Saturday, June 8, 2013
I don’t think I’ll ever forget that night. We were together for hours, standing and sitting near each other, hands mingling together as we kept at it, long and intense; endless. The minutes stretched into hours, but we would not give in to fatigue. Finally, I looked up and stared into her soft hazel eyes. I’m not sure what I was looking for: maybe some soft words of encouragement or some good thoughts. She seemed to sense my anxiety, my deep needs as I stared into those eyes. It wouldn’t have taken much, maybe just a nod of her head, to keep me going. It seemed like an eternity, but then those eyes lit up and the light danced in them. Then I heard the words I’d been waiting for:
“Why don’t you just cut the damned leg off?”
“Harrumph,” was my reply and bent my head and went back to work, doing my best to salvage poor Melvin’s leg.
Melvin was a retired mailman. He was used to walking and the blocked artery prevented him from pursuing this favorite activity. He could barely walk fifty feet when I first met him.
“The pain in my calf is just terrible, Doc,” he reported. “I can’t do anything anymore, Can’t you help me?”
He went through the usual evaluation which revealed a fairly straightforward occlusion of the right superficial femoral artery with pretty normal arteries beyond the blockage. He still smoked cigarettes and had hypertension. In short, he was the typical vascular patient. I had advised him to give up smoking and he had cut back from two packs per day to half a pack; an improvement, but not would I would have liked.
His symptoms warranted surgery and he underwent and uneventful right femoral-popliteal bypass, six months before Paula and I were to join together for our eventful night together.
Melvin called my office complaining of severe pain in his leg the day before. A quick exam confirmed that his graft was occluded. Off to the hospital he went, a friendly Radiologist whisked him to the angio suite where catheters were inserted into his arteries and an attempt was made to dissolve the offending clot. Unfortunately, the thrombolysis didn’t work. The catheter could not be properly positioned in the graft and a day of infusing thrombolytic medication did nothing. Melvin’s leg was still ischemic.
Surgery was the next option. A simple thrombectomy. Open up the groin run the Fogarty up and down a few times, close the artery and be done in less than an hour. The best laid plans…
The whole affair did not begin well. I had been waiting for hours to begin the surgery. I called the OR at about 5:00 pm and asked Melissa, the head nurse on evenings, when I’d be able to start my case. Melvin’s foot did have some circulation and he was not in any immediate danger of losing his it, but he was having considerable pain.
“Come on now,” was Melissa’s answer.
So, I made the short drive over to the hospital.
“You have to wait for Dr. So and So to finish,” she announced after I arrived.
“But, you told me to come in now,” I protested.
“I thought the other room would be done and anesthesia can only run one room,” she replied.
Melissa did this over and over, that is tell me to come to do a case when it really wouldn’t start for hours and I soon learned not to come in unless they were definitely ready to start. But, for Melvin I waited and waited and waited. Almost three hours later, at about 8:00 pm, we were ready to start. Initially, Martha was the surgical tech scrubbed on the case, but she had to leave at about nine, replaced by Paula. We had barely started at that point.
The incision and initial dissection were unremarkable. There was the expected scarring, but the graft was easy to expose and the dissection of the scarred in common, superficial and profunda femoris arteries was not unusually difficult.
“This shouldn’t take much longer,” I said to Paula as she tied her gown and ambled up to the table. “Hopefully just run the Fogarty up and down and we’ll be done.”
“Good,” was all she said.
With the arteries exposed and controlled and everything in place, the real operation was ready to commence: give some heparin, clamp the arteries, open the graft close to the anastamosis to the common femoral and we’re on our way.
As expected there was thrombus (clot) in the graft. The clot we could see was pulled out and then a #4 Fogarty catheter is passed, distally first, removing a long snake of maroon thrombus, a large amount first, and smaller amounts with each pass. There is a bit of resistance with the last pass, but no more clot is retrieved and we are rewarded by bright red blood filling up the graft, suggesting that the artery is open.
Now, the other way. The first pass restores some inflow, but not completely as the blood weakly squirts out, instead of the blast of blood under pressure one would expect from an unobstructed femoral artery. Two more passes and there is a sudden burst of bright red blood as normal inflow is restored.
Everything is going well, just close it up and we should be done.
I smile at Paula who is sitting across from me.
“We should be done soon,” I comment.
“Good, because it’s past my bedtime,” she replies.
OK, sew up the graft with some 5-0 Prolene open her up, good pulse here and down the graft. Check the foot: no pulse.
“Do you have a Doppler?” I inquire of the circulator.
“I’ve got it already,” Paula states.
Always on top of things, that Paula.
I listen at the ankle. There is a weak regular pulse, audible, but not what I would expect if the graft was open. I listen over the graft and here the short staccato of the pulse, like waves beating against a closed door.
