Tuesday, July 25, 2006

Memorable patients: part one

I got the call from the ER because I was the "no-doc" surgeon, meaning I was the guy to call when a patient showed up needing a surgeon, and who had no primary care doc to direct the referral. Usually it meant trouble. A drunk who smashed his car and himself, possibly others. Stab-wound, gun-shot. People who don't have their own doctors include more than those down on their luck; not all of them are nice. So when the ER doc calls and starts with "You're the no-doc surgeon, right?" it raises hackles.

"Got an acute abdomen down here. Older lady, goes to Seattle for her care, comes in looking real bad." Jesus, I'm thinking. We're not good enough here for her elective care, but when the shit hits the fan, she takes a shot at anyone? Little did I know. About the shit, I mean.

Gotta admit, it's annoying. Turns out this lady had had innumberable orthopedic operations for horrible arthritis. New joints, fusions. Infections, removal of joints. So why not call her docs in Seattle, if they're so great? Such were my thoughts, having to leave an office full of patients and head to the hospital.

She was, indeed, sick as hell. Low blood pressure, rapid pulse, flushed, feverish, not entirely coherent. And her belly felt like stone: a rigid abdomen is pretty much a sine qua non of something real bad going on. No need for a lot of fancy xrays: check her cardiogram, blood work, call the OR, fill her back up with lots of IV fluids, cover her with antibiotics, get her upstairs. At her side, holding her hand, looking worried, her husband turned to me and asked "Is she going to be ok, Doc?" What an interesting thing: they chose their doctors carefully, so it would seem, bypassing us for those in Seattle. But now I'm "Doc" and instantly trusted to save her life. But that's not my point. It is interesting, however.

A simple abdominal xray had already been done, and it showed "fee air," meaning air in the belly outside of the confines of the stomach or intestine, where it ought to have been. Perforation, of something. Usually, there's no point in trying in advance to figure out the source: surgery is needed, no matter what. Sometimes there are clues from the history or physical exam: history of heartburn, indigestion, taking antacids, more tenderness in the upper abdomen, all suggest ulcer, for example. Nothing of that sort here. Because of chronic pain from her arthritis and many failed operations, she took high doses of narcotics, and was always constipated. Hadn't had a bowel movement in several days. Well, actually, she had; it's just that it all went inside.

The adult colon, if stretched out, is usually four or five feet long. In situ,which sounds, appropriately enough, like "inside you," it's like an inverted horseshoe, starting in the right lower abdomen at the end of the small intestine, heading up the right side toward the liver, turning to your left and crossing under the stomach, making a U-turn at the spleen, then heading south along the left side toward the pelvis, where it makes a corkscrew shape into the rectum. It can be pretty capacious, as Sally's most certainly had been, until it emptied itself.

Pretty rare and highly deadly as a cause of colon rupture is a thing called stercoral perforation. It means a hard piece of feces has rubbed its way right through the bowel (nearly always at the south end of the colon); a seriously bad thing. Opening Sally's abdomen, I encountered more stool than I could ever have imagined, spread everywhere: there were several enormous (what else is there to call them, really) turds, hard as rock, maybe a dozen. Swimming in no less than a gallon of liquid stool. Owners of motor homes who've had accidents with sewer hoses may have a vague idea...

The smell was astounding. The entire crew in the OR was bug-eyed. No one had ever seen anything like it, nor sensed it with pretty much all five. I filled a couple of big pans as I scooped out the solid stuff with my hands, then suctioned quarts more. (Despite the gloves, and vigorous washing many times after, my hands smelled like stool for days.) This was really bad: a huge bacterial load in an older woman who'd been in shock, portends a grim outcome. But she was hanging in there, having been properly resuscitated and maintained. Fast surgery is not always best per se, but sometimes it matters: the less anesthesia the better when a person is really sick. It's impossible safely to close such a hole; a colostomy is mandatory, getting the damaged colon out of the abdomen, letting bowel movements happen into a bag until such time as the patient is recovered and suitable for reoperation to hook things back up. So that's what I did, after irrigating the belly with about 10 liters of saline, followed by a diluted solution of bacteriocidal agent (povidone, if you care.) And closing with big "retention sutures," big and widely-spaced: not pretty, but protecting against the wound falling apart which is highly likely in such circumstances as these. Closing the skin would be asking for major infection.

