Sunday, April 30, 2017
“Thank you,” Bruce’s father said as he took my hand and shook it with great vigor. “Thank you for taking such good care of my son.”
He shook my had again.
I’m not sure I deserve this.
Not deserve thanks after toiling for hours in the operating room?
Bruce was a complicated case.
He was transferred to our hospital from a sister facility in anticipation of having surgery by one of our Cardiothoracic specialists. He had a large paraesophageal hiatal hernia. The General surgeon at the other facility thought the best approach to his problem would be a thoracic approach, rather than the usual abdominal approach.
Beyond the hiatal hernia Bruce had a few other issues. He was bipolar and possibly schizophrenic. He also tipped the scales at just under three hundred pounds which were packed into his five foot three frame.
I became involved on a Thursday afternoon.
“I know you’re not on call,” Dr. D, the hospitalist, apologized, but Dr. M., who is on call, is tied up at another hospital and says he doesn’t think he can do the necessary surgery anyway.”
“What’s the problem,” I asked, a bit of trepidation in my voice.
She told me the tale of Bruce’s hiatal hernia and transfer to our facility and then came to the point.
“Bruce became short of breath today. We were thinking Pulmonary Embolus and did a CT of the chest. He doesn’t have a PE, but he does have free intraperitoneal air.”
Free air. A surgical emergency. At least it’s two in the afternoon, rather than two am.
“What’s Bruce’s overall condition?” I queried.
“Septic shock, BP 80/50, heart rate 130, O2 saturation 91%, about to be intubated,” she answered.
“OK, I’ll be there shortly.”
I called the OR as I drove the short distance back to the hospital.
I didn’t have anything else to do today, anyway.
Bruce was intubated and unresponsive when I arrived. His BP was 105/60 on IV fluids and some Levophed, a pressor which helps maintain blood pressure by driving the heart to work harder.
“Open up his fluids,” I ordered. “We need to get him as good as we can to go to surgery.”
Sitting at Bruce’s bedside was his father, very concerned and worried.
“You’re going to help my boy?” he asked softly.
“I will do all I can,” I replied. “It looks like he has a hole in his stomach or intestines somewhere. Most likely it’s related to his hiatal hernia. His stomach probably twisted and then ruptured.”
“He is going to be alright?” his father asked again, hope in his voice.
“I hope so, but he’s very sick right now. He has a severe infection affecting his whole body and most of his organs. He may not survive. But, we will do all we can.”
The OR crew arrived and he was wheeled down to surgery.
“Thank you,” Bruce’s father said as I turned to follow the stretcher down to surgery.
I looked back at him.
“I haven’t done anything yet,” I responded.
“Yes, you have done a great deal.”
I didn’t answer, just turned and walked out of the ICU, following Bruce to the OR.
I hope he still wants to thank me after I’m done.
I was not too confident about Bruce’s chances.
Bruce managed to survive the induction of anesthesia, maintaining his blood pressure, although his oxygenation was borderline, hovering around 94%, even with 100% oxygen.
“OK, let’s go,” I exhorted the OR crew.
I made an upper midline incision and was in the belly in about a minute, greeted by a flood of turbid, green fluid.
“Suction and some laps and a culture tube,” I requested, all neatly passed to me and my assistant.
Not good, not good at all.
We managed to suck out and wash all the vile fluid which allowed me to track down its source. I put my money on the stomach. I put my hand up under the liver where I could feel the stomach herniated through the esophageal hiatus.
Looks like this is the problem. Why do you have such a big liver?
I mobilized the left lobe of the liver and moved it out of my way and then I began to gently tease and cajole the herniated stomach back into the abdomen.
Easy, gently, don’t make things worse.
“It feels like there is a little gremlin up in the chest holding onto the stomach,” I remarked to no one in particular.
Bit by bit the stomach started to move, first a few millimeters, then a couple of centimeters and, finally, almost with a “Whoosh” the stomach was out of the chest where I could see the damage.
“Quite a mess,” I commented out loud.
Looks like it’s been going on for two or three days.
The stomach had twisted around itself, a gastric volvulus, and had patches of frank necrosis along with extensive ischemic change. There was a large perforation along the necrotic fundus which was leaking the same foul green fluid which had filled Bruce’s belly.
Looks like a mixture of antifreeze and poop.
The area of necrosis started a couple of centimeters from the gastroesophageal junction and extended along the greater curvature to the proximal antrum.
Looks like he’ll be getting a sleeve gastrectomy. He certainly qualifies as overweight.
