Friday, December 22, 2006
A Winter's Tale
Tending toward the heavy myself (losing it when I get back into cycling, periodically), I have sympathy with those who are overweight. Nevertheless, it's a fact that the obese present a broad spectrum of problems for surgeons: higher risk of wound infections or hernias, slippery hands when tying knots, harder to find the proper tissue planes for dissection. Difficult anesthetic management, blood sugar issues, blood pressure, too. Lots of things make it less than pleasant to have patients who are significantly overweight. So when the guy showed up in the ER and I was called, I wasn't thrilled. On the other hand, his problem was one I'd not seen before. I like a challenge, most of the time. Not necessarily in the middle of the night, in the middle of winter.
It being late when I got the call, and cold outside, my first thought was that I could punt the case to the plastic surgeon. But they'd already tried him, and he was having none of it. So with my usual expletives and foul wee-hour mood, I got out of bed and headed to the hospital. "Circumferential pressure sore," they'd said. Fat necrosis, risk of a necrotizing infection. Gonna have to take him to the OR, cut away a huge amount of tissue, maybe a few times. Dressing changes for weeks. Skin grafts. Royal pain in the ass. Such were my thoughts on the dark drive, watching out for black ice, sliding on snow.
In the ER, reading his chart before going into the room, I could hear the man referring, it seemed, to every nurse within shouting distance as a "ho'." So I was primed for an unpleasant encounter when I walked in, and I must admit I was a little rude to him. Didn't ask how he'd gotten the injury, didn't exchange pleasantries. Just lifted up his garish shirt and had a look (what was this guy, a pimp? He called me a "ho," too. Several times.) Occupying the entire circumference of his enormous belly (the kind that transmits waves across it, like Jello -- not a good prognostic sign, in terms of pleasant surgery) was a band of mottled skin, maybe five or six inches in width, pocked here and there with open sores; oozing, and dirty.
Mixed in a disgusting brew, with what looked like a bunch of tiny hairs, was a fine black powder, like pencil-filings without the wood. Like uniformly ground dirt. Like soot. And despite wearing gloves and boots and the most ridiculous pants I'd seen in a while, the man had cold skin, without the erythema you'd expect in someone successfully being re-warmed. Clearly, he'd been out in the cold for a long time, raising all sorts of other possible untoward scenarios. Given the potential for rapidly progressing infection I reluctantly opted for immediate surgical debridement, put in a page for the anesthesiologist, and called the OR.
Uncharitably, as I contemplated the problems this guy was going to entail, possibly for weeks, I noted he was a "John Doe," from out of town, no local contacts, no insurance. Of course not: if he'd been insured, they'd have called one of the fancier docs.
"You're going to hate me for this," I confessed to Larry, who happened to be one of my favorite anesthesiologists. "He's huge, I'm going to have to reposition him two or three times during the case, and he has an enormous beard [anesthesia guys hate beards: they make it hard to fit a mask while inducing anesthesia, obscure the view while intubating, and resist taping to secure the tube] which he refuses to let anyone near. Dirty as hell, too. Soot or some crap like that." Trying to be candid up front, letting the man know what he was in for. "Great," said Larry, as he hung up the phone. "I'll be there when I get there."
By the time I next saw my patient, in the pre-op holding room, they'd removed his clothes and put them in a couple of bags. Boots, gloves, heavy coat with fur-crested sleeves (who wears crap like that? Heard of PETA?); and now, in the warmth of the room the stuff smelled like a barn. So did he, for that matter. Looked like cow-shit on his boots, too. I don't mean to denigrate the man -- he was a human being, after all -- but a fat smelly guy at three a.m. or whatever it was by then: I like to think of myself as more empathetic than your typical surgeon, but it was just a bad situation, getting worse at every turn. Larry was much more mellow than I, probably getting a laugh over my obvious displeasure. He gave the man the usual once-over and piloted the gurney to the OR.
It took six of us to move him onto the OR table. He'd told us he was two-eighty, two-ninety pounds, but he was three-fifty if he was an ounce. I work with bariatric surgeons of late, and we have these very ingenious Hovermats for moving the patients: they literally float on cushion of air, and glide so easily you have to worry about zooming the patient off the other side. No such thing this night, in this OR. My back hurt, to make a bad situation still worse.
I won't belabor the surgical details. Suffice it to say it was as depressing as I'd imagined it would be: fat upon fat, greasy, slippery, smelly. Rolling the man from side to side, to Larry's grumbling (he'd crossed over to my mood half way through trying to intubate), I cut away a belt of skin and subcutaneous crud which, had I been able to do it all in one piece, could have wrapped twice around a telephone pole. It had taken the poor nurse fifteen minutes to scrub clean the man's stomach: ground-in dirt, intertriginous gooey grime. What had he been doing that he couldn't stop for a shower once in a while? No running water where he lives? Everyone had his or her own reason to be repulsed by the whole thing.
Having written post-op orders and assured myself it looked like he'd wake up OK, I went to take a shower. Unlike the description in my recent post I wasn't covered in blood. It was just the stink of the whole situation that needed cleansing, I guess. When I came back to the recovery room, the man was gone.
Gone!! Kathy, the world's best recovery nurse, seemed uncharacteristically befuddled. "What the hell happened?" I inquired (you might call it). "Where's my patient? What's going on around here???" I was pissed: I hadn't yet decided whether to send him to the floor or the ICU. Who'd made that decision without me??
"He checked out," Kathy said.
"Checked out?! What are you talking about?? He died??"
"No. I mean he checked out. He said he felt fine, and had to leave. Pulled out his IV, insisted I take off his bandages. Said he had important work to do that absolutely couldn't wait. He said he'd been so cold in the ER he couldn't even remember who he was, could barely talk."
"You gotta be kidding. There's no way he... How could you let him..."
"I don't know. Really, I don't. I know he couldn't, shouldn't... he just talked me into it, like I was a child. I know it's wrong, but it's like I couldn't argue. I didn't even think to call you, or security, or anyone. I don't know, I just went blank, like he..."
"Oh, man! This is really bad. We gotta call the cops or something. He's gonna die out there..."
"I know you won't believe this, but he looked great. And the wound? Either you did an amazing job or, or, I don't know what. It looked like it was healing already. Almost like it never happened."
"Jeez, Kathy! What have you been drinking? I don't believe this. This is.... I'm calling the supervisor. We gotta..." I was as flummoxed as I've ever been; didn't know what to do. Finally, I just decided to go home. It was the most screwed up thing I'd ever heard of, and I just wanted to pretend it hadn't happened.
"Sid?" Kathy asked as I tried to storm out the recovery room door.
"What!!??" I responded, with zero patience.
"How about his story? About how he got the injury?"
"What story? I didn't even hear the story. What story?"
"Getting stuck trying to get into someone's chimney, being pulled out by some animals. The way he said it, he seemed serious. Oh, and he left these for you," Kathy grinned, tentatively, as she handed me half a dozen wrapped boxes.
"Yeah, right. Keep 'em. Guy's a liar, some sort of sociopath. I gotta get home and get Danny's presents under the tree before he wakes up. Merry frickin' Christmas."