The family was gathered in the waiting area, and listened silently and tearfully as I told them what I'd found and what we were up against. The odds were greatly against us, but there were no signs that we couldn't win, and we'd be doing everything we could. Expect a long stay in intensive care, under the best of circumstances.

Sally, it turns out, is an amazing woman, and became one of my favorites and a life-long patient. She never, as we like to say, turned a hair. (Where-ever the hell that comes from, it's an expression all doctors use for someone who makes an entirely unexpectedly smooth recovery.) At minimum, I'd told the family, expect several reoperations or procedures to drain abscesses, to tidy the wound. Plan on respiratory failure, maybe liver or kidney failure. Pneumonia. And this was the best-case scenario. Nada. She sailed. She was walking around on her kneeless legs in a day or two. I'm gonna take some credit here: thorough cleansing, quick operation, good postop management. But Sally, she's incredible. Nothing holds her back. A will of the hardest diamond.

Her belly is another story, or maybe the same one: it hardened, too. After six months or so, when I figured it'd be safe to go back in to close her colostomy, I encountered adhesions like I'd never seen. She hated her colostomy, and really wanted to get rid of it. As I struggled my way through, I thought a dozen times that keeping the colostomy would be better than suffering the complications of injuring the rest of her bowel to get there. But I managed to unravel the mystery without great harm and hooked her back up. She was delighted.

Surgically speaking, her life wasn't easy before she met me, and the struggle continued after. She had innumerable bowel obstructions, as she formed adhesions like they were money. Some went away without operating; some didn't. Each time I operated on her, I thought it was the worst obstruction I'd ever dealt with; the hardest to unravel, the most dangerous to tackle. Finally, there was the ultimate, and I thought I might have killed her.

Sally had come in with another obstruction (we're talking many years after we first met, by now.) As usual, I'd dragged my feet well beyond what I was taught in training ("never let the sun rise or set on a bowel obstruction," is what they told us. The worry is that whatever is kinking off the bowel could be compromising circulation, leading eventually to perforation. But there are times for clinical judgment.) After a few days of sucking on a stomach tube and high-calorie IV feeding, she hadn't improved, and had developed a low-grade fever. Drag the feet no more, doc. And as usual, it was hell in there. Just entering the abdominal cavity was a nightmare: bowel stuck everywhere, no recognizable separation planes. It's one of the most challenging and frightening things a general surgeon does.

Long story short. After spending hours moving my way into and through the abdominal cavity, and having nicked into the bowel several times ("inadvertent enterotomy," we used to call that in training, at D and C conference ((by all means, read my book to find out more)). My professor hated the term "inadvertent." Have a suction device where you're working: it means you expected it, he'd say. Good one.), I finally encountered the bowel that wouldn't budge. A loop of small intestine was plastered into her pelvis, fat as a salami, but thin and fragile as the wet toilet paper she'd have used the day I met her, if things had been different. Having switched all her care to my clinic, she had a new doc (excellent guy. My own doc) who had her on a new regimen for her constipation. Unfortunately, all the fiber she'd eaten for the past days had congealed in that one loop of small bowel, and it was going nowhere. I simply didn't think I could get it out of there without irreparably damaging the bowel, and, if I did so without the ability to work my way beyond it, and given the general immobility of the rest of her swollen and thin and surgically damaged intestine, I could imagine an insoluble (like the fiber!) problem. So I bailed. I found a loop of small intestine above the blockage that was barely mobile enough to bring out, and made a loop ileostomy, hoping it was downstream enough (no way to tell, given the tanglements and adhesions) that it wouldn't be a high-flow faucet. I told her husband in the waiting room that I wasn't sure it would work, I thought she might leak from everywhere, and she might or might not be able to eat again. Having operated on her several times, by now he never questioned a thing I told him.

Longer story short. She couldn't eat without flowing out her stoma like a river. I installed a special IV feeding line, and arranged for her to hook up at home, at night, so she could be up and around during the day. We waited for months. Eventually I took an xray by squirting dye through the south side of the loop: the fibrous obstruction had auto-digested, and the pipes were clear. Could I close the ileostomy? Was it possible to cut it loose from the abdominal wall, mobilize enough inches to work with, and safely close it and drop it inside? Would I try? Should I?

Yes yes, yes, and yes.

