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.