Sunday, December 6, 2015

Surgical Dilemma, Part Two

                          

“I’ll be about an hour late for my first case,” I informed the OR desk.
“OK, Doctor,” Eve replied. “There’s nothing behind you, so that shouldn’t be a problem. I’ll let anesthesia know.”
After another shower I pulled on some clean scrubs. The dogs sniffed me more than usual as I put out their bowls and filled each with a mixture of dry and canned dog food. While the pack went to work on the daily meal I sipped a cup of tea and read the paper.
Nothing new under the sun.
The sweet sound of Bach filled my car during the twenty minute drive to work.
“Good Morning, Dr.” the preop nurse greeted me with a big smile. “Your first patient is in room twelve.”
“Thank you, nurse. You’re always so efficient,” I replied smiling back, weakly.
Mr. Jackson, right inguinal hernia. At least all the cases are pretty straight forward today. Two hernias, a gallbladder and a breast biopsy. I don’t feel like working too hard today.
“Hey, Jeb,” I called out to Dr. Samson, my anesthesiologist for the day. “Sorry I’m late.”
“It’ll be the death of you, burning the candle at both ends. Up all night? You need to give that nurse a rest once in a while.”
“Lori is upstate at her mother’s for a few weeks. I was working, if you must know.”
“Really? It wasn’t here.”
“Long, complicated story. Maybe, I’ll tell you when I have more time. Anyway, let’s get to work.”
Mr. Jackson’s hernia took only about twenty five minutes. With minimal fuss he was followed by Mr. Kendall’s umbilical hernia, Miss Cates’ gallbladder and Mrs. Lane’s right breast lump. It was noon and all I had left was rounds on five hospital patients and a dozen patients in the office.
I stopped for lunch in the doctor’s lounge. The TV was blaring a popular talk show which featured an abrasive and pompous host, Annabelle, no last name.
“Today, looking through Annabelle’s book shelf I discovered an extraordinary book about surgery. The title is ‘The Amazing Journey….’
At the mention of the title I almost choked, spilling my water. “The Amazing Journey” was the book I had written about surgery, self published five years before. Why would Annabelle, of all people, suddenly ‘discover’ such an obscure book?
Well, I suppose I may sell a few more copies. A little extra cash never hurts. Maybe I’ll get enough to take Lori out to Peter’s Steakhouse for a nice dinner.
I finished my lunch and made quick work of my rounds. I called the office and arranged for my patients to come in earlier.
My office manager, Suzy, was waiting for me as I arrived through the back door.
The regional director for Affiliated Health Care sent this e-mail.
“We have finished our audit on the recent claims which we had disputed. We have determined that all of your claims are appropriate. We will be sending you a check for $86,355.61 as payment for those claims which had been under investigation. This amount includes the outstanding fees plus interest. We consider the matter closed. If you have any questions do not hesitate to contact me.”
“This should ease your burden, Dr.” Suzy stated.
“Not enough to retire, though.
“Maybe you won’t have to work quite so hard.”
“Perhaps, but I like to work. All I have at home are the dogs.”
“You could see them more.”
“Their fine. Jeannie from next door takes care of them and gives them plenty of attention when I’m not there. I like to think my patients need me.”
“Speaking of patients, all the rooms are full. You should be out of here by three today.”
“Good, because I’m really tired.”
“I thought Lori was away visiting her mother.”
“I was working last night, Miss Know-it-all. You know, saving lives, stamping out disease, making the world a safer place for society.”
Maybe the last part isn’t true.
I zipped through ten post op patients, a new patient with gallstones and another with colon cancer and was on my way home by three thirty.
My cell phone buzzed. I didn’t recognize the number.
“Yes, this is the doctor.”
“Doctor__?”
“Yes, that’s me.”
“This is Saul Lewin, from the Sun Times. I was wondering if you might be free for an interview? Your name came up as a local personality that we could feature in our ‘Hero of the Day’ column.”
What’s going on? Anabelle and now the local paper? I suppose the President will be next.
“I’m sort of tired today and I think I’m pretty booked up this week. Maybe, next Tuesday? Call my office, Suzy can tell you when I’m free,” I answered.
