For all of you wondering whatever happened to Ms. Brown, This is a quick update.
After 10 days of up and down progress, It became clear that she was in for a long, long, haul, and her chances of ever returning home were pretty much non existent. Even after 10 days of intense effort, she still couldn't hold her own blood pressure, and wasn't waking up after being off sedatives for 4 days. And so, after a long family conference, her family granted her peace, and withdrew support. She passed away shortly after, surrounded by her family, who alternately cried for her, and then shared her antics with each other and laughed. She died peacefully, bathed in the love of a caring family. While I never got to know her very well, her family will always hold a place in my heart.
Good night, and God's peace on you.
Tuesday, May 19, 2009
In and Out
OK, so I promised a further discussion of diabetes, but we're going to take a little detour to answer the Iconoclast's questions, because it raises several interesting topics, all of them pertinent to healthcare today.
First off, the Iconoclast asks if the sequential toe/foot/leg amps that occur with these diabetics is part of the high re-admission rates that are currently blamed for the high costs of medicine. The answer is: Yes. And No. Hey! That's dodging the question. Actually, what it means is that this population group of poorly controlled diabetics is a huge drain on the healthcare budget due to frequent admissions and significant complications, both with their diabetes as well as with their other medical conditions that are made worse by the diabetes. It's not necessarily the sequential amps that lead to readmission, but rather a continuous spectrum of problems that could often be managed as an outpatient in the general population. And that's something I need to clarify here, as well. When I dicuss diabetes, and diabetics, from a surgeon's perspective, what I'm talking is that group who do not maintain tight control over their disease. As a surgeon, the only diabetics who practice tight control of their blood sugars I know are social contacts and those that show up in my office for an appendix or gallbladder. Diabetics who monitor their blood sugars frequently throughout the day, and maintain their sugars in a very tight range approximating normal, don't have diabetic complications, certainly not at the level of the poorly controlled diabetic. This brings up the whole topic of self responsibility, but I'll save that for another time -- It has so many implications. Anyway, the sequential amputation of the diabetic is variable in it's progression, sometimes a toe every year or two, and ten years to the finale, other times, it's the massive debridement and a BKA less than a month later. So much depends on the patient's compliance with management, just how poorly and for how long they've been diabetic, how many other health problems they've got, and finally (but certainly not least), the patient's socio-economic support system. Sad but true, wealthy diabetics fare much better than poorer diabetics. While we have healthcare for everyone, there's still a lot of cost that isn't covered by any insurance or aid.
The Iconclast's second question is broader:
"what are the issues of readmission from your point -- poor hospital care, insurance/Medicare/Medicad refusing to pay for longer initial stays, poor followup by the home health care folks (part of the insurance issue probably), etc.?"
How about all the above? Poor hospital care is probably the least of all the reasons, at least in my world. Poor care from either the hospital or the doctors generally is a manifestation of external pressures, ie insurance carriers, pushing to have the patients out faster, sooner, quicker. Hospital readmissions were rare because we would keep the patient that extra day to make sure everything was working right. I've discovered a little line in the litany of the insurance providers from several of my battles to get the proper care for my patients. When I ask the medical director (a physician) his/her name, because I'm going to transfer care to them, since they are telling me what to do with the patient, their response is, "I'm not telling you what to do for the patient. You can do whatever you (and the patient) want to do. We're just not going to pay for it. " No fault insurance. They're not interfering with the management of the patient in any way. Of course, we all know the prices are so astronomical that you have no choice to follow their lead, but they're not telling you what to do.
Poor follow up by home health is generally not a reason. These people are dedicated to what they do, and as a general rule, their care is excellent. The actual care providers are in this for the same reason the hospital providers are in it, because they like caring for people. If anything, I say their strong devotion to duty and attention to detail may contribute to readmission just by seeing critical issues and alerting the docs in a timely fashion.
The third reason for high readmissions goes back to the poorly controlled diabetic we discussed earlier. Patients who don't take responsibility for themselves. These are self declared victims, and expect the world to serve them. "why didn't you get your prescription filled?" "The hospital didn't call it in." Or, our favorite, "I couldn't afford the ($4) copay" (while smoking 2 packs a day @ $4/pack). The other day, a patient in my office told me she hadn't been taking her meds because the pharmacy hadn't called the doctor for a refill, even after she had checked back twice. I asked her if she had called the doctor herself. Of course not. That's not her responsibility. Well, hell, if she's not going to take responsibility for her health, why the hell should I? Well, because I'm required to by law, for one thing. When she shows up in the ER, sick from her own irresponsibility, I will come in, no matter what the hour, and bust my ass to save her, and know that she's going to be in the hospital for weeks, on my dollar, because of her failure to take responsibility for her own health care. And that is the doozer of hospital readmissions, usually thru the ER, that contributes to the high cost of medicine.
And on that note, I will sign off, good readers.
Good night, and farewell.
First off, the Iconoclast asks if the sequential toe/foot/leg amps that occur with these diabetics is part of the high re-admission rates that are currently blamed for the high costs of medicine. The answer is: Yes. And No. Hey! That's dodging the question. Actually, what it means is that this population group of poorly controlled diabetics is a huge drain on the healthcare budget due to frequent admissions and significant complications, both with their diabetes as well as with their other medical conditions that are made worse by the diabetes. It's not necessarily the sequential amps that lead to readmission, but rather a continuous spectrum of problems that could often be managed as an outpatient in the general population. And that's something I need to clarify here, as well. When I dicuss diabetes, and diabetics, from a surgeon's perspective, what I'm talking is that group who do not maintain tight control over their disease. As a surgeon, the only diabetics who practice tight control of their blood sugars I know are social contacts and those that show up in my office for an appendix or gallbladder. Diabetics who monitor their blood sugars frequently throughout the day, and maintain their sugars in a very tight range approximating normal, don't have diabetic complications, certainly not at the level of the poorly controlled diabetic. This brings up the whole topic of self responsibility, but I'll save that for another time -- It has so many implications. Anyway, the sequential amputation of the diabetic is variable in it's progression, sometimes a toe every year or two, and ten years to the finale, other times, it's the massive debridement and a BKA less than a month later. So much depends on the patient's compliance with management, just how poorly and for how long they've been diabetic, how many other health problems they've got, and finally (but certainly not least), the patient's socio-economic support system. Sad but true, wealthy diabetics fare much better than poorer diabetics. While we have healthcare for everyone, there's still a lot of cost that isn't covered by any insurance or aid.
The Iconclast's second question is broader:
"what are the issues of readmission from your point -- poor hospital care, insurance/Medicare/Medicad refusing to pay for longer initial stays, poor followup by the home health care folks (part of the insurance issue probably), etc.?"