“Something’s not right,” I say out loud to no one in particular. “Give me something to open up this graft again.”
And, we start anew.
Pass the catheter, restore backbleeding, no pulse. OK, let’s open up at the distal anastamosis. The old, healed wound at the distal thigh is incised and carried down to where the graft is encased in scar tissue. This scar is gingerly cut away, exposing the graft material which is cleaned down to the connection at the popliteal artery. There is a pulse in the graft, but none in the native artery.
Next step: clamp the graft and open the artery just above the distal anastamosis. The inflow is excellent and there is some backbleeding finto the graft. Pass the catheter and it stops about ten centimeters into the graft. There must be some occlusion at that level. It’s time to stop for a moment and look at the arteriogram.
The artery is open on this film. What’s going on. Must be a dissection of the artery.
“We may be here a while,” I remark, once again to no one in particular. I look up at the clock, now reading 10:15 pm.
“You may want to call in the call team,” I remark, “we definitely will not be done by 11:00.”
“That’s me,” Paula reports.
“I guess we’re in this together,” is all I can say.
I return to the patient and start to dissect more. Paula follows my every move, handing me scissors, clamp, pick-ups, right angle, vessel loop, whatever I need without my asking, anticipating my every need. I follow the graft down to the artery and begin to tease it away from scar tissue and delicate veins which entwine around the artery. Careful, try not to tear anything.
A pool of dark blood wells up. Suction…suction some more. There’s the culprit: a branch from one the veins. Clip, clip, a bit more suction, on with the fight. I’m reaching the limits of what I can dissect around the knee. The artery is diving deep behind the knee, a difficult place to expose. But, it looks like there is enough artery beyond the junction with the graft to work with.
Clamp,. Clamp, cut and look inside the artery. There is no question that the artery is dissected, a bad thing in this case. What it means is that the lining of the artery, or intima, has lifted away from the muscular wall, creating a false passage. I’m left with two options: try to repair the dissected artery or bypass to a different spot, probably below the knee.
At this point I have to confess that I’ve never had much luck with repairing arterial dissections, although I keep trying. I don’t know if it’s my technique or if I underestimate the extent of damage. All I do know is that I’ve tried to do it over and over again, but I never learn, it never works and I always end up redoing the bypass at some point away from the damaged artery.
Even with the above disclaimer, I try to repair the artery. A number of interrupted 7-0 sutures tacking the back wall down, then close the artery and open the graft and, voila, a pulse appears in the artery.
Good, good, let’s close up and be done with this case. But, it was not to be. After five minutes the pulse disappears and I’m back to square one. The clock now reads 1:30 am. I stare at the arteriogram and proceed.
Paula looks up at me from across the table, sighs, and hands me the scalpel. She’s too slow this time, however, as I make the next incision below the knee using the cutting mode on the electrocautery, a sign that I am getting a little frustrated with the whole affair. Deeper and deeper into the leg, through fat, fascia, around muscle, more fat, more fascia until a bundle of veins is exposed. More gingerly dissection identifies the popliteal artery below the knee, a hard pipe of calcified artery that, although appearing to be adequate on the X-Ray will not serve my purposes, because it is severely diseased.
Maybe a bit more proximal? Dissecting up a bit exposes more of the same. Now what? It’s at this point Paula offers her words of encouragement.
“Why don’t you just cut the damn leg off?”
It’s now getting close to 3:00 am and I’m not much better off than when we started. One last effort: bypass farther down the leg, to the anterior tibial artery, which looks good on the arteriogram and runs all the way into the foot.
At this point I recall a case I scrubbed on as a resident. I was helping one of the vascular surgeons do a similar case. This particular surgeon was one I considered to be of marginal skill at best. He had filleted the leg open in the groin, thigh, proximal leg and was about to go to the ankle when I asked:
“Do you think this will work?”
Surprisingly, he didn’t become angry or command me to leave the OR suite, much to my dismay. He just shrugged and replied that sometimes, in Vascular Surgery, you do what you have to do, because the alternative is loss of limb or life.
Paula and I embarked on the next stage of our journey as I began to expose the anterior tibial artery. The artery was small as expected, but appeared adequate for my purposes. I harvested a segment of saphenous vein from the groin and thigh, long enough to run from the graft in the thigh to the mid calf. Next I opened the artery, greeted by some back bleeding. I embarked on the first anastamosis, vein to artery, with the vein reversed to avoid the problem of its valves. Next the vein was tunneled from the anterolateral leg to the medial thigh and then the next anastamosis was done, graft to vein.
And, the moment of truth, the clamps are removed and…nothing. No pulse in the new vein graft. I examine the graft in the groin, where there is a pulse and in the thigh, where there isn’t.
Maybe, it’s something simple, just some thrombus in the graft. The way this case is going there are probably gremlins inside the graft.