Sleeve gastrectomy is the preferred operation du jour for weight reduction.
The surgery was pretty simple at this point. Most of the vessels along the area of necrosis were already thrombosed. I divided them all with the Ligasure anyway, just in case. Then I stapled along the stomach where it looked to be healthy. I was a little concerned about the blood supply to the most proximal portion, so I added a layer of sutures to the staple line and then buttressed the entire closure with the omentum.
That should do the job.
Bruce’s belly was washed, rinsed and washed some more, until the fluid out was as clear as the fluid in. He was back in the ICU in short order, looking very stable. Oxygen saturation 100%, urine flowing in the bag, blood pressure holding at 115/70.
Should be a save for modern medicine.
I went to talk to Bruce’s father.
“We found the problem and fixed it. His stomach had gone up into his chest and twisted and ruptured. He’s still very sick, but he looks stable right now and the source of his problems is fixed. Now he just has to heal…”
I added a few words about sepsis and organ failure, but I could tell that he had heard only a few of the words I’d said.
“Do you have any questions?” I finished.
“Thank you, thank you for your efforts and taking the time to talk to me,” he replied and we shook hands.
He sat down, waiting for a signal that he could go to see his son.
‘Give the nurses a few minutes to get Bruce all settled and then they should let you come to see him,” I added.
“Thank you,” he said again.
I went back in to the ICU.
Bruce was kept intubated and on a ventilator. He was remarkably stable with normal blood pressure, heart rate around one hundred, urine filling the Foley bag. He was still under the effects of anesthesia which made any assessment of his mental status impossible. But, all things considered he was as good as he could be.
I checked on him later that evening and there was little change.
“Very stable,” the nurse reported, “but, he’s still not moving much. He does open his eyes and stares straight up, but that’s it. The hospitalist consulted Neuro, but they won’t be by until tomorrow. We are also taking him for a CT of his head.”
“Ok, sounds like everything is being done,” I commented.
The CT of his head was normal. He continued to stare at nothing and did not remove or respond. For five days he was in this catatonic state. That’s what our Psychiatrist consultant called it: “Catatonic State.”
Besides this psychiatric disorder, he was otherwise healing quite well. His vital signs and all his other organ functions normalized. He was extubated and breathing well on his own. Then, on post op day number five he decided it was time to wake up. He smiled and asked the nurse for some water and started talking and behaving as if the past five days never existed.
“Looks like he’s turned the corner,” I told his father.
“Thank you,” was the reply.
Except, it wasn’t all smooth sailing. Bruce complained of persistent nausea and vomiting.
X-rays of his abdomen reported: “Retained Barium in the gastric fundus, mild ileus.”
Something’s amiss. I took out his fundus.
Consultation was obtained with Gastroenterology and an EGD (endoscopy of the UGI tract) was scheduled. Normally I would merely read the report, but I was present for Bruce’s endoscopy.
“Looks like a fold or ridge leading to the fundus,” Dr. S commented.
“Except, I took out that part of his stomach. I think that’s a large contained perforation,” I observed.
“Should I biopsy it?”
“Maybe not. That could be the spleen. I don’t think such a large hole is going to heal. I think he’ll need surgery, again.”
It was Thursday and Bruce was very stable. Correlation with CT scan suggested that the cavity was contained in the left subphrenic space. The opening in the stomach was about five centimeters.
I met with Bruce and his father a few hours later and explained the situation.
“It looks like where I removed part of your stomach, where it was stapled closed, has not healed. Sometimes, a small hole can heal on its own, but in your case the area that is open is just too large. I need to do surgery to fix it.”
Bruce just nodded his head.
“Thank you for explaining it to us and for working so hard to take care of my son,” Bruce’s father replied.
“It’s my job,” I answered.
I wasn’t sure I deserved any thanks for what I viewed as a failure.
Maybe I should have removed more stomach. Maybe I should not have oversewed that part of the stomach. Maybe a bigger, thicker omental patch should have been used…
When a complication rears its ugly head there is a lot of second guessing. Sometimes it’s hard to accept “thank you” when things have gone awry.
Bruce went back to surgery and I managed to wade through a morass of fibrosis and adhesions to find the hole in his stomach, six centimeters long, but confined to the left subphrenic space.
I was able to close the hole in 2 layers, wash out the abscess cavity and leave a drain without causing any damage. The spleen was left intact and Bruce avoided the catatonic state which followed the first operation.
“Thank you,” his father said.
