Sunday, September 7, 2014
It started at 4:30 pm. Another night on call, only today I was covering two busy emergency rooms. It was like that, back in those days, years ago. Our group provided emergency care at four different hospitals and sometimes we covered all of them. Tonight it was two. I wasn’t really concerned. There was another surgeon on back-up call and in all the years I’d been in practice there had only been a single episode of simultaneous life threatening emergencies which would have required me to be in two different places at the same time. Luckily, the back-up surgeon came to the rescue in that instance.
But, back to today. This first call from hospital A was about Lester, 55 years old with abdominal pain for two days. The pain started in the mid abdomen and then moved to the right lower quadrant. His white blood cell count was sixteen thousand and CT Scan of the abdomen and pelvis revealed acute appendicitis.
A no brainer.
I called the OR and told them to crank up the laparoscope as I made my way to the ER to see Lester. He was the manager of a well known used car dealership. His story and exam were textbook, he had an IV, antibiotics were flowing and the OR crew was ready to take him away.
I commented on the steady beeping of the OR monitors as he drifted off to sleep. The surgery went off without a hitch as I encountered a straightforward inflamed appendix which I deftly liberated with my trusty Endo GIA stapler, popped into an endopouch and pulled it out in all of twelve minutes.
As I placed the last stitch my phone went off again. The ER from hospital B was calling. Dr. P was on the other end of the call.
“I’ve got a nine year old girl with belly pain for four days, temp is 102 and CT shows appendicitis, possibly with an abscess. Do you do kids?”
I answered in the affirmative.
“Does she look very sick?”
“A little flushed, but her heart rate is around a hundred, BP is OK.”
“Does she have diffuse tenderness or is it localized?”
“Seems to only in the right lower quadrant.”
“I think we can do her surgery there. I’ll call the OR and I’ll be there in a little bit,” I informed Dr. P.
I tucked Lester away in the Hospital A PACU and made the fifteen minute drive to Hospital B. It was now 6:15 pm.
Luisa was a skinny nine year old. She smiled at me when I walked in the ER room and winced when I lightly tapped on her RLQ. Her pain had started four days previously, she’d had nausea and vomited about ten times and also had diarrhea. Her primary care doctor had diagnosed her with gastroenteritis and prescribed Pedialyte and Bactrim. It’s pretty common for appendicitis to be misdiagnosed and present late in its clinical course. Conditions such as gastroenteritis are very common and, as we are taught, common things occur commonly and gastroenteritis is more common than appendicitis.
She was wheeled off to surgery at 7:12.
She was asleep by 7:35. I put the scope in through her belly button and was greeted by a mass of inflamed bowel and omentum which was oozing pus. It wasn’t very attractive and it presented a bit of a challenge. Luisa was not going to be a twelve minute appendectomy.
I started to gingerly dissect. First the omentum. I could see the plane and gently pulled on the tissue. The “watchdog” peeled away so that I could now see a fat, grayish black appendix nesting against the small bowel, which was my next target. Carefully, carefully I separated the appendix from the small bowel. A well of brownish pus poured out and a large brown “fecalith” rolled down.
“Pac Man,” I requested.
The surgical tech rummaged around on her back table and produced the desired instrument, a device which opens and closes its jaws just like the creatures which race around the maze in the Pac Man video game. I’m not sure what this instrument’s proper name is.
I scooped up the fecalith and whisked it away, deposited it in the basin which was awaiting the offending (and offensive) appendix. Back to the task at hand, I finally had all the bowel and omentum away from the appendix and was able to proceed with what was now a “routine” appendectomy. Once the appendix gone, the final task was irrigating, washing, irrigating and more washing until the peritoneum was clean.
With the final steri placed my phone chimed again. Hospital A ER was calling.
“This is Dr. T. I’ve got a 22 year old male with two days of right lower quadrant abdominal pain, White blood count 22,000, CT shows appendicitis.”
Back I went to hospital A. It was now 8:52.
When I arrived in the ER at Hospital A I met Esteban. He had been having pain for about a day and half. He was lying motionless on the stretcher, his face was slightly flushed. He was thin with a black moustache and he only spoke Spanish.
“Tiene dolor en el estomago?” I asked reaching the limits of my Spanish.
“Cuando empezado el dolor?”
And so it went. I can take a reasonable history in Spanish as long as the patient’s symptoms are limited to the abdomen and their answers are limited to yes or no. Esteban reminded me of one of the rules I learned during residency:
If a young Latino male comes to the ER complaining of right lower quadrant abdominal pain you can schedule him for appendectomy without seeing him. You will make the proper diagnosis almost one hundred per cent of the time.
This was true because it was not considered “macho” to go to the doctor. In my experience, in the 1980’s, this rule held true. Esteban fell into this category, but he still had been evaluated with the requisite CT Scan which confirmed the obvious diagnosis of acute appendicitis.
He was in the OR by 9:45 and underwent a straightforward “lap appy,” which I finished just in time to get paged to the ER at hospital B.