From the graft in the thigh I pass a Fogarty catheter proximally and distally and, thankfully, some clot is removed from the proximal graft. Now there is excellent inflow. The graft flushes easily with no resistance. I suture the graft closed and, crossing my fingers and toes, open it up to allow flow. To my, and Paula’s, great relief there is a good pulse in the graft and in the artery beyond the graft.
It’s now 8:00 am.
All that remains is to make sure there is no bleeding and close it up. Brian, Paula’s relief comes in and offers to take her place. To her credit, she volunteers to stay and finish what she has started. We put the last dressing on at about 9:00 am. We both leave for a much needed bathroom break, after which I sit down to the tedium of writing orders and dictating the marathon operative note.
Melvin recovered uneventfully. His graft remained patent for about eight months and then re-occluded. This time it was reopened by our Interventional Radiologist. It eventually occluded again sometime later and he learned to live with the pain for a while. Eventually, he had to undergo a below knee amputation.
He underscores what one of my teachers told me years ago.
“All vascular surgery is palliative. What we do staves off the inevitable.”
As I think about these words now, it strikes me that what he said can be applied to all of medicine. What we doctors do is purely palliative. The end result is the same for everyone and the best a physician can do is put off, for a time, the inevitable.
I did see Paula before she left that morning; both of us were exhausted, completely and totally spent, but also quietly satisfied after the night’s affair. She has continued to assist me over the years, now as a Licensed First Assistant. She remains one of the best assistants, perhaps because she understands the way I operate better than most, one of the fruits of our night together.
Sunday, May 19, 2013
Has common sense been lost forever from the world healthcare? I ask this question because of a recent call I received about a patient of mine who had arrived in the ER hypotensive, hypoxic and fast approaching death. The ER doctor called me suspecting she had an intestinal obstruction. Then he told me her name: Linda X.
The name immediately resonated with me because I knew her well, having operated on her twice in the last year. I had first seen her when she was admitted with abdominal pain about a year before. She had a history of moderately severe COPD and was intermittently on home oxygen. Workup at that time revealed a mass in the head of the pancreas. She was not jaundiced nor obstructed at that time. CT Scan suggested her tumor was resectable, therefore her underlying medical condition was optimized and then she underwent surgery. At operation she was found to have adenocarcinoma of the pancreas with involvement of the superior mesenteric artery and vein, making the tumor unresectable. After surgery she was referred to the Medical Oncologist who gave her chemotherapy for 6 courses and then referred back to me to be reexplored. Although my past experience suggested that her tumor still would not be resectable, a second look represented her only chance for cure. She opted to proceed with surgery. The findings at the second operation were almost identical to the first. The tumor had not increased significantly in size, but also had not shrunk, a finding which was not very surprising.
It was Linda who was in the ER now, about 8 months after her second exploration. In addition to the suspected intestinal obstruction she also was found to have a pulmonary embolus, pneumonia, acute renal failure and was profoundly acidotic. The ER physician asked me when I would be taking her to surgery. My polite answer was “never;” I thought I heard a gasp on the other end of the phone.
“But, she’s obstructed and may have dead bowel, and she’s not a DNR,” he stated.
“She has unresectable pancreatic cancer which has not responded to any other treatment. What am I going to do? Keep her alive to suffer for an extra few days. I think you should just keep her comfortable and let her go peacefully,” was my reply.
He hung up, but did follow my advice, which was a bit of a surprise, someone actually thinking about the patient’s best interests.
I was involved with a similar patient many years ago, when I was Chief Resident in surgery. Allen came to our clinic with a carcinoma of the rectum. The diagnosis had been confirmed by colonoscopy and biopsy. He was having intermittent rectal bleeding and tenesmus. He did have moderately severe COPD, but his symptoms warranted surgery. He was further evaluated with a CT Scan of his abdomen and pelvis which revealed liver metastases. Still, surgery for palliation was indicated; besides, abdominoperineal resection was a good case for a Chief Resident. This was in the days before rectal cancers were treated with preoperative chemo/XRT. Allen was scheduled for surgery, but a few days before he was to undergo the procedure he was admitted to my service with shortness of breath. His chest X-ray revealed probable lymphangitic spread of his cancer, something that had not been apparent a few days earlier on his CT scan.
I sat and talked with him after the all the workup had been completed. I explained that he had a very aggressive cancer and that, even with chemotherapy, surgery and radiation, he had a very limited life expectancy. I asked him what treatment he wanted, explaining all the options from aggressive chemo to hospice. He asked for time to consider the options and, before he could make a decision, he suffered a cardiopulmonary arrest. At that moment, I had just finished a surgery and was in the PACU when I heard the all too familiar “Code Blue” for room 623, Allen’s room. I raced up the stairs and found the medical team doing a full resuscitation, about to intubate him. I pulled the senior medical resident aside and politely asked him to stop, explaining Allen’s condition.