“Your welcome,” I replied. “I hope this is the last surgery Bruce needs.”
All was well for a week, The drain in the left subphrenic space collected only diminishing amounts of serous fluid, Bruce felt well and there were no signs of any new problems. Until day eight.
Why is Bruce’s heart rate 125? Nothing much in the drain. What was his temperature? A hundred point seven last night? Something is going on.
Something was going on. The requisite CT of the abdomen revealed a new fluid collection starting in the left subphrenic area extending down to the tail of the pancreas. My surgically placed drain was going right through the middle of it, obviously not doing its job
Maybe Interventional Radiology can help.
I reviewed the scan with the radiologist and determined a new could be safely placed. Bruce had the procedure the following day.
Two hundred milliliters of slightly greenish fluid was drained and Bruce was better,
But, he still had a fistula.
I guess he needs more time.
I met with Bruce and his father and explained the situation. Bruce just nodded his head, resigned to waiting.
“Thank you for taking the time to explain Bruce’s condition,” his father said.
I don’t deserve thanks. I should be apologizing.
Such are the thoughts I have when serious complications develop. If I had done things in a different way, managed things differently then the complication could have been avoided. Of course, I never know for sure. It’s true that Bruce had been very sick when I first met him, but now he had gone through two operations along with other procedures and he still wasn’t out of the woods.
Bruce just smoldered along, neither getting better nor worse. The drainage from the fistula decreased, but didn’t stop. He was very stable, however, and arrangements were made for continued care at home. He was being fed intravenously with TPN, had the drain in place and overall was fine, at least for someone with a hole in their stomach.
Bruce was home about four days when his father called.
“Bruce keeps vomiting and he had fever this morning,” he reported.
“Bring him back to the hospital,” I advised.
“Thank you for calling me back so quickly,” he replied.
Bruce was readmitted with pneumonia. He still had a fistula, but there was less output, less than one hundred cc’s per day. I ordered an UGI series to try to get a better picture of the fistula.
“No extravasation or fistula demonstrated on this exam” the X-Ray report stated.
I reviewed the images with the Radiologist.
“Everything went straight through and I don’t see anything outside the stomach,” Dr. H stated, a touch of excitement in his voice.
Looks good to me.
Bruce was started on a liquid diet. There was no change in the output from the drain. His pneumonia improved. He was started on solid food which he tolerated in small amounts. Finally, the day came for his discharge.
“See you in about a week or ten days, Bruce,” I said as Bruce moved into a wheelchair. He had been in the hospital off and on for three and a half months.
“Thank you for being so patient with my son and for taking care of him,” Bruce’s father remarked.
“You’ll be with him when he comes to the office?” I asked.
“Yes, I’ll be sure to get him there, Thank you again.”
“Your welcome,” I replied.
Every time Bruce suffered through one of his many complications and I tried to explain his condition to his father I heard those two words.
Each time he said them there was genuine, heart felt gratitude behind the words, gratitude I’m not sure I warranted. Whenever a patient of mine suffers a complication I wonder what I did wrong. Sometimes I can think of a particular step in the surgery or a suture that I placed that maybe wasn’t quite right, or I think maybe I should have left a drain or done a different procedure or taken a different approach. Sometimes … most of the time…I can’t think of any reason for the complication. But, it still happened and I was and am responsible.
I do appreciate these words even when I don’t merit them. And, after every operation I do I try to remember them. My parting words to my OR crew, as I walk out the door, are, almost always:
The only bit of Texas I’ve adopted after more than twenty five years.
Sunday, March 5, 2017
It started about three and a half years ago: an episode of pain in my abdomen. Not terrible pain, but a gnawing pain in my upper abdomen, coupled with a queasy feeling.
Probably just my GERD acting up.
I took my Prilosec and an antacid and went on my way. The pain, however, stayed with me.
And the next day.
And the next.
This is annoying. It must be more than reflux. Maybe it’s my gallbladder?
One would think that I would have thought of gallbladder disease first. I see patients with gallstones, dysfunctional gallbladders, biliary dyskinesia and every other manifestation of biliary tract disease almost every day.
“Do you think you can do a quick sono on my gallbladder?” I asked Dr. L., a Radiologist friend. “I’ve been having epigastric pain for four days and I think it might be my gallbladder. That is, if you’re not too busy and the ultrasound is available.”
“Sure,” he answered.
“No doubt about it,” he remarked a few minutes later. “Those are gallstones. You should get an official ultrasound if you are going to have anything done.”
