Wednesday, November 11, 2015

Surgical Dilemma Part 1


“Come on, quickly, quickly, we think he’s dying,” a female voice called, the sense of urgency was unmistakable.
I tried to shake the sleep from my head as I pulled on some scrubs and followed this stranger.
Who is dying and who is this stranger? How did she get into my house, past all the dogs without making any noise at all?
“None of us know what’s wrong, but we can tell he’s really sick. No one else would lift a finger for him. They just want him to die,” she explained, looking back at me while she strided towards the black Mercedes which was parked in front. My five dogs didn’t budge as we went by, like we weren’t even there.
“Where are we going?” I asked, naively.
Why do I feel like I’m in some sort of bad movie?
We rode in silence in the back seat. There was a dark partition between us and the driver. The pitch black, cloudy night only allowed me to see the silhouette of my escort which revealed a large hat and overcoat.
“We should be there in a couple of minutes. I think this could be the end for him. He’s survived other serious catastrophes, so many other illnesses and surgery, but,” she paused, seemingly holding back tears, “but, this time…this time I’m sure he’s too far gone.”
“Could you tell me who he is?” I wondered out loud.
“The boss, the ruler of everything, at least everything in this world. If you can’t save him it will be the end…the end of everything we’ve fought for all these years. There’s the garage. I think we’ve made it in time.”
The Boss? Who’s the boss? The President? The Pope? Springsteen?
We pulled into the black garage. A faint light illuminated an elevator door which is where we stopped.
“Get out here,” she requested/commanded.
The elevator doors opened and I stepped in, alone.
The doors closed with a faint whoosh and the elevator started its ascent. There was only faint light which illuminated blank walls; there were no marks to tell me what floor I was passing. Finally, I came to a stop and the doors opened.
Must have been forty or fifty floors judging by the time it took to stop.
A stark corridor with red lights on each side led to a double door. I assumed that was my destination as I walked past more blank walls.
I guess my patient will be on the other side of those doors. This is all too James Bondish.
The doors flew open as I approached and I entered a bright, white, warm room. And, there was my patient covered up to his neck by a white sheet.
Even from across the room I was struck by his rapid, shallow breathing. As I walked closer I saw hollow flushed cheeks and the eyes were slightly yellow.
This does not look good for “the boss.”
A nurse came into the room through a different door as I approached the bed.
“Hello, Dr…”
I looked up at the nurse, “Excuse me, do you know ‘the boss’s name?”
“Satan,” she answered with a smile on her face. “I’m sure you can see that he is very ill.”
“That’s for sure, Ms…”
“Miss Vargus. I’m Satan’s personal nurse. I’ve been with him for many, many years. In the past I’ve always been able to pull him through his many accidents and illnesses, but this time he needs a surgeon. He needs you, Doctor.”
Wait, did I hear her right?
“You did say Satan, as in Lucipher, the Devil, Father of all Lies?”
“Yes, you heard correctly.”
“Why should the Devil need a surgeon? Isn’t he immortal, a fallen angel?”
“Yes, but his ‘physiology’ is not what you think. And, don’t believe everything you read. He has suffered so much. If you look from his perspective everything that he is accused of being and doing can be justified.”
Sounds like someone trying to convince themselves.
“If I refuse to be ‘Satan’s’ surgeon? What happens? Is it one of those if he dies, you die scenarios?”
“Please, just don’t think about that. Now, take this and these: his chart and the most recent labs and a CT Scan of his chest, abdomen and pelvis. Please hurry; he may not have much time.”
“You may be right about that. He doesn’t look too good. Do you have any monitors here?”
“Of course. I’ll hook him up while you look through his chart. These are his last vital signs.”
110/60, 110, 28, 37.9. Normal Saline hanging. OK, Satan, let’s see what you’ve been up to.
The chart was voluminous. There were entries written in Greek, others in Latin, and still others that I didn’t recognize. Miss Vargus must have seen the perplexed look on my face.
“I’m sorry,” she said, “start with this one. Everything from the beginning is translated into English.”
She pulled out a blue chart from the middle of the stack and handed it to me.