“But there’s no DNR on the chart,” he protested.
“I know, but with his cancer his chance for long term survival is just about zero and all you will do is make him suffer,” I answered.
He finally agreed and Al was allowed to pass away. (sounds better than “die”).
Such scenarios occur on a regular basis. We physicians expend a great deal of time, effort and money caring for patients with hopeless conditions. I am frequently called to see elderly, bedridden patients with advanced Alzheimer’s for debridement of necrotic sacral or hip or ischial wounds. Often they have been ignored by their families until they have become too ill to stay in the Nursing Home and are sent to the hospital. Out of guilt or misplaced sense of duty, family members often want “everything done” even if it means making Grandma suffer and while doing nothing to improve quality of life. In such cases I will usually explain that the chances of the wounds healing are poor, but it usually falls to deaf ears. Most often, if the family insists, I go ahead with the procedure as it is low risk and does provide some small benefit.
Statistics show that a large portion of the health care dollar is spent on patients in the last six months or year of their life. In my book about surgery, “Behind the Mask”, I state that the problem with this statement is that physicians very often do not know which octogenarian with a perforated colon is going to walk out of the hospital completely recovered or succumb to overwhelming sepsis. However, in cases like Linda’s or Allen’s, the treating physicians should know that their prognosis is hopeless and that they should be kept comfortable and allowed to die with dignity.
Where does all this lead? The practice of medicine demands that physicians make medical decisions and judgments on a regular basis. It is our duty to explain options, risks and benefits to our patients and their families. Very often such discussions involve treatment options for life threatening illness and it is best that doctor, patient and family reach a decision together and that such decision be clearly documented. Ultimately it is the competent patient’s choice, not the doctor’s or patient’s family.
But, in a situation where the patient is unable to make the decision and an immediate decision is needed sometimes a doctor must exercise common sense and do what is right. This does not mean care should be withdrawn; rather it means that extraordinary measures which will only prolong suffering should not be instituted. Does this mean the doctor is playing “god?” I don’t think so. We physicians spend four years in medical school and even more years afterwards in residency. We should understand the disease processes we treat and should be properly equipped to exercise judgment in cases like the ones cited above. A little bit of common sense in such situations serves our patients and their families well.
Wednesday, May 15, 2013
A Great Tragedy
I’ll never forget…
It was always there for me, like a great and faithful friend. Every morning I’d wait, full of anticipation and the expectation of being completely satisfied. I know what you might think. It was just an inanimate object, lifeless and cold. But it was a thing of comfort for me. Of course, it wasn’t the only thing in my world, but it gave me life, at least in a sense.
Let me spell it out more clearly for you. Every morning I would get up from my comfy bed, stretch and then come downstairs. After the usual morning constitutional I patiently waited, always calm, but also with the tremendous eagerness seething inside. I would sit and stare up at it as everything was prepared. First a little of this, then a little of that and a smidgeon more of this on top. When it was finally done I could never contain myself. I would jump up and down and then race to my designated spot.
After what seemed to be ages my dear friend would be set down in front of me and, finally, I could relax and commune with it in a way few people really understand. Afterwards we both felt satisfied, the emotional letdown was usually so great that I would have to settle down and take a nap. My treasured companion would go away for the rest of the day, but I knew we’d be back together the next day and the next and the next. As a matter of fact I couldn’t imagine any day when we would not be together.
Then came the great tragedy, the day we were parted forever. I remember it like it was yesterday. The morning was darker than usual, perhaps it was the clouds or maybe it was the time of year; there was thunder in the distance. All I know is that it was pitch black outside and the lights inside were dimmer than normal. My whole body shook as I was filled with a sense of dread and foreboding, but I wasn’t sure why. I felt a little better when my dear friend was brought out, looking as always, smooth and sleek. And, just like every morning, I sat patiently and waited. The were others there, sort of like a great fraternity of servant/friends, but those others didn’t matter to me. I only had eyes for my faithful companion.
I’m not sure how it really happened. All I know is I closed my eyes just for a second, nothing more than a blink and, in that brief moment, I was abandoned. A clumsy slip of the hand, followed by a crash and then a shattered existence. There were bits of glass and food scattered everywhere; nothing could be saved.
This can’t be I thought. How can I survive, surely I’ll starve… Pull yourself together. Take slow deep breaths. Maybe it’s all just a terrible nightmare. That’s right, pinch yourself and you’ll wake up and everything will be Ok.
But, it was real and nothing could stop the ache I felt in my heart … and stomach. All I could do was lie on the floor and let out mournful wails of sorrow. Only a miracle could save me from everlasting despair.
