Sunday, September 17, 2006
Tales From the Right Lower Quadrant, Part three
She was among the sickest kids I've ever seen: as close to death as any who eventually made it. And I never figured out if her parents were just incredibly clueless, or criminally negligent. When I saw her in the ER, her pulse was thready, barely palpable, and slow -- as in nearly agonal. Undoubtedly, a day or two ago it had been rapid, a desperate staccato plea for help. She moaned a little to deep stimulation, but her eyes -- like a doll's, like a pathetic imitation of some cliched cartoon -- were rolled up with only the whites showing. Instead of flushed and hot, as would be consistent with the rigid abdomen that told me her likely diagnosis, she was dusky and cool. Temperature below normal, heart slowing down. Jesus Christ!!! This little girl is dying of a ruptured appendix. I was as shocked and angry as I was scared I couldn't save her.
It had started over a week ago, her parents said: upset stomach, vomiting, fever. They put her to bed, figuring, they said, it was the flu. They just planned on waiting it out, as she got more and more lethargic. OK, yeah, kids get sick, they get a bug; don't call the doc for every sniffle. But vomiting for a week, becoming unresponsive: this is cult-worshipping craziness. You have to be nuts, or a committed conspiracy theorist -- a believer that doctors plot to make people sick, a snake-oil consumer -- to ignore all that for so long. Their daughter was no more than hours from death.
Cleverly called "the policeman of the abdomen," the omentum is there for a reason: it hangs down in front of the intestines like an apron, sliding around looking for trouble. If it finds it, in the form of an infection or inflammation, it sticks to the area, sealing it off with its layer of fat, richly endowed with lymphocytes and fibroblasts. Plug holes, send in the repel and repair crews. It works quite well when it works quite well. I mentioned previously that rupture leads either to pus all over the place, or to an abscess. Which one, depends largely on the omentum. If it finds the appendix early in the process and sticks to it -- and if in the process the nearby intestines close in as well -- the area gets effectively walled off. In kids, the omentum is thin and can be small. In the case of this little girl, for whatever reason it didn't do the job: she had a belly as full of pus as I've ever seen. And see it I did.
With warm IV fluids, heating blankets, and having given broad-spectrum antibiotics and medications to improve heart function, we got her in shape to handle an operation. I made an incision in her pretty little belly, up and down, in the middle. It would be there as long as she'd be there. I never cared too much about putting a belly-scar on an adult: whatever the indication, they'd know it was worth it. But cutting into a child's belly always bothered me a lot, no matter the reason. The bigger the cut, the worse I felt. The thrill of being the cavalry, riding to the rescue, was and is absent. That perfect skin, the vulnerable little child.
It was as if someone had taken a gallon jug of ugly gruel and poured it in: her insides were literally afloat in it. Raw and red, her intestines bobbed in pus. Her liver and spleen, surrounded. Sickly consistent, the same soup in her pelvis, the lateral gutters (that's the term for the area to the right of the ascending colon, and to the left of the descending. Never more appropriate), under her diaphragms. I sucked it out with catheters, and irrigated and irrigated, flooded her over and over again with liter after liter of warm and clean saline. Lastly, with antiseptic-laden solution. Assuring an un-cosmetic scar, of necessity I left the edges of her skin apart, lest she get infection in her wound.
Oxygen has antibiotic powers, and I kept her on it postop, to the (only slight) consternation of the pediatrician, since her measured oxygen levels were fine without it. The irrigations, the antibiotics and oxygen, her youth and who-knows-what other factors combined to give her a remarkably easy recovery. I was even able to tape her skin edges together, and her scar wasn't, as these things go, too bad after all.
Miracle? Not to me. The miracle would have been giving her parents who'd not let it happen in the first place.
Speaking of God, at the opposite end of the spectrum of parental involvement was a girl of similar age I was asked to see after she'd been in the hospital for three or four days with abdominal pain and not much else. No fever, no vomiting, no abnormal blood tests (the white blood cell count, a reflector of infection under usual circumstances, is nearly always elevated in appendicitis), Xrays, tea-leaves all OK. Was an operation indicated, I was asked? Look around, see if it's her appendix or something else surgical? I reviewed all the data, examined the child, and was as certain as I've ever been that it was neither appendicitis nor any other surgical situation. "That's what they told us about my other daughter, in Colorado," her mother said. "And she had a ruptured appendix and nearly died." I told her I understood how scary it was, that I couldn't comment on how that situation might have differed from this, but I was as sure as I could be that her daughter didn't have appendicitis, and I didn't think surgery would be of value. I told her I'd keep seeing her daughter every few hours to be sure, and moved toward the door. At which point the mom took that other daughter by the arm, and they both knelt and prayed at the child's bedside.
I was young then. I don't know if it was wise or not, but then and there I decided the little girl would never be really well -- never free of her mom's fear -- until her appendix was removed. So I did. When I told the mom I'd go ahead, her relief filled the room like fresh air; she looked as if she'd sprout wings and fly. And here's the amazing thing: in the face of my certainty, the normal lab work, the Xrays, the repeated exams, when I got in there it was as obvious as could be: her appendix, that mysterious little worm, that innocent little stripe-cum-killer, was.... entirely, amazingly, completely..... normal and pure as the first snow.
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