“The blue charts are the complete record in English. Also, if you want to save some time, the last chart is a summary. Dates, diagnoses, medications and procedures are tabulated. It might be quicker for you to start there. You’ll also find that each entry in the summary is cross referenced to the more detailed notes.”
‘Very efficient,” I mumbled as I opened this summary chart. I murmured under my breath, “You’d think, in these modern times, it would all be on a computer disc somewhere.”
“I’m working on that,” she called out, letting me know that even my whispered unintelligible comments did not go unnoticed.
Better be very careful.
I started at the beginning:
May 23, 2300 BC: URI, resolved spontaneously
April 11, 1302 BC: lacerated left arm from fall from chariot, healed over 4 weeks by secondary intention.
June 6, 998 BC: suffered food poisoning while in the house of Ahab, severe diarrhea for 4 days, recovered completely.
I glanced through a couple of thousand years of minor ailments and injuries, but, starting in the 1890’s, something changed. The illness became more severe, the injuries worse and both were more frequent. Instead of the rare URI every fifty years or a sprained ankle once a decade, now there were bouts of pneumonia, GI bleeding, debilitating back pain and more.
I guess our modern world does not agree with Mr. Satan.
I opened up the full chart and perused the most recent notes.
“UGI bleeding secondary to esophageal varices.”
“Drinks a quart of whiskey a day.”
“Previous stent in LAD and right coronary.”
“Poorly controlled diabetes.”
The notes were all signed with an “X.”
There was another chart with the results of his most recent lab, each test was done within the last two days.
WBC 27.4
H/H 9.2/27.7
Na+ 135
K+ 4.4
Cl- 109
HCO3- 19
T. Bili 7.6
ALT 205
AST 320
Alk. Phos 887
BUN 38
Cr 2.4
CT Abdomen and Pelvis: Bilateral Pleural Effusions, Cardiomegaly, Dilated Bile Ducts, Three cm mass in the head of the pancreas or distal bile duct.
Let me look at these images
“Portal vein is patent and appears uninvolved by the mass, the rest of the pancreas looks normal, no obvious mass in the liver or enlarged nodes,” I said softly out loud.
“That’s why you’re here, Miss Vargus interjected. “Satan needs a Whipple. And, for whatever reason, your name kept coming up as the surgeon to do it.”
At first I felt a bit flattered. Out of all the surgeons in the world, all the academic All Stars and hot shots, Satan or his manager wanted me?
Then the indignation started to rise.
“You want me to save the life of the individual who has orchestrated all the evil and woe that has ever been in this world? Really? And, if I refuse?”
“We’ll pay you well. You won’t ever have another care in the world. All your debts wiped clean, your two kid’s college paid for and we promise to take care of you forever,” Miss Vargus explained.
“I don’t know, I just don’t know. Oh, by the way, who is this Dr. X. who has been signing these notes?”
“His personal physician. I’ve never met him, actually. He insisted on complete anonymity. He would visit him here or at one of the other locations. He never let me or anyone else learn his identity. Only the boss knows and, as you can see, he is not in any condition to tell you, at least not at the moment.”
“So, let me see if I I have the complete picture. Satan, the Satan, as in the serpent in the Garden of Eden, Job’s tormenter, the fallen angel, and the author of all that is evil in this world lies dying in the next room. He needs major surgery or he will surely perish. For some inexplicable reason you and your cohorts have chosen me to perform this operation. If all goes smoothly and he recovers he will be free to wreak havoc on humanity for the next ten or hundred or thousand years. But, if I refuse and you don’t kidnap some other poor surgeon, he will die and evil will die with him?”
“That is one perspective. But is he really evil? And, even if all that is evil has come from him and will continue to originate from him, can you in all good conscience, let a man die. Didn’t you take an oath? And, although I’m being selfish, there’s me. If he dies I go with him. I’ve been with him for so many years; he has kept me young, kept me alive. If he becomes dust and blows away with the wind, I go with him.”
“And his minions, his demons?” I wondered out loud.
“I only know what will happen to me.”