“Mary Rogers, 59 years old, right lower abdominal pain for two days, White count is 12,000, CT shows a retrocecal appendicitis,” reported the familiar voice of Dr. M.
“Isn’t it early for you to call?” I asked Dr. M. “It’s usually two am when I get to hear your voice.”
“Be thankful you get an early start tonight,” she advised. “Oh and there may be another appendix brewing.”
“I’ll be there shortly,” I answered.
Luckily, the OR crew had not gone home yet. Mary was waiting in the OR holding area when I arrived. I did a quick history and physical and explained the surgery and they whisked her away to OR five. It was now 11:10.
The CT scan was one hundred per cent accurate in this case. Mary’s appendix was very retrocecal, which means it was hiding behind the Cecum (the first part of the colon which is where the appendix is attached to the colon), and behind the ascending colon, which is the next part of the colon.
I started by picking up the cecum and identifying the tenia coli, which are bands of muscular tissue in the wall of the colon. There are three tenia on the colon and they meet at the base of the appendix. Following these tenia coli allows the surgeon to find the appendix, which occasionally can be a difficult task. Using this technique I found the base of the appendix, but that was the only portion I could identify. The rest disappeared behind the colon, heading north towards the liver. In order to see what I needed to see I had to mobilize the right colon, which means divide the peritoneal attachments which keep the colon from flopping around.
This done I now could see the appendix, at least see where it was going. And so I began the tedious task of step by step clipping of the “mesoappendix” which contains the blood vessels going into the appendix. Normally I would take a stapling device and simply divide and staple this mesoappendix with one squeeze, but there was nothing easy about Mary.
Finally, the end was in sight as the inferior edge of the liver came into view. The appendix was inflamed over the distal half, not ruptured and it was finally completely free. Once it was out of the abdomen I measure it at eight inches in length, probably more than twice the norm.
No such luck. The phone went off again.
At least it was Hospital B again. Dr. M greeted me.
“Megan Bartlett is sixteen years old, right lower quadrant abdominal pain for eight hours, White Blood cell count is ten and her CT is normal. She is pretty tender, however.”
“OK, I’m still here. I’ll come take a look at her,” I replied.
Megan was there with two very worried parents, but it soon became obvious that the parents were no longer together and didn’t agree on much. Daddy wanted to take his little girl downtown to “World Famous Medical Center.” Mommy thought she could stay at Hospital B. I did my usual history and physical exam, reviewed the CT Scan and then sat down to talk to all the partied involved.
“Megan’s history and exam are strongly suggestive of appendicitis,” I began, “but the CT looks normal. She’s only been sick for eight hours and sometimes the CT won’t show any of the usual changes we see with appendicitis if her pain hasn’t been going on very long.”
I recommended she stay in the hospital to be examined later and if her pain and tenderness persisted then operate at that time. Mommy was in agreement, but Daddy was still skeptical. I left them alone for a few minutes to hash it out and, in the end, Mommy won out. Daddy was not there when I returned.
Megan was admitted to the Pediatric floor and I went home. It was two am.
I reevaluated Megan in the morning. She was still tender and subsequently underwent an uncomplicated appendectomy.
This night confirmed the old medical adage: “Common things occur commonly.”
Appendicitis is one of the most common maladies General Surgeons are called upon to treat. Most of the time this means surgery, although there have been recent efforts made to treat appendicitis nonoperatively with antibiotics. In the end, removal of this offending organ seems to be the best approach. Most patients with uncomplicated appendicitis are discharged within twenty four hours and are back to normal activity in a few days.
The advent of CT Scanning to evaluate possible appendicitis has made my life much easier. When I started in the surgery business (too many years ago) the diagnosis and treatment of appendicitis usually took three hours. Appendicitis was diagnosed based on history, physical exam and labs. I would drive to the hospital, do my H&P, then call the OR crew, wait for them to arrive and set up, do the surgery and then go home. Total time: three hours. Now, the ER physician presents the patient, tells me the CT Scan result, I call the OR crew from home, arrive just before the surgery, perform the operation and go home. Total time: one hour.
But, I still have to come and evaluate the patient in cases like Megan. Watchful waiting sometimes prevents unnecessary surgery. It is not unusual for the pain to fade away and the patient discharged without any surgical intervention. Often we never find out what caused the pain. Presumably it is a virus or some other self limiting condition.
Five appendectomies in twenty four hours is a bit unusual. Recently, I broke this record by doing seven laparoscopic appendectomies in a twenty four hour period. Maybe this disease is becoming more common. When I was in medical school Denis Burkitt, a durgeon who lived in Africa, famous for describing Burkitt’s Lymphoma, spoke at one of my classes. He said that appendicitis, among several other diseases like hemorrhoids and colon cancer, was almost never seen in Africa. He chalked it up to Americans being “constipated society,” one where the highly processed, low fiber diet caused these colonic maladies. I don’t know if he is correct. I do know that that appendicitis is very common and seems to becoming even more prevalent.
Patients will sometimes ask: “What is the purpose of the appendix?”
I answer: “It gives General Surgeons something to do when we are bored or need to make a car payment.”
