Saturday, January 11, 2014
“Cold, wet and dreary,” I muttered shaking the water off my coat. “It should make for a quiet night.”
“Now you’ve jinxed us,” Miss James remarked as she patted me on my butt. “But, nobody’s here at the moment, maybe you’ll be right.”
She looked at me and then at the clock.
“Ten minutes early. Maybe miracles can happen,” she commented.
I just smiled as we took the time for a cup of coffee while waiting for some business. It wasn’t long before the buzz of the front door opening filled our little break room and Miss James went to see our first patient.
“Abdominal pain for four days,” she announced when she returned. “I put him in room one and drew some labs. He doesn’t look too sick to me.”
“David Rampart, 45… no previous surgery, no allergies… heart rate 65, BP 122/60, no fever…” I read. I knocked on the door and went in.
Mr. Rampart was sprawled out on the exam table, his face flushed with beads of sweat dripping off his forehead.
“Good evening, Mr. Rampart,” I began, “what brings you in…”
He turned his head and vomited at my feet before I could finish my usual intro. Luckily, his emesis missed me completely.
Maybe a good omen.
“I’ve got this terrible pain right here,” he reported as he pointed to his right upper abdomen. “It’s been going on for two days. I can’t eat, nothing makes it go away. My back hurts and I’ve thrown up about twenty times.”
“Ever have a pain like this before?” I asked.
“Never this bad,” he answered as he winced in pain.
“Had much to drink recently?”
“Just the usual. No alcohol, just beer. I never touch alcohol.”
“How much beer have you had today?” I continued my inquiry.
“Just my usual amount, maybe a twelvepack.”
“And how many yesterday?”
“About the same. I drink that amount every day, after I get home from work. But, it’s just beer.”
I felt his abdomen which was soft, but diffusely tender. There was no scleral icterus. Heart and lungs were normal.
“What kind of work do you do?”
“Cop. I walk the day time beat over on Main and Maple.”
“Ever have pancreatitis?”
“Inflammation in your pancreas. It can be caused by alcohol and I suspect that is what you have. We’ll need to get you to the hospital. And, you should think about giving up drinking beer. It’s going to kill you.”
He lay on the table with a confused look on his face when Miss James came in.
“Don’t tell me,” I said, before she had a chance to speak. “His Lipase and amylase are elevated.”
“Correct, Dr. Barnes,” she responded. “You’re some kind of Svengali or something.”
She had a big smile on her face and then she added, “Dr. Svengali, I’ve already called for an ambulance. I’ll start an IV and you can go use your amazing talents on a kid with a sore throat in room two.”
“Thank you, kind nurse, I will do just that.”
I went on to room two and quickly dispatched a three year old girl with a simple case of Strep throat. The ambulance arrived and Mr. Rampart was shipped off to the County Hospital.
Business was slow and we had about an hour without any patients. Miss James took out her knitting and worked on a sweater she had started more than a year ago. I took the time to study up on the latest treatments for Non Hodgkin’s lymphoma; I was on my last rotation through the Oncology service before I finished my residency.
We were both roused by a crash which came from the lobby, followed by the buzz of a patient waiting at the front desk.
We went to investigate and found a portly man dressed in brown tights, with a black and brown striped cape. There was a large “R” embroidered on his chest and on the cape. He wore a black mask which made him look, pardon the pun, bug-eyed. His suit was torn at the right shoulder where there was a deep bloody wound.
“Can I get some help here?” he demanded. “Patch me up quick, I need to get after them before they escape.”
“That’s a nasty wound you’ve got there, Mister…?” Miss James observed.
“Roachman, at your service,” he replied.
Miss James almost gagged as she tried to stifle her laughter and then she coughed.
“People always seem to get choked up like that when they first see me,” Roachman commented.
Miss James composed herself and then handed our patient a clipboard while ushering him into room three. She emerged a few minutes later.
“He’s got about an eight centimeter laceration on his right shoulder, clean, looks like it was made by a sharp blade; doesn’t go into muscle. You should be able to suture it here. We made need to get Psych involved here. Surely he’s delusional and may be a danger, if not to others, then to himself.
Just great. A wacko with delusions of grandeur. First things first; check out his wound.
I knocked on the door and went in.
“Good evening, Roachman, I’m Dr. Barnes. Let me check out that shoulder of yours.”