How about all the above? Poor hospital care is probably the least of all the reasons, at least in my world. Poor care from either the hospital or the doctors generally is a manifestation of external pressures, ie insurance carriers, pushing to have the patients out faster, sooner, quicker. Hospital readmissions were rare because we would keep the patient that extra day to make sure everything was working right. I've discovered a little line in the litany of the insurance providers from several of my battles to get the proper care for my patients. When I ask the medical director (a physician) his/her name, because I'm going to transfer care to them, since they are telling me what to do with the patient, their response is, "I'm not telling you what to do for the patient. You can do whatever you (and the patient) want to do. We're just not going to pay for it. " No fault insurance. They're not interfering with the management of the patient in any way. Of course, we all know the prices are so astronomical that you have no choice to follow their lead, but they're not telling you what to do.
Poor follow up by home health is generally not a reason. These people are dedicated to what they do, and as a general rule, their care is excellent. The actual care providers are in this for the same reason the hospital providers are in it, because they like caring for people. If anything, I say their strong devotion to duty and attention to detail may contribute to readmission just by seeing critical issues and alerting the docs in a timely fashion.
The third reason for high readmissions goes back to the poorly controlled diabetic we discussed earlier. Patients who don't take responsibility for themselves. These are self declared victims, and expect the world to serve them. "why didn't you get your prescription filled?" "The hospital didn't call it in." Or, our favorite, "I couldn't afford the ($4) copay" (while smoking 2 packs a day @ $4/pack). The other day, a patient in my office told me she hadn't been taking her meds because the pharmacy hadn't called the doctor for a refill, even after she had checked back twice. I asked her if she had called the doctor herself. Of course not. That's not her responsibility. Well, hell, if she's not going to take responsibility for her health, why the hell should I? Well, because I'm required to by law, for one thing. When she shows up in the ER, sick from her own irresponsibility, I will come in, no matter what the hour, and bust my ass to save her, and know that she's going to be in the hospital for weeks, on my dollar, because of her failure to take responsibility for her own health care. And that is the doozer of hospital readmissions, usually thru the ER, that contributes to the high cost of medicine.
And on that note, I will sign off, good readers.
Good night, and farewell.
Wednesday, May 13, 2009
Diabetes
OK, this is another post I started a couple days ago, and am trying to get finished. So let's give it a shot.
Today, along with a host of other tasks, I put a Hickman Catheter (a special central IV good for a couple of months) in a Diabetic with poorly controlled diabetes. It is to give IV antibiotics long term to treat osteomyelitis (infection of the bone) of his foot. I also debrided the complex, foul smelling wound on the outside of his foot. He'll be non weight bearing on this foot for the next 2-3 months while we try to heal this. If this doesn't work, he'll lose the foot. His kidney function is about 1/2 of normal, and odds are good that within a year or two, I'll be putting in some form of dialysis access. This is the real world of Diabetes.
Lee Iaccoca, in his autobiography, talks of his wife dying of diabetes, and his desire to try to promote education about this terrible disease. To the general public, diabetes means insulin shots, but not much else. To those of us in medicine, it is a whole category of patients. Type "cost of diabetes" in your google search box, and your mind will reel with the numbers. A recent study calculates the US cost of diabetes at $174 Billion. That's a pretty mind numbing number for me, sort of like the bailout figures. So I'll just talk about diabetes from a personal viewpoint.
There is an old, rather morbid joke we tell about diabetics. "What do you call a diabetic with 2 legs?" "Pre-Op." "What do you call a diabetic with 1 leg?" "Pre-Op." For surgeons, a diabetic means chronic, nasty, foot wounds. These wounds are a result of several factors. First, the chronically elevated blood sugars slowly destroy the sensory nerves. This happens from longest to shortest, so the first to go are the feet. So when a diabetic steps on a tack, or starts rubbing up a blister because their shoes aren't fitting properly, they don't feel the pain, and so, don't treat the early injury. Second, the diabetes is a disease of microvessels, the tiniest little vessels that supply blood to the tissues. Once again, the farthest vessels are affected first, ie, the feet. So when the diabetic has an injury, there is inadequate blood to the area to allow proper wound healing, and inadequate delivery of white blood cells to fight infection. Third, the high sugars essentially poison the white blood cells, impairing their ability to fight infection even more. Finally, diabetics have a very high incidence of what is, for lack of a better term, a complete collapse of the structure of the mid-foot, meaning the arch collapses, the bones of the ankle collapse to the middle, and the patient is left with a near crippling deformity of the foot, all the more prone to ulcers and pressure injuries. For the surgeon, it means months of treating these wounds, with pretty poor results, and more often than not, amputation. Sometimes this is in stages -- a couple of toes, then mid foot, then rear foot, then below knee. Other times, there's already a raging gangrene set up when we first see them in the ER, and the first cut is an above knee amp. It's frustrating, because we all know where the outcome lies, in a below knee amp, but the patient generally will not accept this early on in the process. What we, as surgeons, know, is that with the conservative approach, the patient will be non weight bearing for months, with multiple courses of antibiotics, hospitalizations, surgeries, and chronic pain. If we go almost directly to a below knee amputation (almost always successful), the patient can be up walking with a prosthetic in a matter of a couple of months. Today's modern BKA prosthetics allow fairly normal ambulation and activity, and most estimates suggest about a 25% increase in the effort of walking. Diabetes is the number one cause of amputations in my personal practice.
OK, I've got more to say, but I was up early doing an appendectomy, so I'm gonna get this posted, and in our next installment, we'll discuss diabetes and the kidneys.
Sleep tight.
Today, along with a host of other tasks, I put a Hickman Catheter (a special central IV good for a couple of months) in a Diabetic with poorly controlled diabetes. It is to give IV antibiotics long term to treat osteomyelitis (infection of the bone) of his foot. I also debrided the complex, foul smelling wound on the outside of his foot. He'll be non weight bearing on this foot for the next 2-3 months while we try to heal this. If this doesn't work, he'll lose the foot. His kidney function is about 1/2 of normal, and odds are good that within a year or two, I'll be putting in some form of dialysis access. This is the real world of Diabetes.
Lee Iaccoca, in his autobiography, talks of his wife dying of diabetes, and his desire to try to promote education about this terrible disease. To the general public, diabetes means insulin shots, but not much else. To those of us in medicine, it is a whole category of patients. Type "cost of diabetes" in your google search box, and your mind will reel with the numbers. A recent study calculates the US cost of diabetes at $174 Billion. That's a pretty mind numbing number for me, sort of like the bailout figures. So I'll just talk about diabetes from a personal viewpoint.