Friday, August 22, 2014
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Sunday, August 3, 2014
I’ve been practicing surgery for more than twenty five years. Over these many years I’ve had innumerable interactions and encounters with patients, nurses, doctors and other health care professionals. Sometimes I’m left scratching my head in wonder and amazement. This is not always a good thing.
A few years ago Martha, a patient of one of my partners, called on a Sunday morning, which also happened to be July 4th. She had a colostomy created along with what’s called a mucus fistula following surgery for a colon perforation a few years before. A colostomy means that the colon (large intestine) was brought out to the skin level so that stool passes into a bag instead of taking its normal course to the rectum and out through the anus, a common practice when patients require emergency colon surgery. A mucus fistula means the other end of the intestinal tube is also brought out to the skin where a small amount of mucus will drain intermittently. Such mucus fistulas usually only require a light gauze dressing, not a complete stoma appliance.
Back to Martha. She was concerned because she was out of bags for her colostomy and she needed to change it and the medical equipment stores were closed. She gave me a brief rundown on her history and assured me that besides needing a new a new bag everything else was OK.
I gave some thought about what she should do. We don’t keep such appliances at our office, so I couldn’t help her directly and it was true that the medical supply shops were closed. All I could think to do was to send her to the hospital where one of the nurses could fix her up. I advised her to go to the ER and then I called and spoke with the head nurse in the ER, explaining the situation and asking if she could do the patient a favor and find her a colostomy bag to get her through the holiday weekend.
I didn’t give the matter a second thought, assuming the nurses would be able to accommodate the desperate patient without any fuss. But, I was wrong. Three hours later I get a call from the ER doctor informing me that Martha was there and he had just eyeballed her. Now he was asking me about my concerns. At first I didn’t remember her, but the lightbulb went off in my head and I told him:
“Oh, she just needs a new colostomy bag. She called me a few hours ago and I spoke to your head nurse about her.”
There was a long pause and then the ER doctor replied, “She has two colostomies and nothing is coming out of one.”
“Oh, that’s just a mucus fistula. I wouldn’t expect her to have much drainage from it. Just get her a bag and she’ll be fine,” I reassured him.
“Do you think I can talk to your partner who did her surgery? Because if she has a colostomy something should be coming out,” he deduced, again.
“Well, he’s usually not available on the weekends when he’s off, but Martha will be fine if you just fix her up with a colostomy bag.”
“Unless, I can speak with your partner I feel I’m obligated to do a CAT Scan,” he reiterated more forcefully. “Colostomies should have some drainage and I don’t see anything coming out.”
I was beginning to get a little annoyed.
“Did you actually talk to the patient?” I asked. “Did she tell you what the problem is?”
“I did talk to her,” he replied, his frustration also beginning to surface, “and she told me just what you said. But, she could be confused and a colostomy should have something coming out. I really think I should do a CAT Scan.”
I realized I was going nowhere fast.
“OK, OK, do what you have to do. I haven’t seen her and you have. I’ll see if I can get a hold of my partner.”
I realize that once the ER doctor saw poor Martha he was responsible for her care and he was only trying to practice good medicine, at least from his perspective, but he really broke a few rules. He didn’t listen to the patient, he assumed an elderly patient must be confused if she didn’t tell him what he expected to hear, he ignored his consultant and refused to consider anything but his own inaccurate diagnosis. This also is an example of relying too heavily on CAT Scans for diagnosis, while refusing to utilize any clinical judgment.
In the end, Martha got her bags and a completely unnecessary CAT Scan of her abdomen and pelvis. That particular ER physician was fired about a month later, my encounter being only one of many similar episodes. It made me wonder how some people make it through medical school and residency.
I had another incident today that made me stop and think. I was called to consult on a patient at one of the Long Term Acute Care (LTAC) facilities. LTAC’s are hospitals for patients who are not sick enough to be in a regular acute care hospital, but are too sick for a nursing home. I consult at these facilities when necessary to evaluate surgical problems.
Mitch was a complicated patient who had undergone major intra-abdominal surgery and had numerous drains which had been placed to treat abscesses which had developed after his surgery. I had not done any of the surgery and I had never seen him before, but I was called because the patient’s actual surgeons did not go to LTAC’s.
“Dr. P wants you to see Mitch because his drain broke,” the nurse reported.
I did my best to extract as much information as I could from the nurse. Mitch was stable, the drain hadn’t been collecting much fluid and it sounded like a closed suction drain’s tubing had broken off near where it attached to the suction bulb.
“Sounds like you can just cut the tube a little shorter and reconnect it to the bulb,” I deduced.
“It’s broke, I can’t do that.”
“OK, I’ll see him tomorrow.”
“But doctor. The tube isn’t draining into anything; it’s open to air.”
This was not much of a problem to me, the tube would behave like a different type of drain, called a Penrose, but I could tell the nurse was very worried.
“Just wrap it with some sterile gauze and tape it and he should be fine,” I suggested.
I went to see Mitch and found just what I expected. He had an intraperitoneal closed suction drain with plenty of tubing outside his abdomen.
