Wednesday, July 26, 2006

Memorable patients: part two

"Musta been the ham sandwich," he said as he leaned onto the operating table and belched a couple of times. We were half-way through a thyroid operation and Doug, my partner, didn't look all that good. I'd been in practice for all of a year, and Doug, ten years my senior, was my guardian angel, my guide through the vagaries of the world of private practice, and the best surgeon I'd ever seen. Suddenly, he was definitely off his game.

We managed to get through the operation. Doug had an appendectomy teed up to follow, but instead of showing up to get it going, he'd gone to the ER, from which I got a call telling me Doug was down there being evaluated, and requesting that I do his case. Introducing myself to the patient, explaining the strange situation, convincing the man that this shiny-faced kid (a 33 year-old kid, but still...) was a satisfactory stand-in, I had more on my mind than the operation at hand. But the patient was fine with it, and I finished removing the appendix in time to take another ER call: Doug needed a surgical consult, and was requesting me.

Stone-faced, stiffly trying not to writhe, Doug was clearly in a lot of pain. Xrays didn't show much. Lab work showed a very mild elevation of amylase, a digestive enzyme produced mostly in the pancreas (and salivary glands); high levels most often signal pancreatitis. Alcoholism and gallstones are by far the most common causes of pancreatitis, and Doug wasn't a victim of either. His abdomen was pretty tender in the upper portion, which is where pancreatitis pain usually shows, but it wasn't rigid (as you know from the previous post, rigid ain't good.) For now, I'm thinking it's his pancreas, for one of the less common causes. I didn't think operation was indicated, and admitted him to the floor. Before that, Doug said to me, "Look, I know it's not easy taking care of a partner, and if you want to get someone else, I'll understand. But there's no one I'd rather have care for me than you." That's the thing: Doug and I had an amazing relationship: in the OR we clicked like we'd been doing it forever. I loved him as an assistant; he loved me. We were perfect together.

Proudly referring to himself as a "closet hick," Doug usually wore jeans, had a few acres, occasionally skipped town to buy a cow. He was tall and thin, taciturn, had an Adam's apple from which you could make an entire pie. Mostly serious, he had an occasional but fine sense of humor, was very respectful of and engaged with his patients, but less than empathetic: tough it out, he seemed to say. Now he was trying to do it himself.

Over the next few hours, Doug's pain persisted. He threw up a couple of times, so I put in a stomach tube (did it myself). Amylase levels remained only slightly up, repeat films remained non-specific, but his white blood cell count was rising. Having no clear idea what was going on, I called another surgeon for moral support, and scheduled surgery.

Closed loop bowel obstruction has a typical xray appearance; but if the case were typical, it wouldn't be memorable, now, would it? I opened Doug up and found about an twelve-inch segment of small intestine twisted around a single band-like adhesion (cf: previous post). Adhesions by far most commonly occur as a result of prior operations; they're rare in virgin abdomens, like Doug's. They can be congenital, result from a prior infection, or who the hell knows? Doug had one, and only one, and it killed a piece of bowel -- or close enough to make me afraid to leave it in. It took one quick snip to release the adhesion, but the bowel remained pretty black and motionless, so I cut it out and sewed the ends together. Piece of cake, routine stuff.

When doing his own operations, Doug had a thing about closing the mesentery after bowel resection. He sewed up both sides, instead of just one. Sewing it prevents a hole through which other intestine could slip, causing obstruction. Sewing both sides cuts down on the raw surface to which bowel could adhere, or so Doug believed. Nevertheless, most surgeons, myself included, don't take the time and don't think it makes much difference because the surface heals to smooth pretty fast. But I figured Doug'd be pleased; so I did both sides, and used his favorite suture, the old-fashioned "chromic" suture" (click the link and check out the contraindications) instead of the newer style I liked.

Doug woke up with a smile on his face. "You cured me," he said. His pain was gone; tough as nails, he was walking around, impatient to get the hell out of there, within hours. Until he started to vomit a couple of days later.

For brevity let me just say it was hell on earth. I was miserable: Doug wasn't getting better, I didn't know why, and the other surgeons in town hardly wanted to look at me in the doctors' lounge. They knew what I was going through; and if any of them was too dense to know, I was broadcasting it at 50,000 watts with every bone and muscle of my body. I couldn't sleep. I couldn't think. I got second opinions. Then Doug started to go nuts.

It's not all that rare: the combined effects of altered sleep, drugs, whatever, mean a certain number of patients will develop postop psychosis. Unlike some who go really crazy (it always clears up, by the way), Doug was just mildly paranoid. He started coming up with bizarre diagnoses, eventually became convinced he had horrible infection inside, and began to accuse me of deliberately withholding reoperation. Miserable ain't the half of it.

Early postop bowel obstruction happens sometimes, and it's one of the situations (cf: previous post) in which there's good reason not to reoperate very soon: more often than not, it clears on its own. I hung in there as long as I could stand to, with Doug getting more and more dour and accusatory, and finally I decided to re-operate. The surgeon I asked to assist didn't agree, but I thought I was right, for psychological as well as physical reasons.

Doug, it turns out, is allergic as hell to chromic suture. No reason for him to have known, since he only handled it with rubber gloves. Everywhere I'd placed it, in his honor, he'd reacted by swelling and hardening the tissues containing it. His bowel anastomosis had been puckered into a tight kink, in a way I'd never seen before, nor have since. "Well," the assistant said, "I guess you were right. This never would have opened up." So I re-did it, with my kind of suture. And before he woke up, because I feared he might not be able to eat for several more days, I inserted a special IV catheter into a vein below Doug's collar bone, to allow high-calorie intravenous feedings.

