what’s wrong; helps me do the right thing or order the right tests.”
This could take a while.
“Tests? I’ve already had every test. I’ve had CAT Scans, Ultrasounds, EGD, colonoscopy, HIDA Scan, and MRI’s. My gallbladder is gone, along with my uterus.”
I glanced at her history form.
“Your hysterectomy was eight years ago. Did the pain start immediately afterwards? Or a few weeks or months later.”

“I think it was immediately, or, maybe a month or two later. Then again, maybe I had the pain before that surgery.”
I need a different approach.
“Has the pain become worse recently? Why did you decide to come today?”
“Dr. M. told me you could help me. I guess he’s tired of seeing me.”
“Where is the pain the worst? Upper abdomen, around your belly button or lower down?”
“Lower down, I guess. It’s really bad when have to go to the bathroom. I have to push on the left side of my old hysterectomy scar or else it doubles me over.”
Really? Could it be something so simple?
Let me have you put this gown on so I can examine you, Ms. Muller.”
I gave her a few minutes to change.
“Let me check you standing up first. Can you cough?”
She gave a weak cough.
“A bit harder, if you can?”
Sure enough, there was a definite bulge along with the typical findings of a hernia. I finished my exam, not finding any other abnormality.
“I think you have a hernia, that is, I’m sure you have a hernia at the end of you hysterectomy wound. You will definitely benefit from having it fixed.”
I explained the procedure and surgery was scheduled.
Hazy Racy Autumn had an inguinal node excised which was benign, a reactive node. The enlarged nodes eventually were determined to be caused by Epstein Barr Virus, a benign condition.
J. F. Romanov had two lipomas removed. I did not get any more demonstrations of acrobatic ability.
Karen Smythe was treated with neoadjuvant chemotherapy which shrank her tumor to almost nothing. She underwent a lumpectomy and axillary node dissection months later and is still with us today.
Billie Jean Muller had an uneventful repair of her Spigelian Hernia. She did feel better, but still complained of some pain. She saw a Pain Management specialist who helped her get the pain under control.
All in an afternoon’s work.