“Where’s the bulb?” I asked the nurse, who was not the same nurse I had spoken with yesterday.
“I told them to save it, but they didn’t listen,” Mitch said. “They threw it away yesterday.”
The nurse was able to scrounge up another bulb, the tube was cut a little shorter and the crisis was averted, but only after I made a special trip to the LTAC to take care of a problem that should not have been a problem.
Then there are the techniques I have observed in other surgeons. I hear stories of surgeons taking two or three hours to do very simple procedures and I wonder what they are doing for so long a time. Sometimes I will ask that very question of the OR staff. The answers are scary:
“He wasn’t sure about the anatomy. He asked me my opinion, but I couldn’t help him,” reported by a surgical technician.
“He made a hole in the bladder and we had to wait for the Urologist.” I know things like this can happen, but not on a cholecystectomy.
“She just dissects very slowly, like she’s not sure what’s what.”
It’s always best to be as sure as you can be during surgery, and never cut anything unless you know what it is, but there is also some truth to the saying that “a good fast operation is always better than a bad slow operation.”
On occasion I assist younger surgeons in the OR. Most are careful and meticulous as they should be, but I have also helped some who can best be described as cavalier and sometimes dangerous.
I was assisting another surgeon on a colon resection for diverticulitis, an inflammatory condition of the colon. The segment of colon which was diseased was adherent to structures posterior to it. These structures are the ureter, iliac artery and iliac vein. Rather than carefully dissect the colon away, this surgeon took a pair of scissors and just cut away blindly, injuring the iliac vein in the process. I had to fix the vein as this surgeon did not do any vascular surgery. The patient lost about a liter of blood, because of this surgeon’s carelessness and inattention to the most basic rules of proper operative technique.
Incidents such as these make me wonder and worry a bit. If a nurse is not familiar with a particular drain, that’s OK. But, it would have been prudent to ask her head nurse what to do, rather than call in a consultant to address what was really a very simple nursing problem. I worry about the judgment, training and basic knowledge of personnel who are in positions where decision making and responsibility are of central importance. I see more and more incidents like these and I worry what will happen as I get older and face the infirmities that always come with age.
Saturday, July 26, 2014
I suppose the title above is a bit facetious and I really don’t mean it, but there have been times over the years when collaborating with my Orthopedic Surgery colleagues has caused sleepless nights; some I didn’t deserve.
Almost all these joint ventures have been on major trauma cases where severe bone injury has been paired with major vascular damage. Priority of repair, that is, who gets to go first is a common discussion. The answer to the question depends on the patient and the injury. In general life and limb threatening injury take precedence.
Such was the case of Mary, who suffered a closed fracture of her proximal tibia and fibula with associated occlusion of her popliteal artery and ischemia of her leg. The severe vascular injury could have led to Mary losing her leg and mending of the artery took precedence over the bony repair.
But, how could I have had the prescience to know that during the process of repairing the tibial fracture the orthopedic surgeon would cause a bony fragment to compress the artery which had just been patched and cleared of thrombus, (a blood clot which was occluding the vessel)? The vessel became occluded again. My protests went unheeded and I was forced to bite the bullet and redo the vascular repair utilizing a vein graft to bypass around the injured area.
At least I didn’t have to drive back to the hospital. As a resident I learned to never leave the vicinity until the bone doctor had driven his or her last screw, nailed the last nail and placed the final skin staple. Only after checking my work would it be safe to leave, secure with the knowledge that my orthopedic colleague could not wreak anymore havoc.
Mary, by the way, recovered uneventfully.
Then there was Glenn.
It was a Friday night and I was not on call. My family and I had just walked in the door after dining out when my phone went off and there was a message. Dr. Black was consulting me to see Glenn, who was admitted to the hospital with a fracture of the proximal right humerus. The nurse was concerned because she could not feel a pulse and Glenn complained of his hand being numb. It was about eight o’clock in the evening.
I called and talked to the nurse and then headed in to the hospital. Glenn was in his mid fifties, lived with his parents and had no significant medical problems other than being “a little slow” to use his expression. He told me had tripped while on his parent’s front porch and fallen down the three stairs to the sidewalk, landing on his right arm and shoulder. This had occurred at 11:00 am, now almost ten hours earlier.
My exam confirmed that he had almost certainly injured his brachial artery. There was a large hematoma (collection of blood) in the upper arm and axilla, he could not move his hand, which was also numb, and there was no pulse in the arm, radial or brachial.
I called down to the OR where they weren’t very busy and told the crew that Glenn needed surgery immediately. Next I called Dr. Black and reported my findings and he responded that he was on his way to the hospital
I called the OR, again, and asked how quickly they would be ready, informing them, again, that this was a limb threatening emergency and that the patient should have had his surgery hours before.
“We’re opening now and anesthesia is on their way in,” was the reply.
I have to admit I was a more than a little frustrated. Mostly it was the lack of attention that threatened to cause serious harm to Glenn that bothered me. It’s not right for a patient to languish in the hospital with such an injury.