I saw him sitting on the exam table, his legs folded. He was licking his hands and then his feet. I noticed an unusual odor and his cape was folded in a funny way, like wings tucked into each other.
“Hello, Dr. Barnes. I’m glad to meet you.”
He grabbed my hand and gave it a vigorous shake, leaving a slimy feeling on my hand. I went to the sink and washed my hands and put on some gloves.
“You’re the second superhero I’ve had the privilege of meeting. Captain Surgery popped in here a few months ago and saved the lives of a couple of kids. Anyway, let me look at your shoulder. How’d this happen?”
“Careful, Doctor,” he winced as I took the dressing off his shoulder and then he recounted his story. “I came upon an old lady being mugged by some young punks. Of course I had to intervene and that’s when I got this. Believe me, those two punks got much worse. They’re probably in Intensive Care.”
“I’ll get this stitched up in no time, go on, tell me about Roachman.”
I cleaned the wound with some chlorhexidine and injected some local anesthetic as he began his story.
“Well, Dr. Barnes, I’m sure you’ve heard of Spiderman and Batman and the Wolverine, all with their special powers. But what’s so great about spiders or bats. What do spiders do, spin a web, crawl around, wait for some poor unsuspecting fly to fall into their trap? Big deal. Bats are even more mundane. They can fly, so? Batman is all hype. A fancy car, fancy toys and attitude. And Spiderman? He’s more screwed up than most of the villains he faces. Guilt should not be part of the superhero gestalt. Ow…”
“Sorry, I guess I didn’t numb that spot. Go on.”
“But roaches, there’s something timeless and almost invincible about us. No matter how hard you try to get rid of us, we just keep being around. And, if there’s a nuclear apocalypse or some other natural disaster, if the earth gets smashed out of its orbit around the sun by an asteroid, who do you think will survive? I’d bet on us; the roaches and the rats.”
“First layer is done. Now just the skin to close. What about roaches and rats?”
“We’re survivors, that’s all. A million years from now, when humans have been wiped away from the face of this planet the rats and roaches will survive.”
“I guess that’s good news for my Uncle Sacha,” I observed.
Roachman gave me a dirty look and then continued his story.
“I discovered my special powers about a year ago. I was working at the waste collection center, shoveling garbage into the furnaces and compactors. So, one day I slip and fall into the trash compactor. I did all I could to avoid its vicious grinders and wheels, but needless to say I was mangled to the point where I was almost dead. It was a Friday and that Monday was a holiday, so I would have been left for days if it hadn’t been for them?”
“Them?” I asked, almost afraid of what the answer would be.
“The roaches. Put them together and they’re pretty strong. They managed to carry me out of there and nursed me back to health. It took months, but I survived and with a new appreciation for my saviors. But, even more amazing, as I healed I felt something new, a power flowing though my veins. I had super powers, Roach powers and I vowed to use them for good; to restore the good name of the cockroach forever.”
I finished putting a dressing on his shoulder.
He seems crazy and he may be a danger to himself. We’d better have him evaluated at the hospital.
“Uh…Roachman, wait here for a few minutes. I want to check your shoulder before you leave,” I instructed.
I left him alone and went to find Miss James.
“I’ve already called the hospital,” she reported. “They’re sending an ambulance. Oh, and there’s another patient in room one. You might be interested in this one. He claims he was attacked by a rat wearing a cape.”
“First roaches and now rats. What’s going on here?” I asked to no one in particular.
I picked up the chart outside room one. Manuel Custer, 28, no medical problems, complaining of “rat bite.”
“Good Evening, Mr. Custer, I’m Dr. Barnes. What’s the problem that brought you in here tonight?” I greeted him, with my usual bedside banter.
“Man, Dr. Barnes, it was a rat, big as a German Shepherd attacked me and bit me right here.”
He pointed to his arm where there was an ugly wound, macerated, but not bleeding.
“What time did this happen?”
“About an hour ago. I was just minding my own business, walking down the street. First I feel something crawl up my leg.”
“The huge rat?” I asked.
“No…no, it was a roach. Crawled right along my chest and between my eyes. Well, I swatted it away and then there was this rat, wearing a black cape, stood up on its hind legs and took I bite out of my arm. Well I pulled out my knife and took a swipe at it. Then, this fat guy in tights and a mask shows up and I get him instead. That fat guy had a cape on, too. Well, it was just too weird for me, so I got out of there. I’m telling you this neighborhood ain’t safe. Vicious roaches, giant rats and crazy fat dudes.”