“We were hoping that we could feature you in this Sunday’s paper. I can make it early. Why don’t you meet me at ‘Leo’s’ at five thirty. Drinks and dinner are on me.”
Free dinner at Leo’s? I guess I do have to eat.
“OK, five thirty, but it will need to be fairly short. Like I said, I was up most of the night and I need some sleep.”
“I know. It must be rough being a surgeon. See you at Leo’s.”
Coincidence? Or is Satan paying me back. Scotch and steak from Leo’s isn’t a bad start. I just have time to shower and change.
Saul Lewin wrote a weekly column in the Sun Times. Once a month he featured the ‘Hero of the Day.’ Most of the time this was a police man who had thwarted a robbery or fire fighter who had rescued a kitten from a storm drain. Occasionally, a returning war hero was interviewed. Medical professionals had never been included in the ‘Hero’s Club.’ I was anxious to learn why I was being honored.
I arrived at five forty and met Saul at the bar where he was finishing a double Scotch on the rocks.
“Mr. Lewin?” I inquired.
He stuck out his hand and gave me a limp handshake.
“Saul,” he replied. “You are the famous surgeon I’ve heard so much about?”
“Surgeon? Yes. Famous? Only in the eyes of my mother.”
“Annabelle disagrees.”
I didn’t answer. The Maîtres d’ ushered us to our table where a bottle of champagne was waiting.
“Dom Perignon? You must want more than an interview.”
“The paper gave me free reign and an expense account.”
“So, tell me Saul, why this sudden interest in me. How did Annabelle stumble upon my obscure book and why should you have any interest in a run of the mill general surgeon?”
“I find surgery fascinating. I’ve been planning to do a feature on a general surgeon for months and when I asked around your name kept popping up as the best. Now, if you don’t mind, I’ll ask the questions.”
“Can we order dinner first? I’ve barely eaten all day.”
“Sure.”
We each ordered a steak.
“Now, tell me, surgeon, what is about surgery that made you choose it as your specialty?”
“Well, back in the stone age, when I was finishing medical school and it was time to apply for residency I seriously considered Pediatrics. There was something about taking care of sick kids, making them better which I found very appealing. But, as I talked with other Pediatricians and residents it became clear that most of Pediatrics is mundane and routine. Surgery, however, also cured people, sometimes dramatically. I saw patients who were dying from disease or injury go into surgery and then walk out of the hospital a week later.”
“Has your opinion of surgery changed over the years?”
“No. ‘To cut is to cure’ the poet once said. This hasn’t changed.”
“What’s your favorite operation?”
“Big cancer surgeries, such as those on the stomach or pancreas or colon. Such operations are very anatomic, require a bit of thoughtful planning and often are curative.”
He went on asking similar trivial questions for a while until dinner was served and devoured. With the arrival of dessert and coffee the tone and substance of the questions changed.
“Have you ever operated on someone; someone seriously ill let’s say, who didn’t deserve to live?”
Does he know something? How could he?
I think he saw the perplexed, distressed look on my face.
“I mean,” he added, “for instance, suppose you had a gang member who had been shot by the police after he had performed some heinous act, say after raping a little girl. He’s now bleeding to death on your OR table. Would you be tempted to not do your best?”
Coincidence? Tempted? Tempted is not the same as doing.
“Never, I’ve never considered not doing my best for my patient,” I lied. “When I graduated I took an oath. It is not my place to act as judge. When I do surgery I do nothing but my best. Now, I’m going to finish my coffee and be on my way. I really need to get some sleep tonight.”
“You were up all night last night, doing surgery?” He wondered out loud.
“Yup, saving a life.”
“What were you doing?”
Why would he ask? Does he know? I think he’s fishing.
“Sorry, can’t say. HIPAA and all that,” I replied.
I finished my coffee and said my goodbyes, thanking him for dinner and for the free publicity.
“Be sure to mention my book,” I added as I got into my car.
I took a long hot shower before going to bed. I stared at the ceiling for hours, tossed, turned and stared some more. I think I finally drifted into fitful sleep around four am.
That night sleep was anything but peaceful as images of children being tortured and murdered punctuated my dreams. I awoke drenched in sweat, lay on my back staring at the ceiling for another hour before I gave and climbed into the shower again.