And, like a light from heaven, a miracle occurred. It was only few minutes, although at the time it was more like an eternity of suffering. A replacement came, quickly and silently. It was shiny and full to the brim with my favorite food. I couldn’t contain myself and ran up to greet it. First I nuzzled it with my lips and then I almost devoured it, finally licking it all over until its shiny metal gleamed like a mirror. It was at that moment I knew that this new and wonderful companion would be with me forever.
Stainless steel won’t break like glass.
Zoe is a six year old, slightly overweight Norwich Terrier.
Sunday, May 12, 2013
Training in the medical fields emphasizes paying close attention to our patients and every little detail of their medical care. Medical students and residents are taught to take note of a patient’s appearance, demeanor, voice along with a detailed history and physical exam. When I walk into a patient’s room my assessment begins.
Such attention to detail becomes even more important after surgery is performed. As a resident I was taught to anticipate the worst, diligently search for signs of infection or poor healing and intervene as early as possible. Proper preoperative evaluation and post operative care are of paramount importance to successful surgical outcomes. Sometimes I thought that the actual surgery was de-emphasized, the implication being that anyone can perform an operation properly and it is the before and after care that mattered the most.
But, I’m not so sure…
Debbie was seen in my office with complaints of lower abdominal pain for almost one year. She had been worked up extensively with Abdominal and Pelvic CT Scan, Upper and Lower GI endoscopy, Pelvic Ultrasound and all pertinent blood and urine tests. Everything was normal. Cholecystectomy, Appendectomy, and Total Abdominal Hysterectomy and bilateral Salpingo-ophorectomy had been performed in the past. I discussed the options with her, offering to do a laparoscopy with the forewarning that it was very possible everything would be normal and her pain would persist. The surgery was performed, a few adhesions were lysed and all was well.
About two hours after surgery I was called by the recovery room nurse who informed me that Debbie was recovering satisfactorily, but she was requiring parenteral pain medication and wished to stay overnight. I gave her the appropriate orders and then went on my way to enjoy my weekend off.
Monday morning comes around and I’m called by the nurses about Debbie, asking if she can be discharged. Why is she still in the hospital? Then it hit me. I had failed to include her in my sign out to my partner. She was supposed to go home after surgery and I had forgotten to call my office and add her to my list after deciding she should stay in the hospital overnight. I went to see her first thing and found her sitting up in bed smiling.
“I feel just fine,” she informed me.
I gave a brief apology for neglecting her over the weekend and discharged her home. She had received proper nursing care over the weekend, her pain was better and, except for my own embarrassment, and a couple of extra days in the hospital, no one suffered. All the usual mental cogitating over post op care was not necessary in her case.
Then there are the patients we used to operate on at night at the county hospital where I trained. This hospital was a county hospital in the traditional sense, perpetually understaffed and underfunded. If we performed surgery at night, that is, after 7:00 pm there was no PACU nurse. These patients were taken to the ICU after surgery where there immediate post op recovery was spent parked in front of the ICU nursing station. This did not mean they were actually monitored by the ICU nurses. The often sparsely staffed surgical ICU sometimes had as few as four nurses for fifteen very sick patients. A healthy 23 y-o male who had just had his appendix out just did not measure up to a trauma patient with a pelvic fracture, bilateral chest tubes and severe closed head injury.
The nurses did check on these post op patients. This meant they walked by the stretcher every few minutes and made sure the patient was still breathing. This constituted close monitoring of the airway in a fresh post op patient. After the requisite 45 minutes the patient was sent to the surgical floor where there might be four nurses for forty patients. More benign neglect. Over the years I never became of aware of any patient who suffered from the arrangement.
I do have to report that the night time PACU (Post Anesthesia Care Unit, a fancy name for Recovery Room) situation changed with the start of my Chief Resident year. The new hospital CEO saw fit to include 24 hour Recovery Room nursing in his budget. Laurie was given the job. Laurie was the best ICU nurse we had. She understood surgical patients better than most of the doctors. She also did not mind taking it easy. It’s not that she was lazy; it was more that she didn’t do anything more than she was required. As the primary night time PACU nurse she spent most of time knitting. The occasional post op patient was attended to and then she went back to knitting. It was a win-win arrangement for all. Our night time patients were recovered properly by an excellent nurse and Laurie did a lot of knitting. It turned out to be even better. I soon learned that I could write an order, “Keep in Recovery Room overnight.” This was perfect for patients who had undergone big cancer operations or major vascular procedures. Most of them needed overnight observation in the perpetually understaffed ICU. Keeping them in the PACU gave them mostly one on one nursing and most often with the best nurse in the hospital. Laurie didn’t mind. The patients were almost always stable and she was still able to do a lot of knitting.
But, I am straying away from the topic of neglect.
