Wednesday, January 6, 2016
He was a sweet man. That’s what the Chief said about Adrian. Adrian did have issues, that’s for sure. Number one was that he was yellow. I don’t mean yellow in the sense that he was cowardly; quite the opposite was true. Adrian was literally yellow.
That was why he was in our clinic. His skin and eyes were yellow and he had been having abdominal pain. He couldn’t eat and had lost almost twenty pounds. Obstructive jaundice was the diagnosis. I put him in the hospital to find out why.
Besides his yellowness, Adrian had other problems. He had been born with cerebral palsy and had spent most of his life in a variety of institutions. Maybe he was a bit slow to collect his thoughts, perhaps his words weren’t always clear and his eyes looked a little “off.” But, he had a smile that lit up the room. And when he smiled his eyes had a little twinkle that said “I know I look a little different, but looks are nothing. It’s the heart which counts.”
He and the Chief hit it off almost immediately. Even though they were worlds apart intellectually, socially and in every other way, the Chief saw something special in Adrian; call it purity or sincerity.
I, on the other hand, was given the task of finding out why poor Adrian was yellow and what could be done to fix him.
The history offered some clues. Adrian had suffered repeated episodes of upper abdominal pain, back pain with nausea. The pain lasted a few hours, occurred at all hours, but was worse at night.
So far, classic gallbladder disease with episodes of biliary colic.
Physical exam revealed scleral icterus and not much else. Specifically, there was no abdominal mass and neither the liver nor spleen was enlarged.
Lab tests were significant for a total bilirubin of 9.3, Alkaline phosphatase was 815. CBC, electrolytes, BUN, Creatinine and everything else was essentially normal. Ultrasound revealed gallstones and a dilated common bile duct.
Adrian was a classic case of chronic cholecystitis, cholelithiasis and choledocholithiasis, which means he had pain secondary to stones in the gallbladder and common bile duct. Surgery would be the proper treatment.
The time was 1989. Laparoscopic Surgery had not yet hit the United States in any big way. There was no MRCP and ERCP’s were not done if the patient was going to need surgery anyway. Besides, I was a resident, this was a teaching hospital and Cholecystectomy and Common Bile Duct Exploration was a good case; it was what we called a “Complex Interchangeable Case.” A minimum of sixty such cases were needed to sit for the boards. And, to top it off, this particular surgery, specifically common bile duct exploration, was the Chief’s favorite type of operation.
I scheduled Adrian during my regular operating time, which was on Thursday, three days hence. I notified the Chief and thought everything was set.
That’s when the problems started. Not with Adrian, he was fine waiting a couple of days. He greeted us every morning with his special smile. He told us how much he liked the food and how comfortable the bed was. And, and he waved goodbye as we left and told us how he looked forward to seeing us on afternoon rounds.
No, it wasn’t Adrian. It was me and a sudden flurry of very sick and complicated patients. Gregory had a mass in the right middle lobe of his lung and needed a resection. Thomas had a mass in the left upper lobe of his lung and he needed a resection. Jesse had stomach cancer, Johnny had colon cancer, Phil had a chest wall mass. All were in the hospital and all needed complex surgery. So much work, so little time. And the Chief was involved with not only Adrian, but Gregory and Thomas.
I must point out that at the county hospital each chief resident is allotted a certain amount of OR time. I had room twelve on Tuesday, Thursday and Friday. Scheduled cases had to be finished by three pm. I would need to do some wheeling and dealing to find the time to do this windfall of Complex Interchangeable Cases.
I called my co chief resident on the Trauma service and “borrowed his time on Wednesday and I rescheduled a few other smaller cases. Because of scheduling conflicts with other attending surgeons Adrian’s surgery was moved to Friday. Finally, I went up to the office to tell the Chief about the change in schedule.
He was not happy.
“I cancelled an important meeting to do that surgery. Do not ever take me for granted. Change it back,” he almost shouted, the first and last time he ever raised his voice at me.
A bit sheepishly, I got on the phone with scheduling, some of the other attending surgeons and the other chief residents and managed to put things back so that Adrian’s case, with the Chief, was back on Thursday. Of course, the other chief residents, feigning helpfulness, said that they would be willing to make the sacrifice and do one or more of these complicated surgeries for me. “Just to be helpful.”
