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