Dr. Black finally arrived.
“The ER physician told me it was an uncomplicated fracture. I had planned to fix it tomorrow,” he explained without my ever asking a question or making a comment.
Finally, at 10:00 the OR team was ready and Glenn was wheeled down to surgery. The operation began about thirty minutes later. Glenn’s arm had been ischemic for almost twelve hours.
I began to work, starting with an incision over the area where the subclavian artery emerges from beneath and behind the clavicle, following the rules and obtaining what’s called proximal control. What this means is that the artery is identified and dissected free in area closer to the heart than the injured area. Blood flows from the heart out to the organs under considerable pressure. Proximal control allows flow into the injured area to be interrupted should bleeding develop during the course of isolating the damaged artery.
I followed the artery out to the axilla, dissecting it free from the pectoralis major muscle and then into the upper arm where I encountered a large hematoma (collection of blood). This is where the artery had bled before the pressure caused by the blood spilling into Glenn’s tissues along with the body’s normal clotting mechanism caused the bleeding to stop. If this mechanism had failed Glenn would have bled to death, but the human body is remarkable in its ability to fend off such calamity.
I evacuated the large blood clot and found one end of the transected artery, pulsing away, but not actively bleeding as the end had efficiently clotted.
Next I had to find the other end of the artery. Rather than start digging through the bloody, damaged tissue at the site of injury, I decide it would be more prudent to start at a site beyond the injury. The distal artery was easily dissected free and then followed back to the other injured end.
The two ends were a bit macerated and had retracted such that a direct end to end anastamosis (like reconnecting two ends of a pipe) was not feasible. Luckily I had the foresight to prep out Glenn’s groin so that it was already sterile and I could harvest a segment of saphenous vein. This is the same vein commonly used for heart bypass surgery. Before starting on Glenn’s leg I placed a shunt between the two divided ends of the injured artery, allowing blood to flow to the distal arm, thus giving the starved tissue a “drink” of blood, delivering oxygen and nutrients.
An adequate segment of vein was removed from his leg and the reconstruction proceeded without incident. I added a fasciotomy to my procedure, which means I divided the fibrous tissue around the muscular compartments of the forearm to allow the muscle additional room to swell after it was reperfused, thus preventing what is termed “compartment syndrome.” This condition can lead to muscle and nerve damage as the tissue swelling which can occur after prolonged periods of ischemia becomes confined by the tight, closed space of a muscular compartment.
I felt the strong pulse in the artery beyond my repair and saw that the muscle, although pale, looked viable and I believed Glenn would be left with a functional arm.
At this point I must add I had considered allowing Dr. Black to do his repair first. I could have placed the shunt to allow the arm to be perfused and then done the definitive repair after Dr. Black had finished. But, he assured me it was a simple fracture which was minimally displaced. He anticipated an uncomplicated ORIF (Open Reduction Internal Fixation). Being the trusting soul that I am performed the more vital arterial repair first.
However, I am not 100% naïve. I did stay around until Dr. Black finished. I’m glad I did. It was about 1:00 am when I lay down on the couch in the doctor’s lounge and dozed off and on. Over the years I’ve never slept well at the hospital and I’ve always opted for driving home for a couple of hours sleep in my own bed rather than getting an extra thirty minutes in the less comfortable confines of a hospital call room. In this case, however, it was fortunate that I did not leave.
The phone in the lounge rang at about 3:00 am.
“Dr. Gelber, you need to come check this arm,” more of a command than request from the circulating nurse.
“Is Dr. Black finished?” I queried.
“Finished and gone, but you need to come.”
“OK, OK, I’ll be there in a minute.”
I made a quick pit stop, donned my hat and mask and went back to the OR room where the surgical tech recounted the sad and tragic “saga of Glenn’s repair.”
“Well, he was doing the repair with a Rush rod and it only took a few minutes. I thought we’d be home by two, but then I picked up the arm and asked him if the rod was supposed to come out the back of the arm? So he had to pull it out and that took a while. Then he had to do it again. I’m no Orthopedic Surgeon, but I don’t think it’s positioned very well. But, fFor what it’s worth, he’s done.”
The circulator then spoke up.
“The hand looks white.”
Sure enough there was no pulse or Doppler signal. So I was back at square one. I opened the wound and looked at my repair. There was an excellent pulse at the site of the repair and for at least three or four centimeters distal. I started dissecting farther and it wasn’t long before I found the problem.
Dr. Black had not only driven that Rod through the back of Glenn’s arm, but he had also managed to put it through the brachial artery at a point beyond the original injury. So, I repaired the artery a second time. At least I didn’t have to do another fasciotomy.
I finished at around 5:00 am. Glenn woke and had much improved function of his hand. He could move it and there was some sensation. He maintained good perfusion of his arm, but did have to have the orthopedic reconstruction revised at a later date. Eventually he regained 100% full, normal function of his arm and hand.
Dr. Black never talked about this particular case with me. A couple of years later he gave up the practice of Orthopedics. He was, overall a competent surgeon and his retirement from Orthopedics was for personal and health reasons, unrelated to Glenn’s case..