“I need some time to think this through. Give me a few minutes.”
“Very well,” she answered, “but I’m going to try to be positive and begin to get him ready for surgery.”
I sat on the lone chair and closed my eyes.
This presents quite the ethical problem. Let him die? Maybe, and I’m really not sure, maybe the world will be a far better place. Or, is it true that evil is so ingrained in this world that nothing will change. War, murder, hatred, greed and everything else will just go on.
On the other hand, suppose I do the surgery, cure him of his cancer. Could I go on? How could I live with myself knowing that I had the chance to eliminate the source of all evil. If I let him go, wouldn’t his demise bring humanity back to a semblance of Paradise?
What if I do the surgery and he dies anyway? Then what?Will his demons look for revenge? Or, would they celebrate? Suppose his demise creates a massive vacuum in the realm of evil? Would one of his demons rise up to fill it? And, maybe the world will suffer even more.
What to do? What to do? Maybe if I go in to look at him I’ll find some sort of clue; maybe God will guide me. What would my old chairman do? One thing I do know: Operating on Satan definitely does not fall into any “evidence based medicine” that I’ve ever heard of, nor do I  remember any chapter in “Schwartz” called “What to do if Satan needs surgery.
Life and death decisions are one thing, but life and death for all of mankind?”
I opened the door and went into the next room. I was greeted by the steady beeps of the monitors.
“Satan,” I began, “I’m Dr. __, a surgeon. They’ve asked me to come to see you, to perform an operation. The operation you need is called a pancreatoduodenectomy, also called a Whipple. It’s a big surgery, but it really is your only chance for survival. Do you want to have the surgery?”
He did not answer, but he opened his eyes and stared up at me with a  look of hope and fear. He grabbed my hand and gave a light squeeze and then his eyes rolled back in his head and his body convulsed in a spasm of pain. He calmed down after a minute and stared into my eyes again. This time I saw only fear.
Ok, I’ll do the surgery.
“Let’s go ahead and put him to sleep,” I ordered. “Did you happen to steal an Anesthesiologist?”
“Don’t worry, everything’s taken care of,” Miss Vargus replied. “The OR is in the next room. You relax for a few minutes while we put him to sleep.”
Relax? I don’t think so.
The truth was that I never “relaxed” before a big operation. Surgeries like Whipples or removing large tumors from the abdomen required planning, time to think about each possibility, the anatomy and potential pitfalls. Unfortunately, I wasn’t given the luxury of time to plan for Satan. I faced a very sick patient with a very complicated problem.
“We’re ready, doctor,” Miss Vargus reported interrupting all the worries which were brewing inside my head.
The operating room was certainly one for the ages. Bright light and all the latest equipment greeted me. Satan was prepped and draped, his head disappeared behind the drapes to an unseen Anesthesiologist. Vargus was circulating nurse, while two gowned and gloved assistants stood by to help.
I washed my hands, stepped into my gown, donned my size 8 white gloves and we were off.
I looked at Satan’s exposed abdomen and the OR lights followed my eyes.
Amazing lights.
“Scalpel,” I began.
The knife was slapped into my hand and I started with my usual chevron incision.
Lots of big veins. I hope Satan’s not cirrhotic.
Despite the big veins I entered the peritoneal cavity with little fuss. The liver was discolored by Satan’s jaundice, but not cirrhotic, there was no fluid, no signs that the tumor sitting in his pancreas or bile duct had spread.
You’re going to make this easy for me, Satan?
Indeed, so far it was shaping up as a very straightforward surgery. My initial exploration did not find anything that would preclude me from doing the necessary surgery. There was a definite mass in the pancreas and the common bile duct was enlarged, but nothing else appeared out of the ordinary or pathologic.
Satan, as a matter of fact, had very little fat. The structures stared out at me like pages in an anatomy book. I started my dissection, dividing the attachments to the second part of the duodenum. I was now able to pick up the entire duodenum and the head of the pancreas all the way back to the aorta.