There is an old, rather morbid joke we tell about diabetics. "What do you call a diabetic with 2 legs?" "Pre-Op." "What do you call a diabetic with 1 leg?" "Pre-Op." For surgeons, a diabetic means chronic, nasty, foot wounds. These wounds are a result of several factors. First, the chronically elevated blood sugars slowly destroy the sensory nerves. This happens from longest to shortest, so the first to go are the feet. So when a diabetic steps on a tack, or starts rubbing up a blister because their shoes aren't fitting properly, they don't feel the pain, and so, don't treat the early injury. Second, the diabetes is a disease of microvessels, the tiniest little vessels that supply blood to the tissues. Once again, the farthest vessels are affected first, ie, the feet. So when the diabetic has an injury, there is inadequate blood to the area to allow proper wound healing, and inadequate delivery of white blood cells to fight infection. Third, the high sugars essentially poison the white blood cells, impairing their ability to fight infection even more. Finally, diabetics have a very high incidence of what is, for lack of a better term, a complete collapse of the structure of the mid-foot, meaning the arch collapses, the bones of the ankle collapse to the middle, and the patient is left with a near crippling deformity of the foot, all the more prone to ulcers and pressure injuries. For the surgeon, it means months of treating these wounds, with pretty poor results, and more often than not, amputation. Sometimes this is in stages -- a couple of toes, then mid foot, then rear foot, then below knee. Other times, there's already a raging gangrene set up when we first see them in the ER, and the first cut is an above knee amp. It's frustrating, because we all know where the outcome lies, in a below knee amp, but the patient generally will not accept this early on in the process. What we, as surgeons, know, is that with the conservative approach, the patient will be non weight bearing for months, with multiple courses of antibiotics, hospitalizations, surgeries, and chronic pain. If we go almost directly to a below knee amputation (almost always successful), the patient can be up walking with a prosthetic in a matter of a couple of months. Today's modern BKA prosthetics allow fairly normal ambulation and activity, and most estimates suggest about a 25% increase in the effort of walking. Diabetes is the number one cause of amputations in my personal practice.
OK, I've got more to say, but I was up early doing an appendectomy, so I'm gonna get this posted, and in our next installment, we'll discuss diabetes and the kidneys.
Sleep tight.
Sunday, May 10, 2009
Updates
Good evening. Tonight's will be a short post, as I've still got some chores to do around the house. It has been an interesting day, and I've got some updates for you all.
In "The House of God," a satirical novel detailing an intern's hellish year, our hero, Roy G. Batsch, is taught by the iconic senior resident (The Fatman), "the less you do to the little old ladies, the better they do." My 95 yr old is backing this theory. When last we talked about her, she was knocking on death's door. I didn't expect her to live through Friday night, much less the weekend. In talks with the family, we had decided comfort measures only. Well, yesterday afternoon, she looked better. Today, she was awake and alert, not complaining of any pain, and hungry. I shot an Xray, and her bowels have decompressed. She's still FOS (Full of S******), but has managed to squeak through this latest crisis. With her doing so much better, we're going to try to get her cleaned out, and maybe give her another year. With her colon no longer looking like the Hindenburg, I can give her cathartics from above, and try to move all that CaCa south.
Ms. Brown is also still with us. Over night, she started having some arrythmias, and is now being followed by the cardiologist as well. She continues to soak up the fluids, and is trying hard to pee. Her prognosis remains grim, but she's dodged some bullets so far. I'm currently waiting for a call with updates on her labs, tweaking them several times a day is necessary.
And now, if you all will excuse me, I'm going to sign off, and go pay some bills. They're never ending, ya know.
In "The House of God," a satirical novel detailing an intern's hellish year, our hero, Roy G. Batsch, is taught by the iconic senior resident (The Fatman), "the less you do to the little old ladies, the better they do." My 95 yr old is backing this theory. When last we talked about her, she was knocking on death's door. I didn't expect her to live through Friday night, much less the weekend. In talks with the family, we had decided comfort measures only. Well, yesterday afternoon, she looked better. Today, she was awake and alert, not complaining of any pain, and hungry. I shot an Xray, and her bowels have decompressed. She's still FOS (Full of S******), but has managed to squeak through this latest crisis. With her doing so much better, we're going to try to get her cleaned out, and maybe give her another year. With her colon no longer looking like the Hindenburg, I can give her cathartics from above, and try to move all that CaCa south.
Ms. Brown is also still with us. Over night, she started having some arrythmias, and is now being followed by the cardiologist as well. She continues to soak up the fluids, and is trying hard to pee. Her prognosis remains grim, but she's dodged some bullets so far. I'm currently waiting for a call with updates on her labs, tweaking them several times a day is necessary.
And now, if you all will excuse me, I'm going to sign off, and go pay some bills. They're never ending, ya know.
Happy Mother's Day
Well, good morning. It's been a busy 24 hrs since I last posted, and I'm sure you're anxious for an update on Ms. Brown. It was yesterday afternoon when she and I met in the OR for the second time. As of this morning, she's still alive, and when I'd last checked on her last night, she was producing a little urine. A lot rests with her spirit now. If she's a fighter, she'll go home, if not, she'll go Home. So let's get to it.
It was close to noon yesterday by the time I got to the ICU to check on Ms. Brown. I had taken a couple of phone calls on her the previous evening, and tweaked a few labs, and then again yesterday morning I'd gotten a few calls and once again made some changes to get her a little more tuned up for the OR. When I see her at noon, she's sedated, but will respond slightly if she's stimulated. She's off the medicines that are supporting her blood pressure and her vitals look pretty good. I'm concerned because her urine output has dropped significantly over the last few hours. Her kidneys took a hell of a hit with the sepsis and hypotension (low blood pressure) and I suspect Acute Tubular Necrosis (ATN, essentially, shock kidney). I've asked the nephrologist (kidney specialist) to see her. I also discuss her with the hospitalist who is following along. I then have a sitdown conversation with the family about the surgery today, plans, and prognosis. They have made her a Do Not Resuscitate with the exception of what we are doing now-- the ventilator and medicines we are using now. I don't argue with this, because it's the right decision. If she has a cardiac event, no matter what reason, her chances of leaving the hospital alive are less than one percent. As I'm waiting for the team to collect and get her to the OR, I finish my rounds. Hopefully, when I finish up with Ms. Brown, I'm done for the day.