Sally called frequently over the next many years, came in often. Always wearing shorts, showing her scarred and stiff legs. Always trusting, always pleasant, often just wanting a laying on of the hands and a reassuring word. I knew and cared for her for years, until her recent death for unrelated reasons. Her husband was always with her, always telling me how they'd never have gotten along without me. No doc. What a day that was.

38 comments:

Ali said...

That was a wonderful entry. Thank you for sharing.

Andy Fragen said...

Great post. It really brings back memories. Fortunately not great ones. I empathize. But well done.

Anonymous said...

That was a great entry. I'm a new resident and this gives me quite a perspective.

Dr. Wannabe said...

Wow, that was quite a story. I can't imagine ever being in your or the patient's shoes.

Willow-esque said...

Very interesting and well-written entry about gut surgery.

I'm a psychiatrist and haven't been in someone's gut in....well, along time, and boy am I glad! Instead, I muck around in the mind. Your entries do bring back some memories.

I suppose I now have you to thank for the very unmistakeable, poignant (pungent?) recollection of the GI bleed.

Glad to see you sharing your experiences with us younger docs.

Jon Mikel, M.D. said...

This is a really nice case!

By the way, why you didn't us that abdominal bag called "Bogota's Bag" (at least here in Mexico), the one that comes with a zipper, how do you call it?

This reminds me a very rare case with a very strange patient who has visceral myopathy (he nor we didn't knew it at the first place), he went for elective anterior approach vertebral instrumentation performed by neurosurgeons and by us as abdominal surgery team.

On the second postop day, he turn tu be with evident signs of shock and a THAT rigid abdomen; this guy's gut was perforated.

It was pretty difficult (technical and mental) the first reoperation... of course we left him with a colostomy.

Later the colostomy was closed and so the skin with no complications at all.

Couple of months later he developed a postincisional hernia and we had to put him a vicryl (non permanent) mesh laparoscopically.

Months later we scheduled a permenent mesh to deal with that giant ventral hernia. At the time we put it, the mesh became infected, but with the antecedent of visceral myopathy we cannot perform a mesh removal, so we wait, and wait with IV antibiotics by about a month while he was in the hospital. It wasn't until a graft was inserted in the new skin hole and the infection was controled that this patient was discharged.

Kind of weird.

Danielle said...

Oh my goodness! That was so vivid (in the good way, not in the "oh that was gross way). I am dreading my surgery rotation in Septemeber, but some of your stuff makes surgery sound, well, pretty darn cool.

Danielle said...

Oh, plug away! I just looked the book up on Amazon.com. Great title. Cool front. You got a good review from some reader.

Why does surgery scare me so much? I am for sure going to check out the book. Will let you know what I think.

R3 said...

Excellent story. As a surgical resident currently working at the County hospital, I've been encountering more than my fair share of abdominal distasters recently. Currently have 3 or 4 patients on service with low level obstructions and the concommitant frustration (on their part and mine). This story was the perfect reminder of the good we can do despite the nightmare abdomens. Thank you for taking the time to make blog posts; your experiences are elequently rendered and highly encouraging.

Mimi said...

Fascinating story! You sound like a bit of a super hero, making those life altering decisons in a moment on the spot. Yikes, what a job you have and what a writer you are to boot.

Mimi

Mama Kelly said...

wandered in via a related search

wish i had had a surgeon as thorough as you in any of my surgeries ...

despite 2 laparascopies and an open abdominal hysterectomy due to severe endometriosis (resulting in frozen pelvis) I am still stuck (pun intentional) with many bowel adhesions ... including my acending colon which is adhered to the pelvic side wall and adhesions which prevent my appendix from ebing visualized

the amount of time and detail that went into just one of these surgeries it is obvious that you are not just a doctor but a healer!

Sid Schwab said...

Thanks to the recent commenters. This blogger thing notifies me of new comments rarely/never, and I hadn't seen these most recent ones. I appreciate the visits and the comments. This case remains as vivid to me now as it was when I met "Sally." (One of my favorite nurses is named Sally, and she wondered why I named this patient after her, since the woman had been so full of sh#t. Because, I told her, she turned out to be one of my favorite patients.

kim said...

Geeze, I learn a lot from this blog.

And I will take every constipated ER patient seriously....I had no idea this could happen.

I know it's rare, but you would have thought after a couple o' decades I'd have at least heard of it!

Kim said...

Oh yeah, and why is it that GI smells come back to haunt you days later.

It's like the smell gets in your hair.

Ugh!