But, as I dissected, a vision popped into my head. The serpent in the Garden of Eden, tempting Adam and Eve, their Fall and the exile from Eden. I saw Satan laughing. I hated what he did to them and I hated him. I stopped my work and shook my head, as if I was trying to rid my brain of cobwebs fouling its synapses.
“Is everything OK, doctor?” I heard Vargus ask.
“Yes,” I mumbled and the image faded away.
I still can do it. Maybe an “accidental” laceration to the portal vein, or a nick in the bowel. The world will be a better place.
I went back to concentrating on the surgery. It was time to begin the part of the operation which required the greatest care and judgment. I opened the peritoneum over the bile duct and began to dissect around the duct, freeing the hepatic artery in the process. I exposed the artery and followed it until I saw branches, which were the gastroduodenal artery and the right gastric artery which I dissected free.
As I worked, a new vision appeared. I saw Job in his suffering, sitting in a pit, his body covered with sores, a product of Satan’s “largesse.” Then I saw Jesus and Satan arguing in the wilderness, and then there was Jesus being nailed to the cross. I even turned my head to avoid the splatter as seven inch spikes pierced his hands and feet.
Horrible, horrible. Do it, do it now. Nothing will happen to you. You’ll probably become famous. Just a quick slip of the hand and he’ll be gone in five minutes.
But, I couldn’t. I guess it was too many years of “do no harm,” too many surgeries spent hoping against hope to snap another dying soul from death. But, now my patient was the author of death? It would be right to eliminate death.
Is it murder to kill a murderer?
 I kept on working, gently retracting and teasing the common bile duct, separating it from the portal vein.
“Hold the retractor this way, Mephistopheles,” I said to one of my silent assistants, moving his hand to the right.
“Or is it Beelzebub, Whoever you are, I need to see what’s behind the duct. Afterall, you don’t want me to make a hole in the portal vein, do you?”
I glanced across the table and, I swear, there was the faint red glow of anger filling my assistant’s eyes.
Now’s the time. No one would ever question you. Just say the vein was stuck to the bile duct and it tore. It happens all the time. Yes it happens…to others…but never to me.
 A bit more dissection and the bile duct was completely free. I encircled it with a vessel loop. The anterior surface of the portal vein was now exposed as I began to dissect between this vein and the neck of the pancreas. The pancreas easily lifted off the vein. Everything of importance had been dissected free. It was time to make a commitment. First, the gastroduodenal artery was ligated and divided. Next, the bile duct was transected. Pus and bile poured out from the obstructed duct.
I guess that’s why he was so sick. Ascending Cholangitis. He should be much better after the surgery, if he doesn’t die of sepsis.
Next came the duodenum, just beyond the pylorus, I fired the GIA stapler. Finally the neck of the pancreas was divided. I didn’t even have to ask as sutures of 3-0 Prolene were popped into my hand to ligate the bleeding vessels which ran along the pancreas. I took care not to ligate the pancreatic duct.
That would be far too obvious. Now is the time, just a little slip while dividing all the branches coming into the portal and superior mesenteric vein. Don’t be a wimp. Just do it. Do it now…do it…
Just do it. A common saying. I don’t think Nike meant commit murder.
I can’t…can’t do it, not that.
There I was, staring at the portal and superior mesenteric veins. I’d reached the part of the operation where the pancreas has to be separated from these venous structures, requiring dissection and ligation of each little (and sometimes not so little) vein which drained from the head of the pancreas into these very substantial venous structures.
I started on the end closest to the liver and carefully and gently dissected each little branch, then clipped and divided each one. As I worked around one of the larger vessels the operative field suddenly was filled with dark blood. My surgical instincts told me to put my finger over the hole, but the flow continued.
“Suction,” I called out and one of the assistants thrust the suction device into the wound.
“Lap, another lap, sponge stick,” were my next commands. Each appeared in my hand and I packed the area and held pressure, buying time while I contemplated my next step.
What a fool you are, that could have been his end and you didn’t even plan it.
“No, no,” I spoke loudly.
“It’s Ok, Dr., you’ll get it under control,” Vargus reassured.
I knew that I would. I’d faced far worse situations without turning a hair more times than I cared to remember.