It took a few more days, during which I was pretty much a total wreck. But Doug started eating, doing well. One night I removed the IV, planning discharge for the next morning. "OK, Doug, looks like we made it," I said that morning, feeling elated in ways not felt for seemingly eons. And there it was: his right arm was swollen like a dead pig. Blood clot in the subclavian (below the clavicle) vein, no doubt from the IV I'd inserted.

Sometimes it's hard as hell, placing a subclavian IV: poking in and out, hitting the artery, causing bruising and pain. Doug's had gone in easily, first shot, like driving a scooter into a tunnel. So which is it, I thought? Push Doug out the window, or jump myself? Now he needed anticoagulation (not entirely clear, but majority position says so); of course, as a result he'd bleed somewhere, probably into his head. Or get a post-phlebitic syndrome-- uncommon as hell in the arm -- never operate again. Somebody kill me, please. Insurance doesn't cover suicide.

Well, he got better. No arm problems, no bowel problems. He brought me a bottle of wine or something one day; we never talked about his accusations. I did ask him if he thought the experience would change his attitude toward patients with problems. "Nope," he said. "Let's get to work."

16 comments:

Intelinurse2B said...

This post reinforces for me that perserverance builds character.

I am dying to know how quickly your pt switched his suture material of choice, or if he ever did...

Sid Schwab said...

That's an excellent question!! It was a long time ago, and I can't honestly say I remember (I practiced with him for five years, then moved to where I am now 25 years ago.) Knowing "Doug" if he did change, it was with reluctance... But he was a great guy who, incredibly sadly, died of a PE about a year into retirement, having just returned from buying another cow....

Dan said...

Question: Don't you have to have been exposed to an allergen at least once before to develop a sensitivity to it? (i.e., you can't have an allergic reaction to something you've never been exposed to).

Am I mistaken?

Otherwise a scary situation! A few years ago, one of the cardiologists that I work with ended up having to do a Transesophageal Echocardiogram on one of his former Med School professors. He seemed pretty cool about it, but I have to imagine it unnerved him somewhere inside.

Sid Schwab said...

Another great question! Two possibilites: first, chromic catgut causes much more tissue reaction than the newer synthetic absorbable sutures; so it could be that his response was just a very exaggerated local reaction as opposed to true "allergy." He was, far as I know, never tested for allergy: but the local reaction was very impressive. Second: it may be that he'd had it used on him on some minor procedure or another. In the back room of my mind, lo these many years later, there rattles a possible memory of something to that effect.

james gaulte said...

These stories (sagas?) are fantastic,I hope you keep them coming.

keagirl said...

Typical Murphy's law...Operate on a healthcare professional, especially another MD, and you are guaranteed WEIRD complications. Never fails...

Mimi said...

This is the scariest medical story I've read thus far. It reminds me that even modern medicine is lots of guess work.

Mimi

Willow-esque said...

How awful! I can certainly imagine your distress. I suppose the analogous situation for me would be performing ECT on a colleague. ECT is so controversial anyway.

Post-op psychosis, too. He likely didn't remember any of it afterwards. I've been consulted on hundreds (maybe more) of post-op delirium cases, and that seems to be the rule.

The one who seemed to remember the most was only able to recall that she'd been very frightened, and that she felt confused.

Great story.

kim said...

Oh man, my heart was in my throat the entire time.

It takes a strong character to function under that kind of pressure.

Either that, or functioning under that kind of pressure builds character.

Hell of a way to find out.....

andrew said...

I was 2 years out from fellowship, and I'd just moved back to where I did my fellowship, having worked for a year in California. A few weeks into work, an old attending of mine from residency called. His dad, who lived in town, was having an uncontrollable lower GI bleed and he wanted me to be his surgeon. Great. Really great. The case was hard, the anastamosis low, and of course there were bubbles. I did some anastamotic patchwork, the bubbles stopped but I agonized about diverting him regardless. I didn't. He did fine. Well, not entirely fine, he did get a wound infection and now has a hernia. His son doesn't want me to touch it and I think I'm fine with that.

Ewall67 said...

Do you suppose he had some hypercoagulable state? Adhesion in a virgin abdomen, dvt from a central line, and died of a PE? I don't know that the literature days anything about adhesions in virgin abdomens and clotting, but it would make sense with the whole inflammatory cascade / clotting cascade / tissue restructuring pathways dovetailing as they do.

Sid Schwab said...

Could be, although he was around 70 when he died.

Nicholas Fogelson, MD said...

Great story. The thing I hate to tell you is that I think that Grey's Anatomy plagiarized it in last week's episode (Season 6 Ep 16: Perfect Little Accident). The situation in that episode is your story almost exactly, down the presentation, chromic suture allergy, and the mentor/student relationship that led the younger surgeon to use chromic instead of their preferred vicryl. I hope they asked you first!

Sid Schwab said...

Someone else told me that, too. Wonder if they read this. Maybe they owe me money?

Carlos said...

I just wanted to say that was a great story. I am in my first year of practice and you reminded me how important your senior partner is in mentoring you through your first cases. It reminds me of the importance of teaching and being a mentor. I felt for you as you had to operate on your partner and had the unexpected (or expected) complications. It would be hard for any surgeon to be in those shoes. Hope you are enjoying your retirement and keep the stories coming!

lifmd13 said...

As a newbie surgeon, I am googling "failed my surgery" and I find your blog. Thanks for sharing your experience with others, I really enjoy and I always learn something from your post. I try to find your book in google play but can't find it...