Finally, there is the case of Mike. Mike came to our hospital after leaving AMA (Against Medical Advice) from an academic hospital down the road from our community hospital. He had been admitted with a bowel obstruction and most of the work up had been done at the other facility. The short version is that he had a large mass in his right colon that was causing his obstruction; biopsy revealed carcinoma of the colon. Mike had grown frustrated waiting to have surgery; therefore he left and showed up in our ER.
After obtaining his records from the other facility his surgery was scheduled for the next day, Sunday morning. He had a large tumor growing into his abdominal wall and multiple enlarged lymph nodes in the mesentery, without any obvious distant disease. He had en bloc resection which included a right hemicolectomy with all the enlarged nodes along with resection and reconstruction of the abdominal wall. He was taken to the ICU post operatively with a nasogastric tube, arterial line, foley catheter and IV lines. He was very stable in the immediate post operative period.
I made rounds early the following morning; he was still recovering well and I gave orders to transfer him out of the ICU. He asked me how long he would be in the hospital. I responded “about five more days depending…”
“But doc, I need to leave. My dog is tied up in my back yard and I need to feed him.”
I thought for a moment. “Isn’t there anyone you can call who will feed him?”
“He’s one mean pit bull, doc. No one can go near him but me.”
This created a bit of a dilemma for me, (I have six dogs of my own) but I could not let him leave. I left his bedside and was seriously trying to think of a solution to this problem when Mike solved it for me. I received a call from the ICU nurse. Mike had gotten out of bed, pulled out his NG tube, art line, IV’s, insisted the foley be removed and signed out AMA. He was already gone and no amount of talk could have changed his mind.
I shook my head and silently hoped he would be OK. Well, two weeks later Mike showed up in my office, looking remarkably fit and well.
“Doc, I haven’t felt this good in years,” he reported.
“Are you eating OK?”
“Anything I want.”
“Going to the bathroom?”
He had gained ten pounds, his wound was healing well; he was a true surgical success. I removed his staples and set him up to see the Medical Oncologist, still marveling at his recovery without any of the usual post operative gyrations. He had done all of his post operative care based on how he felt and he was his own best doctor.
I think there are lessons to be learned from all this, ones that I have incorporated into my practice over the years.
First, and most important: do the best operation you can do. A properly performed surgery will usually be successful no matter what is done afterwards.
Second: listen to the patient. They will tell you if they are ready to eat or go home or if there is a complication brewing.
Despite everything that is happening in the world of medicine these days there is still some truth in the term “healing arts.” The science of medicine has come a long way from the days of Hippocrates, but medicine will never be reduced to simple algorithms and protocols until humans are constructed on assembly lines. And, although we are taught to be vigilant and to pay close attention to detail, a bit of benign neglect from time to time can be a good thing.
Wednesday, May 1, 2013
1. S/P Right Colon Resection
2. Diet: Consult Dietary for recommendation
3. IV: consult Nephrology.
4. VS: Per Routine
5. Monitor Intake and Output. If urine output is low, consult Nephrology
6. PCA pump per Pain Management
7. Antibiotics per Infectious Disease
8. Consult GI for recommendation for proton pump inhibitor
9. Foley catheter to gravity, D/C in am if OK with Urology
10. AM lab per Medicine
11. Consult Physical Therapy for ambulation per their recommendation
12. Consult Cardiology for Beta Blocker administration
13. Hematology to see for DVT prophylaxis
14. If patient develops temp above 99.0 0r WBC above 10,000 consult Infectious Disease
15. Consult Cardiology if patient complains of chest pain
16. Critical Care Consult while patient is in ICU
The Age of No Reasoning
Sunday, April 28, 2013
“First do no harm…” Hippocratic Oath
What should a surgeon do with an impossible case? For the first time in my career I asked myself that question. Over the years, I’ve had more than my share of difficult cases. I’ve had patients with life threatening conditions whom I wished I could offer more than to just shake my head and speak empty words of encouragement. They stare back at me and I see their eyes full of hope. How many times have been forced to say: “I’m sorry, there’s nothing I can do that will make you better, or cure you, or ease your pain.”
I hate moments like those.
A patient comes to me with cancer of the stomach. Major surgery is scheduled. All the preoperative testing indicates that there is a good chance for the surgery to be curative. An incision is made and the abdomen is explored. My heart sinks with the first glance. Grayish white nodules stud the abdomen. The normal yellow fat of my trusted friend, the omentum, is caked with an ugly gray mass of cancer. Nothing can be done. “Maybe chemotherapy will shrink the tumor,” I say, although I know that this cancer rarely responds. The tumor was there before the operation. The surgery offered hope and no harm was done. And, the patient thanks me. Irony.