Such help I did not need.
It took a bit of finagling, begging and dealing, but I managed to get all my cases scheduled in a timely manner, fulfill all my necessary duties and keep the Chief happy.
Adrian waited patiently. He remained yellow, but otherwise was well. On rounds the following day he was doing his best to help out some other patients as well as the hospital staff. We found him emptying the wastebasket in his room into the janitor’s larger trash can. He called the nurses when his roommate’s IV ran out, he bought food from the vending machines on the floor and shared his Frito’s and Cheetoh’s with the other patients.
The day before surgery I sat down at his bedside and explained his surgery to him. I presented the alternatives, risks, benefits and all the other details as simply and clearly as I could. He listened intently, nodding his head once in a while, but I was never sure if he truly understood. When I finished I asked him if he had any questions.
“You know,” he began, “it would be really nice if I could get a job here after my surgery. Maybe, I could sweep up or take out the trash.”
And he smiled his sweet smile.
“Let’s get you better first,” I answered. “I don’t have much influence over such things, but the Chief might be able to help. I’ll talk to him.”
“Thank you, thank you,” he responded and his smile grew even larger.
There are parts of being a doctor which have nothing to do with physical wellbeing. For example, I have a patient who had rectal cancer many years ago. I remember before his surgery that his biggest concern was getting back to work, which was janitorial. He was the sole support for his family. Neither he nor his wife spoke English, yet they managed. He told me that the worst thing was to be unproductive. He needed to be doing something which helped others, even if it was just mopping floors.
“Clean floors,” he told me through an interpreter, “are important to a hospital. My floors are the cleanest.”
And, I believed they were.
Adrian, I’m sure, had similar beliefs. He wanted to be productive. He wanted to look at a floor or an empty waste basket and feel pride in a job well done. Yes, he suffered from a chronic infirmity, but this so called disability was in no way an impediment to his productivity.
The question was: “When should I bring it up to the Chief?”
He was already annoyed with me. Should I do it now, figuring two annoyances at the same time will pass sooner than one after another? Or, maybe, wait until he calms down and forgets about my transgression. He likes Adrian; I’m sure he would be happy to help out one of his patients.
After considerable mental deliberation I decided to bring the issue up while we were operating. During the surgery Adrian would be center stage and doing all things possible to help him would be foremost in all our minds.
Finally, Adrian’s big day came.
The Chief waited in our tiny lounge while I began the surgery with one of the junior residents. The Chief always preferred midline incisions, even for gallbladder surgery. He poked his head into the room shortly after we started and scrubbed in as the gallbladder was passed to the scrub tech.
Adrian was very thin with a paucity of intraabdominal fat. The structures of the Porta Hepatis: bile duct, hepatic artery and portal vein each stood out. The bile duct looked dilated, almost two centimeters in diameter. This was about three times the normal size of about six millimeters.
“Looks pretty obvious, don’t you think Chief?” I asked, pointing to the bile duct.
“You still need to follow the rules,” he responded.
“I know, I was just testing you,” I shot back; he smiled at me.
The rule was that the bile duct always should be aspirated with a needle before it is opened. It was considered bad form to make an incision in a structure, assuming it was the common bile duct, only to discover it was the portal vein. Bad form for the surgeon and especially bad for the patient.
With 23 gauge needle and syringe in hand I aspirated the structure which I was sure was the CBD and was happy to see the syringe fill up with yellow fluid. I put stay sutures in the duct and made my incision. Bile and a big stone popped out.
Maybe this won’t be too difficult. Be careful. Don’t say anything or you’ll jinx yourself.
“Choledochoscope,” the Chief requested. As we were waiting for Jeanette, the scrub tech, to set up the scope the Chief looked up at me and then down at Adrian’s abdominal viscera.
“You know,” he began in his slightly gruff, grandfatherly way, “when you die and go to that big operating room in the sky, all your cases will be like this.”
This was the second time during my residency that the Chief made this observation; the other was on a similar case in a very thin, young healthy woman. And, I knew exactly what he meant. Surgery like Adrian’s were the Chief’s favorite type of case. But, this particular surgery was shaping up to be interesting, but without the struggles that we sometimes face when confronted with a patient who is very obese or has extensive inflammation or scar tissue. All of which can make for very tedious operations. Adrian, however, also proved to be a challenge.
