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.
Sunday, April 7, 2013
(I recently posted an article called “Inquisition.” Below is a partial transcript of the secret proceedings, smuggled out by a sympathetic spy.)
Grand Inquisitor: You have blasphemed the holy god of SCIP, committed heresy against the society of the ACP and you must repent. Will you denounce your heresy?
Me (facing my accusers, who are attired in the traditional garb of the inquisitor which is the ceremonial white coat and the holy stethoscope draped around the neck. The Grand Inquisitor can be distinguished by his three headed stethoscope): Your Eminence, I know not of what you speak. I have only been led by my conscience and what I deemed to be excellent surgical judgment.
Grand Inquisitor: There, you have all heard it for yourselves, esteemed members of the Inquisition. He freely admits his heresy. He has stated, and let the record reflect this, that he allowed surgical judgment to enter into his thought processes. Do we need any more testimony?
Me: Your Grace, I beg your pardon. But if we are not to employ judgment, then how are we to care for our patients?
Inquisitor: The great god of SCIP has placed our path before us. He has given us the holy Protocols and will lead us to Medical Paradise. So it is written and so it will come to pass.
Grand Inquisitor: Yes, Yes, We shall worship at the altar of SCIP and so be greatly enriched.
Me: But what if SCIP is wrong?
Grand Inquisitor (crossing himself and then standing):Blasphemy, blasphemy, I will not listen to such heresy. The holy scripture of ACP is clear and precise. There can be no variance: “Lovenox will be given! Lovenox will be given! exception will not and cannot be tolerated!”
Me: But, Your Emptiness, I have not had a DVT in a patient for more than three years, and I have performed some extremely complex surgery. Surely my record has some value?
Inquisitor: “You are playing dangerous game, Doctor, careening down a path of destruction and you will surely crash and burn. If, however, you repent of this evil, join the holy order of SCIP, worship at our altar, let us lead you out of the fog you are mired, then we will all be enriched beyond our wildest dreams.
All the Inquisitors together: Blessed is the Holy SCIP, Blessed is the Holy SCIP, Blessed is the Holy SCIP!!!
Me: Unless this very “learned” panel can offer me solid evidence that the protocols are of great value and can actually improve my patient outcomes, I cannot, in good conscience, recant. I will not put my patients at risk. I cannot practice in a way I consider dangerous.
Grand Inquisitor: Blasphemy, Blasphemy. You, members of this august council, have heard his blasphemy with your own ears. But, for we shall offer mercy. You. Blasphemer, I ask you one more time: “Will you place your hand on the holy scripture of the ACP, will you recant of your heretical ways, will you faithfully and blindly give your patients the sacred and blessed Lovenox?”
Me: In all good conscience, I cannot.
Grand Inquisitor, standing, tearing his garments: You have all heard it. There can be no other verdict but guilty of all charges. Punishment must be immediate and swift. We are all in agreement?
The Inquisition remained silent.
Grand Inquisitor: There being no dissension, we will proceed with the punishment.
Shouts and whoops rang out. A large, hairy, hooded man entered the room, carrying a large ax.
Grand Inquisitor: You will go with the Executioner and may the great god SCIP have mercy on your soul.
And I was led away…
Wednesday, April 3, 2013
“Only fifteen minutes, Samuel.”
I stared at my big hands and picked at the callous on my left index finger.
“Is it that late, Peter? You don’t mind if I call you Peter, do you?” I asked as I looked up and saw Peter’s shadow on the wall. His voice seemed far away.
“It is my name,” he answered. “Are you ready?”
“Can anyone ever be ready for the end, Peter?” Peter. I liked calling out a real name. I had always called everyone “sir” or “boss” before, never a first name. Now that the end was near it seemed perfectly natural to be more familiar.
“We both knew this day would come,” Peter said, his monotone voice sounded like he was in another room. “Are you ready?”
“You don’t have to keep asking me. Of course, I’m not ready. Even though I’ve known this time would arrive, can one ever prepare for the inevitable? Think about it. People die every day. Death comes in so many forms: disease or violence or accidents. But, how many people know the exact time? Even those suffering horribly with cancer or some other terminal disease never know the precise moment to the second. Yet, you and I, we know that at 10:58 and twelve seconds it will be over. That’s only…” I looked at my watch, “twelve minutes and twenty eight seconds from now.”
“We’ve done everything to stop it. Checked every detail, contacted everyone we could contact. Nothing can be done, there can be no reprieve,” Peter replied, his voice seemed even farther away.