I was beginning to think that maybe Roachman wasn’t so crazy, but then a thought crossed my head. First I dressed Mr. Custer’s wound and applied some topical local anesthetic; then I went back to room three.
“Let me check this wound before you go,” I requested as I peaked at Roachman’s bandage, which was dry.
“By the way,” I continued, “does Roachman have a sidekick? Batman has Robin and the Green Hornet has Kato or something.”
“Well yes, as a matter of fact, I do. He’s right here. Super Rat.”
He reached under his cape and pulled out a medium sized rat with gray brown fur and wearing a black cape with a large “R” on it. Roachman held his companion up and then kissed the rat on its nose.
“He’s the best, most reliable buddy anyone could have. He saved me from those muggers tonight.”
Curioser and curioser.
“What did Super Rat do, if I might be so bold to ask?” I inquired.
“Why, he drove them off. Bit one of them on the arm, he did. Those cowards took off as if they’d seen a ghost.”
“Was one of the muggers about five foot ten, black curly hair, thick black moustache, really thin?”
“Yeah, how’d you know?”
“Let’s just say that we doctors have some super powers also. Wait here for a few more minutes, please, and we might catch one of the muggers.”
“They’re here, the muggers, I know it, I felt it. One thing about us roaches and rats: we have an uncanny ability to sense when garbage is nearby. Let us at ’em. We’ll teach them to leave poor defenseless ladies alone.”
“You just wait here while I call the police. I don’t want you getting cut any worse.”
“No mugger scares me. I’m Roachman and I can take on the vilest villains this world can dish out.”
“I’m sure you can, but you’ve done your part for tonight. It’s time to let the police do their job.”
As I left him Miss James grabbed me and whispered in my ear, “I think another of the muggers is in room four.”
“Call the police, Nurse, while I check out our new patient.”
She nodded as I picked up the chart outside room four.
Malcolm Johnson, twenty two, no medical problems, chief complaint, insect bites on the groin, rat bite on leg.
“Good evening, Mr. Johnson, I’m Dr. Barnes. From your chart it looks like you have been attacked while visiting a garbage dump or sewer. What happened?”
“I don’t know, exactly. I was minding my own business when this huge roach crawled up my leg and bit me. It took me a while to shoe it away and then this big rat comes out of nowhere and bites me, right through my jeans. I’m not going to get the plague, am I? I hear that rats carry the plague.”
“We’ll just have to wait and see, won’t we,” I replied as I scribbled some notes on his chart.
“Tell me Mr. Johnson, why do you think a roach and a rat would attack you? What were you doing? And, did you see where they went? We might need to try to catch that rat and have it tested, to see if it’s carrying the Plague. In the meantime, let me check your injuries.”
I handed him a gown and told him I’d be back in few minutes. I found Miss James in the front.
“Mr. Custer and Mr. Johnson definitely have some bond between them. They each have a dragon tattooed on their left forearm,” I reported.
“The police are on the way, as a matter of fact there they are now,” Miss James answered as we both noticed the flashing lights outside. We greeted two uniformed officers at the door when we all heard it:
“YEOW, GET AWAY, GET AWAY.”
We hurried to room four and found Mr. Johnson cowering in the corner, looking like he had been accosted by the devil himself. I heard some scurrying from somewhere in the room, but I didn’t see anyone or anything. Then there was a second scream from down the hall. One of the officers and Miss James stayed with the terrified Mr. Johnson while I took the other policeman to investigate Mr. Custer.
“There he goes…look there,” Mr. Custer said with terror in his voice, pointing to the far corner of the room.
“I don’t see any…,” the Officer Krupa started to say but then we both saw him or it. A big, dark brown roach, the size of big mouse. It raced under a table and when we pulled that table away from the wall, it was gone.
“Stay here, Officer,” I requested and I stepped out of room four and into room one where I found Roachman calmly sitting in the chair stroking the belly of Super Rat.
“Sorry, Roachman, but there’s been some excitement. You haven’t left this room?”
“Not for a moment, Dr. Barnes,” and he licked his hands again before resuming his gentle caressing of Super Rat.