The choledochoscope was finally ready. The Chief preferred the rigid scope. He thought the visualization was better and instrumentation was easier. This scope consisted of an optics portion which was inserted into the bile duct and an eyepiece which was at a right angle to the optical portion. Using this particular choledochoscope required a Kocher maneuver, which meant mobilizing the duodenum, so that downward traction could be exerted to straighten out the duct and allow for inspection of the entire duct.
The Chief inserted this scope through the opening in the bile duct and then handed the scope to me. A stone was clearly visible.
We went to work and fished it out using a stone forceps. The scope went back in and another stone was seen and removed, then another and another. Before long we had ten stones.
“There are more in there,” I commented.
“Keep at it,” the Chief replied.
Five more stones were removed and there was at least one more.
“This last stone is stuck,” I noted. Looking with the scope we both saw the stone wedged in the duct and I could feel it behind the duodenum,
“I’ll try a Fogarty,” I decided and the Chief nodded his head in concurrence.
The Fogarty, a catheter with an inflatable balloon on its tip, would not pass beyond the stone. We tried stone forceps, irrigation, another go around with the Fogarty, but that stone did an excellent imitation of a mule and refused to budge.
“If this is what I have to look forward to in Heaven, I hate to think about the alternative,” I quipped.
The Chief gave me a look of frustration, then asked, “What’s your plan now?”
“The duct is big, I think a choledochoduodenostomy would be best. Adrian has a lot of stones. I wonder if some or all of them formed in the duct, rather than passing from the gallbladder,” I explained my reasoning.
“You wouldn’t consider a transduodenal sphincteroplasty?” He asked, playing Devil’s advocate I suspected.
“With the big duct and so many stones, I think the bypass operation is better,” I replied, “besides, we won’t have to worry about a cholangiogram.
These two procedures are similar. But have different potential for complications, short term and long term. A choledochoduodenostomy means anastomosing the duodenum and the common bile duct, thus bypassing the obstructed portion of the duct behind the duodenum. This allows for much improved drainage from the bile duct. A transduodenal sphincteroplasty means approaching the bile duct through the duodenum at the ampulla of Vater. The duodenum is opened and the ampulla, which is where the bile duct and pancreatic duct enter the bowel, is identified. This ampulla is then incised, which opens the sphincter, which is then sutured to the duodenal mucosa. This enlarges the opening between the common bile duct and duodenum. The latter procedure, in my opinion is best for impacted stones at the ampulla and short ampullary strictures. The sphincteroplasty also is useful when the bile duct is small as the biliary bypass procedure is more likely to fail if the duct is less than one centimeter. Long term, the sphincteroplasty is more physiologic and less likely to have the complication of ascending cholangitis, which means infection of the biliary system, which is more common after choledochoduodenostomy.
In Adrian’s case, his duct was large and there was concern that the stones may have developed within the common bile duct. Both these facts led me to recommend the choledochoduodenostomy.
The Chief agreed.
I already had a hole in the bile duct. I made an opening in the duodenum and hooked the two together with a minimum of fuss.
While suturing away I asked the Chief about Adrian.
“Chief,” I started, “Adrian asked if he could have a job with the County. Maybe, a janitor or something like that. He really will do whatever he can. I think he would be a good worker.”
“Such a nice, sweet man,” he answered. “You know, it would be the right thing to help him. I’ll talk to some of the administrative types.”
And that was that.
I finished Adrian’s operation in short order and he made a rapid, uneventful recovery, going from yellow to pink over a couple of weeks, when I saw him back in the clinic.
“I haven’t forgot about what you asked,” I reminded him as I felt his abdomen. “The Chief spoke with the Hospital CEO and you have an appointment with Human Resources on Friday. Can you make it?”
He gave me his big smile and his eyes shone.
“I’ll be there,” he answered and he smiled again.
“Wait, before you go the Chief wants to say hello,” I added.
The Chief came from the back and shook Adrian’s hand.
“Good luck, Adrian,” was all the Chief said and he walked away.
However, I did hear him murmur, “such a sweet man.”