I hope that anyone who reads these words does not believe that I have no regard or respect for my Orthopedic colleagues. I could never do what they do and most are excellent physicians and surgeons. They do, however, have a singlemindedness in their approach to their patients. Their job is to fix, reconstruct and otherwise mend broken, worn out, degenerated bones and joints. Orthopedic surgical procedures are designed to stay away from vital structures such as nerves, major blood vessels and other organs which are soft and not amenable to nails, screws and plates.
What I’ve learned is that injuries and medical conditions which bring me into the Orthopedic Surgeon’s realm require that I maintain my utmost vigilance. And, never completely trust a bone doctor.
Sunday, June 29, 2014
Back in the day, that is the distant past of 1985 the word “Internship” could fill a medical student with anxiety and stress. The internship was a rite of passage, a necessary stop on the road to becoming a full fledged, finished doctor, rather than a person with a couple of initials after his or her name.
And, the surgical internship was supposed to be the worst: thirty six hour shifts, every other night call, holding retractors for hours without a break, this was the plight of those of us who chose to pursue the surgical arts. It was a period of initiation which led to joining an exclusive fraternity called “Surgeon.”
I have to report that, at least for me, my internship was nothing like this. I was in a large private hospital where there was no “scut” work, the name given such mundane tasks like drawing blood, starting IV’s, doing EKG’s and such. These duties are important to patient care, but do little to advance the knowledge of the medical trainee. I do think there is some value in learning to draw blood and start IV’s, but doing my own CBC’s or urinalysis would have been a waste of my time.
All this being said there were days when the work was never ending and there was one day in particular which stands out as a shining example of what an internship can be.
It was during my final month, a month I spent away from the safe confines of my mother hospital and its friendly IV, EKG and phlebotomy teams; thus the aforementioned “scut” work still plagued the lowly intern. I finished out my intern year rotating through the Pediatric Surgical Service at Children’s Medical Center (CMC) in Dallas. This included responsibility not only for CMC, but also Parkland Hospital, the county hospital for Dallas. I was paired with a fourth year resident as well as interns and residents from the program at UT Southwestern. We were responsible for all the pediatric surgery which included elective surgeries, trauma, the Parkland Emergency room, surgical consultation for pediatric patients in both hospitals and, finally, the nascent Pediatric Liver Transplant program.
The intern’s duties included: history and physical on all admissions, morning rounds which commenced around 6:00 am, drawing blood on all the liver transplant patients which needed to be done before morning rounds, assisting in surgery, afternoon rounds, making sure all tests that had been ordered were done and being the first to respond to any emergency that should arise throughout the day. In between all this we all hoped to find the time to actually do some surgery, the occasional appendectomy or a hernia, remove some lumps and bumps and so on.
There was a day, an unforgettable day which snuck up on me about two thirds of the way through the month. It was a Saturday which started like every other day. I arrived early enough to help the intern coming off call draw blood on the liver transplant patients and to check on my other patients before the fourth year resident arrived and formal rounds began. So far, so good.
Round and round we went, from Children’s Medical Center, to Parkland, which included a brief stop in the newly minted, but as yet untested, Pediatric Trauma Unit. There was a post op appendectomy, the previously mentioned post liver transplant patients, including little Terry. Terry had received her new liver four days ago, but was still looking green. We were all concerned that something wasn’t right. Diagnosing and treating her was priority number one for this Saturday.
“See if Radiology can do an ultrasound of Terry’s abdomen with Doppler to check her hepatic artery,” the Transplant surgeon attending commanded.
“Yes sir,” the fourth year resident agreed.
Rounds ending, this fourth year resident, who aspired to be a Pediatric Transplant surgeon, which meant an unusual amount of groveling and brown nosing of the Attending staff, turned to me and gave me the job of tending to all of Terry’s needs.
It was seven a.m. and the proverbial shit was poised to hit the fan. I started at the top of the scut list and ran down to Radiology to request the stat ultrasound on Terry. I checked the requisition up and down and front to back, made sure all the t’s were crossed and I’s dotted and ventured in to find the senior radiology resident. I finally found him hidden away in the dark, which is the usual place to find Radiologists, the vampires of the medical world who shun all light and live in shadow. I begged and pleaded and convinced him of the urgent need. I have to admit I almost brought tears to his eyes as I related the “Plight of Baby Terry.” The ultrasound was scheduled stat.
One task settled I moved on to the daily, mundane chores an intern battled. In those days, before computers, I gathered lab results and X-Ray reports and started writing my progress notes on each patient. It wasn't too long when I received the first of many "rude" interruptions.
"Dr. Gelber," the sweet voice called, "we've got a premie down here in NICU with a distended abdomen and the KUB shows pneumotosis."
A bothersome, but ocassionally disastrous NEC watch. One more thing to complicate what was turning out to be a far from peaceful Saturday.
What, pray tell, is "NEC" watch?