Another patient comes with pain in his legs and black patches on his feet. He smokes two packs of cigarettes a day, has been hypertensive for years and sporadically takes his medication. My exam reveals areas of dry (not infected) gangrene on his feet, bluish discoloration of his toes and no pulses can be felt in the groins or feet. The patient is sent off for a battery of tests which confirm my suspicions. All of his major arteries from just below the aorta and throughout his legs are occluded. In this case there is no reason to try to do any surgery. Any operation will surely fail and probably leave the patient worse than he is now.
The two cases above are difficult, no question. But they were handled in the best way possible and in neither case was the patient harmed; Hippocrates fulfilled. They were difficult, but not impossible.
But then there was Lucia, a thirty seven year lady who had been in federal prison for three years; the reason for her incarceration unknown. She had previous surgery performed in Mexico, one for Crohn’s disease, the other for carcinoma of the colon. Details of these surgeries were unavailable. During her three years in prison she had been on and off Total Parenteral Nutrition, which is receiving all of one’s nutrition through an IV, and had required nasogastric tube placement for bowel obstructions on a regular basis. Her sentence finished while she was in the prison hospital. Her TPN was stopped and she was discharged from the prison with instructions to go to the hospital right away.
Of course, she doesn’t choose to go to a hospital close to the prison. No, she must travel 250 miles and show up in the ER where I happen to be on call. The workup demonstrates a definite small bowel obstruction characterized by dilated proximal bowel and a paucity of air in the colon. She tells me she has had no passage of stool or flatus by for three weeks, hallmarks of a complete intestinal obstruction. She appears, on CT Scan, to have some sort of mass surrounding and encasing her small bowel and possibly a portion of her colon.
Lucia is admitted to the hospital. A biopsy of the mass seen on CT reveals only inflammation, no cancer. Her obstruction persists. From my perspective there is no choice. After four days in the hospital without improvement, I bite the bullet and bring her to surgery to embark on the impossible.
Her abdomen was marked by a wide scar running from xiphoid to pubis which meant that I should expect to find adhesions (scar tissue) along the entire length of her abdomen and I should not anticipate any relatively easy spot, free from adhesions, to enter the peritoneal cavity. Start with the simple things first. The wide scar is excised which carries me into the subcutaneous tissue, usually marked by yellow fat. Hers is filled with fat and off white scar. Gingerly I go deeper, through the scar to the expected fascia, the fibrous tissue which surrounds our muscles and provides the strength we needed to hold our abdomen together.
Carefully the fascia is incised, separating as it is divided. I am greeted by bowel, intact and pink. Maybe this won’t be as hard as I thought. Wrong, wrong, wrong. I tease the bowel away from the undersurface of the abdominal wall and what should have been peritoneum, the thin membrane which lines and surrounds our abdominal viscera.
Careful, gentle, not too much tension or traction. No good, the distinctive flower of bowel mucosa stares back at me, indicating a hole in the bowel, as I my worst fears are realized and I settle in for what is sure to be a very long process. And, the hole in the bowel means I’m committed to finishing what I’ve started, no backing out now. I suppose I could have just repaired the hole, but such a repair without freeing the bowel from all the adhesions is very likely to break down. So, it’s onward into the morass of fused bowels and adhesions. Lucia’s and my troubles had barely started. Very gradually I manage to separate the abdominal wall from the underlying viscera. In the process I discover there is no “peritoneal cavity,” only a solid mass of congealed intestine.
There must be one place where the bowel can be freed in a safe manner, I think.
Aha, this looks promising. It turns out that it was and it wasn’t. I was able to free that particular loop, but it was transverse colon, which does nothing to help me cure her small bowel obstruction.
Maybe here, no just more colon.
The bowel in the middle is definitely small bowel and from its collapsed appearance and the CT Scan images, it is probably beyond the point of obstruction. So, I start to try to free it from some very dense adhesions. No luck, however; every attempt to pry even a centimeter loose threatens irreparable damage. At this point I also realize that she doesn’t have much small bowel. She wasn’t sure exactly what surgery she’d had before, but it appears to me that she only has about three feet of small intestine and cannot afford to lose anymore.
Try somewhere else. Maybe find the most proximal small bowel.
I gingerly attack the left upper quadrant and am rewarded with some definitely dilated small bowel, which means I’m proximal to the point of obstruction. Unfortunately, despite my cautious zeal, I’ve made another hole in the small bowel. I toil onward, gradually delineating the entire colon.
I am now left with the colon which is completely free, a loop of dilated bowel, probably jejunum just beyond the Ligament of Trietz, (which marks the beginning of the small bowel beyond the duodenum) and then a solid mass of small bowel which is congealed together as if someone had embedded it in concrete.
If I try to pry apart the remaining small bowel I may cause such damage as to leave it all unsalvageable which would require its resection and leave her with almost no small bowel. If I just close the holes I’ve made I may be able to back off, but she would still be obstructed and the closures would likely to leak. Impossible.