And, at the risk of sounding stupid, if you irrigated with that much saline, it had to go somewhere...you must have one BIG suction cannister......

Anonymous said...

Thank you. I'm an almost-40yo nursing student and have been wondering what the hell I'm doing this for... thank you.

MTWorkin01 said...

I am a medical transcriptionist in a bigger hospital and love running across sites like this. It helps make sense of what we're typing, as well as always learning interesting new things. Thanks much for sharing.

Anonymous said...

This was a great entry. I just wanted to mention that a coworker and now, close friend of mine happened to make the mistake of drinking and driving and breaking his ankle. He is 22 and had yet to have a primary care doctor because before this, he was in good health. I don't think he's a bad person, and it really irks me to think that doctors and nurses will look down on him for making a foolish mistake, but judging his whole character based on not having a primary care doctor and drunk driving.

KathyMac said...

I really enjoyed reading about this patient!! Why? Because I was 42 when this exact thing happened to me! No history of bowel or stomach problems, no history of chronic constipation, no ulcers or diarhea. I was, however, on pain medication for chronic pain. When the doc opened me up he found what you found: a piece of hardened stool (not very big at all) that had worked its way back and forth (like a knife) right through the wall of my colon. I had a colostomy that was reveresed about 7 months after the event. I'll never forget that night as long as I live. KathyMac

Buckeye Surgeon said...

great story.

R said...

dear dr.
i was told today my intestines are adhering all over a hernia mesh. i've been in the ER 5x, gastric tubed 4-5 days and no one can figure out what to say except, its a bowel obstruction. so surgery is on the horizon. i googled 'intestines stuck to hernia mesh' and your blog came up. i tend to be a bit cynical and cautious before going in for surgeries but i am so sick and exhausted. i just want to say thank you for your honesty and frankness because patients are told condensed versions of information that have been cleaned up for our consumption. the thought of being 54 and living with a bag or trying to work with one, had me terrified.

Sid Schwab said...

R: thanks, and good luck (I saw your blog, so I should say "mazel tov." The good news is when there's a specific point of obstruction as you describe, the surgery is very likely to be successful.

rouxeny said...

Ha! I had a similar patient in residency. Same deal, stercoral ulcer in an elderly woman. Upon, opening, a RIVER of stool poured out, much of it landing on my attending's shoes. (Actually the same guy who's dad I eventually had to operate on.) Very memorably, he cried out, "My new shoes!!!" as he had just come in from a nice dinner. I think I actually have a video of the moment that a fellow resident shot. 10 L of saline later, she did fine! I'm convinced that operating early and the high volume of washout really helped.

athenivanidx said...

Holy sh*t, doc!

I'm a doctors' kid.......and I find medical stuff very, very, VERY fascinating.

Yay, I'm so glad I found your blog........now I get to read about what my dad wouldn't tell me..........real raw medical stories of perseverance by medical professionals and patient resilience........or unfortunate outcomes whatever the case is........

It's just interesting to hear/read doctors telling their stories.......

When I was younger I used to fire twenty questions or more at my dad........what did you do today, any interesting cases............I'd keep prying for details until he got irritated......I just fixated and fixated on details and stuff like that.........still do, but at least now I know when to bite my tongue and quit asking a zillion questions........

thanks for sharing

I clicked on a link from Orac (Resp.Insolence) and got here from the blog I clicked on.........can't remember which one now..........I think it was to cut is to cure...........

The Integral

Hinata said...

I loved your story. I m also a doc (in training), I actually want to be a surgeon, and looking for books about the subject I came a cross your s (cutting remarks). Right now I m waiting for its arrival (I live in Panama), waiting waiting waiting...quite impatiently.

Sid Schwab said...

Hinata: thanks for your comment, and for buying the book. As to the waiting, well, surgical training is all about deferred gratification...

Anonymous said...

Just a couple of weeks ago, I went to visit my 88 year old aunt in the hospital. She, like your patient, had perforated her colon because of prolonged constipation.

A surgeon at the hospital also gave my aunt a second chance at life. She now has a colostomy bag and her health has improved significantly since her surgery. She is gaining some of the weight back that she'd lost and her skin color has returned to normal.

When it happened to my aunt a couple of weeks ago, I had never heard of anyone experiencing a perforated colon. It was amazing for me to stumble across your blog site tonight, while I was researching the benefits of music and relaxing messages during surgery. How I happened to find your story, I have no idea. I think a higher-up(she looks upward) wanted me to find your story. God bless and thank you for sharing your story!