I don’t know why I find Roachman so disgusting ... Yes, I do know why.
I went back to room four.
“What did you see, Mr. Custer?” I queried.
“It was a roach, eight feet tall, standing over me, threatening me. It threatened to bite my head off, only it wasn’t really talking. I mean I heard this voice inside my head and I knew it was from that monster standing over me. There it is again…that voice….AIEEEE!!!”
And he passed out.
I turned and saw Roachman in the doorway.
“It’s strange what games guilt can play with the mind and soul,” he commented and then went back to room three.
I went back to Mr. Custer, who was coming around.
“Where am …” he started to say and then he looked at me and Officer Krupa and blurted out, “I did it, I attacked that lady and stole her purse and beat her up. Please, please, take me away from here. Protect me from them.”
“Well, officer, you can’t get a cleaner confession than that, spontaneous, no cercion. Let me finish cleaning up his wounds and then you can have him; rather, both of them. Mr. Johnson was your partner in crime, Mr. Custer?”
“Yes, yes, just get me out of here. I’ll feel safer in jail.”
The policeman gathered the two petty thieves together in handcuffs and carted them away to jail. I went back to check on our “superheroes.”
Room three was empty. I went out to the lobby just in time to see a large rat with a cape out on the sidewalk. Perched on the back of its neck was a big dark brown roach. I watched in amazement as the rat spread its four legs out and took off, flying through the air with, pardon my English, the greatest of ease. As they made their escape I heard Roachman’s voice inside my head.
“Thanks for patching me up, Dr, Barnes, you did a great job. And, never underestimate the powers that we vermin possess. Remember, when the apocalypse comes and most life on this planet is destroyed, it will be the rats and roaches who inherit the earth.”
“Doctor, Dr. Barnes,” I heard the voice of Miss James and felt her hand rubbing my shoulder. “Are you OK?”
“Yes, nurse, I am quite well,” I answered, but I think I still had a peculiar look on my face.
“You don’t look ‘quite well.’ You look like you’ve been staring into the eyes of a vicious monster or something.”
“It’s funny Miss James. Something which is good can also be terrifying and it’s ironic that this terror can be used to combat evil. I guess it’s sort of like the pain one feels from a shot. At first, all the recipient feels is the pain of the injection. The good after effect, be it a vaccination which prevents a dread disease or the well being which may come from medication; this may not be associated with the pain at all. Maybe Roachman is something like that. Anyway, I don’t think he’s any sort of a danger. You can call the hospital and cancel the Psych eval.”
She gave me a funny look.
“Roachman is just a crazy fat guy in Spandex with a pet rat, Dr. Barnes. See there he goes.”
Sure enough, there was Roachman walking past the Clinic, Super Rat gently cradled in his arm. He smiled and winked as he passed by.
Saturday, January 4, 2014
I had a brief encounter with Big Blue today. I was doing a fairly routine laparoscopic hiatal hernia repair when it appeared, staring me straight in the face. It wasn’t lurking around the corner or hiding behind another structure, it was right there, only millimeters away from the area in need of repair. Such are the pitfalls and dangers we intrepid surgeons face on a daily basis.
Big Blue is better known as the Inferior Vena Cava, the largest vein in the human body. This monster’s function is to receive deoxygenated blood from most of the veins below the diaphragm and return it to the heart for processing, which means unwanted carbon dioxide is exchanged in the lungs for vital oxygen which is then delivered to the body.
This Inferior Vena Cava is a structure that demands respect and should be given a wide berth, if possible. Many surgeons reserve this attitude for the pancreas, but this large, thin walled blood vessel can be most unforgiving.
For any readers unfamiliar with human anatomy the body has several different types of vessels which carry blood and bodily fluids. Arteries are flexible, often muscular conduits which carry oxygenated blood under high pressure from the heart to body organs. The arteries progressively decrease in size as they branch into smaller arterioles and then capillaries, tiny thin walled, porous vessels which only allow cells to pass in single file affording them the opportunity to deliver their wares (oxygen, nutrients and such) to the body’s organs, while picking up unwanted waste materials to be carried to the various outlets which will eliminate said waste. These capillaries then coalesce into veins which merge into larger and larger vessels, culminating in the vena cavas, of which there are two, superior which carries blood from the head and arms to the heart, and inferior which is the subject of this treatise. There is one other type of vessel, lymphatics, which carry fluid which has been dumped into the environment outside the usual circulatory system, eventually bringing it back into the network of arteries, veins and capillaries.
