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.