“Agreed,” I answered as I went on my way, still with pain, but at least with the knowledge of what was causing the problem.
The next day the pain was gone. I thought about having surgery at that time, but the pain stayed away and I didn’t think about it again until about five months ago.
Pain came back, but different than before.
It’s just my reflux. I’ll go back on my Prilosec.
The pain was a little sharper than previous, but only lasted about twenty minutes, at first.
The days went by and the pain lasted longer, still not terribly severe. It was always in my epigastrium, now lasted about an hour, almost always in the morning. And, it got better if I ate, particularly a large meal.
Definitely atypical for gallbladder.
Pain from gallstones typically is worse after eating, often occurs at night. Pain the morning, relieved by food was more consistent with peptic ulcer disease. Except, I’d had an Upper GI endoscopy only about a month before which did not reveal any ulcer.
Still, it was just an annoyance. And, I did have gallstones.
There was a change for the worse about two months ago. The pain I had was sharper, just to the right of the midline in the epigastrium and it persisted for about three hours. Then, it moved to my back for an hour before vanishing completely.
RUQ abdominal pain, lasting for hours, radiating to the back? No question. This is my gallbladder.
Still, I considered it an annoyance rather than something dire, something mandating immediate intervention. I occasionally took two Tylenol which helped, but otherwise went about my daily buisiness.
Pain, however, can wear you down. Particularly when it occurs every day and lasts for hours.
A daily cycle began.
I awoke each morning feeling well. After about an hour the pain would start in my upper abdomen, always in the middle. It would intensify for about an hour. By the time lunch rolled around it would start to diminish and disappeared by early evening.
You need to be a good patient.
I scheduled myself for an ultrasound of my gallbladder which confirmed a gallbladder packed full of stones. Then I went to see my partner, gave him the whole story and scheduled my surgery.
I guess there’s no way I can operate on myself? I’ll just have to trust my partner.
We scheduled the surgery for a Friday about ten days hence. The abdominal pain continued its daily pattern unabated. Some days the pain was sharper and lasted for 4-5 hours. It eventually moved to my back and then dissipated. Unlike so many of my patients who say the pain occurs at night, mine almost always started in the morning and disappeared completely by dinner time.
Three days before surgery the pain was less, merely a mild gnawing ache which only lasted a couple of hours. Two days before surgery I only felt a slight queasiness without real pain.
Maybe I don’t really need this surgery.
But, the day before surgery the real pain returned.
I guess it’s time.
The morning of surgery I did my usual thing: got up a little after five, fed the bird, fed the dogs, fed everybody but myself.
My wife and I parked the car at six twenty five and went into Bayshore Hospital’s Day Surgery.
“This way Dr. Gelber, we’ve got the VIP suite ready,” one of the nurses chimed.
“Room fifteen?” I answered. “Nothing very VIP about it.”
Back in the old Day surgery unit there was Room Twenty Two. It was larger and had its own bathroom. Now the only difference between room fifteen and the other rooms is that is separated from the other rooms by a hallway. I suppose it does afford a little more privacy.
I donned my hospital gown and my red, no skid socks and lay down on the stretcher to wait.
It wasn’t very long.
Two pre op nurses descended. One asked the usual questions: medical history, allergies, previous surgery, was I wanted by the FBI; you know, routine. The other started my IV. I pointed out my prominent “intern vein” which is at my right wrist and she started the IV like the pro she was.
There was another short wait until the anesthesiologist made an appearance. Unlike some other VIP’s I did not choose any particular anesthesiologist.
They all strike me as having equivalent levels of skill and I trust my patients with all of them.
Dr. M arrived and had me sign his consent. He didn’t give me a lot of explanation, rightly assuming that I was well versed in the anesthesia routine.
Dinah and JR, who would be circulating and scrubbing the case stopped in to say hello, asked if I had any questions or concerns and then left to make sure the room was ready.
Finally, the star of this endeavor, the surgeon, Dr. L., arrived, ten minutes early, a record for him. He smiled, introduced himself to Laura and said the surgery would take about an hour.
Finally time to start.
Dr. M made another appearance. He plugged an infusion of morphine into my IV, watched as the steady drip…drip…drip began and left.
Dinah reappeared and we were off. I remember being wheeled down the hall and the doors to the OR room, #8, I believe, opening and that was it.
I can only imagine being asked to move from stretcher to table. I don’t remember any of it. I suspect Dr. M said I might feel a little sting as the Propofol was injected, but I don’t know for sure. There certainly was a time out, maybe a joke or two at my expense and the ensuing surgery.