In the OR, we get off to a much better start. She's already intubated and sedated, and she's now had a full 20 hrs or so of aggressive fluid resuscitation, and when anesthesia is induced, she holds her pressures much better. We peel away the dressings and prep and drape the abdomen. Within a minute, I'm back in the abdomen. It's a good choice to second look, the culprit of yesterday's persistent odor has declared itself. I find two spots of necrosis on the right colon, both about the size of a silver dollar, maybe a little bigger. One is near the cecum, the other is on the transverse colon, close to where I cut across the colon the day before. Another guilty party is also now here-- her gallbladder has that green-black color that tells me it's died too. It's got to come out, too. I'd love to leave her some colon, and if she was young and healthy, I might try resecting just these two spots. If she was young and healthy, she would be here in the first place. I remove the remaining colon, along with a few inches of the small bowel. The gallbladder comes out next. It's actually pretty easy getting the gallbladder out when the colon's not there to get in your way. I wash out the abdomen with another 4 liters of saline, then run the bowel again from the ligament of trietz (where it starts), to the terminal illeum (where it joins the colon). It all looks good. With the removal of the colon, I've now got good exposure of the duodenum (the first 5 inches of small bowel, which runs from the stomach to the ligament of treitz), and it's also healthy. I create a hole in the abdominal wall and pass the end of the bowel through. This will be the ileostomy, the permanent end of her GI tract. I take another run down the bowel to make sure I don't have any twists in the gut or in the vessels feeding the gut, and then do a formal closure of the fascia. The skin I leave open, with a wet to dry dressing that will have to be changed twice a day until the wound heals from the inside out. If I were to close the skin, she would almost definately develop a wound infection, and she doesn't need anymore setbacks. I then mature the ileostomy, that is, I open up the end of it and fold it back on itself to create a "rosebud" that will project far enough away from the skin to keep the stool off it. The bowel contents coming out of the small bowel tend to be more caustic, and if it's chronically on the skin around the ileostomy, she'll develop a nasty rash and skin breakdown, not too different from a bad diaper rash. As I open up the illeum, I find another marker for just how tenuous her condition is. The lining of the small bowel has necrosed (died). If I thought I'd find something better farther up, I'd reopen and move farther up the small bowel, but I suspect this is going to be the pattern for most of her bowel. Since the wall of the bowel is still alive, and looks to have some degree of blood flow, I mature the ostomy and we get her back to the ICU. It's now up to her. I expect that this necrotic lining will slough off in a few days to a week, leaving healthy pink tissue behind. All I can do now is support her, watch, and wait. After tucking her in, I finally head home.
About midnight, I went in for an appendectomy. It was around 3 this morning when I climbed back into bed. Now that I've finished updating you all, my kind readers, I'm heading back to the hospital. It's time to check on Ms. Brown, my appy from this morning, and a host of other players. My biggest priority today: Remember to call Mom and wish her happy mother's day.
Have a wonderful mother's day.
It was close to noon yesterday by the time I got to the ICU to check on Ms. Brown. I had taken a couple of phone calls on her the previous evening, and tweaked a few labs, and then again yesterday morning I'd gotten a few calls and once again made some changes to get her a little more tuned up for the OR. When I see her at noon, she's sedated, but will respond slightly if she's stimulated. She's off the medicines that are supporting her blood pressure and her vitals look pretty good. I'm concerned because her urine output has dropped significantly over the last few hours. Her kidneys took a hell of a hit with the sepsis and hypotension (low blood pressure) and I suspect Acute Tubular Necrosis (ATN, essentially, shock kidney). I've asked the nephrologist (kidney specialist) to see her. I also discuss her with the hospitalist who is following along. I then have a sitdown conversation with the family about the surgery today, plans, and prognosis. They have made her a Do Not Resuscitate with the exception of what we are doing now-- the ventilator and medicines we are using now. I don't argue with this, because it's the right decision. If she has a cardiac event, no matter what reason, her chances of leaving the hospital alive are less than one percent. As I'm waiting for the team to collect and get her to the OR, I finish my rounds. Hopefully, when I finish up with Ms. Brown, I'm done for the day.
In the OR, we get off to a much better start. She's already intubated and sedated, and she's now had a full 20 hrs or so of aggressive fluid resuscitation, and when anesthesia is induced, she holds her pressures much better. We peel away the dressings and prep and drape the abdomen. Within a minute, I'm back in the abdomen. It's a good choice to second look, the culprit of yesterday's persistent odor has declared itself. I find two spots of necrosis on the right colon, both about the size of a silver dollar, maybe a little bigger. One is near the cecum, the other is on the transverse colon, close to where I cut across the colon the day before. Another guilty party is also now here-- her gallbladder has that green-black color that tells me it's died too. It's got to come out, too. I'd love to leave her some colon, and if she was young and healthy, I might try resecting just these two spots. If she was young and healthy, she would be here in the first place. I remove the remaining colon, along with a few inches of the small bowel. The gallbladder comes out next. It's actually pretty easy getting the gallbladder out when the colon's not there to get in your way. I wash out the abdomen with another 4 liters of saline, then run the bowel again from the ligament of trietz (where it starts), to the terminal illeum (where it joins the colon). It all looks good. With the removal of the colon, I've now got good exposure of the duodenum (the first 5 inches of small bowel, which runs from the stomach to the ligament of treitz), and it's also healthy. I create a hole in the abdominal wall and pass the end of the bowel through. This will be the ileostomy, the permanent end of her GI tract. I take another run down the bowel to make sure I don't have any twists in the gut or in the vessels feeding the gut, and then do a formal closure of the fascia. The skin I leave open, with a wet to dry dressing that will have to be changed twice a day until the wound heals from the inside out. If I were to close the skin, she would almost definately develop a wound infection, and she doesn't need anymore setbacks. I then mature the ileostomy, that is, I open up the end of it and fold it back on itself to create a "rosebud" that will project far enough away from the skin to keep the stool off it. The bowel contents coming out of the small bowel tend to be more caustic, and if it's chronically on the skin around the ileostomy, she'll develop a nasty rash and skin breakdown, not too different from a bad diaper rash. As I open up the illeum, I find another marker for just how tenuous her condition is. The lining of the small bowel has necrosed (died). If I thought I'd find something better farther up, I'd reopen and move farther up the small bowel, but I suspect this is going to be the pattern for most of her bowel. Since the wall of the bowel is still alive, and looks to have some degree of blood flow, I mature the ostomy and we get her back to the ICU. It's now up to her. I expect that this necrotic lining will slough off in a few days to a week, leaving healthy pink tissue behind. All I can do now is support her, watch, and wait. After tucking her in, I finally head home.
About midnight, I went in for an appendectomy. It was around 3 this morning when I climbed back into bed. Now that I've finished updating you all, my kind readers, I'm heading back to the hospital. It's time to check on Ms. Brown, my appy from this morning, and a host of other players. My biggest priority today: Remember to call Mom and wish her happy mother's day.
Have a wonderful mother's day.