This is not meant to be a dialogue on circulation, however. Rather, it is a discourse on the Inferior Vena Cava.
Getting back to my case, there it was, Big Blue confronting me and my surgical skills. A lesser man would have been reduced to a tower of quivering Jello by the mere proximity of such a beast, but your humble correspondent is made of sterner stuff. It is true that one misstep, one single slip of the hand would lead to disaster, a hole in the suprahepatic inferior vena cava.
Such an injury is very difficult to control and repair. This very short segment of the Inferior Vena Cava is right at the base of the heart. Bleeding from this area is akin to having a hole in the bottom of the heart. This is true because an injury to the suprahepatic vena cava really is a hole in the bottom of the heart. Every time the heart contracts its blood would be squeezed out this hole and the patient would bleed to death in short order. Traumatic injuries of this type are almost always fatal.
I did have to care for a patient with such an injury many years ago. Lydia had been in automobile accident. She arrived in our ER awake, alert, with a pulse, but we could not get a blood pressure. A peritoneal tap returned gross blood and she was whisked away to the OR. She was able to talk to us on the way and she had a weakly palpable femoral pulse.
As soon as we opened her abdomen we encountered blood, but where was it coming from? We packed all around the abdomen and then started our exploration. When I retracted downward on the liver blood poured out, the hallmark of a retrohepatic or suprahepatic vena caval injury. The problem now was that our exploration had disrupted any tamponade (compression) that was limiting the bleeding from the injured vessel. Blood started to pour out with every contraction of her heart.
The treatment of such an injury requires placement of an atrio-caval shunt, a large tube which is passed through the right atrium of the heart into the vena cava and then secured so that the blood will flow through the tube and not the injured blood vessel, thus maintaining blood flow while allowing the surgical team to make repairs. Such a shunt can usually be placed in a few minutes. Lydia however did not have even a few minutes and she died of this lethal injury.
Excuse my digression, back to my encounter with Big Blue. The truth is that on every hiatal hernia repair I am fully cognizant of the proximity of the Inferior Vena Cava. Often I see it clearly, sometimes I just wave at its presumed location. In this particular case I took my usual care and placed each suture exactly where I wanted it and was able to let sleeping monsters lie.
My first real encounter with Big Blue was many years ago, as a fourth year surgical resident. I had been seeing a patient who had barely survived a complicated Gynecologic/Surgical operation. She was in the ICU and developed a pulmonary embolus, which is a blood clot from the legs or pelvis which breaks away and becomes lodged in the lungs, a life-threatening, sometimes fatal condition. She could not be placed on blood thinners because of the potential for bleeding which comes with these medications, therefore it was decided to place a “clip” on her Inferior Vena Cava. This clip allows blood to flow through the large vein, but prevents large, possibly fatal, clots from passing. This was before the use of intraluminal vena caval filters became the norm.
Normally, this procedure would be a Chief Resident case, but I managed to schedule it at a time when all the Chief residents would be tied up in a conference, thus affording me the opportunity to do this rarely performed surgical procedure. Up until that time I had never done a similar operation and had never really worked on or around Big Blue. But, he who hesitates is lost. I read up on the technique before hand and was filled with the confidence of youth. And, I pulled it off like a pro. With two of my attending assisting Big Blue was approached form the right side, the peritoneal structures were dissected off the retroperitoneum and there I was, staring at the Inferior Vena Cava.
I gently began to spread and cut and spread until it was completely free. I slid the clip into place and closed it and that was it, my first successful encounter with Blue. My Chief Resident, however, was really mad that I stole this case.
There is another case that demonstrates just how dangerous and unforgiving the Inferior Vena Cava can be. It was actually one of my partners who started the surgery, which was the repair of a ruptured Abdominal Aortic Aneurysm. This is a condition where the major artery in body has weakened and then burst, most often fatal with or without surgery.
I was called to see if I could lend a hand. I found him up to his elbows in blood, doing his best to stop the bleeding from the vena cava adjacent to the abdominal aorta. Multiple sutures had been placed and torn through and now this giant vein was a macerated mess. With the patient already in extremis all we could do was ligate, or tie off, the vena cava above its bifurcation and then go on and fix the aneurysm. Unfortunately, this patient didn’t survive. Two lethal conditions simultaneously are too much for almost any individual or surgeon.