“I wish there was some way to stop it. Some way to make time stop. Maybe this is all just a dream. Maybe, when the time comes, I’ll wake up and be in my own bed, but not just any bed; It would be the bottom bunk in the big room at the end of the hall, with my brother Michael asleep in the top bunk. Did I ever tell you about him?”
I saw the shadow of Peter’s head sway back and forth signaling no.
“We shared a room growing up. There were two sets of bunk beds and he slept on the top one. I remember waking up one night and there he was on the floor. He had fallen out. I think it was the ‘thump’ of him landing on the floor next to me that woke me. But he wasn’t hurt, at least not physically. But, after that I slept on the top bunk.” I told the story in a hushed voice as if I were revealing all the secrets of the universe.
“Where is he now?” the even more distant Peter asked.
“I haven’t seen or heard from him in years. He got married and moved away. I think he has a few kids now…and a dog,” I said, my voice betraying my weariness. I gave a long sigh. “The dog’s probably dead now, it’s been so many years. It was a Shih Tzu, stupidest dog you’ve ever seen. But, I won’t miss him; I don’t even know where he is, Michael that is.”
What’s wrong with me? Ten minutes left on this God foresaken world and I’m babbling on about a stupid Shih Tzu.
“You know what I really miss,” I added, “having sex. Oh, not just having sex with anyone. I mean having sex with her. She’s the only person I ever loved and when we were together it was pure ecstasy. I don’t mean just the act. It was the closeness, the way she sat and caressed my hair. Her soft lips, smooth, silky skin. The incredible intimacy of those moments, that’s what I miss. I think those moments of true intimacy are what make humans what they are, sets us apart from apes and birds. Listen to me, a philosopher.” I looked up again and saw Peter’s shadow.
“I wish I could hold her one more time; completely immerse myself in her and carry her, what would you call it, her womanliness with me.”
I closed my eyes and I could almost touch her. The image of her loveliness filled the dark recesses of my brain, while her sweet fragrance, a mixture of lilac and the slightly musty perfume that comes with those intimate moments was all too real.
“How much time?” I asked.
“Nine minutes four seconds,” replied the distant voice, it was little more than a whisper.
“Maybe if I fall asleep and dream I can make the time last forever. You know how sometimes you dream and it seems like you’re in another place and you have an adventure that goes on for days and days. Then, at the crucial moment you wake up and look at the clock and realize that it was only ten minutes. I think I’ll try that now. If I do it right, time truly will stop and the end will never come.”
I closed my eyes and waited. I thought about younger days, school days, travels, friends and lovers. And, I saw her, I saw her come into my life, I heard her laughter and her sweet voice and then I saw her slip away from me forever. Tears filled my eyes. I opened them and saw only the faint light and shadow, now grown larger.
“IT’S NOT FAIR,” I screamed, jumping up from my chair. “I didn’t ask for this, this shouldn’t be happening. Suppose I get up and leave. What could happen? Run away from it all, hide, let it all blow over.”
“You can’t get away; there’s no place to go,” Peter answered, his voice an annoying, soft, monotonous drone.
“WHAT ABOUT YOU? You stand back there as if this whole mess is a small bump in the road. It’s the end, not just the end for me, but for everything and you, Peter, you act like it’s just a stroll in the park.”
“Only five more minutes,” he murmured. “Let’s start to walk; it will calm you.”
“I don’t want to be calm. How can you be so calm at such a time?”
He didn’t say anything and, like some sort of robot, I did as he said, got up from my chair and walked into the hallway. There were only dim lights and the windows were open allowing a hot breeze to blow through the corridor. Apart from the faint whistling created by the wind there was silence.
“If this were a movie, I’d be lighting up a cigarette, coolly smoking as I walk bravely down this final pathway. But, I don’t smoke,” I let out a little chuckle as we reached the end of hall.
“Sit down. I think you’ll be more comfortable,” Peter advised.
Comfortable…Comfortable, what does comfort matter at a moment like this.
I saw Peter’s tall shadow opposite me and then I felt his hand on my shoulder, felt his hot breath on my neck as he whispered in my ear.
“Just a brief flash and it will be over. You probably won’t even hear the boom. And, I promise, no pain.”
“How much time now?”
“Only thirty seconds…twenty nine…twenty eight…”
“Don’t …don’t count,” I tried to scream but my mouth was too dry as I could only muster a faint rasp. I still felt Peter’s hand on my shoulder and turned to look at his face.
“Oh, my God…”
Then there was a bright flash…