Friday, May 8, 2009
A Long Day
Some days are physically exhausting, others are mental exhausting. Today was the latter. There are days when I might do 7 cases, and feel tired at the end of the day, but mentally feel fresh. Today, I did 5 cases, and am mentally wiped. It really hinges on 3 patients.
It started with a consult, an elderly lady in her 90's with a probable bowel obstruction. Doing routine surgery on 90+yr olds isn't routine, doing it for an acute problem is even less encouraging. Even better, she has family working in the hospital, which, for me, makes her family for me as well. After shooting Xrays, it appeared she had a blockage in the colon (large intestine). Surgery would be a colostomy (a bag on the abdominal wall), and possibly removing the blockage, depending on what it really was. Up until this acute event, this lady had been pretty active and living independently. But even a perfect operation was probably going to leave this woman bedridden-- at 95, she just doesn't have the reserve for even a little set back. I spent a long time talking with family about her, including my least favorite question, "If this was your mother, what would you do?" I'm sorry, but it's not my mom, and that's exactly why I can't answer that question. I've known my mom all my life, and have visited with her over the last 6 months, and so know exactly what her quality of life is, and exactly what her wishes are. I've "known" the patient for 2 hrs, and have no clue as to her spark, her drive, her wishes except for what her children have told me. I can't answer the question, not honestly. Besides, my professional curiosity and drive makes me want to go find out what's wrong, and fix her. In the end, the family decided on comfort measures only. This is a good and merciful decision, and I agree with it. But the whole event leaves a little hole in me.
The second strike comes with my third case in the OR. This is a very pleasant gentleman, who, in the parlance, "has been rode hard and put away wet." He's lived a rough life, and he's a hell of a lot older than the birthdays he's had. He comes to my office by cab, as he has no real support in the community. He came to my office with a whole litany of illnesses, all pretty much real. His complaint to me was rectal pain and bleeding-- severe pain that would leave him unable to walk after a bowel movement. I'm the third doctor he's seen in 5 yrs, he's had two colonoscopies, and no improvement. I've run several tests as an outpatient, looking for some of the less common sources. A look at his bottom in the office is difficult because it is so tender, and so today I'm going to do a colonoscopy, rectal exam under anesthesia, and probably a hemmorhoidectomy. The colonoscopy is challenging because the prep wasn't very good, but the rectal exam shows the real problem. An anal cancer, extending from the outer skin adjacent to the anus across the anal ring to the lining of the rectum. He also does have significant hemmorhoids, but fixing those is now out of the question. I biopsy the tumor for to get a definative tissue diagnosis, and send him to recovery. Anal cancer has been in the news recently, as Farah Fawcett has advanced anal cancer. I'm left frustrated. Once again, I couldn't fix his problem, will have to give him the bad news when he's back in my office, and I know that, with his overall health and poor socioeconomical support, he's not going to do well.
I finish up my last case, and head to hospital B to see one more sick patient. Ms. Brown is a patient I've seen in my office for abdominal pain. She's a vasculopath, someone with severe peripheral arterial disease, and I suspect she's got some mesenteric ischemia (inadequate blood flow to the gut), that's causing her pain. She's also getting worked up by a vascular surgeon for a blockage in one of the arteries to the brain. She roled in to the ER this morning with 10 out of 10 pain and looking septic, going into kidney failure, with a lactic acid level of 8.8 (normal less than 2). A CAT scan suggests she's got small bowel that has died. This is not a good prognosis. (Are you seeing a pattern in my patients here?) I route her straight to the OR, after talking with the family about options and risks. From the clinical picture and the CT, I'm worried I'm going to find the entire gut dead, or so much so that she won't be able to live without IV nutrition. To add to my happiness, she's had a couple of operations in the past, so I might have to fight my way through a thick web of adhesions to evaluate anything. In the OR, we almost lose her on induction (starting anesthesia). My first break comes on the way in-- after a few minor adhesions, the belly is free. I almost immediately smell it. Dead gut. It's a distinct odor, and anyone who's ever worked in an OR recognizes it immediately. I run the small bowel, and come up empty. Nothing. Where is it? I check the right colon. It's a little pale, but it's not the problem. I switch to the patient's right side to look at the left colon, and Bingo! The colon from the splenic flexure down to the pelvic brim is green-gray in color. This is where the problem is. It also fits with her surgical history that I'd reviewed a week earlier. I mobilize the colon from it's various attachments, fire a stapler-cutter across the two ends of the dead area, and pass it off the field. I wash out the abdomen with 5 liters of saline, and run the bowel again. The cecum (the point where the small bowel and right colon join) still looks pale, but otherwise, nothing. But I can still smell dead gut. But there's little else I can do right now. I run a fast whip stitch to close the fascia, put a damp dressing over the open skin incision, and get her back to the ICU. We'll resuscitate her hard overnight, hope her kidneys kick in, and bring her back tomorrow for a second look. I'll create a colostomy at that time as well. By the time I finish up writing orders in the ICU, dictating the op note, talking with family, and a last check on her (collectively called, "tucking her in"), it's close to 830p. I've kept her alive for the time being, but I don't have that warm feeling of success. I question if I've extended her life, or prolonged her death. Only time will tell. I had planned to visit with some friends this evening, about an hour up the road. I call and cancel my plans, and head home. Tomorrow I'm on call, and it will be busy.
Good night
It started with a consult, an elderly lady in her 90's with a probable bowel obstruction. Doing routine surgery on 90+yr olds isn't routine, doing it for an acute problem is even less encouraging. Even better, she has family working in the hospital, which, for me, makes her family for me as well. After shooting Xrays, it appeared she had a blockage in the colon (large intestine). Surgery would be a colostomy (a bag on the abdominal wall), and possibly removing the blockage, depending on what it really was. Up until this acute event, this lady had been pretty active and living independently. But even a perfect operation was probably going to leave this woman bedridden-- at 95, she just doesn't have the reserve for even a little set back. I spent a long time talking with family about her, including my least favorite question, "If this was your mother, what would you do?" I'm sorry, but it's not my mom, and that's exactly why I can't answer that question. I've known my mom all my life, and have visited with her over the last 6 months, and so know exactly what her quality of life is, and exactly what her wishes are. I've "known" the patient for 2 hrs, and have no clue as to her spark, her drive, her wishes except for what her children have told me. I can't answer the question, not honestly. Besides, my professional curiosity and drive makes me want to go find out what's wrong, and fix her. In the end, the family decided on comfort measures only. This is a good and merciful decision, and I agree with it. But the whole event leaves a little hole in me.