Sid Schwab said...

Thank you for your comment. And good luck to your aunt. At 88, an event like that takes the wind out of your sails for a while, but it sounds like she's well past the worst of it.

Sacharissa SKho said...

wow..

Moms Hugs (Eve) said...

Found your Surgeonblog through your Crapcuttingblog by way of a post (by RockRoq) in "US Liberals Politics" on about.com's forums. (Will comment on Crap blog.)

This is a great story about your surgeon's skills, but even more about your patient's will. My ex-husband, head of a burn unit, often said his patient's attitude was the first line of defense, and those patients who managed to survive severe burns with complications against all odds had an incredible will to live.

He learned the value of being a diagnostician first & surgeon second from his father, a rural general practitioner & surgeon who's skills were sharpened on troops during WWII. (See your political blog for more about him.)

Idealist said...

just discovered your blog. reminds me of what i LOVED about my general surgery rotation in med school. while my new career as an OB/GYN resident has me in the OR quite frequently, i do miss the days of seeing those big fun abdominal surgeries. thanks for sharing!

Nurse and Hospital Stories said...

"Her husband was always with her, always telling me how they'd never have gotten along without me."

Wow! That is one of the best words that a patient/patient's relative could say to his/her healthcare provider. Memorable case, memorable patient and as well as memorable moments. Medical career is sure a difficult career, and yet it is also so rewarding and fulfilling, eh.

Thanks for sharing,
Peny@blood pressure gauge

Sally said...

Well, it was as interesting of a post as you could make on the subject matter. I can't imagine performing a procedure with an open colon, gross.

Anonymous said...

Thank you so so much for writing about your experiences so vividly! I am a highschool student considering a career in the medical field and it is difficult to find such reliable inspiring and detailed accounts anywhere else. I worry though that even if I could find a way to cope with the demanding circumstances of a life and death job such as this regularly I would be unable to handle the lack of sleep. Any advice anyone?

Sid Schwab said...

Surgical training has changed a lot from my time: now there are rules regarding hours worked, and lack of sleep in training is much less of a problem.

After training, it depends on the situation. Unless you are a solo practitioner in a community with no other surgeons, you'd have people sharing the load; and by the time you'd be there, the "hospitalist" model will be even more prevalent, where there are surgeons full time in hospitals doing the emergency work, working regular and predictable hours; and surgeons doing non emergency surgery aren't facing many calls in the middle of the night. It's a pretty sweet life. If it'd been like that when I was practicing, I might still be!

Danielle said...

Doc:
I'm in med school, just a few months away from graduation. I found your blog when I was reading the "choosing a specialty blog" in medscape and I felt like I could have written some of those words. I love the idea of never getting tired of it, of always feeling the amazement of getting inside someone and fixing whatever they need to get fixed.I think i'm going into surgery too, and I love it. When I read your stories it reminds me why I chose to do what I do. Thak you for sharing, it reinforces my desision, specially because I feel exactly what you say you feel.

Sid Schwab said...

Thanks, Danielle, and good luck in your career. I like your attitude!

Anonymous said...

Hi Sid,

I wanted to ask you, I almost know that I have what Sally had but am scared to go about the surgery & possibility of death from it. If I go request a x-ray/CT scan in ER and can confirm my diagnosis, can I still choose whether to have the surgery or not? I know there's gas or feces in legs & other places that's not in my colon and I have been fatigued and smell bad to like a 3 meter radius around me. I feel like I'm rotting inside or full of toxins. I wake up feeling heavy or just quite frankly full of shit. Constipation, stool blood, weird shaped stool, feeling bloated & gasy, etc. There was one night my breathing rate slowed down to minimal and I didn't know if i closed my eyes if I would wake up...How should I handle this situation? Is it too late? Please provide some advice as it would be greatly appreciated.

Sid Schwab said...

What Sally had is a true and immediate emergency, that happens suddenly and would cause death if not operated on within hours. You wouldn't be writing a blog comment if that's what was going on.

So whatever is happening with you, it's impossible that it's that. Beyond that, there's not much I can say because it sounds like you need to be examined and thoroughly evaluated in a way that I can't from so far away.

You should start by seeing a doctor and between the two of you deciding what needs to be done to figure it out.