NEC stands for Necrotizing Enterocolitis. This is a condition which most commonly arises in premature babies. Whether from ischemia, or infection, or some other unknown agent, the neonate becomes very sick. The child cannot be fed, they demonstrate signs of sepsis and their condition can deteriorate before your eyes.
I made my way to the NICU and took a look at baby girl Nicole born at 28 weeks and now sporting all the findings one would expect in early NEC, distended abdomen, mild tachycardia and an abdominal X-ray which revealed an area of “pneumotosis intestinale” which means air in the wall of the bowel. I communicated my findings and assessment to my fourth year resident, specifically that baby Nicole could be watched, tube feedings were put on hold and she was to start on IV fluids and antibiotics.
One crisis stopped before it started, I hoped.
I had just hung up the phone with the my senior resident when my beeper went off.
Parkland ER. Just great, what now?
“You are the surgery intern on call today?” asked the voice form the ER.
“This is Dr. Gelber, I am on call today.”
“This is Dr. Barry. We’ve got a seven year old who we think has appendicitis. Do you think you can come check him out?”
“OK, I’ll be there in a little bit.”
I took the time to write a couple of progress notes on the patients I’d seen earlier in the day and then made my way through the tunnel which connected Children’s Medical Center and Parkland. It was like moving from one world to another.
CMC always looked new and clean. It was a place I would want to bring my kids if they were ill. Parkland, although not dirty, looked older and worn, a spot which looked beaten down by years of caring for the sickest, most severely injured patients Dallas could offer.
I found Mikey in the pediatric ER accompanied by his worried mother. He had been sick for three days. From the door way it was obvious he was ill. He lay still on the exam table, his face was flushed. The bedside chart listed Vital signs: heartrate 130, Temp 103.1, blood pressure 86/40, Respirations: 20.
A typical history for appendicitis was obtained and a gentle tap on his abdomen elicited a grimace and wincing that screamed “PERITONITIS.”
I called my senior resident again and schedule Mikey for surgery. My beeper went off again: call the transplant floor.
“Terry needs to go for abdominal ultrasound now. The Radiologist is here and you need to bring her,” the unit secretary informed me.
Four years of college, four years of medical school and almost a year of internship and I’m still just a glorified orderly.
“OK, I’ll be right up.”
I left orders for Mikey and called the OR and told them I would call when we were ready for surgery. One good thing about Mikey and most patients with appendicitis was that an appendectomy was an intern case, so I would get to do the operation. I hustled my way back to CMC to wheel little Casey to ultrasound. On my way my beeper went off again and again and again.
“Michelle has a temp of 102.”
“Michelle who?” I inquire.
“Michelle S. in 204, She had a liver transplant ten days ago.”
“Oh, that Michelle. Get a UA, draw two sets of blood cultures and a CBC. I’ll be over to check her shortly.”
“Are you going to come draw the blood?”
“Yeah, OK, I’ll get to it as soon as I can.”
“IV is out on Darren in 331.”
“He had an appendectomy two days ago.”
“Is he eating?”
“Clear liquid diet.”
“Is he on any meds?”
“Ampicillin, Gentamicin and Clindamycin.”
“No fever for twenty four hours.”
“Was the appendix ruptured?”
“How should I know?”
I looked at my sign out sheet. No mention of how bad the appendix was.
“OK,” I finally answered. “Could you please put everything at the bedside and I’ll be there when I can.”
And the third call:
“Dr. Gelber, Scott in 320 has a headache…”
Finally, something simple.
Now, onto the Transplant floor and little Terry. She was very small for her age and her skin was green because of her liver failure. Even after her transplant she stayed green and now she had fever. Everything said her new liver wasn’t right. But, the question remained: Was it a technical problem? Or rejection? Or infection? Thus the ultrasound and Doppler of her hepatic artery which would start to provide some answers, we hoped.
The nurses already had her loaded up on the stretcher. We began wheeling her down the hall to the elevator. She gave me a weak smile. Father and Mother trailed behind us talking in whispers. Terry was four days post transplant. I knew her fairly well and was very well acquainted with the veins of her right arm where I drew her blood every morning. Her mother was only worried, while her father seemed to mix his worry with distrust, as if the Transplant team was somehow conspiring to harm his little girl.
The Radiologist and the Transplant Attending were waiting for us. The ultrasound clearly demonstrated a patent hepatic artery and we brought Terry back to her room. On the way my beeper went off again. It was my Chief resident. It was a good time to do the appendectomy on Mikey. I called the OR and met the team in the ER and we wheeled our patient up to surgery.
With my Chief across the table from me I started the surgery. This was the final month of my internship and I was pretty adept at appendectomies. I delivered the offending organ, which was ruptured, and completed the surgery like a pro. No sooner had I tucked Mikey into the Recovery Room when my beeper went off again. Terry was crashing.
I raced through the tunnel and up the stairs to her bedside. My Chief was right behind. Her nurse wasted no time informing me that an ICU bed was ready. Terry was barely responsive, her BP was fifty over zero and she looked even greener. I scooped her up in my arms while her father stood behind me, screaming.