The second strike comes with my third case in the OR. This is a very pleasant gentleman, who, in the parlance, "has been rode hard and put away wet." He's lived a rough life, and he's a hell of a lot older than the birthdays he's had. He comes to my office by cab, as he has no real support in the community. He came to my office with a whole litany of illnesses, all pretty much real. His complaint to me was rectal pain and bleeding-- severe pain that would leave him unable to walk after a bowel movement. I'm the third doctor he's seen in 5 yrs, he's had two colonoscopies, and no improvement. I've run several tests as an outpatient, looking for some of the less common sources. A look at his bottom in the office is difficult because it is so tender, and so today I'm going to do a colonoscopy, rectal exam under anesthesia, and probably a hemmorhoidectomy. The colonoscopy is challenging because the prep wasn't very good, but the rectal exam shows the real problem. An anal cancer, extending from the outer skin adjacent to the anus across the anal ring to the lining of the rectum. He also does have significant hemmorhoids, but fixing those is now out of the question. I biopsy the tumor for to get a definative tissue diagnosis, and send him to recovery. Anal cancer has been in the news recently, as Farah Fawcett has advanced anal cancer. I'm left frustrated. Once again, I couldn't fix his problem, will have to give him the bad news when he's back in my office, and I know that, with his overall health and poor socioeconomical support, he's not going to do well.
I finish up my last case, and head to hospital B to see one more sick patient. Ms. Brown is a patient I've seen in my office for abdominal pain. She's a vasculopath, someone with severe peripheral arterial disease, and I suspect she's got some mesenteric ischemia (inadequate blood flow to the gut), that's causing her pain. She's also getting worked up by a vascular surgeon for a blockage in one of the arteries to the brain. She roled in to the ER this morning with 10 out of 10 pain and looking septic, going into kidney failure, with a lactic acid level of 8.8 (normal less than 2). A CAT scan suggests she's got small bowel that has died. This is not a good prognosis. (Are you seeing a pattern in my patients here?) I route her straight to the OR, after talking with the family about options and risks. From the clinical picture and the CT, I'm worried I'm going to find the entire gut dead, or so much so that she won't be able to live without IV nutrition. To add to my happiness, she's had a couple of operations in the past, so I might have to fight my way through a thick web of adhesions to evaluate anything. In the OR, we almost lose her on induction (starting anesthesia). My first break comes on the way in-- after a few minor adhesions, the belly is free. I almost immediately smell it. Dead gut. It's a distinct odor, and anyone who's ever worked in an OR recognizes it immediately. I run the small bowel, and come up empty. Nothing. Where is it? I check the right colon. It's a little pale, but it's not the problem. I switch to the patient's right side to look at the left colon, and Bingo! The colon from the splenic flexure down to the pelvic brim is green-gray in color. This is where the problem is. It also fits with her surgical history that I'd reviewed a week earlier. I mobilize the colon from it's various attachments, fire a stapler-cutter across the two ends of the dead area, and pass it off the field. I wash out the abdomen with 5 liters of saline, and run the bowel again. The cecum (the point where the small bowel and right colon join) still looks pale, but otherwise, nothing. But I can still smell dead gut. But there's little else I can do right now. I run a fast whip stitch to close the fascia, put a damp dressing over the open skin incision, and get her back to the ICU. We'll resuscitate her hard overnight, hope her kidneys kick in, and bring her back tomorrow for a second look. I'll create a colostomy at that time as well. By the time I finish up writing orders in the ICU, dictating the op note, talking with family, and a last check on her (collectively called, "tucking her in"), it's close to 830p. I've kept her alive for the time being, but I don't have that warm feeling of success. I question if I've extended her life, or prolonged her death. Only time will tell. I had planned to visit with some friends this evening, about an hour up the road. I call and cancel my plans, and head home. Tomorrow I'm on call, and it will be busy.
Good night
Ol Clet
I wrote this post about a week ago, but then tabled it. It seems I have a lot of memories of patients who have passed away. But Clet deserves mention.
I thought I would continue with some memories from my practice of the people, patients, and friends that have made a difference. In many cases, the line between patient and friend has blurred over a couple of years of caring for a patient. Clet was one of these people who was both a patient and a man I considered my friend.
I thought I would continue with some memories from my practice of the people, patients, and friends that have made a difference. In many cases, the line between patient and friend has blurred over a couple of years of caring for a patient. Clet was one of these people who was both a patient and a man I considered my friend.
Clet came to me after a biopsy by his primary doctor. The biopsy had turned up an extremely rare kind of cancer, not quite skin cancer, not quite a neuro cancer. Even after fairly extensive searches by myself as well as my oncologist and radiation oncologist, we never really had a good handle on how to treat this thing, mainly because it was so rare there were no organized studies on treatment. All of the literature was based on case reports, "I treated one of these cancers," type items. So none of us were really sure how to best treat this. In addition, Clet was pushing 80, so using a highly toxic regimen really didn't make a lot of sense either, as the treatment would be worse than the disease.
Clet and his wife were much like the Green's, both upright by leaning on the other. They came to every appointment together, sometimes with one of their children, other times, just the two of them, but always together. I quickly learned that despite a neuro condition that slowed his speech considerably, Clet was sharp as a tack, with a wonderful sense of humor. My office staff planned on a little extra time for Clet, they knew it took him a bit to get out what he had to say.
After first doing a wide excision of the skin lesion, I then followed Clet as the wound healed. As soon as we had healing, he underwent a course of radiation to the site, and, for about a year, he did well. He then showed up back in my office with a lump in his armpit. A biopsy showed this was a recurrence, and he underwent another round of radiation. It was during this period that Mrs. Clet fell and broke a hip. She recovered nicely, and after a short stay in assisted living, they were back home again, and, Oh, the tales Clet told. Both of them were using walkers now, and they quickly discovered that they couldn't pass in the hallway of their home-- one or the other had to turn around and go back. So they developed the habit of calling an all clear down the hall before starting down to avoid these one lane tie-ups. Since Clet was a good half foot taller than Mrs., it made for a hilarious tale when he got up in the middle of the night to take care of business and grabbed the wrong walker.
Over the course of another year, I followed Clet, meeting more and more of his family as different sons, daughters, nieces and nephews helped shuttle he and Mrs. back and forth. He asked me about my children, and I kept up to date on the comings and goings of his extended family. Eventually, the cancer returned, and now it was in the vital organs. Once again, I found myself visiting with Clet, now in the hospital. I was there with Clet on the day he passed away. Up until the end, Clet's humor never let up, and he continued to cheer up those around him. Clet's was a funeral I attended, as he had passed from patient to friend a couple of years ago. Although I had done very little to treat him over the last year -- his disease was now in the realm of oncologists and radiation therapy -- his family told me that he treasured his visits with me, and that mine was the opinion he valued most. With his slow speech, Clet could have been someone I rushed through and never got to know. So often I think of him, and how grateful I am that I didn't miss this wonderful person in my life.
