Sunday, November 18, 2007
Snakes On A Pan
A very nice lady (and, one infers, an excellent doctor) who sutures for a living asked me a question which reminded me of a good story.
Rarely seen nowadays, there was a time when super-long intestinal tubes were used to treat certain conditions of the bowel; particularly in a person with many prior obstructions in whom reöperation was undesirable. Snoogled through the nose and into the stomach, these tubes had bags of mercury on the end (for its heaviness and loogilability, allowing passage) and were fifteen feet or more (guessing) long. The idea was that once in the stomach, the muscular action of the gut (peristalsis) would drag the bag and the tube downstream to the point of obstruction, decompressing it by sucking out the backed-up juices, and allowing unkinking; maybe by eventually working its way past the blockage. Sometimes it actually worked.
Having passed the tube, often over regurgitive objections, and having had the patient lie for hours on his/her right side so the bag would drop into the duodenum (which heads to the right out of the stomach), it would occasionally occur that the tube -- draped in some way by the bed and hung to allow unravelling -- would take on a life of its own and begin disappearing into the person in question, slower than but not unlike a baited line that had been glugged by a fish. (After many years of use, studies were done which showed no difference in non-operative success using these tubes as opposed to the much more hassle-free ones that just went into the stomach. Which is why you don't see them much any more, except in museums.)
It's one of those stories you hear: not actually witnessed, but told by unimpeachable sources. I think it happened where I trained, when I was there. A woman had been treated with such a tube, and it had passed as hoped. She seemed to be improving: belly decompressing, cramps gone. But suddenly one day things took a turn. Her urine output dropped and the amount of drainage from the tube began to climb -- signs of recurrent obstruction. With diminished urine output, it could mean even more dire things. IV fluids were increased, labs were checked, and on paper at least things didn't seem scary. But the upped drainage and downed urination continued, flummoxing her caregivers and frustrating the patient. Until observation solved the mystery.
The long tube had passed through the lady's entire intestinal tract, and was hanging out her rectum. When she sat on a bedpan to pee, it sucked the urine up and away, draining into the bucket for collecting intestinal juices, turning her fluid accounting upside down.
Let's ignore a couple of obvious questions and just agree: it's a great story.