After a few minutes I removed the packs. The bleeding had slowed to a slow trickle and I was able to repair the portal vein with a single Prolene suture.
Should be smooth sailing from here.
I began the last parts of the resection: dividing the proximal jejunum and freeing it from the Ligament of Treitz so that it could be delivered into the lesser sac and then I started dividing the short mesenteric vessels which supplied the duodenum and pancreas using my trusty Ligasure device.
As I worked, new visions started to invade my mind: thousands upon thousands of innocent men, women and children dying of plague, slaves beaten and tortured by their masters, boys and girls, some still babies, horribly maimed and tortured by “adults,” Jews in concentration camps starved, beaten, gassed and then burned and other, more hideous sights I can’t even whisper. And, each ghastly vision had one common element, Satan, my patient, standing by, smiling, laughing, exhorting his human pawns to even more hideous acts.
What kind of monster am I saving? Can I be responsible? Look, there’s a big artery right here, bigger than usual. Just cut it, it’s too big for the Ligasure. You can just say that the Ligasure didn’t work properly. No one could ever know.
I looked up at the head of the table, saw the tube coming out of Satan’s mouth, his black hair peeking out from beneath the bouffant cap, heard the monotony of the monitors, the steady rhythm of the ventilator. And, then a new image appeared. It was the Warsaw ghetto. I saw a little girl, dressed in rags, running and then a loud noise and she was falling; falling in slow motion, blood and brain filling the air as the bullet pierced her skull; and then she just lay in the street, blood pouring from her head as uniformed soldiers walked by, laughing.
Satan, you don’t deserve to live.
I closed my eyes for a moment before I went back to work. I couldn’t do it. I finished the resection and threw the specimen in the bucket.
“OK, let’s put Mr. Satan back together,” I announced to my silent assistants.
I brought the small bowel and pancreas together and ducked the end of the pancreas into the side of the jejunum.  Then I connected the end of the common bile duct to the side of the small bowel and, finally, the duodenum was anastamosed to the small bowel, completing a Billroth II reconstruction. I checked each anastomosis, looked for bleeding, washed Satan out, put in some drains and closed him up.
I don’t deserve to live.
“You do fine work, doctor,” Ms. Vargus declared as I ripped off my gown. “You deserve to be rewarded.”
“I’m tired,” I declared. I looked at my watch and my blood stained scrubs. “Five thirty. I need to be at work in an hour. Just take me home.”
She gazed at me with a look I could not comprehend. Fear? Envy? Longing?  By rote I sat down to write orders.
“That task has been taken care of and there is no need for you to dictate an operative note. There will be no record of this procedure and no one will ever know of your great service. We will take you home now. I wish you well. And, thank you.”
“What about his postoperative care?” I protested. “I am not in the habit of performing major surgery and then leaving my patients to fend for themselves.”
“Don’t worry. He will recover completely. I promise.”
Somehow, she knew that he was cured. Sadly, so did I.
I felt a bit lightheaded and then I must have fainted. The next thing I remember is waking up in my bed with the buzz of the alarm clock at six am.
A horrible nightmare?
But, it was all too real. I was lying on the bed, still wearing my bloody scrubs. My mind was filled with the visions; disease, suffering, death. I couldn’t get the images out of my head. Satan’s cold, clammy hand grasping my wrist. I stared at my arm and could almost see his fingers. And, Vargus, that final look, what did it mean.
I couldn’t stay in bed. I crawled out and into the shower. I had never felt so dirty, even after wading through septic abdomen’s elbow deep in pus and stool I’d never felt like this. I scrubbed and scrubbed, but the taint clung to me. I saw a flash of light, followed by the boom of thunder. Jumping from the shower I ran outside and stood naked in the rain.
God, please, make me clean.
I stretched out my arms, and stared up into the heavens as the rain poured down on me. Ten minutes later the rain stopped and I saw the red aura of the sunrise in the east. I went back inside, dressed and went to work. Before I left I threw the soiled scrubs into the fireplace and burned them.
The nightmare was far from over.

Look for Part 2 in a few weeks. Comments about what you would do in this situation are welcome.