The dogs greeted me with their usual energy in anticipation of their morning meal. As they munched away I read the morning paper. My eye caught one of the front page headlines:
“Israel and Palestine Reach Historic Accord”
Farther down on the page was another headline extolling good news:
“Terrorist Cell Arrested”
And on page three:
“Serial Rapist and Killer Apprehended”
Finally:
“Mother Dog rescues Puppies”
All this good news. Maybe Satan’s being sick has kept him from meddling in human affairs. Or, maybe my act of decency has rubbed off on the Prince of Evil.
The dogs finished their food and I was off to work. First would be rounds and then surgery, a few small cases followed by a big gastric cancer.
Miles Belson was the patient with the stomach tumor. He was sixty six, rotund with a bit of heart disease, diabetes and a tumor which started just below the esophagus and covered the lesser curvature. Workup suggested the tumor extended close to the aorta and maybe the vena cava, but should be resectable.
I made my incision at eleven. I found nothing unexpected upon entering his abdomen. The tumor was palpable along the lesser curvature of the stomach and there was some extension into the surrounding fat. As I mobilized the stomach a bit more, there was about one centimeter where the left lobe of the liver was stuck, so I sliced out a wedge of liver with the specimen.
It was after this, as I freed the tumor from the right side of the abdomen that I noticed it.
It’s nothing, just lack of sleep.
There was a tremor. In my hands. I don’t think the scrub tech or my assistant noticed, but I did. As I worked around the vena cava behind the liver my hand shook. I stopped for a minute and then I rested my hand on a lap pad as I worked. This seemed to help. The tumor lifted off the vena cava and I thought I was home free. I finished the resection which required removal of the entire stomach and sent the tumor off to pathology for frozen section.
Never had a problem like that before, even with lack of sleep. Maybe I’m getting old.
The phone rang bringing the free and clear message from pathology.
“Let’s put Mr. Belson back together,” I announced to no one in particular.
I was left with the end of the esophagus and the closed off duodenum, which meant reconstruction of his GI tract would require an esophagojejunostomy. I went to work mobilizing the small bowel. As I started sewing esophagus to jejunum the tremor returned, a bit more pronounced.
“Is everything OK, doctor?” the tech asked.
She sees the shaking. I’ll bet everyone can see it.
“Fine, just a bit of a reach putting him back together,” I answered, doing my best to hide my concerns.
I managed to finish the anastomoses and close up Mr. Belson. As I sat in the dictation room I stared at my hands.
Are you trying to tell me something? Is it time to put the old scalpel away?
My hands failed to answer. I finished the post op chores and went off to the office where twenty four patients were scheduled. I gazed into my phone as I crossed the street to see that “The Amazing Journey” was number one among surgery books on Amazon. I checked the sales, 44,303 copies of the e-book had been sold in the last two days, which translated into over $80,000 dollars in my pocket.
Well, at least if my hands are betraying me, I can live off royalties from my little book. Probably a lot of print books have gone out the door, too. I’ll check later.
But, I was not ready to give up surgery. The office brought me six new patients. One with breast cancer, one with a large polyp in the colon, three with gallbladder disease and one hernia. The post op patients were all recovering without problem and I was done by five.
The next few weeks brought little change. Work stayed busy, the tremor in my hand remained, although it didn’t get any worse, book sales continued unabated and the world looked like it was on its way to becoming a better place. Economic news was all positive, accords were reached between NATO and Russia which promised to make the world a safer place. A new antibiotic was approved which was effective against a large number of resistant bacteria and advances were announced in genetics which promised new weapons in the battle against many cancers. The world was a better place.
I was a wreck.
Sleep, for the most part, eluded me. I started taking sleeping pills on my weekends off. They did put me to sleep, but at the price of a hangover which usually lingered for hours. And, the nightmarish images still haunted me, day and night. Surgery became more of a chore rather than the pleasure and refuge it used to be.
There was one bright spot, although too brief. Lori returned from her mother’s. She was sitting in my living room waiting for me about four weeks after my momentous Whipple.
“You,” I exclaimed as I wrapped my arms around her, “are a site for sore eyes.”
I gave her a very long kiss.
“Your mother is better?” I asked.