My fondest memory of battling the Vena Cava comes from Victor. Fond? Maybe not, but certainly challenging and interesting. He was forty eight years old and came to see me because his abdomen was swelling. He was a mailman and he had noticed the prominence when his mailbag hit against his abdomen. He had never had any surgery or medical problems. He had only vague discomfort and no other symptoms. He was sent off for work up with an abdominal and pelvic CT Scan and basic blood tests.
The results of these tests revealed a large intrabdominal mass overlying his Inferior Vena Cava and right Renal Vein, while displacing the right colon and duodenum. He was mildly anemic, but otherwise his blood tests were normal. A needle biopsy was also done which revealed a spindle cell tumor. Sarcoma, a type of cnacer, was suspected and surgery was scheduled.
Preoperative preparation included an arteriogram which provided a road map of the vessels supplying the tumor, a bowel prep because resection of a portion of the colon would likely be necessary along with all the routine antibiotics, type and cross match and such.
The big day (for the patient) arrived and he was whisked away to room five where he was epiduralized, catheterized, intubated, painted and draped. I made my usual grand entrance, with the theme from Rocky playing in the background, as my assistant, the circulating nurse, surgical tech and anesthesiologist bowed, my freshly washed and sanitized hands held high (not really). I was gowned and gloved and the surgery commenced.
A xiphoid to pubis midline incision brought us into the abdomen where the expected large mass was residing, pushing the colon up. The tumor was adherent to the mesentery of the right colon, but a bit of dissection revealed that the duodenum easily separated from the mass. With the duodenum out of the way and the tumor exposed, the operation could really begin. This mass was sitting on top of Big Blue.
I switched gears and began attacking this mass from behind the right kidney. The renal artery was not involved, but the mass was stuck to the right kidney, right renal vein and the Inferior Vena Cava. Next I started to gingerly dissect along Big Blue, starting on top of the right Iliac vein which is the vein which joins with its partner on the left to form the Inferior Vena Cava. The tumor became adherent to Blue a few centimeters above this bifurcation.
Decision time was at hand. It was clear that a proper, curative resection would require removing a portion of Big Blue, as well as the right colon and right kidney. The big question loomed, however: Should the vena cava be ligated (closed completely by tying the divided ends) or reconstructed?
It wasn’t really a difficult decision as I barely paused before asking to see what grafts were available. I chose an appropriately sized “Platinum” graft and then really went to work. The terminal ileum was divided as was the transverse colon and the colonic mesentery (blood supply). Thus the colon was now free. The right kidney was dissected away from the surrounding tissue and the right renal artery ligated and divided. Finally the vena cava was dissected away from its resting place next to the aorta. Multiple lumbar veins were dissected free, clipped and divided. Finally I was left with only Big Blue. There was about seven centimeters of vena cava which would require removal. The big vein was clamped above its bifurcation and below the liver, divided and the cantaloupe sized tumor was removed en bloc with the right colon, right kidney and a portion of Big Blue.
Next it was time for reconstruction. Although I’m never thrilled about putting a prosthetic graft into a patient at the same time as a colon resection there was little choice in Victor’s case. His bowel was clean, however, and I made every attempt to limit the risk of contamination.
First, I rebuilt the vena cava. Some 5-0 Prolene suture, a bit of care and the first anastamosis was done. A few minutes later and the second was completed. Now the moment of truth: the clamps were removed and, voila, blood was flowing through the graft and there was no leak. I put his colon back together next, doing my best to shield the new graft from any potential contamination.
Victor didn’t turn a hair during his postoperative recovery. The tumor was found to be a liposarcoma, a type of cancer which probably originated in a single fat cell. After he had recovered from surgery and returned to work I didn’t give him much thought. As I tell many of my patients: “If you had surgery years ago and I remember you well, it means you either had a very unusual case or you had a significant complication. So be glad that I don’t recall doing your gallbladder surgery fifteen years ago.”
Victor did return however, eight years after his surgery. He appeared to be in robust health but he had developed a hernia in his midline wound. I repaired this without any fuss, managing to stay well away from “Big Blue” during this particular operation.