Thursday, May 7, 2009
Doctor humor
Four surgeons were talking about their favorite patients.
The first surgeon spoke up and said, "I like operating on librarians, because when you get in there, everything is organized alphabetically and with the dewey decimal system."
The second surgeon then spoke up. "I prefer electricians, because everything is color coded inside."
The third surgeon also had his preference. "My favorite patient is a mechanic, because they understand when you've got a few parts left over."
The three surgeons looked at the forth surgeon. "What's your preference?" they asked.
"Me? I like operating on lawyers." Needless to say, his associates were aghast. "Lawyers!?! Why in the hell would you prefer to operate on lawyers?"
"Simple," he replied, "They're heartless, gutless, and spineless, and the ass and the mouth are interchangable."
The first surgeon spoke up and said, "I like operating on librarians, because when you get in there, everything is organized alphabetically and with the dewey decimal system."
The second surgeon then spoke up. "I prefer electricians, because everything is color coded inside."
The third surgeon also had his preference. "My favorite patient is a mechanic, because they understand when you've got a few parts left over."
The three surgeons looked at the forth surgeon. "What's your preference?" they asked.
"Me? I like operating on lawyers." Needless to say, his associates were aghast. "Lawyers!?! Why in the hell would you prefer to operate on lawyers?"
"Simple," he replied, "They're heartless, gutless, and spineless, and the ass and the mouth are interchangable."
Wednesday, May 6, 2009
Stress management
Lately, my significant other's daughter has been asking to get her belly button pierced, something pretty common these days. The request got me thinking about a time, oh, so many years ago, when another shining example of our finest graced my trauma bay. It was, of course, during my residency, when so many of my favorite tales have come. So come now and listen, while I tell of stress management, trauma style.
Kelly (for lack of any other name) was a young lady of about 20 yrs when I met her. It was a mid morning trauma, a little unusual, since most trauma is mid night. She and her 18 yr old boyfriend had been drinking and smoking, ahhh, something, and had had a little mishap in their van. Well, actually, not so little. They rolled it over. Of course, they weren't wearing seatbelts, and so they wound up in our trauma room, with me taking the head on Kelly-- that is, trying to get a history from her, assessing the airway, trying to keep her calm. As the clothes were cut away, it became apparent that Kelly had a penchant for piercing-- There were 6 or 7 earrings in each ear, a stud in her tongue, and both nipples were pierced. And don't forget, this was 10 yrs ago, when piercing was much less common. Interestingly enough, with all these different piercings, Kelly just about came unglued with.... You guessed it. The IV. She pretty much freaked out, even with all the self administered sedation. Because we were going to the CAT scanner, all of the metal hardware had to come out-- A learning experience in itself, and one that I still find useful. She wasn't happy about this, either, as she was sure all of her holes would close up. She went through the scanner, got Xrays of her spine, and everything else she said hurt, and after everything was cleared, she got a bed for the night to detox.
The following morning, she was sober, sore, and ready to go home. Since she was pleasant, I took the plunge and inquired. "Explain to me, please. You come into the trauma bay with piercing everywhere, but you freaked out when we started the IV." She explained that she didn't like needles. Uh-huh. Still brave, I asked if she had managed to get all the hardware back in. She told me the tongue stud was OK, but her nipples had already closed. But then it got better (and hence this blog's title). She explained to me that the Native Americans had been using piercings for relieving stress for thousands of years. She continued on, telling me that it was a well known fact that women carry a great deal of stress in their breasts. Finally, she proudly informed me that every since she had had her nipples pierced, she had been so much more relaxed, and her life just seemed so much less stressful.
I kid you not.
I have related this story several times over the years, and asked several very stressed women I have met if they would be interested in testing this theory, but to date, have had no one offer to explore this approach to stress management.
May your evening be stress free.
Good night.
Kelly (for lack of any other name) was a young lady of about 20 yrs when I met her. It was a mid morning trauma, a little unusual, since most trauma is mid night. She and her 18 yr old boyfriend had been drinking and smoking, ahhh, something, and had had a little mishap in their van. Well, actually, not so little. They rolled it over. Of course, they weren't wearing seatbelts, and so they wound up in our trauma room, with me taking the head on Kelly-- that is, trying to get a history from her, assessing the airway, trying to keep her calm. As the clothes were cut away, it became apparent that Kelly had a penchant for piercing-- There were 6 or 7 earrings in each ear, a stud in her tongue, and both nipples were pierced. And don't forget, this was 10 yrs ago, when piercing was much less common. Interestingly enough, with all these different piercings, Kelly just about came unglued with.... You guessed it. The IV. She pretty much freaked out, even with all the self administered sedation. Because we were going to the CAT scanner, all of the metal hardware had to come out-- A learning experience in itself, and one that I still find useful. She wasn't happy about this, either, as she was sure all of her holes would close up. She went through the scanner, got Xrays of her spine, and everything else she said hurt, and after everything was cleared, she got a bed for the night to detox.
The following morning, she was sober, sore, and ready to go home. Since she was pleasant, I took the plunge and inquired. "Explain to me, please. You come into the trauma bay with piercing everywhere, but you freaked out when we started the IV." She explained that she didn't like needles. Uh-huh. Still brave, I asked if she had managed to get all the hardware back in. She told me the tongue stud was OK, but her nipples had already closed. But then it got better (and hence this blog's title). She explained to me that the Native Americans had been using piercings for relieving stress for thousands of years. She continued on, telling me that it was a well known fact that women carry a great deal of stress in their breasts. Finally, she proudly informed me that every since she had had her nipples pierced, she had been so much more relaxed, and her life just seemed so much less stressful.
I kid you not.
I have related this story several times over the years, and asked several very stressed women I have met if they would be interested in testing this theory, but to date, have had no one offer to explore this approach to stress management.
May your evening be stress free.
Good night.
Tuesday, May 5, 2009
Successes
Well, we're back, after a short hiatus--this doctoring business takes up a lot of time, ya know. I was thinking back to some more of my successes, and what keeps me in the business, and I started thinking about Bob (another pseudonym, of course). Bob and I did not meet on the best of terms, at least, not for him, and they were pretty crazy for me. It all started one bright spring day a few years ago.