“If she doesn’t get better, you’ll never work in this city again,” he shouted. I think he would have punched me if he had the chance.
Meanwhile I laid her in the ICU bed. The Pediatric Anesthesiologist was standing by and deftly intubated her while the nurses opened up her IV and gave her a bolus of fluid.
“Rejection,” the Transplant Attending decided.
Terry was now functioning without a liver, more or less; her transplanted liver was causing more harm than help. She was placed at the top of the list so that the first ABO compatible liver that came available would be hers. Her father came in and stood at her bedside, glaring at me while I stood at the foot of the bed staring at the monitors. Her BP was better at 70/40 and her oxygen saturation was 100%. Still, she wouldn’t last long without a new liver.
It was early evening now and I finally had a few moments to catch up. I finished my charting for the day, drew some overdue blood tests and started a few IV’s which had been waiting for me. I was about to have “breakfast” when my Chief called me.
“A two year old girl is on her way by helicopter to the Trauma ICU. She was accidentally run over by her father.”
A minute later the call came. I was already on my way.
A crowd of nurses and paramedics surrounded the stretched as Christina was wheeled inside.
“BP 60/30, heart rate 125, O2 sat 100%,” a nurse screamed.
Two clear but terrified eyes stared up at me as my Chief arrived just behind me. Christina was awake and alert and breathing comfortably. A quick survey revealed bruising across her lower abdomen and pelvis and blood staining her diaper. There was obvious deformity of both legs.
Two distraught parents waited outside as the trauma team went to work. New IV lines were established and fluids administered. Blood was drawn for the blood bank and baseline lab tests. Antibiotics were given, oxygen administered. We did a quick peritoneal tap which was negative. Her vital signs were holding steady.
X-rays revealed a fractured pelvis and bilateral femur fractures. Her chest X-Ray was normal.
The OR was standing by and at 8:57 pm surgery commenced. My job, as intern, was holding retractors as the Attending and Chief Resident began the task of putting her lacerated perineum back together. Her vagina was torn down the middle and there was a small laceration of her rectum. Her fractures were to be treated without surgery, at least at this time.
The surgery dragged on, past nine o’clock, past ten o’clock, past eleven o’clock. All the while messages came, baby A needs a new IV, Mikey has a fever, Terry’s urine output is low and on and on. As midnight approached I began to feel a little dizzy. I sensed my heart was racing and I remembered I had not eaten anything all day. I concluded my blood sugar was probably around forty. I asked the OR circulating nurse to get me some orange juice.
The nurse found some apple juice and fixed it up with a straw and managed to get it into me. A few minutes later I was back among the living as the sugar filled my bloodstream. I was able to continue my relationship with the end of a Richardson retractor without passing out. Finally, shortly after one in the morning the vaginal and perineal repairs were finished. All that was left was to do a colostomy. I begged to be allowed to leave and finish all my undone work and to check on my other sick patients.
My superiors took pity on me and I was dismissed. I scrounged up a couple of Oreo cookies and went about the business of catching up. I checked on Terry first, gave her some more fluid and was informed that there was a potential liver in Houston. I started IV’s, answered calls for patients with fever or drainage from their wounds, drew the morning labs and thought I could see a glimmer of light at the end of the tunnel.
Christina was now back in the Trauma ICU and she looked stable, if not a little forlorn as she lay in bed with both legs up in traction, IV’s in each arm and tubes going every which way. However, she was OK and she still had those beautiful clear eyes, only now I didn’t see the terror.
Then my beeper went off. It was the ICU where Terry was clinging to life.
My Chief answered, “There’s a compatible liver in Houston. We’re leaving in ten minutes. Make rounds with the next crew and then you can go. We won’t be starting the surgery until about ten.
And there it was. My twenty four hour shift was now growing to twenty six. I did take a few minutes to get a real breakfast before starting morning rounds with the next team of residents.
Rounds were uneventful. We finished around eight thirty, but instead of leaving to get a little rest I stayed around to help with Terry. Dedication or stupidity? Both, I guess, but I assume it was mostly dedication and a sense of responsibility.
We started Terry’s surgery at around ten thirty and I took my position on the patient’s left where I would become reacquainted with my old friend, Richardson. The case went fairly quickly, at least for a liver transplant and after about two hours the new liver was in place. Every one left to take a break, that is everyone but me. Someone had to stay with the patient, who was still under anesthesia while the new liver “breathed.” I sat and watched the liver take on new life as Terry’s blood percolated through its sinusoids and it started to sweat bile. After about thirty minutes the rest of the team returned to do the final step, which was the biliary anastamosis.
I was happy to see the intern on call for that day return with them, which meant I was to be set free. It was almost two in the afternoon. My twenty four hour shift had lasted thirty two; a typical day for a surgery intern in 1985.
Christina, by the way made a complete recovery. Mikey spent about a week in the hospital but also recovered, while Nicole recovered from her NEC. Terry’s new liver worked for a few days, but she suffered through another rejection and this time it was too much and she passed away.
Modern medicine does indeed have its limitations.