“Amazingly. She is out of bed, walking, eating and in Rehab. I didn’t think she was going to survive. She is, after all, eighty five, bad heart, arthritis, but there is something inside of her which keeps her going.”
Another gift of gratitude?
I shook my head.
“Everything OK?” she wondered out loud.
I kissed her again.
 “It is now.”
I gave her another long, deep kiss, then another and another.
“I’m starving,” she said, as she pulled away, “for dinner. Bed can wait a bit.”
“Alright, fair maiden. What will it be? Pizza? Sushi? Something quick would be better.”
We sent out for pizza and then fell into each other’s arms. That night, for the first time in weeks I slept peacefully; seven uninterrupted hours. The only dream I had was filled with puppies, butterflies and sunlight. I even looked forward to going to surgery the next day. I thought it was a good omen as I faced the day, the schedule filled with six cases and I was on call for the ER.
The first three surgeries went by without a hitch: two inguinal hernias and a big lipoma on the back. As I finished dictating on the lipoma my phone went off.
“This is Dr. Jonas in the ER. We’ve got a Level I trauma, pedestrian struck by auto.”
“I’ll be right over. I’m just down the hall.”
The trauma room was at the far end of the ER and it was filled with yellow gowned nurses, technician, and the ER physician, Dr. Pete Jonas.
“What happened?” I asked.
“Pedestrian struck by a pickup truck. The truck drove away.”  Looks like a fractured pelvis, broken ribs on the right; C-spine and head are OK. I’m waiting on the Abdomen CT.”
“She stable?”
“Last BP was 90/65, heart rate is 110. She’s awake. I bet she’ll have something in her belly.”
We went into the trauma room together.
What? Lori?
Even through the blood stains and C-collar I recognized my Lori. I ran to her side.
“Lori, can you hear me?”
She gave me a weak smile.
“Doctor…you’ll take good care of me and we’ll be back together,” she whispered.
At first I couldn’t say anything, I held her hand and she gave me a squeeze back. Then I spoke softly into her ear.
“I promise…promise to do everything.”
“BP is 70/40,” a nurse shouted.
“Do we have blood ready or at least O negative?”
“Here it is.”
“Pump it in, call the OR and make sure they have a room,” I commanded, going into full trauma mode.
“CT says she’s got a lot of blood in her belly,” Dr. Jonas reported.
“OR is ready.”
“Let’s go. Make sure we’ve got more blood available.”
Two nurses and two techs accompanied me as we rolled down the hall and into OR five where the crew was waiting. While Lori was moved to the OR table I washed my hands, ready to start as soon as she was asleep.
Get in, pack everything, stop the bleeding, make sure there aren’t any holes in the bowel and get out. Quick and easy.
I stood gowned and gloved as Lori was prepped. I looked up at the ceiling and closed my eyes trying to picture what I would find inside her abdomen.
With the last swipe of the prep I moved to her right side.
“Let’s go,” I commanded.
A stem to stern incision and some rapid work with the Bovie brought me into her abdomen where I was greeted by blood.
“Laps,” I barked and proceeding to pack every corner of her belly while suctioning and pulling out blood and clots.
Do it right. Start in one corner and work around. She’s stable at the moment.
And she was relatively stable. BP was 110/50, heart rate was 100. So I gingerly pulled the lap pads from the left upper quadrant. The spleen was intact, no hematoma, the stomach was OK. Next the left lower abdomen, also pristine as was the right lower quadrant. The small bowel had only a small mesenteric hematoma.
Looks like the money is on the liver.
I pulled the packs from around the liver and saw a small laceration which was not bleeding. The final lap pads were below the liver. As I lifted these dark blood began to well up.
“Suction.”
I couldn’t tell where the blood was coming from.
Maybe behind the duodenum? Vena Cava? Time for some fancy footwork.
I repacked the area and then cut along the lateral right colon and in ten seconds had reflected the right colon to the left, followed by the duodenum. Blood was welling up from the area of the right kidney and Inferior Vena Cava.
I need to work fast.
I exposed the vena cava below the kidney and compressed it with a sponge stick.
“Hold this and try not to move,” I instructed my assistant with my “serious” voice.
The bleeding slowed a little. Next I tried to expose the vena cava below the liver. I divided the attachments to the duodenum and began to “Kocherize” it, lifting the duodenum off the cava. Blood poured out even more. I took another sponge stick and pressed it above the area of bleeding.