The next thing I do remember is being asked to breathe in the Recovery room. Laura was sitting at the bedside. The PACU nurse asked if I was having any pain.
A little, certainly not excruciating.
“Some,” I answered.
A half milligram of Dilaudid was pushed through the IV.
The little pain I had went away. Once again I forgot to breathe, so that every so often I would hear “take a deep breath.”
As a matter of fact the accumulated Morphine and Dilaudid worked very well.
I couldn’t stand up, couldn’t pee, couldn’t do much of anything for about four hours.
Finally, the narcotic effects started to wear off. With help, I made it to the bathroom, emptied my bladder and was deemed fit to go home, about six hours after the surgery had finished.
Of course, I still felt the effects of anesthesia and narcotics. I drank a little water and went to bed. Winston, one our dogs, a Miniature Schnauzer/Pomeranian mix made it his personal responsibility to oversee my recovery. He jumped on the bed, sniffed me all over, made sure I was breathing then lay down beside me.
No doubt he’s concerned about me, rather he’s concerned that if anything happens to me he won’t get fed.
After a couple of hours I took my first pain pill, an Ultracet which is relatively mild. After seeing how I reacted to Morphine and Dilaudid Dr. L rightly decided that 7.5 mg of hydrocodone might be too much for my delicate system and added the prescription for Ultracet.
The entire recovery was uneventful. I was able to eat without any problem. I took only two Ultracets. And I was back to work on Monday.
I looked at the photos from the surgery. The gallbladder didn’t look inflamed, my liver looked normal.
“You had a lot of little stones,” Dr. L. reported.
Makes sense, goes along with the pain I was having. Probably passed a little stone every day.
All in all it was, as best as I can tell, a boring operation. Perfectly mundane and boring. Which is the way surgery should be.
This cholecystectomy was my third experience with general anesthesia. First was a fractured fibula which required a closed reduction in seventh grade. Then shoulder surgery after my second year of medical school.
Undergoing surgery, besides the benefit of eliminating the annoying gallbladder pain, should help me empathize with my patients. I now can say to my patients that I know what you are experiencing, even if I never had to take anything stronger than Tylenol for my gallbladder pain. Same story after this surgery, except for two Ultracet.
And, it does underscore the truth that every patient, every illness is unique. We are all individuals and deserve to have our health care tailored to our personal needs. This fact is not evidence based and doesn’t fit into any standard protocol.
It does, however, lead to happy patients and good care.
Sunday, January 29, 2017
It’s that time of year again. The national day of beer, pizza, occasionally clever commercials and one over hyped game. The Super bowl is upon us again.
Super Bowl LI.
When I first read about it I wondered who or what LI was. I did know that the game will be played in Houston, which meant that LI did not stand for Long Island. Maybe LI was a new fashion designer about to make a bold statement with the Super Bowl as his or her backdrop. But, it finally dawned on me that the annual event was always couched in Roman numerals and LI stood for “51.”
Super Bowl LI: New England Patriots vs Atlanta Falcons.
On the surface it shouldn’t even be a close game. Tom Brady, Bill Belichik with all their Super Bowl experience against a team who don’t have one player I’ve ever heard of. The current line is Patriots minus 3 points. A no brainer, at first glance.
But, such an important event deserves far closer scrutiny and analysis. I will start with the Patriots.
What are Patriots, particularly those from New England?
A rag tag band of colonists trying to separate themselves from their mother country. Typically they are armed with muskets; firearms which fire large caliber “balls” with all the accuracy of Shaquille O’Neal shooting free throws. It is true that such muskets can inflict great damage should they hit their mark, a relatively rare event.
And, battling these Patriots? Falcons. Sleek birds with sharp claws and beaks, perfectly designed for hunting and killing mice, rats and other small animals. The Falcon is the fastest of all birds, able to soar at speeds of close to seventy miles per hour and dive at speeds over two hundred miles per hour.
Is this a fair matchup?
A motley crew of colonials armed with inaccurate firearms vs. a deadly, high speed hunter with claws and beaks which could peck out eyes while their hapless prey are trying to reload their worthless muskets.
Surely, dear reader, you have heard of Alfred Hitchcock’s “The Birds.”
There is no question about this year’s ritual game. The Patriots will be caught flat footed by the lightning Falcon attacks and all that will remain will be the bloodied bodies and tattered uniforms of New England’s storied team.
Falcons 27 Patriots 17