I am now faced with a situation I’ve never faced before. Over the years I’ve been in some very difficult abdomens, spent hours and hours teasing apart fused and fibrotic intestines. But I’ve always managed to get it all unstuck. Sometimes resection of irreparably damaged small bowel was necessary, most of the time only a few sutures to repair partial tears were needed. Now I’m facing a new and, I hope, unique situation. My instinct says back off, close the holes I’ve made and see if she’ll resolve the obstruction without needing further intervention. My head tells me this will leave her on TPN and with an NG tube forever. Should I forge ahead, chisel away the concrete and pick up the pieces later, running the risk that irreparable damage could be done, which would be a death sentence? Maybe there’s something else to do.
I know that the loop of small bowel that I’ve freed from adhesions is dilated which means it’s proximal to the point of obstruction. The bowel in the midabdomen is not dilated and thus is beyond the obstruction. What to do? Maybe a bit of probing will help. That’s what doctors are supposed to do best. I stick my finger into the hole in the dilated bowel and feel downstream.
Yes, there is a definite tight stricture, a narrowed area which is most likely responsible for the obstruction. But how to fix it? My finger tells me that the stricture is fairly short, less than two centimeters. I ask for a GIA stapler. This is a device which places parallel rows of staples and cuts the tissue in between, closing off where the staples are fired, while opening in between. GIA stands for gastrointestinal anastamoser, or something like that. I pass the one side of the stapler through the stricture and leave the other on the obstructed side, this all being done through the hole I previously made in the dilated bowel. Once I’m sure everything is positioned properly I fire the stapler, performing what is properly termed a “stricturoplasty.” Looking inside the bowel I see each staple line is where it should be and no bleeding. I feel the area of the stricture and it’s gone. Success, I hope. Now it’s just a matter of closing the holes I’ve made and keeping my fingers crossed, praying that everything will heal.
I finished this impossible ordeal in about three hours. Now I will have to wait to see if anything I did actually works. Have I relived her obstruction? Will she heal the “stricturoplasty”? Will she heal the intestinal closures. Will she ever be able to eat normally? There is plenty to worry about; everything about this case has been a compromise and is far from perfect. Normally, I would take down all the adhesions on a case like this, doing my best to be sure there are no unseen points of obstruction. Also, our bowels are not passive conduits. They are muscular tubes constantly contracting and moving. Repairing holes in bowels which are encased in adhesions allows for increased tension on the closure and, subsequently, increased risk of breakdown and development of a fistula. A fistula is an abnormal communication between two structures.
I’ve been toiling away at surgery for almost thirty years and this is the first time I ever found myself in such a difficult situation. Maybe I’ve been lucky, maybe it’s been good planning, but I cannot recall any other case where there were no good intraoperative options, where it was impossible to back off and look for an alternative treatment, while going forward threatens to create bigger problems.
I suppose this case really did have options, but none of them was particularly satisfying. Even my final solution was fraught with danger, running the risk that she may still be obstructed with a high likelihood she will develop a fistula; I’ll just have to wait and see if I did Lucia any good.
“To cut is to cure” goes the old saying, but for Lucia I’m not so sure. In retrospect her troubles started years before I ever saw her and my part in her care is only the end product of her disease process and previous treatment. Even so, the case leaves me with the feeling I could have done better.
Saturday, April 20, 2013
Official: Stop, stop that swing
Tiger (after abruptly stopping his golf swing): What’s wrong? Are we being attacked?
Official: You’re using the wrong club.
Tiger: I always use a 5 iron from this position on this hole.
Official: If you use that club you will be in violation of the golf club utilization guidelines as established by the USGA under the Obama Administration’s Affordable Golf Act. According to the guidelines you must use a 3 iron.
Tiger: 3 iron? I’ll end up in the next county.
Official: There is no room for argument or discussion. These guidelines have been determined by the highest and most learned authorities, including golfers from the PGA, LPGA, USGA, as well as members of Congress and the Administration. Furthermore, the guidelines have been adopted into our charter and all members must be in compliance, 100%, no exceptions.
Tiger: Surely there is some room for variation in skill. After all, golf is a game of judgment. You don’t truly expect me to play the same as a 70 y-o woman?
Official (shaking his head): How long have you had this prejudice against 70 y-o women?. Do you have something against 70 y-o women playing golf? Perhaps you think they belong in a wheelchair in some nursing home. They have as much right to be playing as you, maybe more.
Tiger: I did not mean to disparage old ladies…
Official: Old? Listen to me. I’m 72 and I certainly don’t consider myself old. You will conform to the golfing protocols as established under the Obamagolf program, which, I don’t need to remind you, is the law of the land, or you will find yourself playing miniature golf for nickels. Do I make myself clear?
Tiger: (pulling out his 3 iron) Yes sir.