“Pressure is 40,” the anesthesiologist called out.
I noticed my hand starting to shake.
Not now.
I reached up to below the diaphragm and felt for the aorta. Once I felt its now weak pulse I squeezed it closed beneath my thumb and first finger.
Good thing you’ve got healthy arteries, Lori.
“Pressures better, 70…90,” the voice at the head of the table reported.
“I’m running out of hands. Can you get me another body?” I requested loudly.
“I’ll try,” the circulator answered.
There I was. One hand clamping down on Lori’s aorta, sponge sticks compressing the vena cava above and below the right kidney which was still bleeding, although less than before.
And my hand was starting to cramp.
“I’m here,” Anson, one of the surgical techs declared.
“Good, I need some more hands,” I answered.
As soon as he scrubbed in I put his hand where mine had been and told him to squeeze, keeping the aorta compressed while I went to work to stop the bleeding. I shook my hand a few times to get rid of the cramping and then I started exposing the vena cava and right renal vein. I noticed the slight shaking of my hand as I dissected.
I rested my hand on the patient trying to steady it, which helped a little. As I approached the site of bleeding the tremor increased.
“Are you OK?” Anson asked.
“It’s just because my hand was cramping while I was compressing the aorta. I should be OK in a minute.”
I kept working and finally found the hole which was right at the junction of the renal vein and IVC. The renal vein had torn and blood was still leaking.
“I need a vascular clamp, actually I need three vascular clamps, two Satinsky’s and a straight one.”
Finally, the injury was isolated and ready to be repaired.
“5-0 Prolene,” I requested.
The hole was about 8 mm. As I started to sew my hand began to shake again. I stopped and steadied my hand, then started again. Once again my hand began to shake so badly that each suture tore out of the vein before it could be pulled through. I backed away from the table, took a deep breath, looked up a that ceiling as if I was appealing for some divine intervention, took another deep breath and went back to work.
The needle driver felt solid in my hand which was steady as a rock. The needle sat properly perched between its jaws and the area of injury was perfectly exposed.
It doesn’t get much easier than this. Just do it. It’s Lori. She’s depending on you.
As the needle moved closer to the vein the violent tremor began anew.
“Nurse, could you call Dr. Ponce, please. Ask him if he can come and help me out,” I requested quietly.
Lori is depending on me.
The silence in the OR was almost deafening. I could almost hear my OR crew’s thoughts.
“He froze.”
“He shouldn’t be operating.”
“This patient may die because of Him.
“…because of his incompetence.”
Dr. William Ponce arrived.
“Bill, sorry to have to call you but I’ve got some sort of problem with my hand. Could you scrub in and help me?”
“Sure, no problem.”
“There’s a hole at the junction of the right renal vein and IVC. Just needs a few stitches.”
He turned and went out to scrub his hands and was gowned in gloved in two minutes. I backed away, allowing him room to do the repair.
They’re all laughing at me, I know it. He’s over the hill, that’s what they’re thinking, can’t cut it anymore. That’s what they’re all thinking.
The sound of laughter; I’m sure it was real laughter, loud and derisive filled my ears. I couldn’t take it. I ripped off my gown and gloves, covered my ears and walked out as fast as I could, leaving a shocked Dr. Ponce and OR crew behind.
I didn’t stop walking until I’d reached Jeena’s Pub across from the hospital. I took a seat at the bar, bloody scrubs and all, and ordered a single blend Scotch on the rocks. I drained it in one gulp and ordered another. I turned around and looked around the bar and I saw him.
Satan.
He was seated at a booth, Ms. Vargus at his side. He looked robust and healthy, dressed in a dark gray business suit. They were meeting with Allen Fender, a well known business man who was also on City Council.
I guess I used to be a pretty good surgeon. Mr. Satan looks like he’s made a complete recovery.
As I glanced in their direction my eyes met Satan’s. He gave a short smile and then went back to his meeting, I left a twenty on the bar and walked out.
As soon as I hit the street my phone chimed. A message from the hospital CEO followed by the Medical Staff President. I kept on walking to my car and drove home.
Repercussions would have to wait.
My career was over.