I was in the OR that day, and was just about to start a case, when one of the anesthesiologist came into my room and asked if I could come down to room one, where, "I might be needed." I walked into the room to find about 4 anesthesia providers at the head of the table. This was an immediately clue that there was trouble, especially as none of them was sitting down. The patient had been undergoing cystoscopy, where a lighted tube with a camera is inserted into the bladder to look for disease, or, in men, to assess and treat the prostate. Somewhere, a hole had been formed, connecting the bladder to the abdominal cavity, and about a gallon and a half of fluid had been pushed into the peritoneal (abdominal) cavity. This was bad for a couple of reasons. First, the fluid was NOT isotonic, that is, the same as the body's normal fluids in its electrolyte composition, and so all of the patient's electrolytes were waaaaaay out of wack, lethal in and of itself. Second, all this fluid led to what is called, "Abdominal Compartment Syndrome." What this means is that the abdominal pressure had been pushed up to the point where all the veins in the abdomen returning blood from the organs and lower extremities were compressed and no longer returning blood to the heart. In addition, this distended the diaphragm up into the chest space, severely compromising the patient's ability to breath. This patient was in a bad, bad, bad way-- a hell of a lot closer to dead than alive. Anesthesia was getting an airway in to assist with the breathing, the urologist was working on getting the bladder decompressed, and that left everything in between to me. What I found was an abdomen the size of a prize winning pumpkin, and at least as firm. I had a dull thud when I tapped on it, telling me it was all fluid. He needed help, and now. I first tried placing a 5mm trocar (a tube used for laparoscopy) to see if i could drain this fluid off without a major intervention. I got a few drops, but it obviously wasn't working, and time was running out. I grabbed a prep stick and sloshed over the abdomen, and yanked on a gown and gloves while the crew got a sterile drap over the abdomen. A midline incision from top to bottom and into the abdominal space took less than a minute, and shortly, we had about a gallon of fluid spilled on the floor and on my shoes. Immediately, anesthesia reported a decrease in pressures on the lungs. He was now getting enough oxygen. Within a minute, his blood pressure rebounded, and along with the BP, his heart rate stabilized. After washing out the abdomen to help prevent any further electrolyte problems, I left the patient in the hands of the urologist, who still needed to work on the bladder, with plans to follow up on the patient the following day in the ICU. I still had a patient waiting for me back in my room. I had spent a total of 20 minutes in the room.
The next day, as I rounded on the patient, I discovered a new problem: His abdominal closure had broken down, and he was in danger of his bowels falling out. It was another trip to the OR to re-close the abdominal wall. It was a lot more pleasant this time, we took our time and spent about an hour and a half rechecking the abdominal contents for any other injuries, cleaning up the edges of the muscle layer, and closing the abdominal wall, using a couple of extra tricks I'd learned doing gastric bypass surgery many years earlier. He did well, and eventually was discharged. On frequent follow up appointments, we learned that we shared a few common interests, including our cynism and slightly off kilter sense of humor, and we have been friends ever since. "Bob" will recognize himself when he reads this, I'm sure. Our discussions on the medical system (he once worked for medicare) have colored several of my commentaries. He thanked me for saving his life, which was really a little embarrassing for me. I mean, what do you say? So I said, "Ahhh, it was nothing. Anybody could have done it." Maybe this isn't exactly right, but this is what surgeons do, I just happened to be the one who was available. But it does help to think about this now and then, especially when the other side of being a doctor (a mistake) occurs, and I question if I really belong in this field.
Well, it's time for me to get back at it, so I'll sign off now. See ya next time.
I was in the OR that day, and was just about to start a case, when one of the anesthesiologist came into my room and asked if I could come down to room one, where, "I might be needed." I walked into the room to find about 4 anesthesia providers at the head of the table. This was an immediately clue that there was trouble, especially as none of them was sitting down. The patient had been undergoing cystoscopy, where a lighted tube with a camera is inserted into the bladder to look for disease, or, in men, to assess and treat the prostate. Somewhere, a hole had been formed, connecting the bladder to the abdominal cavity, and about a gallon and a half of fluid had been pushed into the peritoneal (abdominal) cavity. This was bad for a couple of reasons. First, the fluid was NOT isotonic, that is, the same as the body's normal fluids in its electrolyte composition, and so all of the patient's electrolytes were waaaaaay out of wack, lethal in and of itself. Second, all this fluid led to what is called, "Abdominal Compartment Syndrome." What this means is that the abdominal pressure had been pushed up to the point where all the veins in the abdomen returning blood from the organs and lower extremities were compressed and no longer returning blood to the heart. In addition, this distended the diaphragm up into the chest space, severely compromising the patient's ability to breath. This patient was in a bad, bad, bad way-- a hell of a lot closer to dead than alive. Anesthesia was getting an airway in to assist with the breathing, the urologist was working on getting the bladder decompressed, and that left everything in between to me. What I found was an abdomen the size of a prize winning pumpkin, and at least as firm. I had a dull thud when I tapped on it, telling me it was all fluid. He needed help, and now. I first tried placing a 5mm trocar (a tube used for laparoscopy) to see if i could drain this fluid off without a major intervention. I got a few drops, but it obviously wasn't working, and time was running out. I grabbed a prep stick and sloshed over the abdomen, and yanked on a gown and gloves while the crew got a sterile drap over the abdomen. A midline incision from top to bottom and into the abdominal space took less than a minute, and shortly, we had about a gallon of fluid spilled on the floor and on my shoes. Immediately, anesthesia reported a decrease in pressures on the lungs. He was now getting enough oxygen. Within a minute, his blood pressure rebounded, and along with the BP, his heart rate stabilized. After washing out the abdomen to help prevent any further electrolyte problems, I left the patient in the hands of the urologist, who still needed to work on the bladder, with plans to follow up on the patient the following day in the ICU. I still had a patient waiting for me back in my room. I had spent a total of 20 minutes in the room.
The next day, as I rounded on the patient, I discovered a new problem: His abdominal closure had broken down, and he was in danger of his bowels falling out. It was another trip to the OR to re-close the abdominal wall. It was a lot more pleasant this time, we took our time and spent about an hour and a half rechecking the abdominal contents for any other injuries, cleaning up the edges of the muscle layer, and closing the abdominal wall, using a couple of extra tricks I'd learned doing gastric bypass surgery many years earlier. He did well, and eventually was discharged. On frequent follow up appointments, we learned that we shared a few common interests, including our cynism and slightly off kilter sense of humor, and we have been friends ever since. "Bob" will recognize himself when he reads this, I'm sure. Our discussions on the medical system (he once worked for medicare) have colored several of my commentaries. He thanked me for saving his life, which was really a little embarrassing for me. I mean, what do you say? So I said, "Ahhh, it was nothing. Anybody could have done it." Maybe this isn't exactly right, but this is what surgeons do, I just happened to be the one who was available. But it does help to think about this now and then, especially when the other side of being a doctor (a mistake) occurs, and I question if I really belong in this field.
Well, it's time for me to get back at it, so I'll sign off now. See ya next time.
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